Deborah Kilday, MSN, RN Senior Performance Partner Premier, Inc. Premier’s Focus: OB Harm Reduction September 11, 2015

2 © 2015 PREMIER, INC. Approximately 4.1 million women in the U.S. between the ages of 15 and 50 gave birth from May 2013 to May In 2013, 18 mothers died in the U.S. for every 100,000 live births, The U.S. has FALLEN to 64 th in the world on maternal mortality. The U.S. ranks 3 rd in the world for C/S, where 30% of women have surgical deliveries Adverse events occur in approximately 9% of all deliveries in the US. at a cost of $17 billion annually Maternal mortality Leading causes of maternal death: 1.Obstetric Hemorrhage 2.Preeclampsia 3.Embolism

3 © 2015 PREMIER, INC. For every 1,000 deaths, there are cases of severe morbidity Just the tip of the iceberg

4 © 2015 PREMIER, INC. Preventable harm Maternal Hemorrhage Preeclampsia and Eclampsia Early Elective Deliveries Perineal Trauma

5 © 2015 PREMIER, INC. Improve Readiness Implementing standardized protocols Regular ongoing unit based team drills and education Rapid availability of resources and medications Improve Recognition Patient family education and communication Assessment of risk on admission - ongoing Early warning tools for vitals and symptoms Improve Response Using standardized protocols with checklists Trained and activated teams Improve Reporting Multidisciplinary monitoring and review Debrief/Huddles “The 4 R’s”

6 © 2015 PREMIER, INC. 1.Maternal Early Obstetrical Warning System 2.Obstetric Hemorrhage 3.Hypertension in Pregnancy 4.Venous Thromboembolism in Pregnancy 5.Reducing low-risk primary cesarean deliveries 6.Reduction of Peripartum Racial Disparities 7.Patient Family and Staff Support 8.Standards of Care for the Interconception/Postpartum Visit Safety Bundles “What every birthing facility in the U.S. should have…” The Council on Patient Safety in Maternal Health Care

7 © 2015 PREMIER, INC. Process Maps Perinatal Safety Index Performance Partner QUEST Workgroups Mortality Workgroup Safety Workgroup National Meetings Learning Collaboratives Alliance for Innovation on Maternal Health (AIM) QUEST perinatal resources and support

8 © 2015 PREMIER, INC. Links to recorded 2015 webinars: May 8: Improving outcomes in hypertensive disorders of pregnancyMay 8: Improving outcomes in hypertensive disorders of pregnancy - Premier Advisor Live May 20: What providers should know about maternal opioid use and abuseMay 20: What providers should know about maternal opioid use and abuse - Premier Advisor Live June 9: Maternal substance abuse and neonatal abstinence syndromeJune 9: Maternal substance abuse and neonatal abstinence syndrome - Premier Advisor Live July 21: Introduction of the national safety obstetrical VTE bundleJuly 21: Introduction of the national safety obstetrical VTE bundle - Premier Advisor Live Upcoming 2015 webinars: September 23, 1:00 – 2:30 pm EST: Perinatal Care Core Measures UpdateSeptember 23, 1:00 – 2:30 pm EST: Perinatal Care Core Measures Update - THA October 21, 11:00 am – 12:00 pm EST: Exclusive breastfeeding – GHA October 27, 12:00 pm – 1:00 pm EST: Postpartum Hemorrhage - THA November 18th at 3:00 pm EST: Reducing primary cesarean births - Premier Advisor LiveReducing primary cesarean births Collaboration and education

9 © 2015 PREMIER, INC. Additional areas of focus

10 © 2015 PREMIER, INC. Premier Connect Resources Perinatal Safety Community Open to all Premier Members Networking Share knowledge Current resources Advance evidence-based clinical practices and processes Promote safe, reliable, quality care Links to education External link to the Premier Safety Institute coming soon!

11 © 2015 PREMIER, INC. Safety culture concepts; Strong leadership Multidisciplinary team interaction Adherence to principles of evidence based medicine Standardized policies and procedures for clinical operations Common terminology Timely communication High degree of emergency readiness Culture of Safety Improving Team “Readiness, Recognition and Response” “Collective Mindfulness”

12 © 2015 PREMIER, INC. Advisor Live Education American College of Obstetricians and Gynecologists Association of Women’s Health, Obstetric, and Neonatal Nurses Council on Patient Safety in Women's Health Care California Maternal Quality Care Collaborative The Preeclampsia Foundation Premier Safety Institute Collaborating Partner Links

13 © 2015 PREMIER, INC. Questions and Contact information Deb Kilday, MSN, RN Senior Performance Partner Clinical Advisory Services or Kelly Conklin, MSN, RN Senior Director Member Engagement