About 700 women die each year in the United States as a result of pregnancy or complications during or after childbirth. Black, American Indian, and Alaska Native women suffer disproportionately, as research indicates they are significantly more likely to die during pregnancy, at delivery, or soon after than white women, regardless of their education level or other factors. Since 2014, IHI Strategic Partner Providence St. Joseph Health has put special effort into preventing these tragedies. In this interview, Trina Jellison, Group Vice President, Women and Children’s Institute, and Kevin Pieper, MD, Executive Medical Director, Women and Children’s Institute, describe their health system’s efforts to improve maternal health.
How did Providence St. Joseph Health start focusing on maternal mortality?
Kevin Pieper: As part of organizing our major service line work, our system looked at women’s and children’s [health]. We pulled clinical leaders from across the system together, including physicians and nurses, nurse managers, and directors. We had a summit to ask, “What are the most important things we need to work on as a system to improve clinical quality and safety? What’s manageable? What will have the biggest impact?”
What we initially worked on was driven from the front line. The work was broken into subgroups. We divided into OB (obstetrics), newborn, high-risk newborn, and women’s health. For OB, we initially focused on standardizing labor bundles and management of labor, then moved on to addressing maternal hemorrhage and maternal hypertension. We also picked up some smaller projects, such as management of vaginal birth after Caesarean (VBAC) and using nitrous oxide in labor.
We typically had monthly calls with volunteer groups of physicians and nurse leaders. We evaluated available evidence and system best practice within Providence to develop recommendations. We then built implementation tools, such as specific presentations to use with medical staff, nursing staff, sand executive teams. Finally, we built dashboards to better understand where we’re starting from and to track improvement.
Trina Jellison: Kevin was the leader of the OB work for the first about three and a half years of this journey. Then, when we changed our model, and he was nominated and elected as a medical director for the system for all things [related to] women’s health.
One of the things that’s been remarkable in this journey is how it always starts with a very specific patient story. The clinicians and the care teams never want to lose a patient. When a horrific event occurs, it not only impacts the family, it impacts the care team as well. The focus is patient safety, but also support of our own teams. A lot has come out of that work, including compassionate care work for our employees.
We worked diligently on identifying key stakeholders for each group — like on the VBAC group, we included anesthesia and the operating room team. It means getting everybody together on the front end so that the work goes smoothly on the tail end.
We developed internal toolkits that include electronic protocol samples, policy template (if needed), education materials for providers and the care team, screen shots of EMR changes (if needed), research articles reviewed, and who to contact with questions.
Kevin Pieper: Each facility is different. Being that go-to group that can help facilitate implementation, whether that means bringing different people together or making a site visit, has been an important part of our work.
How is Providence moving from reaction to prevention?
Kevin Pieper: A great example is the risk stratification modifications that were made to the electronic medical record to prevent maternal hemorrhage. By using a few simple questions often asked at OB admission, we were able to stratify women into groups based on low, moderate, and high risk of hemorrhage categories. With that information, care recommendations are made to providers.
Trina Jellison: Staff, regardless of role or title, are feeling empowered. They’ve started to incorporate care teams with anesthesia and newborn providers to create a more comprehensive plan before the patients come in. It’s becoming embedded in our culture.
How have you used improvement methods and spread tactics?
Trina Jellison: Before we even start that work, we define the metrics. Because every hospital or every clinic is a bit different, we ask how it’s going to be implemented and who’s going to be impacted. But the measurement’s the same. This encourages shared learning between groups.
If things aren’t working, Kevin and I ask the care team, “How can we help? Here’s how others are getting success.” We’re facility-by-facility trying to work towards a standardized process.
Kevin Pieper: We’re being methodical and making sure we have representation from, if not every facility, every region, so that there’s a go-to person to help spread the toolkit.
How has your journey toward becoming a high-reliability organization helped achieve your maternal health results?
Kevin Pieper: Decreasing the hierarchy in medicine was a focus of the work. Obstetrics is a team-based practice, and safe labor management requires hypervigilance by everybody on the floor. We’ve always included high-reliability teachings in simulations. Practicing an adverse event has proven helpful for teams to see themselves on video, allowing for critical self-reflection on their team dynamics.
Trina Jellison: We often see people who feel the world should be different and want it to move faster than cultures allow. Early adopters often say, “Well, this is just how we should do business.” It takes a fine balance to keep those folks engaged and excited while ensuring everyone is onboard.
It’s interesting to watch people successfully assisting others to catch up to the people who are in the lead. We’re changing culture while continuously doing work. It’s taking us down a path that is much more open for engagement.
The good news is that we have objective information to share about our results based on data on over 210,000 deliveries. There has been one preventable death in over three years related to hemorrhage. We’ve also seen a decrease in blood utilization, decrease in time to intervention, decrease in ICU admissions, and decrease in hysterectomies resulting from hemorrhage.
What key learnings can other health care systems take from your work?
Trina Jellison: Make sure there’s a compelling story and a shared vision. Start small and build on that. Celebrate success, have people talk about the personal impact of the change. Was there a patient saved because of the work that’s been done?
Don’t let up. Remember why we do the work. Make sure you have the right stakeholders and the right goal in mind.
Kevin Pieper: You need champions for the work who really have a passion. Welcome all newcomers. It may surprise you how much they can contribute. Keep an open mind.
Trina Jellison: The hard work is worth the result.
Emma Robinson is an IHI project coordinator.
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