Institute for Healthcare Improvement: Learning and Innovation Community: Improving Perinatal Care

Overview

Available through the IMPACT network or on a direct-enroll basis, IHI’s most intensive front-line improvement work happens in Learning and Innovation Communities. These are collaborative change laboratories in which teams from a wide variety of organizations work with each other and IHI faculty to rapidly test and implement meaningful, sustainable change within a specific topic area.

Listen to an informational call on this topic.

Download a brief description of this Community.

Improving Perinatal Care is available either through membership in the IMPACT network or through direct enrollment in the Community. Learn more about IMPACT.

The Challenge

The Solution

Adverse events during labor and delivery can impose a heavy physical, psychological, and financial toll on the baby, family, care providers, and the community. In addition, malpractice claims in obstetrics and gynecology are far too common. In 2004, obstetrical physicians were involved in 1,366 obstetrics related award payments at a mean payment of $503,564 and a median payment of $300,000. Physicians are not the only providers at risk. Nurses (including those that are registered, anesthetists, midwives, practitioners and advanced practice) were involved in over 95 award payments at a mean payment of $532,676 and a median payment of $300,000. [National Practitioner Data Bank 2004 Annual Report. US Department of Health and Human Services. Health Resources and Services Administration. Bureau of Health Professions: 63-66.] In part because of these statistics, insurance premiums for obstetricians and nurses have increased dramatically, forcing some practitioners to leave the practice of obstetrics and limiting access for expectant mothers.

Sound science that would allow us to deliver the best perinatal care is often known, yet is applied unreliably. Evidence-based guidelines for safe practices exist. The challenge is to ensure that these guidelines are applied to every patient, every time. Evidence-based care also relies on an effective, high functioning team, complemented by complete and accurate documentation of care provided. In the current model, training and education for physicians and nurses occurs separately. This Community seeks to move to a model of collaborative multidisciplinary training in which all team members function together and are not afraid to speak up.

Based on innovation work currently underway, promising solutions for improving perinatal care include:

Applying IHI’s Reliable Design Model
Implementing the IHI Perinatal Oxytocin Bundles (Elective Induction and Augmentation Bundles)
Adopting a common language for electronic fetal monitoring and training all members of the care team together in its use
Applying communication techniques such as appropriate assertion, conflict resolution, SBAR (Situation-Assessment-Background-Recommendation), and Crew Resource Management techniques
Adopting processes to understand and honor patient preferences
Collaborating with patients to better manage and reduce risk

IHI’s Perinatal Trigger Tool, used to identify and measure reduction of adverse events in the perinatal period, will assist teams in developing a focus for improvement that is specific to their local environment. The Defensibility Tool is used to identify gaps in documentation of care that may hinder the defense of a medical malpractice case.

Areas of Focus

In order to achieve the outstanding results for patients and families, participating teams will focus on:

Improving the safety, effectiveness, and reliability of care: A high functioning team is one that is able to adapt to changing situations, learn from mistakes, respect contributions from all members, and communicate effectively and respectfully in all situations. Reliable processes are used to evaluate and manage labor and delivery based on the principles of a safe system: prevention, detection, and mitigation. Teams will examine and develop processes that help create a culture of patient safety, and that clinicians believe are important in contributing to good care for both the mother and the fetus. Teams will implement bundles focusing on improving the delivery of perinatal care.

Focusing on patient-centeredness: Ensuring that mother (and family) have all the knowledge needed to make informed decisions about care, and that they are the source of control in the birth process is a key principle. Teams will focus on communications between the patient (and her partner) and the care team that honor patient preferences and emphasize the safety of both mother and baby.

Ensuring a timely and efficient system: Teams will apply principles of a high reliability organization and will focus on developing processes to improve handoffs in care. The goal is to ensure that a stabilized mother and baby are handed off to an informed and ready patient care unit.

Aims

Participants will actively test changes aimed at achieving ambitious design targets:

Birth trauma is reduced to zero
Patients state that 95 percent of the time their wishes are known to the entire team and their wishes are respected
Perinatal units will report a 25 percent improvement in their culture survey scores
All claims or allegations may be defended because they meet each institution’s internal standards for defense (e.g., consistent documentation, no lapses in documentation, no lapses in communication)