Debra Bingham

National Partnership for Maternal Safety: Consensus Bundle on Obstetric Hemorrhage.

Hemorrhage is the most frequent cause of severe maternal morbidity and preventable maternal mortality and therefore is an ideal topic for the initial national maternity patient safety bundle. These safety bundles outline critical clinical practices that should be implemented in every maternity unit. They are developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Womens Health Care. The safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and System Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. References contain sample resources and “Potential Best Practices” to assist with implementation.

A State-wide Obstetric Hemorrhage Quality Improvement Initiative

PurposeThe mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and to promote equitable maternity care in California. This article describes California Maternal Quality Care Collaboratives (CMQCCs) statewide multistakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success. Project Design and ApproachIn partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multidisciplinary, multistakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage. Project DescriptionThe OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multilevel strategy to disseminate the guideline, including an open access toolkit, a minimal support-mentoring model, a county partnership model, and a 30-hospital learning collaborative. Clinical ImplicationsIn participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 (or greater) hemorrhage, hosting skills stations for measuring blood loss, and running obstetric (OB) hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the statewide initiative in which nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a difference in the quality of care that can be achieved. Nurses provide significant leadership in multidisciplinary, multistakeholder quality projects in California. Ensuring that nurses have the opportunity to participate in formal leadership of these teams and are represented at all workgroup levels is critical to the overall initiative. Nurses brought key understanding of operational issues within and across departments, mobilized engagement across the state through the regional perinatal programs, and developed innovative approaches to solving clinical problems during implementation. Nursing leadership and integrated participation was especially critical in considering the needs of lower-resource settings, and was essential to the toolkits enthusiastic adoption at the unit/service level in facilities across the state.

Quality improvement in maternity care: promising approaches from the medical and public health perspectives.

Purpose of review Quality-improvement activities affect every obstetrician and every birthing service in the country. This review will serve to introduce the obstetric practitioner to the latest evidence of effective quality-improvement methods and provide an understanding of the different roles of the various organizations involved. Recent findings Maternity quality improvement is an interrelated process with quality-improvement activities that occur at the hospital (e.g. protocols, checklists, drills, simulations, data collection and feedback and rapid-cycle quality-improvement projects), quality-improvement activities that occur at the level of a multihospital system or region (e.g. development of materials to support the hospital, development of quality-improvement leaders, provide pressure for change, benchmark outcomes), quality-improvement activities that occur within public agencies (e.g. public education campaigns) and still others that occur at governmental levels (e.g. selecting measures and targets, setting incentives and regulations, collecting administrative data). Quality collaboratives are relatively new, but can serve to jumpstart and coordinate the quality-improvement process among all the institutions involved. Summary This review helps hospital leaders identify the quality-improvement activities that will be most effective for their needs.

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.

Content Validity Testing of the Maternal Fetal Triage Index

OBJECTIVE To describe the development and content validity testing of the Maternal Fetal Triage Index (MFTI), a standardized tool for obstetric triage. DESIGN Online survey. PARTICIPANTS Participants included 15 registered nurses, 15 certified nurse-midwives, and 15 physicians from across the United States who provided maternity care. METHODS A convenience sample of experienced clinicians was used as content validators for the MFTI. An item content validity index (I-CVI) was computed for the tools items and a scale content validity index (S-CVI) was computed for the tools scale based on the responses submitted via the online survey. Two rounds of content validation occurred. RESULTS In the first round of testing, a total of 12 of 61 items in the MFTI did not meet the I-CVI threshold of greater than 0.78 because of disagreement about clinical condition (75%) or priority level placement (25%). In the second round of testing, all but 3 of the 69 content items in the revised version of the MFTI had I-CVI thresholds greater than 0.78. These 3 items were related to vital sign values. The overall S-CVI score calculated for Round 2 only was 0.95, which was greater than the threshold of 0.90. CONCLUSION The results of the content validity testing of multidisciplinary validators suggest that the MFTI is a valid tool for use in obstetric triage and evaluation settings.

Standardized Severe Maternal Morbidity Review: Rationale and Process

Severe maternal morbidity and mortality have been rising in the United States. To begin a national effort to reduce morbidity, a specific call to identify all pregnant and postpartum women experiencing admission to an intensive care unit or receipt of four or more units of blood for routine review has been made. While advocating for review of these cases, no specific guidance for the review process was provided. Therefore, the aim of this expert opinion is to present guidelines for a standardized severe maternal morbidity interdisciplinary review process to identify systems, professional, and facility factors that can be ameliorated, with the overall goal of improving institutional obstetric safety and reducing severe morbidity and mortality among pregnant and recently pregnant women. This opinion was developed by a multidisciplinary working group that included general obstetrician–gynecologists, maternal–fetal medicine subspecialists, certified nurse–midwives, and registered nurses all with experience in maternal mortality reviews. A process for standardized review of severe maternal morbidity addressing committee organization, review process, medical record abstraction and assessment, review culture, data management, review timing, and review confidentiality is presented. Reference is made to a sample severe maternal morbidity abstraction and assessment form.

Key Findings from the AWHONN Perinatal Staffing Data Collaborative

The Association of Womens Health, Obstetric and Neonatal Nurses (AWHONN) created the Perinatal Staffing Data Collaborative in response to the release of its Guidelines for Professional Registered Nurse Staffing for Perinatal Units. In total, 183 surveys were submitted from 175 birthing hospitals in the United States. These findings represent the largest set of data available to describe current patterns in perinatal registered nurse (RN) staffing. In this article we summarize the findings of the AWHONN Perinatal Staffing Data Collaborative from 2011 through 2012.

Maternal Death from Obstetric Hemorrhage

Obstetric hemorrhage remains the leading cause of maternal death in the United States, and 54% to 93% of these deaths may have been preventable. Leaders must honor the lives of women who die from obstetric hemorrhage by reviewing their deaths and sharing lessons learned. Shortening the current 3 to 7 year data gap will allow for timely initiation of quality improvement efforts. Designated leaders and researchers from the Association of Womens Health, Obstetric, and Neonatal Nurses are ideally positioned to lead these quality initiatives.

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.

Applying the Generic Errors Modeling System to Obstetric Hemorrhage Quality Improvement Efforts

Obstetric hemorrhage is an emergency situation in which clinicians can make errors that cause women to suffer preventable maternal morbidity and mortality. Scrutinizing commonly occurring obstetric hemorrhage-related practice errors by applying the generic errors modeling system, a research-based framework, to quality improvement efforts facilitates the identification of error specific reduction strategies. The common types of errors are skill-based, rule-based, and knowledge-based active and latent errors.