Download a PDF of the Current Issue 2015 Volume 12 Number 3 July- September
Providing patients with the highest quality of care in a safe and effective manner is not a new concept in medicine. Nonmaleficence, which derives from the maxim, “Primum non nocere” or “First, do no harm” is one of the principal precepts of medical ethics. Technological advances have allowed for remarkable improvements in the ability to diagnose, treat and cure disease but at the same time have made the care of patients exponentially more complex. The ultimate ability to synthesize and coordinate our systems to care for patients relies on human effort. Despite clinical knowledge and expertise, technical know-how and individual skill, it is this complexity of care and systems-based issues that have increased the risk of quality failure and adverse patient outcomes.
For example, we know from our experience of reviewing Root Cause Analyses (RCAs), that a failure in communication most often lies at the heart of an adverse patient event.
In the Department of Obstetrics and Gynecology, we recognize that one of the keys to success in improving patient care and outcomes is to improve our system of teamwork and communication both within our own department and across departments. We cannot solely rely on the wealth of individual knowledge, expertise and skill to achieve superior results. To that end, we have implemented several programs to improve patient quality and safety.
The first initiative was to create an OBGYN Quality and Safety Committee. This committee was formed in 2008 under the leadership of our Department Chairman, R. Stanford Williams, MD and is comprised of the Physician Director of Quality (PDQ), Associate Vice President of Nursing Services, Nurse Manager of Labor and Delivery, Nurse Manager of the Mother Baby Units, Labor and Delivery Clinical Nurse Leader, Division Directors of MFM and Gynecology, Nurse Manager of outpatient OBGYN Clinics, a Shands Quality Representative, and a PGY3 OBGYN resident. The committee meets on a monthly basis to review our performance on national quality measures such as venous thromboembolic events, compliance with Surgical Care Improvement Process (SCIP) measures, patient satisfaction, and 30-day readmissions. Patient safety indicator events such as maternal 3rd and 4th degree lacerations, neonatal birth trauma, and surgical complications are reviewed on a case by-case basis. Events which require an RCA, are also routinely referred to the Department Peer Review Committee (Chair, Division Chiefs of MFM and Gynecology) for appropriate action.
TeamSTEPPS (Strategies and Tools to Enhance Performance and Patient Safety) is a national quality initiative sponsored by the Agency for Healthcare Research in Quality
(AHRQ) and the Department of Defense to improve teamwork in healthcare. This program by and large has to do with effective communication and empowering all involved in patient care to speak up about safety concerns. Faculty and nurses within our department participated in formal training to implement TeamSTEPPS into everyday clinical care. Implementation continues to be a work in progress.
In February 2011, we had a site visit by ACOG’s Voluntary Review of Quality Committee (VRQC). This review consisted of a three-day onsite survey by a team of seven experienced OBGYN quality reviewers. The reviewers toured our facilities, conducted 30-minute individual interviews with hospital and departmental leadership, faculty, nurses, and a resident representative. They also performed a chart audit. As a result of this site visit, several positive changes were implemented in areas of resident supervision, professionalism, and re-dedicating to the TeamSTEPPS approach to patient care.
It is well known that medical malpractice lawsuits in Obstetrics and Gynecology are a source of frequent litigation. Shands UF has been identified by our Self Insurance Program underwriter as one of their lowest claims clients in OB/GYN. Lloyd and Partners is our excess liability insurance broker as well as for ten other academic institutions. In a 2009 study, they found that Shands UF performed considerably better than the other participating institutions in the areas of: 1.) cost of medical malpractice indemnity plus expense per delivery, 2.) the likelihood of developing an obstetrical claim or suit, and 3.) the average OB claim cost. We are currently working on a project with our Self-Insurance Program to identify key factors that explain why Shands UF OBGYN is considered “best practice.”
The Comprehensive Unit-based Safety Program (CUSP) is a hospital-wide initiative that all Shands inpatient units have been asked to implement by the Shands Quality Board. After a department wide presentation which included soliciting input from faculty, residents and nursing staff, the patient safety issues receiving the highest number of responses pertained to: 1. Global communication issues and 2. Care of obstetrics patients in collaboration with our Emergency Department. Although communication is a broad topic for which outcomes are difficult to measure, it was decided that we would, in fact, focus on communication and our Quality and Safety Committee is leading the efforts to carry through the next steps of implementation. Furthermore, we have dedicated a separate interdepartmental meeting to address improvement processes for collaboration with our Emergency Department.
Lastly, we are making great strides to focus on OB emergency simulation. More and more, simulation is being implemented to improve resident and medical student education, teamwork and most importantly, patient outcomes. There are a variety of reasons for implementing simulation which include the ethics of patient care, i.e. moving away from the see one, do one, teach one mentality of medical training, as well as reduced resident work hours which limit case numbers and exposure to rare emergency situations to name a few. We recently had a grand rounds presentation given by Dr. Brent Seibel from Shands Jacksonville regarding simulation in OBGYN. Dr. Seibel is the Vice Chair of the ACOG Simulation Consortium and Centers for Excellence and has a wealth of experience and knowledge in this area.
Our goal is to establish simulation drills for the following scenarios: 1.) obstetric hemorrhage, 2.) shoulder dystocia, 3.) emergent cesarean delivery, 4.) eclampsia, 5.) uterine rupture, and 6.) maternal code. For gynecologic surgical training, we already have a curriculum geared toward simulation training in hysteroscopy and laparoscopy.
One area of simulation training that has required significant multidisciplinary effort is in the area of obstetric hemorrhage requiring massive transfusion. Anecdotally, these rare but life-threatening cases do not typically run smoothly, invoking such descriptions as “cluster” and “chaos.” However, the barriers do not necessarily seem to come from a lack of knowledge and skill of the nurses or physicians, but rather challenges with systems-based processes. One example is that our blood bank is housed across the street from our Labor and Delivery unit. Adding to the challenge is the high turnover rate of unit secretaries who are the first line to order blood products in an emergency creating a constant need for training to achieve process consistency.
We have taken a systematic approach toward improving our processes which have included meeting with OB and anesthesia physicians, nursing and the Shands blood bank manager; performing a mock hemorrhage drill to identify systems issues and conducting a multidisciplinary workshop to solve identified issues. The goals of the workshop were to accomplish the following: create a massive transfusion protocol (MTP) blood bank workflow specific for L&D, develop a quick reference laminated card for our unit secretaries and nurses to order blood products and lab tests, develop a Powerpoint education program for new staff orientation and continuing education, create emergency IV access kits and a hemorrhage evaluation cart, and create formal simulation drills. These goals are still a work in progress, but the hope is that once we have all of the necessary pieces put together, we can then conduct drills on an on-going basis.
In summary, our department is committed to improving the quality of care that we provide to our patients. We are doing this by: conducting monthly Quality and Safety meetings, recommitting to the TeamSTEPPs approach to patient care, addressing recommendations from the ACOG VRQC site visit, partnering with the Self-Insurance Program to better understand the results of the Lloyd and Partners data, moving forward with CUSP, and implementing OB emergency simulation. Ultimately, the change in culture to one of teamwork, communication, and collaboration will be the foundation on which we build our future efforts toward safe patient care. 
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