HealthPartners Regions Hospital is a participant in IHI’s Learning and Innovation Community on Improving Perinatal Care.

Angela Miller, BSN, RN, Labor and Delivery Staff Nurse and Clinical Educator
Bonnie Maloney, RNC, Labor and Delivery Charge Nurse
Candy Talley, MSN, RNC, Postpartum Staff Nurse
Cheryl Patterson, BSN, RN, Labor and Delivery Nurse Manager David Baram, MD, OB/GYN Staff Physician, Chair of OB/GYN Peer Review/Credentialing
Linda S. Hart, MPH, RN, Performance Improvement, Senior Project Manager

By August 2008, Regions Hospital Birth Center will improve the reliability of clinical processes in Labor and Delivery (L&D) by using evidence-based induction, augmentation, and vacuum-assisted delivery interventions and by improving communication among care team members. 

Goals include the following:

• 95 percent completion of Fetal Heart Rate (FHR) common language education by L&D nurses and providers
• 95 percent compliance with Elective Induction Bundle as measured by monthly audit of up to 20 elective induction charts
• 95 percent compliance with Augmentation Bundle as measured by monthly audit of 20 augmentation charts
• 90 percent compliance with Vacuum Delivery Composite changes and 75 percent compliance with Vacuum Delivery Bundle as measured by monthly audit of all vacuum assisted deliveries 
• 100 percent compliance with assessment for gauze retention in vaginal deliveries as measured by a monthly audit of at least 50 percent of all vaginal deliveries
• Attainment of Safety Climate Score of 75 percent or better

• Common Language Training and Reinforcement: Identified priority need for Fetal Heart Rate monitoring (FHR) common language training, including use of Situation-Background-Assessment-Recommendation (SBAR) communication.
  • Consultant Michael Fox provided initial staff training and “train-the-trainer” classes so we could carry on this work for new staff.
  • Work continues to define a refresher class for staff, emphasizing indications for action.
  • Enhanced realization of need for quick response led to build out of second 24/7 operating room within Birth Center.
• Unintentionally Retained Vaginal Gauze Audit and Counting Protocol: Tested and implemented weekly audit sheet to track documentation that no unintentional gauze was retained following vaginal delivery. Initial rapid-cycle work led to high compliance and audit became monthly.
  • Regions Hospital representatives worked with Institute for Clinical Systems Improvement (ICSI) colleagues to develop sponge, soft object, and needle counting protocol, which led to publication on their website.
  • 4 x 4 gauze was removed from vaginal delivery trays; lap sponges are available for use only upon provider request.
• IHI Perinatal Bundles Compliance: Implemented IHI Elective Induction, Augmentation, and Vacuum-Assisted Delivery Bundles requiring compliance with evidence-based elements of care.
  • Rapid-cycle work led to initial high compliance; review of cases that fail the bundle are done to look for opportunities for improvement.
  • Results are reviewed monthly by Birth Center leadership. Results are published in electronic “scorecard” for easy access by hospital senior leadership and staff.
  • Tested and made changes to electronic medical record (EMR) to accommodate bundle documentation and to remind providers of bundle requirements.
• L&D Policies and Procedures Review: Key L&D policies related to the IHI Perinatal Bundles were reviewed at the onset of our participation with the Perinatal Learning and Innovation Community and a schedule for re-review established.
  • Initial policy work led to a review of all policies, revisions, and placement in electronic format.
  • As a Level I Trauma Center, collaboration with emergency room colleagues proved useful in re-clarifying roles and responsibilities of the surgical trauma team and the OB physician.
• Oxytocin Audit: Special audits were conducted based on oxytocin “deep dive” work championed by IHI after oxytocin was designated as a high-alert medication by the Institute for Safe Medication Practices. This work helped us decide to conduct weekly FHR strip reviews rather than monthly reviews.
• Drills and Simulations: Our clinical educators have developed, tested, and conducted drills within L&D, Post Partum, and Special Care/Newborn Nurseries. A relationship with the Simulation Center at Metro State University has been developed and is proving mutually beneficial.
• Safety Climate Survey: Safety climate surveys using IHI-recommended methodology are done twice a year to monitor staff perception of safety on the unit. While results steadily improved since inception of IHI Perinatal work, initial results led to an emphasis on improved communication as described below.
• Improved Communication: The Birth Center promotes department-wide initiatives and has enthusiastically joined in hospital-wide endeavors to improve communication.
  • Hospital Daily Huddles: Done on all shifts to communicate important hospital and department information.
  • Charge Nurse Daily Huddles: Charge nurses from L&D, Postpartum/Newborn Nursery and Special Care Nursery meet daily to communicate important patient information and anticipated patient flow.
  • Provider-to-Nurse Communications: Promoted by revising time and format for daily patient report to encourage attendance by residents, OB rounder, Birth Center Charge Nurses from all departments, and any Certified Nurse Midwives (CNMs) or Family Practice MDs on the unit. Report is done early so that key night staff are present and involved in report.
  • Birth Center Special Reports: Special email format devised that is used only for important information coming to all staff from the Birth Center Nursing and Medical Directors. Format has proved useful in separating critical from routine email.
  • Text Pagers: An effort to decrease time to communicate to all needed personnel in emergency situations led to development, testing, and use of text pagers to simultaneously page Provider/OB, Anesthesia, Residents, and Charge Nurse.
  • SBAR: All Birth Center staff trained in the use of SBAR to communicate important information as part of FHR common language education and reinforced with multiple hospital-wide SBAR promotions. Key RN staff attended train-the-trainer workshop to serve as ongoing SBAR mentors within the Birth Center.
  • Rapid Response Team: All Birth Center staff educated on activation of Rapid Response Team to assist in the event of codes or other emergency situations.
• Patient Centeredness: Multiple hospital-wide initiatives are ongoing to enhance our patients’ experience. Led by Best Care Best Experience staff and championed by Birth Center Unit Practice Councils, the following initiatives have proved helpful in improving patient satisfaction:
  • The AIDET initiative encourages staff to Acknowledge the patient by name; Introduce themselves and their role; describe the Duration of any test, procedure or activity; Explain what the staff member is going to do and allow patients to ask questions; and Thank the patient for his/her participation and cooperation and/or ask if there is anything else the staff member can do for the patient.
  • “Who’s My Doc” is an effort to provide a card with photo of the provider who is in charge of the patient’s care. This is especially helpful for patients of Family Practice MDs and CNMs who had an unanticipated need for an OB for a cesarean birth.
  • “Questions About My Care” brochure encourages staff to assist patients in writing down questions to be addressed to their provider so that questions are not forgotten.
  • Roles of L&D staff information sheet: A simple, one-page information sheet explaining the roles of team members within L&D was developed and is available in the 16 languages most commonly spoken by our patients.
  • Dual handsets in patient rooms enable patient, staff member, and phone interpreter to all be on the line at once when onsite interpreters are not available.
  • Discharge phone calls are routinely done to identify any concerns of the parent and to encourage follow-up care for mom and baby.

• Importance of using MD, CNM, and Charge Nurse leaders to request communication in SBAR format and to role-model this important communication methodology.
• Importance of continually reinforcing the use of rapid-cycle tests of change before implementing new procedures and policies.
• Person-to-person distribution of Safety Climate Surveys at daily huddles, with message as to purpose of this confidential survey, improved the rate of return in efforts to assess staff perception of safety on the unit.
• While education is necessary, it is not always sufficient to effect change. Compliance with prevention of unintentionally retained gauze protocol greatly improved when gauze was removed from vaginal delivery tray.
• Use of text pagers needs to be periodically communicated, including mock drills, to accommodate staff turnover.
• Attendance at an event such as Critical Event Team Training is an important way to learn how experienced teams conduct drills and simulations.
• Judiciously manage your data. If you have a downward data trend, it is important to look for common causes. However, micromanaging tiny dips in data when you are at, or very near goal, may use staff resources that could better be spent on other issues.
• Use IHI colleagues via the listserv to quickly solicit needed information on policies, practices and evidence-based guidelines. In turn, share information with colleagues. We are all too busy to reinvent the wheel!
• The support of senior leadership and our board of directors has been crucial to the success of our program. Communicate with senior leaders on a regular basis to share strengths and challenges within the program.