Daniel F. O'Keeffe

Confronting Safety Gaps across Labor and Delivery Teams

We assessed the occurrence of 4 safety concerns among labor and delivery teams: dangerous shortcuts, missing competencies, disrespect, and performance problems. A total of 3282 participants completed surveys, and 92% of physicians (906 of 985), 93% of midwives (385 of 414), and 98% of nurses (1846 of 1884) observed at least 1 concern within the preceding year. A majority of respondents said these concerns undermined patient safety, harmed patients, or led them to seriously consider transferring or leaving their positions. Only 9% of physicians, 13% of midwives, and 13% of nurses shared their full concerns with the person involved. Organizational silence is evident within labor-and-delivery teams. Improvement will require multiple strategies, used at the personal, social, and structural levels.

Transforming Communication and Safety Culture in Intrapartum Care: A Multi-Organization Blueprint

Effective, patient-centered communication facilitates interception and correction of potentially harmful conditions and errors. All team members, including women, their families, physicians, midwives, nurses, and support staff, have roles in identifying the potential for harm during labor and birth. However, the results of collaborative research studies conducted by organizations that represent professionals who care for women during labor and birth indicate that health care providers may frequently witness, but may not always report, problems with safety or clinical performance. Some of these health care providers felt resigned to the continuation of such problems and fearful of retribution if they tried to address them. Speaking up to address safety and quality concerns is a dynamic social process. Every team member must feel empowered to speak up about concerns without fear of put-downs, retribution, or receiving poor-quality care. Patient safety requires mutual accountability: individuals, teams, health care facilities, and professional associations have a shared responsibility for creating and sustaining environments of mutual respect and engaging in highly reliable perinatal care. Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality. The problem is well-known; the time for action is now.

Obstetric ultrasound utilization in the United States: Data from various health plans

There is currently a lack of published data on ultrasound utilization in obstetrics in the United States. In order to get some meaningful information on this topic, we analyzed de-identified data obtained from large insurance providers and underwriters that covered large segment of the United States population in various geographic areas of the country. Our results show an overall significant increase in utilization of obstetric ultrasound over the years, with pregnancies receiving around 4-5 ultrasounds per pregnancy. Another important aspect of the data is a higher than expected utilization of the targeted 76811 ultrasound examination, with utilization rates between 30% and 50%, beyond the original intention of the targeted code. Despite the fact that the data was not intended to shed light on indication of ultrasound or competency of ultrasound providers, in a healthcare world of shrinking reimbursement, as leaders of quality, we should ensure that ultrasound examinations that pregnant women receive are indicated and are performed by competent healthcare workers in ultrasound laboratories that meet accreditation standards.

Transforming communication and safety culture in intrapartum care: a multi-organization blueprint.

Effective, patient-centered communication facilitates interception and correction of potentially harmful conditions and errors. All team members, including women, their families, physicians, midwives, nurses, and support staff, have a role in identifying the potential for harm during labor and birth. However, the results of collaborative research studies conducted by organizations that represent professionals who care for women during labor and birth indicate that health care providers may frequently witness, but may not always report, problems with safety or clinical performance. Some of these health care providers felt resigned to the continuation of such problems and fearful of retribution if they tried to address them. Speaking up to address safety and quality concerns is a dynamic social process. Every team member must feel empowered to speak up about concerns without fear of put-downs, retribution, or receiving poor-quality care. Patient safety requires mutual accountability: individuals, teams, health care facilities, and professional associations have a shared responsibility for creating and sustaining environments of mutual respect and engaging in highly reliable perinatal care. Defects in human factors, communication, and leadership have been the leading contributors to sentinel events in perinatal care for more than a decade. Organizational commitment and executive leadership are essential to creating an environment that proactively supports safety and quality. The problem is well-known; the time for action is now.

The practice of medicine as it should be practiced: Based on scientific evidence

Summary Physicians should lead in the development, implementation, and review of clinical guidelines. They can insist that practice guidelines must be data-driven and statistically credible. They can focus on the process of care rather than reducing cost. What does this mean? We, as physicians, have an opportunity to regain control of the practice of medicine. It we do not take this opportunity, somebody else will force us. This will further increase our frustration, anxiety, and anger, which leads to reduced professional satisfaction with our chosen career. Physicians have established a comfortable pattern of practice over many years and are very reluctant to change even when there is good scientific evidence to suggest change. Physicians have never been accountable for their outcomes except in extreme circumstances. Accountability is frightening and will be resisted. Guidelines are also rejected and feared by physicians because they think that they are being told what to do. Guidelines are strategies that are based on the science available which can be evaluated to determine outcome and cost of care. They will fit most patients in most situations, but not all patients in all situations. The benefits of better patient care, decreased cost, medicolegal protection, and research application far outweigh our reluctance, inertia, and misguided fears. If physicians develop the guidelines based on science, we should be comfortable with them, especially if we can change them if the data suggest change is necessary.

Role of the Hospitalist and Maternal Fetal Medicine Physician in Obstetrical Inpatient Care

OBJECTIVE The objective of this study was to evaluate the role of hospitalists and Maternal Fetal Medicine (MFM) subspecialists in obstetrical inpatient care. STUDY DESIGN This electronic survey study was offered to members of the American College of Obstetrics & Gynecology (ACOG; n = 1,039) and the Society for Maternal-Fetal Medicine (SMFM; n = 1,813). RESULTS Overall, 607 (21%) respondents completed the survey. Overall, 35% reported that hospitalists provided care in at least one of their hospitals. Compared with ACOG respondents, a higher frequency of SMFM respondents reported comfort with hospitalists providing care for all women on labor and delivery (74.4 vs. 43.5%, p = 0.005) and women with complex issues (56.4 vs. 43.5%, p = 0.004). The majority of ACOG respondents somewhat/completely agreed that hospitalists were associated with decreased adverse events (69%) and improved safety/safety culture (70%). Overall, 35% of ACOG respondents have MFM consultation available with 53% having inpatient coverage. Of these, 85% were satisfied with MFM availability. CONCLUSION Over one-third of respondents work in units staffed with hospitalists and more than half have inpatient MFM coverage. It is important to evaluate if and how hospitalists can improve maternal and perinatal outcomes, and the types of hospitals that are best served by them.