Baby proof­ing

As­cen­sion works on ob­stet­rics qual­ity, safety

Modern Healthcare - - From The C-suite - Ann Hen­drich Ann Hen­drich is vice pres­i­dent of clin­i­cal ex­cel­lence op­er­a­tions for As­cen­sion Health, St. Louis, and a prin­ci­pal in­ves­ti­ga­tor for the Agency for Health­care Re­search and Qual­ity.

I’ll never for­get that day. I was early in my ca­reer as a la­bor and de­liv­ery nurse when a tragedy oc­curred that is still fresh in my mem­ory. In the mid1980s, fe­tal heart rate mon­i­tors were big, bulky ma­chines and were dif­fi­cult to trans­port. A mother was in la­bor with her sec­ond child and de­liv­ery was im­mi­nent. The doc­tor re­quested we move her to the de­liv­ery room. We de­cided there was no need to bring the mon­i­tor for the three-minute move; the mother could be reat­tached to the mon­i­tor in the de­liv­ery room.

In the few min­utes it took us to trans­port the mother, her baby de­scended quickly, tight­en­ing a knot in the um­bil­i­cal cord. The baby suf­fered anoxia and later died. The mother was dev­as­tated and wanted to know how some­thing like this could have hap­pened.

That ex­pe­ri­ence keeps me ask­ing, “What can we do to pro­vide qual­ity care and safety for our pa­tients and care providers?”

At As­cen­sion Health, the nation’s largest Ro­man Catholic and not-for-profit health­care sys­tem, we are guided by the prin­ci­ple that we must con­tin­u­ously seek to re­duce and elim­i­nate pre­ventable in­juries and deaths. Our ini­tia­tives have had re­mark­able re­sults for our pa­tients—we have low­ered rates of pre­ventable in­juries to be­low na­tional av­er­ages in a num­ber of ar­eas in­clud­ing mor­tal­ity and pres­sure ul­cers.

Last fall, we be­gan a pro­gram that I am con­fi­dent will help re­duce rates of pre­ventable birth trauma to the low­est lev­els pos­si­ble.

With funds from the Agency for Health­care Re­search and Qual­ity, un­der its pa­tient safety and med­i­cal li­a­bil­ity ini­tia­tive, we launched Ex­cel­lence in Ob­stet­rics at five As­cen­sion sites. Our pro­ject goals are to im­prove pa­tient safety in the birthing process, pre­pare ex­pert birthing teams to han­dle cri­sis events rapidly, and change how med­i­cal li­a­bil­ity is man­aged if a se­ri­ous safety event oc­curs.

The is­sues we are ad­dress­ing through Ex­cel­lence in Ob­stet­rics are es­sen­tial ques­tions all hos­pi­tals should ask: How can we pre­vent se­ri­ous safety events? How can we en­sure trans­parency when tragedies oc­cur so fam­i­lies and doc­tors bet­ter un­der­stand what could have hap­pened dif­fer­ently? And, how can we im­prove our sys­tem of med­i­cal li­a­bil­ity to pro­vide fair and just com­pen­sa­tion if a mis­take oc­curs, yet avoid friv­o­lous law­suits?

By study­ing the med­i­cal records of con­sent­ing moth­ers, we hope to pro­vide in­sight into these ques­tions from which all hos­pi­tals—even be­yond As­cen­sion Health— may learn. Also, the lessons learned could be spread to other high-risk ar­eas of hos­pi­tals, in­clud­ing the emer­gency depart­ment and op­er­at­ing room.

My col­league Dr. Paul Burstein’s re­cent ex­pe­ri­ence sums up the value of this study. Burstein is a prac­tic­ing ob­ste­tri­cian and physi­cian site lead for the AHRQ study at 177bed Columbia St. Mary’s hos­pi­tal in Mil­wau­kee. His pa­tient, Jill, was in la­bor when her baby’s heart rate dropped. Paul dis­cussed the op­tions for de­liv­ery with Jill and to­gether they opted for an emer­gency ce­sarean sec­tion. Upon de­liv­ery, Paul dis­cov­ered an oc­cult pro­lapse and tight nuchal cord, which could have led to a very dif­fer­ent out­come.

Both doc­tor and pa­tient credit the team­work in the op­er­at­ing room as in­stru­men­tal in the suc­cess of the de­liv­ery. Jill’s story il­lus­trates the im­pact of this pro­ject on an in­di­vid­ual level. Imag­ine what the im­pact will be as these learn­ings are shared across the coun­try.

Each of us must be com­mit­ted to build­ing a high-re­li­a­bil­ity health­care or­ga­ni­za­tion. We can’t undo unan­tic­i­pated out­comes, but we can do the right thing by treat­ing the pa­tient and fam­ily with holis­tic, rev­er­ent care through open com­mu­ni­ca­tion. And, most im­por­tant, we can work to as­sure that if the unan­tic­i­pated out­come was caused by an er­ror, the same fail­ure modes that con­trib­uted to the event are not re­peated.

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