Tag: quality improvement

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.
Share this article:
< Back to NPIC blog home

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.
Share this article:
< Back to NPIC blog home

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.
Share this article:
< Back to NPIC blog home

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).







Share this article:
< Back to NPIC blog home