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CLINICAL OBSTETRICS AND GYNECOLOGY Volume 53, Number 3, 559–575 r 2010, Lippincott Williams & Wilkins

Role of Clinician Involvement in Patient Safety in Obstetrics and Gynecology SUSAN MANN, MD,* and STEPHEN PRATT, MDw Departments of *Obstetrics and Gynecology and w Anesthesia, Critical Care & Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

Abstract: Patient safety is a significant concern for healthcare providers. Involving physicians in clinical quality activities in obstetrics and gynecology can be difficult for many reasons including time demands, lack of knowledge of process improvement activities, or change fatigue due to failure of adequate implementation of previous activities. This overview for improving the culture of safety identifies roles physicians can play from participating in quality assessment and improvement activities, improving teamwork between disciplines, communicating effectively, creating departmental guidelines, and deciding on outcome measures for benchmarking. An improved culture of safety is better for our patients and may reduce malpractice exposure. Key words: patient safety, quality improvement obstetrics, teamwork

Introduction It has now been more than a decade since the Institute of Medicine (IOM) published its report highlighting the impact Correspondence: Susan Mann, MD, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA. E-mail: CLINICAL OBSTETRICS AND GYNECOLOGY


that medical errors have on patient safety. Sadly, little has changed in the past decade to lessen the impact of error or to improve the culture of safety in which healthcare providers work. Although some individual successes have been made, we have not changed the nature of medical care to improve patient safety. Obstetrics presents unique challenges to patient safety. Multiple providers are often caring for multiple patients on units with limited resources (operating rooms, anesthesia providers, etc). Traditionally, these providers do not work together to determine the best utilization of these resources. The very nature of obstetric medicine makes it private, and less amenable to open communication. In fact, generally mothers are literally behind closed doors while they labor, limiting the ability of team members to observe the care their colleagues provide and to look for errors. Finally, obstetric care providers are frequently not VOLUME 53




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physically present in the labor and delivery unit. They may be performing surgery, rounding, or seeing patients in their offices. Despite these challenges, developing a culture of safety in obstetric medicine is increasingly urgent. This is the only medical arena in which it is possible to have a 200% mortality rate. Recent data demonstrate that adverse events are common in obstetrics, and a large percentage of major adverse events are preventable.1 Substandard care contributes to approximately 50% of maternal deaths, with poor communication and teamwork being the primary factors in the substandard care.2 Poor communication and coordination in providing care has been identified in 43% of the closed malpractice claims in obstetrics.3 Leadership, at both the executive and clinical levels, is essential to a vibrant culture of patient safety.4 Obstetric nurses who feel supported by their administration are more likely to feel empowered to pursue resolution of clinical conflict.5 Examples of executive leadership include executive walk rounds, and financial and administrative support for patient safety behaviors. Obstetric care providers can provide clinical leadership. Examples of clinical leadership behaviors include ensuring appropriate task completion (delegation, role clarity, and task prioritization), developing protocols and guidelines, working to increase team trust and commitment, monitoring the environment, and encouraging a cooperative climate. Several barriers have prevented obstetricians from taking active clinical leadership roles in patient safety. Fear of liability and lack of knowledge of clinical guidelines have been cited as reasons obstetricians shy away from leadership roles.6 Low scores with regard to patient safety attitudes may reflect a lack of willingness to become clinical leader. In a survey by Stumpf et al,6 nearly 40% of

obstetricians did not believe that communication improved patient safety. One must believe in the concept of patient safety if one has to lead others into them.

Physician Involvement in Quality Activities The discipline of Obstetrics and Gynecology has a long history of studying maternal and neonatal outcomes and pursuing improvements in care. Obstetricians started Maternal Mortality Review committees in the 1920s. The initiation of state maternal mortality study committees in the 1930s coincided with the beginning of significant declines in maternal deaths in the United States.7 The American College of Obstetricians and Gynecologists (ACOG) has supported clinicians with publications regarding peer review, quality assurance, standards for ObstetricGynecologic Services, and guidelines for prenatal care. In 2000, ACOG released Quality Improvement in Women’s Health Care, which helped to lay the foundation for hospital obstetrics and gynecology departments to track and understand their own outcomes. The focus of this monograph was on moving from punitive approach to an educational approach. In 1989, Berwick8 published a sentinel article on continuous quality improvement as the ideal in healthcare which helped to move the focus of healthcare to continuously improving care and reducing waste, rework, and complexity. The Quality Improvement model also known as Quality Assessment (QA), Quality Management, or Process or Performance Improvement has moved from focusing on ‘‘bad apples’’ to improving the systems of care. Recently, Watcher and Provonost9 have raised the concern that patient safety movement needs to strike the correct balance between no blame and individual accountability. In comparing medicine

Patient Safety in Ob/Gyn with the airline industry, using the examples of hand washing and time-outs for surgical procedures individuals should hold one another accountable for defined events. A copilot would not fly with a pilot who refused to use the preflight checklist.

A Model of QA and Improvement and the Physician’s Role It has often been difficult to describe a model for peer review and quality improvement that fits obstetric and gynecological departments of varying sizes and resources. Smaller departments with fewer staff may have difficulty reviewing peer’s charts objectively as they may be practice partners or competitors. Under these circumstances, charts may be presented for review to a hospital-wide committee, but other disciplines may be unfamiliar with the standards of care for the practicing obstetrician/gynecologist. ACOG introduced the Voluntary Review of Quality of Care program, which provides a comprehensive review of obstetrics and gynecology service performed by community-based physicians and nurses.10 The Joint Commission (TJC) requires that hospitals have an executive committee of the medical staff charged with peer review, credentialing, and QA. Table 1 describes the steps involved in creating a strong quality improvement process. The department chairman designates a quality chairperson and committee to perform the necessary activities; the chairman then reports back to the hospital executive committee. Departmental leaders are also often required to post and update a quality dashboard, which allows the public, board of trustees, and department members to view a measure that reflects a snapshot of that department’s ‘‘quality’’ of care.


TABLE 1. Quality Activities 1. Create a committee-broad representation, rotate membership 2. Decide on quality indicators-encourage anonymous event reporting 3. Identify sources to provide charts based on indicators 4. Review charts 5. Present charts at monthly Quality Assessment meetings – gain consensus on review 6. Identify specific education need for individual providers if necessary 7. Identify cases to present for staff education at Morbidity/Mortality conferences 8. Identify care processes that need attention and process improvement 9. Educate staff on processes requiring change based on case based learning 10. Provide annual Quality Update to department – educate all staff on dashboard measures, case review process, review of changes in departmental guidelines 11. Track outcomes of chart reviews to identify trends for procedures or individuals

Developing a structure for QA and work improvement for a department is essential. It is important to get broad representation from different constituencies such as call-group representatives, physicians in private practice, hospitalemployed physicians, midwives, and resident designees appropriately. Hospitals with larger departments often get support from hospital-level quality committees or employ their own nurses and support staff to support the quality activities. Early work in the quality arena focused on retrospective analysis of events. Case identification can be variable among institutions. The identification of these events has been aided by TJC, which has provided a list of sentinel events that require retrospective reviews and root cause analysis. ACOG has also published a list of quality indicators for case review by departmental quality leaders.11 Other sources of indicators for chart review are cases that are mandated for reporting to individual state board of registration of


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medicine or the local public health department. Failure to follow guidelines provided by malpractice carriers for example, dictation of a note for a shoulder dystocia complication, or a fourth degree repair can also be reviewed. Anonymous event reporting in which providers report the concerns of quality of care, failure of instrumentation, or inadequate staffing should be encouraged in all the departments. Selection of indicators that are to be reviewed is the work of the QA committee, with the approval of the department chairperson and buy-in from the staff. The identification and distribution of charts for review by individual committee members is the work of the staff supporting the committee. These charts can be flagged by discharge diagnosis code or length of stay data, laboratory services, admission to neonatal or maternal intensive care units and reports can be created by information technology services department within a hosptial. The process of peer review of the flagged charts can be difficult and at times uncomfortable for members serving on the committee. Landon et al12 describe that often there are no standards for clinical competency or thresholds for acceptable care. Chart review should be performed before a meeting so that the cases can be presented and discussed by the committee members. An effort to respect any conflicts of interest during the review process is necessary, for example, one should not review their own partner’s cases and one should refrain from the discussion of a case if one was a provider of care. Interviews can be performed by quality nursing staff before meetings if the charting of the case is unclear; however, an educational role for physician is to provide feedback when charting does not support clinical decision-making. The chart review and discussions should be based on the standards of care for that community and relevant guidelines.

It is important for a structured process of discussion to occur after the presentation of the case. Goldman and Ciesco13 looked at the poor interrater reliability of single reviewers and recommended the use of multiple reviewers, and structured assessment instruments, particularly for reviews that have major consequences for patients and practitioners. Levine et al14 recommended to use structured peer review without discussion and consensus, when there were single reviewers and there was an enormous variation between the individual reviewers. Therefore, it is recommended that a QA committee presents a case using a structured review, including pathology reports, fetal heart rate monitor strips, and local and national guidelines. After discussion, the committee members should arrive at a consensus regarding the chart review of: no deficiency in care, opportunity for improvement, deficiency in care, and/or system issues identified. In our department of Obstetrics and Gynecology, at Beth Israel Deaconess Medical Center we have used such a system of structured peer review and consensus; for several years we have reviewed between approximately 420 and 460 cases yearly. The average rate of a case with no deficiency is 86% to 89%, opportunity for improvement 7% to 10%, and deficiency in care 1% to 4%. Forster et al15 reviewed the adverse events of an obstetrical service and found that adverse events and potential adverse events were most commonly the result of ‘‘system’’ problems and not individuals. Many charts are reviewed that have no deficiency in care but complications can arise that can cause a prolonged length of stay or scar tissue can cause an unintentional entrance into the bladder. In our experience, an opportunity for improvement is identified when there is an error in dictation of an operative report, or a delay in implementation of plan of care which did not cause harm to a patient, or failure to use a correct

Patient Safety in Ob/Gyn consent form. In cases of opportunity for improvement, the committee chairpersons write a letter to a provider for educational but not punitive reasons. In case there is deficiency of care, the case is referred to the departmental executive committee composed of senior members and division directors who decide whether the provider needs an educational counseling session or not. If there is a significant departure from the standard of care or outcome, it is reported to the hospitalwide patient care assessment committee, a subcommittee of the medical executive committee. All of this work is dependent upon physician involvement and it is often an excellent educational activity for physicians who participate. Thus, it is important to rotate membership or have shared appointments so that more physicians can participate in the review and discussion, and if they are unable to attend a meeting the charts are reviewed in a timely fashion. Each case is also reviewed for potential system issues, which may need further attention. The case is then referred to an established obstetric or gynecological working group to develop a change in processes of care or a checklist to aid providers. The chairperson of the quality assurance also gives input to cases for presentation at the Morbidity and Mortality conferences; the staff could learn from the experience especially when safeguards are put into place. It is also useful to track the outcomes of the chart reviews and indicators for review and provider involved in the case in a database. This trend is important to identify certain types of complications for example, prolonged time in operating room for individuals, who may need additional training for certain types of surgical procedures. Creating a baseline comparison of all physicians in the department may identify a physician who has a spike in the number of cases requiring review, a situation, which may require further attention.


Finally, the work performed and the statistics obtained are reviewed in a yearly quality improvement grand round for all staff.

Physician Involvement in Creating a Culture of Safety Through Improved Teamwork Improving teamwork between the members and disciplines of labor and delivery unit provides a safety net for patients. Communicating plans of care for all patients allows the staff to raise safety concerns about the plan itself or to monitor for deviations from the plan. Raising concerns may cause conflict between providers; learning how to resolve the conflict among members in a respectful way is essential for sending a unified message to patients and maintaining staff morale. These concepts are the essence of a teamwork program in labor and delivery. Creating a team structure in labor and delivery leads to improved outcomes and staff satisfaction.16,17 Nielsen and Mann18 discuss 3 types of teams in labor and delivery. The core team is involved with direct patient care. A coordinating team takes the 30,000-foot view, manages the workflow of the entire unit, helps to triage activities, and resolves conflicts. Members of the coordinating team include the charge nurse, a designated obstetrician, anesthesiologist, and chief resident. The third is a contingency team or a rapid response team composed of predetermined members of the core team who respond to issues such as an emergence of cesarean delivery. The behaviors or communication events that are taught in a teamwork course often include huddles, team meetings, briefings, handoffs of care, debriefings, etc.19 A huddle is a quick communication between 2 providers, for example, an obstetrician and a nurse, or a nurse and an anesthesia provider to update one another regarding


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Team Meeting Agenda

1. Each patient’s care plans 2. Any safety concerns regarding each patient 3. Physician availability and coverage arrangements 4. Individual staff workload and availability 5. Elective work scheduled on the unit

the status of a patient. A team meeting is a multidisciplinary meeting among all providers where important patient and provider information are discussed. Table 2 provides an outline for the discussion of a team meeting. It is important that all disciplines participate in the meetings as they raise their specific concerns regarding care of the patient. Balancing workload at the meeting can provide assistance to an overworked colleague who may perhaps be reluctant to ask for assistance. Identifying work that could be postponed during times of high acuity, could improve patient satisfaction if patients are kept at home instead of waiting for prolonged periods in the waiting area until it is safe to proceed with elective procedures. The third type of communication event is the briefing, which should occur before an operative delivery. The specific concerns about this patient, including possible need for blood products, previous difficult surgeries or issues with anesthesia, and comorbidities are shared with the team to provide a shared vision among all caregivers. A debriefing occurs at the conclusion of a procedure allowing providers to share teamwork or procedure-related concerns with the team. The World Health Organization recently recommended a similar sign in and sign out of the operating room approach that when performed with a TJC mandated timeout was shown to improve morbidity and mortality by 38% in 8 hospitals on different continents.20

Role Clarity The understanding of one’s own roles and responsibilities on the team, and those of

one’s team members is crucial to successful teamwork. In order to perform one’s tasks, or to monitor the task performance of one’s team members one must be clear about what those roles should be. Data suggest that clinicians, especially nurses, are frequently unsure about team members’ roles, and often make inaccurate assumptions about the role of others. The importance of role clarity has been demonstrated in both simulated and clinical arenas in obstetrics. Robertson et al21 found that task completion increased nearly 4 folds during a simulated obstetric emergency when roles and the responsibilities of each role were clearly defined. Staff confidence and feelings of competence also improved with the improvement in role structure. In the clinical environment, Skupski et al22 developed a rapid response team for obstetric hemorrhage with clear expectations for the tasks to be completed and the role of each team member. They educated staff about these processes and better defined the role of inhouse obstetricians with regard to patient monitoring. These changes were associated with improvements in maternal mortality and acid-base status after major hemorrhage. Staff obstetricians can help maintain role clarity by clearly defining patient care plans, giving directions to specific individuals when tasks are assigned, maintaining crowd and noise control during emergent events, and supporting a team-oriented and trusting environment.

Physician’s Role in the Development and Implementation of Guidelines Guidelines can be adopted from existing organizations, and can become the standard of care for the department. Examples include Guidelines for Perinatal Care a joint publication from ACOG and the American Academy of Pediatrics,

Patient Safety in Ob/Gyn a set of broad guidelines ranging from routine labor to maternal transports and management of multiple gestations. More specific guidelines are usually created by departmental members on representative committees in response to an adverse event or prospectively thinking about how to improve care in an area, which may be of a potential challenge. It is important that physicians are familiar with both national guidelines and also specific departmental guidelines. An example of a guideline that a department can create may refer to the requirements for a physician’s presence on labor and delivery. This guideline may be created as a result of an outcome specific to the department for example, an unattended delivery. Another type of guideline can be created using a prospective Failure Mode Effect Analysis, which is a method for predicting possible errors and when combined with an estimate of the severity of the error allows one to prioritize quality improvement projects. Guidelines are usually developed through the work of a multidisciplinary committee including physician representation. After the development and acceptance of the guideline by senior leadership, introduction and implementation to the entire staff can be a challenging process. Tools to gain staff buy-in or acceptance include using case-based learning and sharing the frequency or severity of events while describing the efforts to improve the processes of care.

Effective Communication Improving communication may be the most important factor in the effort to improve patient safety. Ineffective communication has been cited as a leading cause of preventable errors across many disciplines of medicine. A growing body of literature now indicates some of the reasons that healthcare providers communicate poorly. Lingard et al23 found


that up to 30% of intraoperative communication events failed to produce their intended effect due to poor timing of the communication, the wrong audience, or inappropriate content. Other causes of communication failure include interruptions, hierarchy, workload stress, ambient noise, and lack of structure for communication, especially during handoffs. Less data exist on the impact that poor communication has on obstetric outcomes. TJC identified poor communication as a root cause in 72% of perinatal deaths.24 Data do exist demonstrating that obstetric care providers frequently communicate ineffectively in both simulated and clinical environments. Using in situ simulated eclampsia drills, Thompson et al25 found that timely communicating with senior obstetric staff was a recurrent problem. Similarly, Daniels et al26 demonstrated that obstetric residents communicated poorly with their pediatric team members during a simulated emergent delivery. Although 63% called for pediatric help during the simulated maternal cardio-pulmonary arrest, only 10% gave helpful information to the pediatricians when they arrived. More concerning, interdisciplinary communication may be lacking in the clinical care of the parturient. Simpson et al27 used focus groups to describe the communication patterns between the obstetricians and obstetric nurse in 4 labor and delivery units. The authors found that the communication processes were frequently not consistent with effective teamwork. The nurses at 1 site often communicated with obstetricians only for admission orders and at delivery, amounting to only 2 to 4 minutes of interaction. Across the sites, nurses described having to use catch phrases or code words to get the obstetricians to listen to their recommendations. They even purposely withheld information from physicians to influence their interactions. This need to play the ‘‘physician-nurse


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game,’’ clearly has the potential to undermine trust between team members and to lead to patient harm. It is clear that poor communication is a common factor in patient harm. Exactly what clinicians can do to help improve communication is less well described. Recommendations are often broad, without specific goals that can be implemented, for example, TJC recommendation for ‘‘timely communication of critical tests.’’ Even the ACOG Committee Opinion on Patient Safety is relatively silent on interdisciplinary communication. Although ‘‘Improve Communication’’ is 1 of the 7 recommendations of the opinion, this section focuses entirely on the disclosure of adverse events to patients. TJC’s ‘‘Write it down and read it back,’’ recommendation, and prohibited abbreviations list are 2 examples of specific recommendations to improve communication. Obstetric providers can ensure that they meet the communication standard. TeamSTEPPS, a team-training curriculum developed by the US Department of Defense based on the concepts of Crew Resource Management (CRM), defines the standards of effective communication as being complete, clear, brief, and timely.28 It also outlines several tools to help achieve these goals. The most significant of these is the ‘‘check back,’’ a technique in which the receiver of information repeats the information back to the speaker to ensure that it has been heard correctly and understood. Obstetricians should use this tool with all communication events and expect others use it back to them. This is difficult as it often feels forced and unnatural and as clinical leaders on labor and delivery units, physicians must take an active role in ensuring it occurs. Second, obstetricians can ensure that they communicate all appropriate information with their team members. Communicating the plan may seem trivial and obvious in obstetrics, ‘‘Have a healthy

baby and mother.’’ However, nurses and resident physicians frequently cannot articulate the specific goals for their patients, largely because the goals have never been communicated. An example of a specific goal in a laboring patient might be: augment labor, place an intrauterine pressure catheter to assure adequate contractions, and delivery by cesarean section if no progress is made within 2 hours. The plans made for 1 patient may dramatically impact the safety of the rest of the unit and vice versa. For instance, the obstetrician caring for a patient with a protraction disorder and Level 2 (indeterminate) fetal heart rate tracing may wish to ‘‘push the pit’’ to either help labor progress or ‘‘have the baby declare itself.’’ This is a reasonable plan assuming personnel to perform an emergency cesarean delivery are readily available and informed of the possibility. However, if staff is not available, or if multiple providers have the same plan at the same time, both mother and baby could be at risk. Clinicians must communicate their location, how they can be reached, and who will cover their patients during an emergency if they are off the unit. This coverage should be explicitly arranged, and a clear handoff of the patients should occur. With the growing popularity of ‘‘laborists,’’ many units have built-in coverage arrangements. Medical concerns should be communicated with the appropriate team members. Pediatric providers should be warned about potential fetal anomalies. Anesthesia staff should be proactively contacted about patients who might pose a high anesthetic risk (obesity, coagulopathy, significant cardiac or pulmonary comorbidities). Finally, physicians should develop structured processes for handing off or transferring the responsibility of care. One of the specific recommendations of the IOM report was decreased reliance on individual vigilance and an increased attention to handoffs. However, there is still no large-scale structured process for

Patient Safety in Ob/Gyn handoffs. Obstetricians should develop formalized systems for handing off responsibility of their patients, ideally face-to-face. Structured communication techniques such as SBAR (Situation, Background, Assessment, Recommendations) should be used whenever possible. This transfer should be communicated with all team members. Perhaps the most important communication behavior that obstetric care providers can perform is to actively work to foster an atmosphere conducive to patient safety. Patient safety is predicted on trust, open communication, and effective interdisciplinary teamwork.27 Some physicians undermine the atmosphere of trust with disruptive or abusive behavior. A Joint Commission Sentinel Event Alert indicated that ‘‘intimidating and disruptive behaviors can foster medical errors, contribute to poor patient satisfaction, and to preventable adverse outcomes, increase the cost of care, and cause qualified clinicians, administrators, and managers to seek new positions in more professional environments.’’29 It has been estimated that 3% to 5% of physicians present a problem with disruptive behavior. Rosenstein and O’Daniel30 have demonstrated the negative effects that aggressive and disruptive behaviors have on patient safety and staff retention in the perioperative setting. Similar behaviors have been described in obstetrics. Veltman31 found that 60.7% of labor and delivery units noted disruptive behavior, generally occurring at least monthly. In all, 41.9% of the units indicated that adverse patient outcomes had occurred as a direct result of these behaviors, and 39.3% stated that nurses had left the unit due to the intimidation. In another survey, 34% of nurses stated that they had been concerned about a physician’s performance, but only 1% actually shared these concerns.32 Obstetric nurses have described explicit episodes of aggressive behavior: ‘‘I would be petrified if at 7 AM they (the physicians)


walked in and I didn’t have the pit going. They’d yell at me.’’27 Physicians can help create an open and trusting communication atmosphere by asking other team members to raise safety concerns, by expressly giving them permission to question unclear orders or to challenge apparently dangerous actions. Openly communicating in this way during a briefing before surgery (eg, cesarean delivery) can set the tone for better communication throughout the procedure.33 Physicians should thank the staff who question their behavior, even if the questioner is wrong, because the act of questioning is done for patient safety and should be encouraged.

Measurement of Quality of Care There are many organizations and agencies that have proposed measures of quality to help patients, providers, insurers to differentiate healthcare providers. In some cases healthcare organizations have modified care to score well on the measures which may actually improve outcomes for example, Leapfrog—hospitalists in Intensive Care Units 24 hours per day. The organizations make suggestions for of the entire healthcare and rarely focus just on women’s healthcare. Table 3 identifies some of these organizations, their funding source or who the group represents, mission statements or areas of interest and Uniform Resource Locator address. All of the organizations listed here have measures that affect the practicing obstetrician/gynecologist. Although ACOG is the only organization to focus exclusively on women’s healthcare, some organizations, for example, TJC and National Committee for Quality Assurance have significant influence on what measures hospitals or health plans need to collect for accreditation. Other organizations can directly affect physician


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Organizations Involved With Quality Measurement

Name of Organization

Funding Source


Large employer groups who purchase insurance

Joint Commission (JC)

Independent, nonprofit organization

National Quality Forum

Nonprofit organization consumer organizations, public and private purchasers, physicians, nurses, hospitals, accrediting and certifying bodies, supporting industries, and health-care research and quality improvement organizations Independent notfor-profit organization

Institute for Healthcare Improvement

United Health Care (UHC) Parent company: United Healthgroup

For profit managed healthcare and health insurance company

American College of Obstetricians and

Nonprofit organization Largest organization providing

Mission /Focus of Measures Support those who use and pay for healthcare Promoting high-value healthcare through incentives and rewards Sets standards by which healthcare quality is measured in America and around the world. Healthcare organizations obtain accreditation through meeting JC standards Setting national priorities and goals for performance improvement; Endorsing national consensus standards for measuring and publicly reporting on performance; and Promoting the attainment of national goals through education and outreach programs

Works to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping healthcare systems put those ideas into action. Empower people with information, guidance and tools to make personal health choices and decisions Physicians are placed in tiers based on reviews of 30 UHC patients and compliance with guidelines Keeps its members informed about current medical care standards and ACOG’s professional

URL uhc/po/Default.asp

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TABLE 3. (continued) Name of Organization

Funding Source

Gynecologists (ACOG)

healthcare for women

National Committee for Quality Assurance (NCQA)

Private, 501(c)(3) not-for-profit organization


Partners with more than 7,000 healthcare organizations to measure and improve their quality of care.

Mission /Focus of Measures recommendations through the publication of Committee Opinions, Practice Bulletins, and Technology Assessments Builds consensus around important healthcare quality issues by working with large employers, policymakers, doctors, patients and health plans to decide what’s important, how to measure it, and how to promote improvement. Acts upon the needs of all customers to improve the delivery of care and achieve organizational results


URL indicates uniform resource locator.

choice through higher copay, such as the tiering system used by United Healthcare and others. Press-Ganey is a reflection of patient experience with a healthcare organization both inpatient and outpatient in terms of patient satisfaction, which is important for organizations competing in a marketplace. The authors previously described a specific set of measures that can be used for internal and possibly external benchmarking in obstetrics: the Adverse Outcome Index (AOI).34 The AOI was developed as part of a trio of measures to assess obstetric outcomes. The AOI is a composite measure of 10 adverse maternal or neonatal outcomes designated in Table 4. The AOI is defined as percentage of deliveries complicated by one or more of the identified outcomes. A scoring system to assess the severity of the outcomes was developed with assistance

from the ACOG Quality Improvement and Patient Safety Committee. Two other measures were developed along with the AOI to further assess severity and acuity TABLE 4. Adverse Outcome Index Indicator


Maternal death Neonatal death >2500 g Uterine rupture Maternal admission to ICU Birth trauma Return to OR/labor and delivery Admission to NICU >2500 g and for >24 h Apgar <7 at 5 min Blood transfusion 3 or 4-degree perineal tear

750 400 100 65 60 40 35 25 20 5

Adapted from Jt Comm J Qual Patient Saf. 2006;32: 497â&#x20AC;&#x201C;505.34 ICU indicates intensive care unit; NICU, neonatal intensive care unit; OR, operating room.


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of the care on a labor and delivery unit. The Weighted Adverse Outcome Score describes the acuity of the care and is the total score of all adverse events identified in the Table divided by the number of deliveries in a year. The Severity Index describes the severity of the outcomes. It is the sum of the adverse outcome scores divided by the number of deliveries with an identified adverse outcome in a year. The AOI outcome measure has recently been used in studies evaluating interventions such as induction of labor and the description of a comprehensive patient safety initiative in labor and delivery involving team training.17,35 Two tools used to measure staff satisfaction regarding the safety of their working environment are the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety Culture and the Sexton Safety Attitude Questionnaire (SAQ).36,37 Staff attitudes toward safety measured by the SAQ have been shown to correlate with patient outcomes in the intensive care unit and are an important initial measure of the effect of team training. Teamwork training in obstetrics, whether through simulation or classroom-based courses, has consistently been associated with improvements in staff attitudes toward patient safety and teamwork.2,16,38 The Press-Ganey survey tool can be used in the inpatient or outpatient setting to measure patient satisfaction. The PressGaney survey allows an organization to do internal and external benchmarking for the perspective of the patient experience and allows institutions to focus on processes, which may need improvement.

Formal Training to Promote a Culture of Safety A growing body of literature now describes formal training in techniques to improve patient safety. These educational

systems are frequently based on CRM concepts. Other safety training includes task training in high-risk procedures, specific policy and procedure development, and formal conflict resolution techniques. The best way to teach teamwork has not been established and is controversial. The development of clinical protocol and guidelines is perhaps the simplest way to promote teamwork. These guidelines help to define clinical roles, ensure that all tasks are completed, promote monitoring of team members’ action, and develop cohesion within the team. This has been described as an integral part of a multifaceted approach to improvement in patient safety.16,17 Guidelines can be published by professional societies’ risk management organizations, or individual institutions. Protocols for such high-risk areas as the management of obstetric hemorrhage and the management of the administration of magnesium in preeclampsia may improve patient safety. Classroom-based team training allows large numbers of clinical staff to be taught the concepts of teamwork and patient safety. Didactic lectures can be supplemented with clinical scenarios, vignettes, videos, and other media to teach both the intellectual concepts and specific behaviors of team-based care. The advantages of classroom-based training are that it is relatively inexpensive, large numbers of staff can be trained quickly, feedback to and questions from the participants can be included, and multiple specialties can be trained simultaneously. This type of training can highlight patient safety processes that help maintain ‘‘normalcy’’ on the unit to prevent adverse events (eg, multidisciplinary meetings, preprocedure briefings, effective handoffs). This helps teach staff techniques to prevent adverse events instead of concentrating on ways to respond to them. Disadvantages include low fidelity training in the teamwork skills, and little or no practice in actual crisis management.

Patient Safety in Ob/Gyn Classroom-based team training has been effectively used to train large numbers of labor and delivery staff.16,17,38,39 Several curricula are available. The MedTeams program was developed to improve teamwork behaviors and reduced errors in the emergency roomand has been successfully translated to obstetrics.1 TeamSTEPPS, developed by the AHRQ, is a highly adaptable program based on best available research in teamwork. It has been used extensively by the US military to standardize teamwork training in obstetrics.28 Simulation has received considerable attention in both the lay and academic press. To be effective, a simulator must provide a high degree on physical, emotional, and conceptual realism (or fidelity). Full-immersion, high-fidelity simulation performed in a dedicated simulation center is generally considered the gold standard. This method allows the participants to practice both clinical and teamwork skills. Scenarios can be developed that embed the need for teamwork behaviors into the evolution of the clinical event. Clinical staff can be trained individually, or in preformed clinical teams. The disadvantages on this type of training include its cost, the need to remove clinicians from clinical care, a lack of realism compared with the clinicians’ own work environment, and an overemphasis on crisis management. High-fidelity simulation can be effectively used in obstetrics to teach both clinical and teamwork behaviors. Poor leadership and workload management skills have been identified in obstetric trainees.26Common clinical and teamwork errors during obstetric emergencies have been identified among attending obstetricians, identifying potential areas for education. Crofts et al40 found that highfidelity training in the management of shoulder dystocia was associated with a higher degree of successful vaginal delivery than training in lower fidelity models.


The same authors demonstrated that training in a high-fidelity simulator was associated with improved attitudes and team behaviors, and that the addition of didactic, teamwork-specific training did not confer additional benefit.2 Crisis simulation within the clinical setting, in situ simulation or ‘‘fire drills,’’ has been increasingly described. With in situ simulation, a mannequin or actor portrays a patient on the actual unit where clinicians practice. Common drill scenarios in obstetric include maternal hemorrhage, eclampsia, failed intubation, and shoulder dystocia. Advantages of in situ simulation include the ability to train the entire staff on the unit at once, the ability to identify weaknesses within the system of care that are potential barriers to safe care (latent errors), inclusion of other areas within the hospital (eg, laboratories, blood bank, code teams), and the ability to train without leaving one’s clinical environment. Disadvantages include distracting caregivers from their clinical responsibilities, and potential significant cost. Thompson et al25 used eclampsia drills on their unit, and found recurrent communication and coordination failures, inefficiencies, and deficiencies in clinical skill. Similarly, Riley studied teamwork behaviors during simulated, in situ crises in 6 hospitals ranging from 700 to 3300 deliveries per year. They found generally fair scores in teamwork behaviors. These scores tended to decrease as the acuity of the simulated scenario increased.41 Currently, more than 50% of obstetric units in the United Kingdom regularly conduct ‘‘fire drills’’.42 Finally, simulation has been used to improve technical skills in obstetrics. Crofts et al43 used a simulated shoulder dystocia model to identify common errors made by obstetricians and midwives. They were able to demonstrate significant improvements over a 1-year period with continued education and exposure to the


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simulated environment. These improvements in knowledge and technique can last up to 1 year after training.44 The same group found that task performance and neonatal outcomes also improved in the clinical arena during delivery of an actual infant with shoulder dystocia after training in the simulator.45 Improvements in the estimation of maternal blood loss during massive hemorrhage have also been demonstrated with various simulated techniques, including web-based training modules. Irrespective of the method of training, teamwork, and the development of a patient safety culture can only be effective if the concepts and behaviors learned can be translated to the clinical environment. To date, no research has directly studied the impact of any teamwork training method on changes in teamwork behaviors in the clinical setting in obstetrics. This translation is likely to require continual coaching, feedback, behaviors reinforcement, and a long implementation period. The methods of patient safety training described above have all been shown to improve the culture of safety. Teamwork training in obstetrics has consistently been associated with improvements in staff attitudes toward patient safety and teamwork. Pratt and Mann16 used the Safety Attitudes Questionnaire, and found that clinician attitudes toward patient safety were significantly higher among labor and delivery staff after classroom-based team training, than those working on other units who had not been trained.37 Gardner et al3 developed a 6-hour simulation course involving obstetricians, anesthesiologist, obstetric nurses, and midwives. Self-assessment of teamwork and communication demonstrated improvements in both areas more than 1 year after the course. In addition, most clinicians felt that their clinical practice had changed. Finally, Haller et al38 trained 239 obstetric nurses, physicians, midwives and other labor and delivery

staff in a 2-day, classroom-based, CRMstyle course. Initial reactions to the course and evidence that participants learned the CRM concepts were both very positive. Surveys of the staff over the next year demonstrated improvements in attitudes toward patient safety, stress recognition, work conditions, and job satisfaction. Participants reported improved availability of clinical information and the ‘‘feeling part of a bigger family.’’ Staff attitudes toward the culture of safety have been shown to correlate with patient outcomes. Ultimately, an improved culture of safety should improve patient outcomes. A large, prospective, randomized trial evaluating the impact a classroom-based CRM course based on the MedTeams curriculum previously developed for the emergency room failed to demonstrate improvements patient outcomes. The authors did find a 10 minutes (B33%) improvement in the time from decision to incision in emergent cesarean deliveries. Inadequate power, high staff turnover, and a short implementation time for the teamwork behaviors may have contributed to the negative results.1 Others have demonstrated improvements in patient outcomes associated with both classroom and simulation-based team training. Pratt and Mann16 trained more than 220 in a classroom-based CRM teamwork course. In addition, the authors described a structured implementation process involving the use of templates, structured language, coaches, and 3 types of formal teams that helped to translate the behaviors to the clinical environment. They found that obstetric complication rates decreased by 23% after the implementation of teamwork. Pettker et al17 described a multistep process designed to improve safety on their labor and delivery unit, including clinical protocols, fetal monitor certification, a safety committee, and classroombased team training. The entire process required nearly 2 years. The adverse event rate was decreased by nearly 28%. Similar

Patient Safety in Ob/Gyn data have been demonstrated in the private practice obstetric setting. Shea-Lewis described a 43% reduction in the rate of adverse obstetric events after the implementation of a CRM-based team training curriculum in an intermediate-sized community hospital.39 Finally, Draycott et al46 developed a 1-day course that combined didactic and simulation training in both teamwork behaviors and obstetric crisis management. All obstetric care providers at a large, urban center were required to attend the course in multi-disciplinary sessions. Evaluation of more than 19,000 deliveries demonstrated a 50% reduction in the rate of neonatal hypoxic ischemic encephalopathy after the training. Finally, improved teamwork may help decrease malpractice risk. This would be especially important in obstetrics where malpractice premiums are creating crises in many states.47 Decreased complication rates, better patient satisfaction when an adverse event does occur, and a better ability to defend cases that have been cared for by a well-coordinated team are all potential ways to decrease malpractice risk.19



7. 8. 9.




References 1. Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol. 2007;109:48–55. 2. Crofts JF, Ellis D, Draycott TJ, et al. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training. BJOG. 2007; 114:1534–1541. 3. Gardner R, Walzer TB, Simon R, et al. Obstetric simulation as a risk control strategy: course design and evaluation. Simul Healthc. 2008;3:119–127. 4. Ku¨nzle B, Kolbe M, Grote G. Ensuring patient safety through effective leader-






ship behaviour: a literature review. Saf Sci. 2010;48:1–17. Simpson KR, Lyndon A. Clinical disagreements during labor and birth: how does real life compare to best practice? MCN Am J Matern Child Nurs. 2009; 34:31–39. Stumpf PG, Anderson B, Lawrence H, et al. Obstetrician-Gynecologists’ opinions about patient safety: costs and liability remain problems; are mandated reports a solution? Women’s Health Issues. 2009; 19:8–13. Grimes D, Cates W. The impact of state maternal mortality study committees. AJPH. 1977;67:830–833. Berwick D. Continous improvement as an ideal in health care. N Engl J Med. 1989;320:53–56. Watcher RM, Provonost PJ. Balancing ‘‘no blame’’ with accountability in patient safety. N Engl J Med. 2009;361: 1401–1406. Gluck P, Scarrow P. Peer review in obstetrics and gynecology by a national medical specialty society. Jt Comm J Qual Saf. 2003;29:77–84. Quality Indicatiors. In: Quality Improvement in Women’s Health Care. Washington DC: American College of Obstetricians and Gynecologists; 2000: 4–5. Landon BL, Normand ST, Blumenthal D, et al. Physician clinical performance assessment: prospects and barriers. JAMA. 2003;290:1183–1189. Goldman RL, Ciesco E. Improving peer review: alternatives to unstructured judgments by a single reviewer. Jt Comm J Qual Improv. 1996;22:762–769. Levine RD, Sugarman M, Schiller W, et al. The effect of group discussion on interrater reliability of structured peer review. Anesthesiology. 1998;89: 507–515. Forster AJ, Fung I, Caughey S, et al. Adverse events detected by clinical surveillance on an obstetric service. Obstet Gynecol. 2006;108:1073–1083. Pratt S, Mann S. Impact of CRM-based team training of obstetric outcome and clinician’s patient safety attitude. Jt Comm J Qual Saf. 2007;33:720–725.


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17. Pettker CM, Thung SF, Norwitz ER, et al. Impact of a comprehensive patient safety strategy on obstetric adverse events. Am J Obstet Gynecol. 2009;492: e1–e8. 18. Nielsen P, Mann S. Team function in obsterics to reduce errors and improve outcomes. Obstet Gynecol Clin N Am. 2008;35:81–95. 19. Mann S, Pratt S. Team approach to care in labor and delivery. Clin Obstet Gynecol. 2008;51:666–679. 20. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009;360: 491–499. 21. Robertson B, Schumacher L, Gosman G, et al. Simulation-based crisis team training for multidisciplinary obstetric providers. Simul Healthc. 2009;4:77–83. 22. Skupski DW, Lowenwirt IP, Weinbaum FI, et al. Improving hospital systems for the care of women with major obstetric hemorrhage. Obstet Gynecol. 2006;107: 977–983. 23. Lingard L, Espin S, Whyte S, et al. Communication failures in the operating room: an observational classification of recurrent types and effects. Qual Saf Health Care. 2004;13:330–334. 24. Joint Commission Sentinel Event Alert. Issue 30-July 21, 2004 Preventing infant death and injury during delivery. http:// SentinelEventAlert/sea_30.htm. Accessed January 6, 2010. 25. Thompson S, Neal S, Clark V. Clinical risk management in obstetrics: eclampsia drills. Qual Saf Health Care. 2004;13: 127–129. 26. Daniels K, Lipman S, Harney K, et al. Use of simulation based team training for obstetric crises in resident education. Simul Healthc. 2008;3:154–160. 27. Simpson KR, James DC, Knox GE. Nurse-physician communication during labor and birth: implications for patient safety. J Obstet Gynecol Neonatal Nurs. 2006;35:547–556. 28. TeamSTEPPS. Accessed January 10, 2010.

29. Joint Commission Sentinel event alert. Issue 40, July 9, 2008. Behaviors that undermine a culture of safety. http:// SentinelEventAlert/sea_40.htm. Accessed January 10, 2010 30. Rosenstein AH, O’Daniel M. Impact and implications of disruptive behavior in the perioperative arena. J Am Coll Surg. 2006;203:96–105. 31. Veltman LL. Disruptive behavior in obstetrics: a hidden threat to patient safety. Am J Obstet Gynecol. 2007;196: 587.e1–e4. 32. Maxfield D, Grenny J, McMillan R, et al. Silence Kills; The Seven Crucial Conversations for Healthcare Accessed January 10, 2010. 33. Lingard L, Regehr G, Orser B, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143:12–17. 34. Mann S, Pratt S. Assessing quality in obstetrical care: Development of standardized measures. Jt Comm J Qual Patient Saf. 2006;32:497–505. 35. Nicholson JPS. The impact of the active management of risk in pregnancy at term on birth outcomes: a randomized clinical trial. Ob/Gyn Survey. 2008;63:621–623. 36. AHRQ Hospital Survey on Patient Safety Culture. Accessed January 16, 2010 37. Sexton JB, Helmreich RL, Neilands TB, et al. The safety attitudes questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006;6:44. 38. Haller G, Garnerin P, Morales MA, et al. Effect of crew resource management training in a multidisciplinary obstetrical setting. Int J Qual Health Care. 2008; 20:254–263. 39. Shea-Lewis A. Teamwork: crew resource management in a community hospital. J Healthc Qual. 2009;31:14–18. 40. Crofts JF, Bartlett C, Ellis D, et al. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity

Patient Safety in Ob/Gyn mannequins. Obstet Gynecol. 2006;108: 1477–1485. 41. Riley W, Hansen J, Gu¨rses AP, et al. The Nature, Characteristics and Patterns of Perinatal Critical Events Teams. advances2/vol3/Advances-Riley_58. pdf. Accessed Sept. 22, 2009. 42. Anderson ER, Black R, Brocklehurst P. Acute obstetric emergency drill in England and Wales: a survey of practice. BJOG. 2005;112:372–375. 43. Crofts JF, Fox R, Ellis D, et al. Observations from 450 shoulder dystocia simulations: lessons for skills training. Obstet Gynecol. 2008;112:906–912.


44. Crofts JF, Bartlett C, Ellis D, et al. Management of shoulder dystocia: skill retention 6 and 12 months after training. Obstet Gynecol. 2007;110:1069–1074. 45. Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol. 2008;112:14–20. 46. Draycott T, Sibanda T, Owen L, et al. Does training in obstetric emergencies improve neonatal outcome? BJOG. 2006; 113:177–182. 47. Pearlman MD. Patient safety in obstetrics and gynecology: an agenda for the future. Obstet Gynecol. 2006;108: 1266–1271.