Tag: healthcare

Creating Quality Improvement New Year Resolutions: Maternal and Newborn Care

Are you among the hospitals who are seeking to improve quality? Have you explored the Psychology of Quality Improvement?

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

Posted under: Maternal Health, Quality of Care

Hospitals across the country are looking forward to 2024 and sharing the vision of their strategic plans. If you are among the hospitals who are seeking to improve quality, have you explored the Psychology of Quality Improvement?

Last week, I joined others from across the United States at the National Institute for Children’s Health Quality (NICHQ) National Network of Perinatal Quality Collaboratives Annual Meeting. Rhode Island is fortunate to be one of many states funded to support its perinatal quality collaborative.

Many topics were consistently mentioned and I wanted to bring awareness to one of those topics here. Postpartum readmissions were one of the issues being addressed, and how we can continue to bring awareness to the key drivers of readmission.

According to the National Perinatal Information Center, between 2018 – 2022, the most frequently reported diagnosis related to postpartum readmission is preeclampsia. Severe hypertension and preeclampsia have continued to rise over the past five years, and that trend does not seem to be changing. Fortunately, there have been great strides in reductions in readmission due to infection, and postpartum hemorrhage has been relatively stable over the past five years.



Preeclampsia is not only the driver for postpartum readmission, but it has been a driver for cesarean birth as well. During the years 2018 – 2022, the NPIC Perinatal Database follows coded reasons for cesarean birth, and preeclampsia has had the highest increase over this same five year period.



Many hospitals are seeking resources to impact the rate of preeclampsia and hypertension that are being seen in obstetric units. Maternal morbidity and mortality discussions and review committees (MMRCs) continue to review maternal deaths associated with preeclampsia/severe hypertension/stroke and have finally begun to explore the impact that racism may have had in diagnosing/addressing/treating/responding to hypertension in Black women.

One of the most critical areas addressed during the NNPQC meeting was the Psychology of Quality Improvement. Yes, there is a foundational approach to QI projects that cannot be overstated. Dr. Veronica Gillespie-Bell (Louisiana) provided an outstanding primer on Creating Change and Managing Resistance (yes, managing the resistance to change). There are those who will embrace change. And there are those who will resist change. But there is a way ahead. And here are the secrets:

  • Define the change through an effective vision

  • Communicating the change

  • Building an improvement team(MUST include frontline staff)

  • Develop reinforcement strategies

  • Assess the climate for change—cultural, commitment, capacity readiness

  • Creating culture for change

  • Select the model for change

  • Understanding and managing resistance

  • Celebrate small wins


**normalization of deviance can completely derail change management**

It is very important to address normalization of deviance (NoD) within change management. NoD has been mentioned several times in these blogs over the past year. If you need a refresher, check out our previous discussions. Become familiar with the term. There are reasons that, on average, it takes 17 years to translate research to practice. This is one of them.

Are your frontline teams drivers or mere passengers in the quality improvement process? How can you leverage the bench strength of your teams to effectively create changes in patient care? If your frontline teams do not have an active role in your quality improvement initiatives, you are missing a critical voice in successful (and sustainable!!) change.

  • Are they ready to engage in QI work?

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

  • Are there identified champions and informal leaders who can contribute a diverse lens to the process?

  • Is there bandwidth available?

  • How many other projects and initiatives are underway?

  • Is this considered a priority among many others? Who is communicating that priority? (“This is something we have been told to do” versus “We have an opportunity to improve patient care and maternal outcomes”)

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


It is important to include your patients and families in your quality improvement initiatives, particularly if the target population is patients. Let’s use maternal severe hypertension for a moment.

  • Do you have patients with lived experience on your Quality Improvement projects? How are you ensuring that diverse voices are a part of your work?

  • Have your patients reviewed your preeclampsia/hypertension discharge materials? Do they understand them? Are they in a language they understand?

  • Are you disaggregating your outcomes data by race and ethnicity? Are your time to treatment outcomes similar, or do you have glaring differences in treatment outcomes?


No matter your priority for this next year, whether it is maternal hypertension, postpartum hemorrhage, safely reducing primary cesarean birth, sepsis, maternal mental health, or other healthcare needs, creating a strategy to implement change in practice or process can take time. But let’s face it…our patients don’t have 17 years to implement change. They are relying on us now to provide the highest quality of evidence-based care.

As part of your New Year resolutions, think about adding sustainable change to your strategy. Change and sustainable change are two different concepts. Quality and patient safety are at or near the top of many hospitals’ strategic plans in 2024 and beyond, with many including high reliability as a metric of success. Achieving these goals are possible, but only with the cumulative efforts of data, knowledge, commitment to equity, and action. And yes, the psychology of quality improvement.

Here's to sustainable change and outstanding quality improvement in 2024. Happy New Year

If your team would like to incorporate sustainable quality improvement in your organization, NPIC can support your strategy. Reach out to us to learn more.
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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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