Author: Jillian Genereux

How Did We Get Here? Creating and Sustaining Supportive Team Environments

During Neonatal Nurses Week, not only should we be focused on the outstanding work of our neonatal nursing colleagues, but how can we promote collaborative teamwork that undergirds outstanding neonatal care? How can we best support our nursing teams in caring for the smallest and most fragile of patients?

Elizabeth Rochin, PhD, RN, NE-BC | September 14, 2023

Posted under: Other, Quality of Care

During this Neonatal Nurses Week, not only should we be focused on the outstanding work of our neonatal nursing colleagues, but how can we promote collaborative teamwork that undergirds outstanding neonatal care? Sometimes it is easier said than done, but one thing is sure: committing to and caring for our patients AND each other, should be our rallying cry.

Unfortunately, the news cycle of late has been rife with discussions of patient harm resulting from communication challenges and failures within teams:
  • April Valentine: Young woman who died while in labor. Nurses reported they could not call the doctor as they would “cuss them out.”

  • Lucy Letby: NICU nurse in the UK found guilty of murdering seven babies in a neonatal unit and convicted of trying to kill six others. Physicians and others came forward with their concerns, only to be told to “apologize to Lucy” for impugning her of wrongdoing.
As this is Neonatal Nurses Week, I thought I would briefly explore chain-of-command opportunities in the NICU. How can we best support our nursing teams in caring for the smallest and most fragile of patients? Instead, I found a litany of information related to bullying…nurse/nurse, nurse/physician, physician/physician. And I must say, I was not expecting that. While the majority of my work of late has been to support communication challenges in the obstetric setting, perhaps we should also focus on the NICU environment.

Committing to and caring for others, including each other, should be our rallying cry.

Here are two NICU examples I thought I would share, one from a nurse and one from a physician:

Nurse:
“Guess who just got bullied out of their new NICU job? It’s me. This is the most catty, cliquey, TOXIC work environment I have ever seen. I have been yanked off of orientation, belittled, completely unsupported, and now my preceptor says I need to ‘rethink if this is really for me.’ Like…. I have 4+ years of experience, have worked COVID ICU, charged, precepted, been asked to be House Sup…. I know I’m not dumb. But [gosh], they made me feel small. Anyone else go through this? Feeling pretty alone and discouraged right now. Luckily a past job is taking me back and I’m getting out of here.”

Physician:
“The presence of incivility is not new to medicine, and certainly not foreign to us in the NICU environment. Over the past two decades, I have seen several situations develop in different institutions that create an environment where it is uncomfortable, threatening, or unsafe to conduct oneself fluidly as part of a highly functioning team. Incivility can arise simply from people choosing to disregard or disrespect one another’s opinions, or it can manifest more blatantly in the form of harsh public criticism or the deliberate dissemination of misinformation that deteriorates trust levels.” https://www.medela.us/breastfeeding-professionals/blog/going-toxic-in-the-nicu-dealing-with-workplace-negativity

Think about that. Deliberate dissemination of misinformation. Deteriorating trust levels? The question is so timely…how did we get here?

And as I thought about this more, I kept coming back to the patient safety bundles developed by the Alliance for Innovation on Maternal Health (AIM). The 5 Rs, (readiness, recognition, response, reporting/systems learning/respectful interactions) create a consistent and standardized approach to improving patient care. And may even support team synergy and col
But what if there were a Team Communication Patient Care Bundle? What would that look like? How can we establish consistent, standardized ways of meaningful teamwork, enhancing communication, and improving patient outcomes?

So, the real question should be “where do we go from here?” and “How can we work collaboratively to create the best environment for patients AND our teams?”

Here is a start. I hope you will help me finish it.

Readiness
Every hospital Board/Trustees:
  • As part of Governance, routinely assess work environment/psychological safety and establish metrics to evaluate hospital leadership.
  • Expectations of transparency related to patient harm resulting from communication failures.
  • Understand the scope of Directors and Officers Insurance Liability (D & O)/General Liability (GL) in the event of serious maternal/neonatal harm/death that was the direct result of a documented/known team communication challenge (incivility/bullying/intimidation).
  • Yearly Board assessment that includes organizational psychological safety metrics.
Every hospital
  • Establish parameters, expectations, and accountabilities for team communication and share documents and reports openly.
  • Establish a definition of incivility/bullying/intimidation and hold all employees accountable to expectations.
  • Assess psychological safety within units and share findings with all team members, including between/within disciplines.
  • Establish a centralized and representative team to evaluate serious maternal/neonatal harm stemming from potential/real communication failures.
  • Train staff on team communication skills annually/per policy (TeamSTEPPS as an example).
  • Establish a chain-of-command system that is developed and agreed upon by all stakeholders and broadly communicates plans for escalation, including real-time communication tracking.

Recognition and Prevention
Every Unit
  • Provide ongoing education to all team members related to communication expectations and accountability.
  • As a team, identify high-risk and high-stress situations that may facilitate communication challenges.
  • Use simulation as a guide and teaching tool for critical conversations.
  • Collaborative physician/provide/nursing leadership that role models teamwork and open communication style.

Response
Every Unit
  • In the event of a serious communication failure, stabilize the patient as needed/supportive care for the impacted staff member(s).
  • Use a standard, facility-wide reporting system for potential/real patient care challenges related to team communication.
  • Establish a rapid response team/process that can be available to any unit to support communication challenges within patient care.
  • Consistent and equitable actions for behaviors/interactions requiring intervention.
  • Use of Employee Assistance Program (EAP) for support/counseling within serious communication failures/patient events.

Reporting and Systems Learning
Every unit
  • Celebrate improvements in team cohesion and communication at every opportunity.
  • Perform multidisciplinary reviews of any patient care errors that may be the result of team communication failures.
  • Monitor rate of event reports related to team communication issues/errors/failures.

Respectful, Equitable, and Supportive Team Cohesion
Every unit
  • Assess for and act upon real/perceived team communication challenges based on bias, discrimination, or racism.
  • Establish debriefing process for patient harm as a result of communication failures.
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Using Breastmilk Feeding Success to Support the CMS Commitment to Health Equity Measure

The Centers for Medicare and Medicaid Services launched the Commitment to Health Equity Core Measure. This Core Measure has five domains and should be on every hospital’s radar. We are going to use Breastmilk Feeding as an example of how these domains can work together to support hospital and community partnership and engagement.

Elizabeth Rochin, PhD, RN, NE-BC | August 10, 2023

Posted under: Maternal Health, Quality of Care

On January 1, 2023, the Centers for Medicare and Medicaid Services launched the Commitment to Health Equity Core Measure. This Core Measure has five (5) domains and should be on every hospital’s radar for action. This is a requirement for Inpatient Quality Reporting:

Domain 1: Equity is a Strategic Priority
Domain 2: Data Collection
Domain 3: Data Analysis
Domain 4: Quality Improvement
Domain 5: Leadership Engagement

August is National Breastfeeding Month. And what better time to show how these domains can work in action to provide support for your obstetric patients and care teams.

We are going to use Breastmilk Feeding as an example of how these five (5) domains can work together to support hospital and community partnership and engagement.

Implementing Quality Improvement within the Commitment to Health Equity Measure

Hospital Leadership/Boards of Directors
  • Is hospital leadership (yes, I mean the Board of Directors and the C-Suite) invested in improving maternal health?

  • Is maternal health and outcome disparities on the agenda of Boards of Directors/Trustee meetings? How often?

  • Do Boards of Directors/Trustees/C-Suite ask about QI projects on a routine basis?

  • Do they routinely ask about outcome disparities?

  • How often do they see the data? And is this data shared with Boards of Directors? Trustees?

  • How engaged is the Board in reviewing and understanding maternal health QI projects?

  • Do unit leaders have an opportunity to engage directly with the Board and share best practices and success stories of improved maternal healthcare, particularly through a racial and ethnic lens?

  • Do hospital Boards of Directors know which community health organizations are actively involved in patient care/transitions to home?

  • Does your Board of Directors reflect the community it serves?
Nursing and Physician Leadership/Unit Level
  • What does nursing leadership look like?

  • What does physician leadership look like?

  • Do they work well together?

  • Are they committed to the same outcomes and priorities?

  • Are they committed to including the voices of those most impacted in perinatal project planning?

  • In other words, are patients of color or others based upon identified social needs asked to participate in QI initiatives within the unit?

  • Is there a Patient Advisory Council that serves to facilitate connections between patients and care teams?

  • Are there routine communications/meetings between hospital teams and community organizations that support patient care after discharge?

  • Have they assessed the activation and readiness of their teams to engage in QI work?
Frontline Care Teams
Let's explore the teams themselves, the team members who will be doing the work.
  • Are they ready to engage in QI work?

  • Are Doulas considered part of the frontline care team?

  • Did the team have any input in creating the QI project?

  • Are there identified champions and informal leaders?

  • Is there bandwidth available?

  • How many other projects and initiatives are underway?

  • Is this considered a priority among many others?

  • Is the team multidisciplinary and includes all facets of care?

  • Are there identified naysayers?
What? Naysayers?
Believe it or not, naysayers are not only helpful, but can be very valuable to identifying barriers and real/potential pitfalls of a QI project. The "squeaky wheels," if you will, can be some of your most invested team members who sincerely want positive change. Or they have had enough of “one trick ponies” and QI projects that were not sustainable or implemented without frontline feedback. While it may be tempting to dismiss them, it is much more important to listen and hear their concerns.

The Patients Themselves
Earlier I mentioned the engagement of patients in QI project development. Yes, this is a critical component of successful QI implementation. As important as it is for your organization and team to be engaged and dedicated to QI, what if the project you are considering does not meet the needs of your patients?
  • Were assumptions made based upon conscious/unconscious bias rather than data?

  • Are the measures/objectives/metrics in line with the communities you serve?

  • How will patients react to and participate in a QI initiative? Are they passive or active participants?
So, let’s use breastmilk feeding as an example of how to engage the team and communities in supporting this important health initiative.

Hospital Leadership:
  • Awareness of the Commitment to Health Equity Measure?

  • View as a priority within public health initiative and health equity strategic plan?

  • Frequency and evaluation of racial/ethnic disparities in exclusive breastmilk feeding?

  • Rounding on units to assess for engagement? Barriers to implementation?
Nursing and Physician Leadership/Unit Level:
  • Awareness of the Commitment to Health Equity Measure?

  • Agreement on the importance of breastmilk feeding?

  • Mutual support from RN/MD leadership?

  • Awareness and involvement of all team members to support the initiative, including other care team members involved in care? And yes, this includes Environmental Services, Case Management, Food and Nutrition Services, Biomedical Engineering, Pharmacy, Respiratory Therapy, and anyone meeting a patient. Does everyone buy into the importance of breastmilk feeding?

  • Students part of the process and encouraged to participate in and lead QI activities?
Frontline Care Team:
  • Awareness of the Commitment to Health Equity Measure?

  • Does your frontline care team look like the patients you are serving? If not, what steps has your organization taken to diversify your team to ensure breastmilk feeding education is meeting the needs of your patients?

  • How are Doulas used in breastmilk feeding education?

  • Ongoing education? Is it Just-in-Time/bite size for ease of use?

  • Use of Lactation Consultants to promote real-time education?

  • How are QI Champions supported? Dedicated time for support of the QI project?

  • Understanding and appreciating the importance of evidence-based practice?

  • How are breastmilk feeding QI activities incorporated into daily processes? How are they communicated to teams? How do teams communicate initiatives and outcomes to each other?
Naysayers
  • Have they been heard? Have their concerns been addressed? Even if unable to meet the need, have the inability to provide (XXX) been discussed?

  • Are there not enough resources or supplies to support breastmilk feeding in the unit?

  • Are there personal biases against breastmilk feeding? Did a personal experience lead to anger or frustration surrounding breastmilk feeding? (VERY IMPORTANT!!)

  • Have any personal conscious/unconscious racial biases been addressed that may be creating negativity towards equity work?
And here is the important part: Community organizations know the important role they play in supporting patients in the community. Connecting hospitals and care teams with these critical resources is essential in safe and optimal transitions to home.

Patients/Community Organizations
  • Awareness of the Commitment to Health Equity Measure?
  • Have diverse patients been included in providing feedback related to their breastmilk feeding experience?

  • Has the breastmilk feeding QI project been introduced to patients with feedback elicited prior to implementation?

  • Is a Patient Advisory Committee or Team included in the QI project and process for improving breastmilk feeding?
  • Have patients been asked about resources, supplies, and other needs related to breastmilk feeding?

  • Have patients had an opportunity to review any hospital documentation related to Community Health Needs Assessment (CHNA) related to breastmilk feeding? Did they have an opportunity to contribute their experiences or findings?

  • Can patient advocates and community health workers (CHWs) serve as volunteer support to encourage and transition breastmilk feeding success to the community?
There are community partners throughout the US that can provide exceptional support and feedback to hospital teams to support breastmilk feeding after discharge. Creating awareness of the essential connections that hospitals and communities must have to ensure optimal outcomes is key.

But remember…Breastmilk feeding is but one area that community organizations can play a key role in perinatal care. Housing and food security, transportation, physical safety, and many other unmet social needs can benefit from the rich and vibrant hospital/community connections that can support optimal outcomes for new mothers, parents, and newborns.

**And remember…as you survey the unmet social needs of your patients, it is critical that this same exercise be conducted for your own hospital care teams. What community resources do they need to give their best to your patients?
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Creating a Use Case for Maternal Data and Quality Improvement

Every quarter, NPIC provides member hospitals with a plethora of data. Data that can be tremendously helpful in creating and sustaining quality improvement action plans to support optimal outcomes in maternal and newborn inpatient care.

Elizabeth Rochin, PhD, RN, NE-BC | July 20, 2023

Posted under: Data & Analytics, Maternal Health

Every quarter, the National Perinatal Information Center provides member hospitals with a plethora of data…a hospital’s own data and comparisons to their subgroup and the entire NPIC database. This data can be tremendously helpful in creating and sustaining quality improvement action plans to support optimal outcomes in maternal and newborn inpatient care across the United States. While real-time data access is critical for day-to-day patient care, quarter-over-quarter data analysis can be useful to assess interventions and programmatic shifts.

So, I decided to examine a few areas many hospitals focus on, particularly postpartum readmissions and cesarean birth. And I also wanted to look back to 2019 and come forward to 2022, as yearly trends can inform of areas of opportunity. And both postpartum readmission and cesarean birth allow for such reflection and calls to action.

Postpartum Readmission
Many hospitals focus on postpartum readmission and for good reasons. Readmission rates tend to be used as a proxy for quality but can also be bellwethers for population health opportunities.

NPIC Database 2019 – 2023, Delivery Readmissions coded with:


Observations:
  1. Severe maternal hypertension and hemorrhage continue to be areas of focus secondary to AIM patient care bundles and The Joint Commission Patient Care Standards.

  2. Not every readmission is a failure. Education on maternal warning signs and when to seek care may drive some of these readmissions. It is important to identify the drivers of readmission and any education or information that may have led to better recognition of serious maternal complications. Educational tools such as AWHONN’s POST-BIRTH Warning Signs and Save Your Life tools or the Centers for Disease Control Hear Her Campaign should be used with all postpartum discharges.

    AWHONN
    CDC Hear Her Campaign

  3. Major puerperal infections have decreased which is a good sign for postpartum patients. Consistent preventive measures and early identification of infection and sepsis can be lifesaving. Learn more about maternal sepsis at the Sepsis Alliance and the Tara Hansen Foundation.

    Sepsis Alliance
    Tara Hansen Foundation

Cesarean Birth:
Healthy People 2030 has set a cesarean birth target of 23.6% for low-risk women with no prior births. States across the US have participated in the Alliance for Innovation on Maternal Health Safe Reduction of Primary Cesarean Birth patient safety bundle. The original patient safety bundle was launched in 2015. So how are we doing?



Well, as a nation, and as a database, we are not hitting the target. There are some hospitals that are getting it done and doing it well! I hope we can celebrate your work and the work you are doing to promote intended vaginal birth, and to reduce the likelihood of future cesarean birth. We look forward to continuing to engage with our top decile hospitals and supporting their work and supporting other hospitals looking to reduce their primary cesarean birth. Here are a few suggestions from some teams across the country:
  1. Celebrate successes, even small ones. Publicly highlight physicians, providers, nurses, and other team members who consistently finish with a vaginal birth. If you don’t follow Dr. Tiffany Montgomery on LinkedIn, think about it. She is the Lead for Perinatal Quality at Parkland Hospital in Dallas, consistently posting about supporting her teams’ wins in reducing primary cesarean birth. Contacting Dr. Montgomery should be your next step if you are looking for ideas.

  2. Don’t bite off more than you can chew. How many quality improvement projects do you have running at the same time? Are the same team members being tapped every time? Creating space for QI is important, but sustainable change is the key. Take the pulse of your team routinely, and don’t forget that frontline team members AND patient voices should always be included in any QI planning and implementation. The Safe Reduction of Primary Cesarean Birth patient care bundle requires a multidisciplinary approach that includes prenatal and intrapartum teams.

  3. Stratify your data by race and ethnicity. Yes, this is important. Stratify your cesarean delivery outcomes by race and ethnicity. The literature for years, including the NPIC database, has shown that Black women historically have higher cesarean birth rates. There are numerous reasons for this, but lack of shared decision-making and continuous labor support, and bias/racism inside and outside hospitals have been found to contribute to higher cesarean birth rates. When you report that cesarean birth rates are “equitable,” your data can support your efforts.

  4. Understand quality improvement. No, really understand it. QI is not a “one-and-done” approach. A true QI project requires planning, data exploration, team readiness assessment, and an authentic approach to including the patient’s voice (as NPIC has termed #AuthenticQI). Quality improvement also requires an investment of time (= money) and inertia. Institute for Healthcare Improvement has an excellent QI framework for reducing primary cesarean birth.
NPIC is proud to provide this brief overview of key maternal outcomes. Our goal is for you to use your data in the best possible way to promote optimal health, well-being, and outcomes for mothers and newborns in your hospitals and communities, and we are proud to be your partner.
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Respectful Care in the Neonatal Intensive Care Unit

Respectful Care continues to be a priority for maternal and neonatal outcomes, particularly with the continued disparities described throughout the literature, including significant outcome disparities found within Black and Brown women and birthing persons, particularly maternal care and NICU care.

Elizabeth Rochin, PhD, RN, NE-BC | June 29, 2023

Posted under: Other, Quality of Care

In previous blogs, I have offered insight into the Alliance for Innovation on Maternal Health (AIM) patient care bundles, and their importance in maternal health.

It only makes sense to create newborn and NICU patient care bundles that are similar in nature to their maternal patient care bundle counterparts. After all, standardization and reducing variation are key to patient safety outcomes. The NICU is a natural next step in creating and cultivating patient safety bundles.

Patient safety bundles include the following domains:
  • Readiness
  • Recognition
  • Response
  • Reporting/Systems Learning
In 2021, a 5th bundle element was incorporated into the AIM patient care bundles, Respectful Care. This was the fifth element to be incorporated into all maternal patient care bundles. Respectful Maternity Care (RMC) is defined as the preservation of a birthing person’s dignity, choices, and preferences during birth and during the postpartum period. Understanding the value and importance of respectful care in the neonatal care setting is and will be an essential conversation to engage. Respectful Care has been and continues to be a priority for maternal and neonatal outcomes, particularly with the continued disparities described throughout the literature, including significant outcome disparities found within Black and Brown women and birthing persons, particularly maternal care and NICU care. While the Respectful Care model typically focuses on the mother/birthing person, it is essential that these elements are applied to the supportive care of the mother/birthing person and newborn dyad in the Neonatal Intensive Care Unit. Several of these elements are described below:
  • Alleviation of Environmental Stressors: Providing support to the mother/birthing person to assure opportunities for bonding and care provision are essential. Transportation, food security, and the care of other dependent children as needed for frequent visitation to the NICU provides stability. Financial challenges compound these issues and further accelerate the disparities that are found within neonatal care. The promotion of dignity, autonomy and the ability to care for a sick newborn amid turmoil, such as an unexpected admission to the NICU, cannot be overstated.

  • Provision of a NICU Family Navigator/Support Structures: The ability for a mother/birthing person to achieve the highest levels of autonomy during a NICU stay relies on the ability to fully comprehend and understand the course of care. A NICU Family Navigator or NICU Family Support Program can facilitate communication and ensure that every newborn and family are assured the same level of care and discharge planning. Lake and colleagues described disparities in NICU outcomes related to race, and failure to offer the same level of discharge care to all families is antithetical to the Respectful Care model. Any differences in care, specifically racial and/or ethnic outcomes discovered during inpatient care or during the discharge process should be immediately evaluated. The inclusion of postpartum doulas to offer support for the woman/birthing person during the NICU stay should be encouraged. (If you have not thought about using Postpartum doulas in your NICU as a support for your parents, now is the time).

  • Trauma-Informed Care: Trauma-informed care is an essential principle of the Respectful Care model. Facets of trauma-informed care, such as previous experiences of trauma and subsequent response and reducing the impact of a current trauma (such as an unexpected admission to the NICU) provide a meaningful foundation to the care of mothers/birthing people during a stay in the NICU. Maternal/newborn separation can exacerbate trauma, and facilitation of visitation and information is key. Again, identification of environmental and social/structural determinants of health and their mitigation can ease the impact of further trauma to a family unit. These elements are cyclical, and all serve as conduits within a Respectful Care paradigm.





How much does it cost to park in your hospital parking garage? How much is a bottle of water or a small meal in your hospital cafeteria? And if a baby is in the NICU for weeks, what does that cost? Childcare for those children at home? Lost hours at work? The trauma of an unexpected NICU admission can be but the very start of a perpetual traumatic experience for a family.

The Black Mamas Matter Alliance describes best practices for holistic maternal and neonatal care:
  • Addresses gaps in care and ensures continuity of care
  • Affordable and accessible care
  • Ensures informed consent
  • Confidential, safe, and trauma-informed
  • Provides wraparound services and connections to social services
Achieving a care model that not only supports but promotes and sustains Respectful Care should be considered requisite for any facility caring for women/birthing people and their newborns. Strategic planning should include a focus on equity and include the voices of those populations most impacted by disparate outcomes. Continuous quality improvement through an equity lens and self-reflection performed by individuals, departments and organizations is fundamental to the continued evolution of a robust and holistic care program. Respectful Care in maternal and neonatal settings will be critical to elevating both short and long-term outcomes, and supporting a strong foundation for autonomy, dignity, and a well-defined transition to home and equitable access to community resources.

So, let’s start a checklist for Respectful Care in the NICU:
Centering the baby and family for all care and decisions
Dignity and autonomy
Informed consent
Shared decision-making
Equitable access to pain management
Access to Postpartum doulas
Access to Community Health Workers
Postpartum depression assessment of mother and partner with appropriate referrals
24-hour access to baby
Parental presence during resuscitation
Assessment of childcare needs
Assessment of transportation availability
Assessment of nutrition
Equity in access to lactation support and donor milk
A home transition plan that respects and incorporates the culture, values, and lived experience of the family
Ability to measure Respectful Care and its impact on patient outcomes

Building respectful care into any NICU patient safety bundle should be a first step. I hope to hear from you and let’s continue to grow a new and emerging model of Respectful Care in the NICU.

References
1. Moridi M, Pazandeh F, Hajian S, Potrata B. Midwives’ perspectives of respectful maternity care during childbirth: A qualitative study. PLOS ONE. 2020;15(3):e0229941. doi:10.1371/journal.pone.0229941

2. Sacks E, Kinney MV. Respectful maternal and newborn care: building a common agenda. Reproductive Health. 2015;12(1):46. doi:10.1186/s12978-015-0042-7

3.Howell EA. Reducing Disparities in Severe Maternal Morbidity and Mortality. Clin Obstet Gynecol. 2018;61(2):387-399. doi:10.1097/GRF.0000000000000349

4.Harvey SA, Lim E, Gandhi KR, Miyamura J, Nakagawa K. Racial-ethnic Disparities in Postpartum Hemorrhage in Native Hawaiians, Pacific Islanders, and Asians. Hawaii J Med Public Health. 2017;76(5):128-132.

5.Km M, A K-D, R K, et al. Racial Differences in the Cesarean Section Rates Among Women Veterans Using Department of Veterans Affairs Community Care. Med Care. 2021;59(2):131-138. doi:10.1097/mlr.0000000000001461

6.Sacks E, Kinney MV. Respectful maternal and newborn care: building a common agenda. Reproductive Health. 2015;12(1):46. doi:10.1186/s12978-015-0042-7

7.Glazer KB, Sofaer S, Balbierz A, Wang E, Howell EA. Perinatal care experiences among racially and ethnically diverse mothers whose infants required a NICU stay. Journal of Perinatology. Published online July 15, 2020:1-9. doi:10.1038/s41372-020-0721-2

8.Sigurdson K, Morton C, Mitchell B, Profit J. Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of Perinatology. 2018;38(5):600-607. doi:10.1038/s41372-018-0057-3

9.Crear-Perry J, Correa-de-Araujo R, Lewis Johnson T, McLemore MR, Neilson E, Wallace M. Social and Structural Determinants of Health Inequities in Maternal Health. Journal of Women’s Health. 2020;30(2):230-235. doi:10.1089/jwh.2020.8882

10.Barfield WD, Cox S, Henderson ZT. Disparities in Neonatal Intensive Care: Context Matters. Pediatrics. 2019;144(2). doi:10.1542/peds.2019-1688

11.Davidson JE, Aslakson RA, Long AC, et al. Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU. Critical Care Medicine. 2017;45(1):103-128. doi:10.1097/CCM.0000000000002169

12.Sanders MR, Hall SL. Trauma-informed care in the newborn intensive care unit: promoting safety, security and connectedness. Journal of Perinatology. 2018;38(1):3-10. doi:10.1038/jp.2017.124

13. Black Mamas Matter Alliance. Setting the standard for holistic care of and for Black women. http://blackmamasmatter.org/wp-content/uploads/2018/04/BMMA_BlackPaper_April-2018.pdf
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The Last Person You’d Expect to Die in Childbirth…Again…

The past few weeks have been very difficult for families within the United States. Communities are grappling with mothers who are dying on the day of childbirth, or within a day or two.

Elizabeth Rochin, PhD, RN, NE-BC | June 14, 2023

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

The past month has been very difficult for the maternal health community. Simply review the Go Fund Me accounts set up within the past month alone, and you will find the following posts of mothers who have died in childbirth, or before discharge home (not exhaustive):

32-year-old Justine Kostenbauder died of severe complications during childbirth (South Carolina).

Camylle Bowen died two days after childbirth (Texas).

28-year old Vanessa Dannecker died during childbirth (Long Island).

And social media erupted with disbelief this week upon hearing of Tori Bowie’s death during labor at her home, a track star and Olympic champion, the last person you’d expect to die in childbirth.

And that was the exact title of the NPR/ProPublica Lost Mothers Series in 2017. This piece described a white NICU nurse who died at the hospital she worked for due to complications of HELLP Syndrome. A long and detailed overview of the missed clues during labor and the immediate postpartum period was presented. Many other articles were published within this series and deserve another review.

And here we are, 2023, six years later, with the same scenarios playing out. Patients exhibiting signs and symptoms of distress. Patients verbalizing “something is wrong,” and those words falling on deaf ears, or onto team members who do not have adequate resources to support them. Or both. 80% of maternal deaths are preventable…at least.

13% of maternal deaths occur on the day of delivery. 13%.

Let’s do the math:
In 2021, it is reported that 1,205 women died of maternal causes. While that number is likely inflated due to COVID, let’s look at 2019, the last year without COVID diagnoses: 754. That is approximately 2 maternal deaths per day. 13% of 754 is 98. Approximately 98 women died on the day of delivery in 2019. That is approximately 2 per week.

In 2021, that number was 156, which reflects 3 maternal deaths on the day of delivery every week. An average of a maternal death, on the day of delivery, every 2 days, in 2021. That seems impossible in the United States of America.

Don’t Blame the Pregnant Person for their Own Death
There have been many discussions on social media this week about the death of Tori Bowie. Many of those continue the amplify and elevate the real issues of systemic bias, racism, and not listening to Black women’s concerns about their own bodies. But there is something that is looming in the background that needs to be immediately addressed: Blaming the patient. Did Tori use drugs? Did Tori seek early prenatal care? Was Tori compliant with her prenatal care? What? Are we back to blaming the patient?

In 2019, Dr. Monica McLemore and Valentina D’Efilippo published a piece in Scientific American, To Prevent Women from Dying in Childbirth, First Stop Blaming Them.

It is abundantly clear that this piece needs to be read and reread over and over. “Stop blaming women for their own deaths.” If it were only that simple. And trust me, it should be. No woman should be blamed for her own maternal death.

Here is a question you should ask yourself right now: If Tori were a white track star, would you have asked the same questions? Would you have assumed that by the color of her skin that she would be more apt to be compliant in her care? Seek out early prenatal care? Drug use even considered as a discussion point? These are questions that require very honest and deep self-reflection. Project Implicit can be a way to begin to create a pathway for self-reflection and an assessment of internal bias.

Data Speaks Volumes
The National Perinatal Information Center stratifies many maternal and neonatal outcomes by race and ethnicity for member hospitals. And in the aggregate, the following continue to be true, and follow the scientific literature very closely:
  • Black women continue to have the highest rate of cesarean delivery.
  • Black women continue to have the highest rate of severe maternal morbidity.
  • Black women continue to have the highest rate of preeclampsia.
There is a tremendous amount of work to do. Many organizations continue to work side-by-side to provide meaningful changes to the care of all women, but with an intentional focus on assuring the highest quality care for Black women.

Listen to Black women. Don’t make assumptions about Black women. But most importantly, support initiatives that support Black women in their communities.

And let’s all work towards a goal of reducing 13% of maternal deaths on the day of delivery to zero. No woman should lose her life by giving birth to a new life.

#13toZero
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Maternal Mental Health Awareness Month

May is Maternal Mental Health Month, which provides an opportunity for providers, patients, communities, and activists to engage in discussion and dialogue about the importance of recognizing maternal mental health as an unmet, urgent public health need.

Elizabeth Rochin, PhD, RN, NE-BC | May 4, 2023

Posted under: Maternal Health, Mental Health

“I couldn’t bring myself to tell my doctors or nurses, or the doctors and nurses in the NICU about the way I was feeling. I was already that “bipolar patient.” I had used opiates for a few years to cope with the pain that depression brought with the disease. I could feel myself becoming more and more depressed and desperate for help, but thought that if I asked for help, my baby would be taken away from me. My bipolar disorder had haunted me for most of my adult life, had labeled me, and now with a new baby, had no one to reach out to. Each time I left the NICU, I thought it would be the last time I would see my baby. That feeling was so traumatic, and even though my baby is now 1 year old, I still relive that fear every day.” –A.R., during a postpartum interview

Overview
May is Maternal Mental Health Month, which provides an opportunity for providers, patients, communities, and activists to engage in discussion and dialogue about the importance of recognizing maternal mental health as an unmet, urgent public health need. Compound this maternal mental health need with the public health crisis of racism and a stark picture emerges of women and birthing people in need of tremendous support. There are many facets that must be addressed within maternal mental health—access to care, transportation, stigma, insurance coverage, stable housing, to name a few. An area of concern that has been identified is that of opioid use disorder during pregnancy. A greater prevalence of comorbid psychiatric disorders, physical and sexual abuse, intimate partner violence, and chronic pain disorders likely contribute to disproportionate rates of opioid use and misuse in women and particularly women during pregnancy. Beyond opioid use are other substances that are used frequently to mask mental health symptoms that can be treated by other means. But that treatment costs money and access can be sparce depending on location and availability of providers.

The National Perinatal Information Center continues to track maternal mental health outcomes, including substance use disorder. In 2019, substance use disorder (ICD O99.3XX) was coded in 1.9% of patients (n = 334,402) and by September 2023, 2.3% were coded with substance use disorder (n = 325,195). While that number might not seem high, it continues to reinforce the need to remain vigilant in assessing patients in the prenatal, intrapartum, and postpartum period.

In the time period October 1, 2021 through September 30, 2022, 30-40 patient records were coded with postpartum psychosis (ICD -10 F53.1). In seeing this information, I thought about the patient behind the data. I wondered what their support systems were like. I wondered if they had support, or if they were alone in their suffering. I hope these women had what they needed to not only bring life into this world, but also had those to support them while they nurtured that new life.

Maternal mental health directly impacts the outcomes of a newborn. Perinatal mood disorders are some of the most identified maternal mental health concerns and are associated with increased risks of maternal and infant mortality and morbidity and are recognized as a significant patient safety issue. In addition to perinatal mood disorders, there are other mental health diagnoses that must be appreciated, including pre-existing psychiatric illness (major depression, bipolar disorder, schizophrenia, etc.) that often is underreported and undertreated due to stigma and fear of reporting. During the month of May, it is critical to recognize certain elements of maternal mental health that must be addressed:
  1. Destigmatize mental illness: Stigma is a complex phenomenon, that has three different types: public, self and institutional. Self-stigma develops from shame, blame and internalization of mental illness, which is most often fueled by public and institutional stigma. Supporting women and birthing people experiencing maternal mental health illness, and reducing shame and self-blame, is critical in achievement of treatment regimens and continued engagement with healthcare providers.

  2. Screening women for mental health during the postpartum period: NICU’s across the United States have begun to engage in various forms of screening and intervention to assist in reducing stress and depressive symptoms in mothers during newborn admission. In many cases, maternal mental health concerns remain under identified and undertreated during a NICU stay, which can have deleterious effects on the offspring, both in short-term outcomes while in the NICU as well as long-term neurodevelopmental and behavioral outcomes. Mendelson et al performed a systematic review and metanalysis of NICU programs designed to evaluate for postpartum depression and anxiety and found it increasingly important to evaluate maternal mental health during NICU admissions to assure engagement and understanding of treatment and discharge plans.

  3. Disparities in maternal mental health treatment: Overall, Black women are 3-4 times more likely to die during childbirth or within the first year after delivery. Increasingly, studies describe inequity in mental health screening, identification, and treatment for women of color and other vulnerable populations. Sidebottom and colleagues described the findings of their study in which African American, Asian, and non-white women were less likely to be screened for postpartum depression than their white counterparts. In addition, this study also revealed that women insured by Medicaid and other state programs were less likely to be screened than those women with private insurance.

  4. Access to care: Psychiatrists, psychologists, social workers, and others can be difficult to access, particularly in rural environments. Paying for these services can be difficult, if not impossible, as many providers may not accept Medicaid or patients may not have the means to cover services not covered by insurance. Credentialed/certified community health workers (CHW) can be an invaluable resource for supporting patients in seeking resources for maternal mental health care. Psychiatric Mental Health Nurse Practitioners (PMH-NPs) can also be a vital community resource for patients. Supporting legislation to provide avenues for advanced practice is key in further developing this critical community resource. Advocating for coverage for postpartum maternal mental health is critical to supporting mothers in our communities. Finding new and innovative ways of using and supporting telehealth and digital access to maternal mental health access is imperative. But this access to mental health is dependent upon providers, access to broadband, technology, treatment (medication/therapy) and the cycle begins anew.



Telehealth Access Wheel: Foundational Needs for Telehealth (NPIC, 2023).

This month, it is essential that we create space to discuss maternal mental health, and to develop sustainable strategies for treatment and maternal well-being. Whether that be in a prenatal visit, admission to Labor and Delivery, during a NICU visit, or in the community, as a nation we must be prepared to destigmatize maternal mental health, assure equitable care and access, and create a compassionate course of treatment for women and birthing people who continue to suffer in silence.


References
Devakumar D, Selvarajah S, Shannon G, et al. Racism, the public health crisis we can no longer ignore. The Lancet. 2020;395(10242):e112-e113. doi:10.1016/S0140-6736(20)31371-4

Ouyang JX, Mayer JLW, Battle CL, Chambers JE, Salih ZNI. Historical Perspectives: Unsilencing Suffering: Promoting Maternal Mental Health in Neonatal Intensive Care Units. NeoReviews. 2020;21(11):e708-e715. doi:10.1542/neo.21-11-e708

Patrick SW, Schiff DM, Prevention C on SUA. A Public Health Response to Opioid Use in Pregnancy. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-4070

Patrick SW, Barfield WD, Poindexter BB, Committee on Fetus and Newborn C on SU and P. Neonatal Opioid Withdrawal Syndrome. Pediatrics. 2020;146(5). doi:10.1542/peds.2020-029074

Kendig S, Keats JP, Hoffman MC, et al. Consensus Bundle on Maternal Mental Health. Obstet Gynecol. 2017;129(3):422-430. doi:10.1097/AOG.0000000000001902

Pescosolido BA. The Public Stigma of Mental Illness: What Do We Think; What Do We Know; What Can We Prove? J Health Soc Behav. 2013;54(1):1-21. doi:10.1177/0022146512471197

Mendelson T, Cluxton-Keller F, Vullo GC, Tandon SD, Noazin S. NICU-based Interventions to Reduce Maternal Depressive and Anxiety Symptoms: A Meta-analysis. Pediatrics. 2017;139(3). doi:10.1542/peds.2016-1870
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Restoration of Black Autonomy and Joy in Perinatal Nursing Leadership

There is an important intersection between Black women and birthing people, Black perinatal nursing leaders, and maternal health.

Elizabeth Rochin, PhD, RN, NE-BC | April 13, 2023

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

Six years ago, the Black Mamas Matter Alliance launched Black Maternal Health Week, a week each April that would highlight and amplify the unacceptable and sustained increase in Black maternal deaths . Within the global COVID-19 pandemic, the outcome disparities within Black and Brown maternal health communities continued to grow and were impacted at greater rates. On April 13, 2022, Vice President Kamala Harris convened Cabinet secretaries to address the ongoing maternal morbidity and mortality crisis in the United States. The President’s FY23 budget included $470 million to address additional maternal disparities projects, including supporting the perinatal health workforce.

The perinatal health workforce has become an important discussion point, as the need for community health workers, doulas, and other Black maternal health advocates center conversations about the needs of Black mothers and parents. While there is a significant need for a community health focus, inpatient obstetric care requires intentional focus and strong leadership. As reported by the CDC and MMRIA report, 13% of maternal deaths occur on the day of delivery. Inpatient obstetric teams require experienced nursing leadership to support the infrastructure and care delivery required to provide high quality, respectful, and culturally competent care. Open nursing leadership positions within Women’s and Children’s service lines that were once rarely available or open now sit vacant for weeks, and in some cases, months. An area of healthcare leadership that is not often studied is that of frontline perinatal nursing leaders.

So how does this connect to Black Maternal Health Week? There is an important intersection between Black women and birthing people, Black perinatal nursing leaders, and maternal health.

Weeks ago, Synova Associates and the National Perinatal Information Center launched a white paper that reported on the effects of chronic stress on perinatal nursing leaders (Supporting Perinatal and Neonatal Nurse Leaders: Identification and Moderation of Chronic Stress, IRB #1321780). These nursing leaders represented inpatient settings throughout the United States such as neonatal intensive care (NICU), labor and delivery, postpartum, well-baby nurseries, lactation services, antepartum, and those nursing leaders who are responsible for multiple units. The findings of this study revealed significant racial disparities in many areas, including turnover intent (p < .001), job control (p < .001) and organizational constraints (p < .001).

Based on the results of this study, the following recommendations are suggested for hospital leadership to address:
  1. Healthcare leaders and communities must be made aware of the extrinsic stressors that exist for Black/African American and diverse perinatal nursing leaders. Within this study population, stressors were described as physical symptoms (chest pain, shortness of breath, p < .001) that cannot be ignored, and require additional research and development for strategies by and for those most impacted by these findings. We cannot discuss the physical impacts upon Black nursing leaders without recognizing racism and structural barriers that create environments that impact physical health.

  2. Turnover intention, particularly as described in this study (“I won’t be working here one year from now” p < .001) for Black and Brown perinatal nursing leaders must be more thoroughly explored, and the urgency of this finding addressed. It will be important to replicate this study within other service lines to establish if these findings are unique to perinatal services, or if these findings are more global to diverse nursing leaders regardless of setting.

  3. Job Control, or the perceived ability to make decisions or the freedom to decide how to work, was also significantly decreased for Black and Brown nursing leaders (p < .001). In addition, organizational constraints (hospital rules/procedures; adequate help from others) was also significant (p < .001), which continues to generate further need for examining systems and structures in place that create these real and/or perceived barriers to effective leadership. Exploring these differences is critical and may aid in better understanding turnover intent as well as the symptoms of chronic stress described within Black perinatal nurse leaders. #structuralbarriers
During Black Maternal Health Week, it is important to center the conversation around Black women and birthing people and the continued unacceptable outcome disparities that exist despite data saturation. While assuring the health, well-being, and bodily autonomy of our diverse patients and communities continues to be a priority in our healthcare systems, it is just as important to ensure that we are providing that same level of effort and intensity at assuring the health and well-being of Black nursing leaders within our systems. During Black Maternal Health Week this year, celebrate the richness and diversity of Black communities and Black perinatal leaders. Support the Black Mamas Matter Alliance and the Restoration of Black Autonomy and Joy. Commit ourselves to amplifying Black voices and experiences and follow their lead for innovative and sustainable solutions to eradicating Black maternal morbidity and mortality.


References
National Minority Health Month. NIMHD. Accessed April 9, 2022. https://www.nimhd.nih.gov/programs/edu-training/nmhm/

Black Maternal Health Week. Black Mamas Matter Alliance. Accessed April 9, 2022. https://blackmamasmatter.org/bmhw/

Trocado V, Silvestre-Machado J, Azevedo L, Miranda A, Nogueira-Silva C. Pregnancy and COVID-19: a systematic review of maternal, obstetric and neonatal outcomes. The Journal of Maternal-Fetal & Neonatal Medicine. 2020;0(0):1-13. doi:10.1080/14767058.2020.1781809

Di Mascio D, Khalil A, Saccone G, et al. Outcome of coronavirus spectrum infections (SARS, MERS, COVID-19) during pregnancy: a systematic review and meta-analysis. American Journal of Obstetrics & Gynecology MFM. 2020;2(2, Supplement):100107. doi:10.1016/j.ajogmf.2020.100107
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13 to Zero

Preventable maternal morbidity and mortality requires an organizational commitment that is patient-centric.

Elizabeth Rochin, PhD, RN, NE-BC | March 30, 2023

Posted under: Maternal Health, Quality of Care, Social Determinants of Health/Disparities

Inpatient maternal mortality continues to be a significant challenge to healthcare teams in the intrapartum period. Recognition and awareness of inequities in birth outcomes must be a priority for healthcare teams. Preventable maternal morbidity and mortality requires an organizational commitment that is patient-centric.

In many instances, 13% may not sound so high. That is 13 out of 100. You might not think much of it.

But if you were to hear that 13% of maternal deaths occur on the day of delivery, that might change your mind considerably (https://reviewtoaction.org/sites/default/files/2022-10/Pregnancy-Related-Deaths-Data-MMRCs-2017-2019-H.pdf). Of 1,018 deaths reviewed from 36 states, 132 occurred on the day of delivery. That’s approximately 4 patients per month or 1 patient per week. And keeping in mind that this data is not from all states, this number is most likely higher. Building into this model that 84% of these deaths were determined to be preventable creates an even greater sense of urgency.

A study (2020) exploring maternal deaths from 2002 – 2014 during the intrapartum period revealed the following:
  • Black women were three (3) times more likely to die during the intrapartum/in-hospital period than their white counterparts.
  • Three or more severe maternal morbidity indicators were present on admission, including coagulopathy, fluid/electrolyte imbalance, hypertension, and neurological disorders.
  • Acute myocardial infarction, followed by amniotic fluid embolism, and pulmonary edema/acute heart failure were the primary drivers of mortality.
While a study reviewing data from 2002 – 2014 may seem a bit dated, there are still common themes associated with today that must continue to drive the conversation:
  • Cardiovascular disease still contributes to the rate of intrapartum maternal mortality.
  • Black women continue to be 3-4 times more likely to die during or after pregnancy.
To bring more awareness to this issue, the National Perinatal Information Center is embarking on 13 to Zero. This call to action is designed to bring awareness to the continued issues surrounding intrapartum mortality and how to build sustainable quality improvement to reduce and eliminate preventable inpatient maternal mortality.

What does 13 to Zero look like?
  • Using data to inform decisions and quality improvement initiatives, including race and ethnicity data stratification.
  • Recognition of birth outcome disparities and strategic plans in place to address.
  • Measuring and supporting psychological safety within healthcare teams.
  • Foundation of cultural humility and respectful patient care.
The STEEEP acronym (Institute for Healthcare Improvement; National Academy of Sciences, Engineering, and Medicine) focuses obstetric care in a way that can connect teams to purpose:
S: Safe
T: Timely
E: Equitable
E: Efficient
E: Effective
P: Patient-centric

Creating and sustaining high-reliability and equitable inpatient quality improvement programs is critical to eliminating preventable maternal mortality.

High-Reliability Quality Improvement: Layers of Success
Hospital Leadership/Boards of Directors
  • Is hospital leadership (yes, I mean the Board of Directors and the C-Suite) invested in improving maternal health?
  • Is maternal health and outcome disparities on the agenda of Boards of Directors/Trustee meetings? How often?
  • Do Boards of Directors/Trustees/C-Suite ask about QI projects on a routine basis?
  • Do they routinely ask about outcome disparities?
  • How often do they see the data? And is this data shared with Boards of Directors? Trustees?
  • How engaged is the Board in reviewing and understanding maternal health QI projects?
  • Does the Board of Directors/C-suite have a shared mental model of the social drivers/determinants of health specific to maternal care?
  • Do unit leaders have an opportunity to routinely engage directly with the Board and share best practices and success stories of improved maternal healthcare, particularly through a racial and ethnic lens?
Nursing and Physician Leadership/Unit Level
  • What does nursing leadership look like?
  • What does physician leadership look like?
  • Do they work well together?
  • Are they committed to the same outcomes and priorities?
  • Are they committed to including the voices of those most impacted in perinatal project planning?
  • In other words, are patients of color or others based upon identified social needs invited to participate in QI initiatives within the unit?
  • Is there a Patient Advisory Council that serves to facilitate connections between patients and care teams?
  • Have they assessed the activation and readiness of their teams to engage in QI work?
Frontline Care Teams
Let's explore the teams themselves, the team members who will be closest to the work.
  • Are they ready to engage in QI work?
  • Are Doulas considered part of the frontline care team?
  • Did the team have any input in creating the QI project?
  • Are there identified champions and informal leaders?
  • Is there bandwidth available?
  • How many other projects and initiatives are underway?
  • Is this considered a priority among many others?
  • Is the team multidisciplinary and includes all facets of care?
  • Are there identified naysayers?
What? Naysayers?
Believe it or not, naysayers are not only helpful, but can be very valuable to identifying barriers and real/potential pitfalls of a QI project. The "squeaky wheels," if you will, can be some of your most invested team members who sincerely want positive change. Or they have had enough of “one trick ponies” and QI projects that were not sustainable or implemented without frontline feedback. While it may be tempting to dismiss them, it is much more important to listen and hear their concerns.

The Patients Themselves
Earlier I mentioned the engagement of patients in QI project development. Yes, this is a critical component of successful QI implementation. As important as it is for your organization and team to be engaged and dedicated to QI, what if the project you are considering does not meet the needs of your patients?
  • Were assumptions made based upon conscious/unconscious bias rather than data?
  • When was the last time your healthcare teams participated in respectful care training?
  • Are the measures/objectives/metrics in line with the communities you serve?
  • How will patients react to and participate in a QI initiative? Are they passive or active participants?
How will your team be successful in your journey from 13 to Zero?

NPIC can assist your team in assessing, measuring, and developing action plans to support your journey to Zero. Reach out to Elizabeth Rochin to learn more (Elizabeth.Rochin@npic.org).







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Patient Safety Awareness Week

This week is National Patient Safety Awareness Week. Across the United States, hospitals, healthcare organizations, and patient advocacy groups have one singular focus: identifying, elevating, addressing, and normalizing patient safety in conversations across the care continuum.

Elizabeth Rochin, PhD, RN, NE-BC | March 14, 2023

Posted under: Maternal Health, Other, Quality of Care

Last week on LinkedIn, I posted about a young Black woman who died at a hospital shortly after giving birth. She and her boyfriend had been asking for the nurses to call the doctor about the symptoms she was experiencing. Per the report of her boyfriend, the nurses could not call her doctors because “they would get upset.”

Where do I even begin to address the multiple factors that created this tragedy?

This week is National Patient Safety Awareness Week. Across the United States, hospitals, healthcare organizations, and patient advocacy groups have one singular focus: identifying, elevating, addressing, and normalizing patient safety in conversations across the care continuum.

In 2001, the Institute of Medicine (now known as the National Academies of Sciences, Engineering, and Medicine) published Crossing the Quality Chasm: A New Health System for the 21st Century. This landmark document created a conceptual definition of quality, including a focus on care that is:
  • Safe
  • Effective
  • Patient-centered
  • Timely
  • Efficient and
  • Equitable
Let’s return to the scenario described above, and dissect it:

Patient and Boyfriend Asking for Help with Symptoms
April Valentine was a first-time mother and selected her birth hospital as she would “have a Black doctor and a doula to support her” (https://www.theguardian.com/society/2023/mar/03/california-investigation-centinela-hospital-los-angeles-black-woman-death-childbirth). According to April’s boyfriend and father of the baby, April could not feel her legs for a few hours. She had an emergency cesarean section and died shortly after the birth of her baby.

Could there have been an outcome that had resulted in a healthy mom and baby? I would like to think that this scenario could have and would have played out under the right circumstances and in the right environment.

But what is the “right environment?” What type of environment would view the patient as “the expert” in their own experience? In their symptoms? Doesn’t the patient know themselves best? In the past few weeks, I have offered multiple examples of patients who expressed concerns about symptoms, only to be dismissed (or a thermostat adjusted so a feverish patient wasn’t so chilled) and suffered harm (or death).

Welcome to High Reliability
Healthcare teams hear the term “high reliability” and immediately think of two things: hard work and more work. And in some cases, they would be right. But “high reliability” is more than a term. It is a state of mind and a state of perpetual readiness. And high-reliability organizations do not occur overnight. These are processes that take years to create, and even longer to sustain. They require the perfect blend of leadership, accountability, and teamwork It is a shared and common purpose that has a few core tenets:
  1. Sensitivity to operations: Awareness of risks and how to mitigate them, including the use of patient outcomes data as a driver of improvement.

  2. Reluctance to simplify: Avoiding overly simplistic reasons for why things fail (communication failure, understaffing, inadequate training). Why did these particular issues occur? What are the reasons behind them? Simply stating “we were understaffed” does not answer the underlying reason(s) for staffing issues.

  3. Preoccupation with failure: Organizations that recognize the importance of addressing near-misses and finding solutions to reduce repetition.

  4. Deference to expertise: Recognition of the importance of the voices of those closest to the patient or to the work, and systems that support “hierarchy” may not have all of the answers to make an informed decision.

  5. Resilience: Teams are in a state of readiness, are prepared and ready to respond to system failures or issues “outside the norm” (https://archive.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/hroadvice/hroadvice.pdf_
Let’s Return to April’s Story
Imagine for a moment that April had been cared for by a healthcare team that had a foundation of quality and safety as its common purpose and utilized the core elements of a high-reliability organization. Perhaps this is what would have resulted:
  1. April’s care team might have recognized that Black women (even young Black women) are 3-4 times more likely to die in or around childbirth. The team might have considered potential bias and potential forms of institutional racism that may create barriers to safe patient care.

  2. The healthcare team might have deferred to April’s own experience and expertise in her symptoms. She couldn’t feel her legs…what could some of the issues have been? Lack of mobility? Laying in one spot for too long? Something physiologic or worse?

  3. April’s care team might have been more comfortable in calling her providers if there had been a strong, underlying current of psychological safety.
Psychological Safety
Perhaps nothing screams more about this story than the perceived lack of psychological safety within the unit.

“Couldn’t call the doctors because “they might get upset”

Psychological safety has been defined in several ways, but one of the best definitions I have found is an environment that creates the experience of an individual “to be enabled to raise concerns, near misses, and potential errors without fear of negative consequences”. Psychological safety has been discussed in the literature and social media over the last few years, in part due to the challenges of the COVID-19 pandemic. Psychological safety requires crucial conversations about hierarchies within organizations and the importance of team communication. When addressing psychological safety within a healthcare team, it is essential to dissect parts of a unit culture that may need to be addressed more fully. That type I have experienced exceptional leadership dyads within perinatal care. Unfortunately, I have also been witness to those that are a true embodiment of the lack of teamwork and synergy required for patient safety.

Call to Action
I hope a lasting legacy of April’s unfortunate death will shed a light on how important a strong patient safety foundation can be. As we recognize opportunities to address and elevate patient safety, let’s commit to the following actions today:
  1. Recognizing patient care quality must be a daily priority.

  2. Recognizing the patient as an expert in their care.

  3. Recognizing high-reliability opportunities that can promote patient care and multidisciplinary teamwork.

  4. Elevate the concept of psychological safety as a national patient safety goal.
Thank you for everything you do for the care of your teams, patients, families, and communities.

Let’s make every day Patient Safety Awareness Day.

NPIC can assist your team in assessing, measuring, and developing action plans to support psychological safety, and tracking its impact on patient outcomes. Reach out to Elizabeth Rochin to learn more (Elizabeth.Rochin@npic.org).


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The Devastating Impact of Sepsis

Early on in my journey of becoming an advocate for C-diff awareness a quote that has stuck with me. “We are all patients or will be one day.”

Meghan Mimnaugh | February 21, 2023

Posted under: Other, Quality of Care

Earlier this month, our blog focused on An Introduction to Sepsis Survivors Week. Sepsis Survivors Week focuses on the patients and families who are impacted by this life threatening condition. This week, we introduce guest blogger and NPIC team member, Meghan Mimnaugh, to tell the story of how sepsis has impacted her life.


My mother’s death had a significant impact not only on my life but also on the life of everyone she knew. She died on August 5, 2012 of a Hospital Acquired Infection (HAI) called Clostridium Difficile or C-diff. Although C-diff was the underlying cause her cause of death was listed as sepsis. I remember early on in my journey of becoming an advocate for C-diff awareness a quote that has stuck with me. "We are all patients or will be one day." After spending over a decade advocating for patient safety awareness, overuse of antibiotics is a commonly unknown issue to the public. Antibiotics are important medications and are critical to the treatment of sepsis.

According to the Center for Disease Control, Sepsis is the body's extreme response to an infection. In my mother's case it was C-diff.

Every hour that treatment is delayed for sepsis patients results in an increase in mortality. While it is imperative to preserve antibiotics for infections that really need them, it is also crucial to prescribe antibiotics in a timely manner to patients with sepsis.

According to Sepsis Alliance,

"Studies investigating survival and sepsis deaths have reported slightly different numbers, but it appears that on average, approximately 30% of patients diagnosed with severe sepsis do not survive...Until a cure for sepsis is found, early detection and treatment is essential for survival and limiting disability for survivors."

It is important to know how to advocate for yourself and your loved ones. There is plenty of information on sepsis including:

https://www.sepsis.org/
https://www.cdc.gov/sepsis/






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