Forming And Sustaining A Large Quality Improvement Collaborative:

Northwest Obstetric Patient Safety Collaborative

The Quality Colloquium

August 2008

Presented byMarion Constable CNM, MSN

Kristine Larison RN, MBA-HCA

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Objectives

Crisis leads to opportunity

Collaborative Formation

Work of the Collaborative

Accomplishments/results

Crisis and Opportunity

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Oregon Malpractice Crisis

1999 The Oregon Supreme Court struck down the cap on non-economic damages as unconstitutional.

Loss of OB providers in critical access areas

In 2002 the board of NPIC determined that OB claims frequency and severity warranted serious analysis in order to mitigate risk exposure.

Oregon Rates 1983-2008

Northwest Physicians InsuranceOregon Rates by Year for OBG (Class 7/6), 1M/3M limits

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08

Demand – OBG vs All Other

0

1000000

2000000

3000000

4000000

5000000

6000000

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

OBGYN ALL OTHERS

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Retrospective & Actuarial to Prospective & Clinical

Traditional Approach Professional Liability : Retrospective review of claims: Actuarial perspective (frequency, severity by specialty class, premium)

Change in thinking: Clinical Review Review of all OB claims, whether dismissed, settled or went to

trial from the inception of the company through the year 2001 (22 years).

Determine what where the professional liability risks in Obstetrics.

Claims Analysis Findings

Identified areas of risk:

Fetal monitoring: pattern recognition & documentation

VBAC: lack of ability to respond and resource uterine rupture

Injuries associated with operative vaginal delivery

Shoulder Dystocia-management of OB emergency

Cesarean Delivery-decision to incision delays

Teamwork (lack of)

Communication (ineffective, ambiguous, absent)

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2003 Mandate

Once the NPIC task force identified these risk areas they put together a full day OB Symposium in 2003 to address them. “Current Issues in Patient Safety, Practice Performance and Professional Liability Protection”

Attendance Mandated: All “insured's” as a condition for future insurability.

Physicians asked to invite Perinatal nursing leaders, hospital risk managers and nurse educators.

Collaborative Formation

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Shift to Collaborative Learning

Didactic education programs for the individual practitioner were not producing learner satisfaction or desired results.

Research ways to more effectively learn and produce change in cross disciplinary teams.

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Why a Collaborative?

Collaborative Benefits: Intense effort to share knowledge and improve Perinatal patient safety.

Networking

– Frequent communication

– Best practices, access to experts

Cooperation

– Leap Frog

– Share experience, shared information, shared ideas

Coordination

– Intensity

– Repetition

– Support structure-coaches-documented progress-

– Collaborative work products

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Original Collaborative Structure

Northwest Physicians Insurance Company OB Collaborative (NPIC)

VP Patient SafetyD.Zimmer

Program DirectorM. Constable

Chairman OB Task ForceL. Marzano

Participating Hospitals Oregon/Idaho

Adventist Medical Center-Asante Rogue Valley Medical Center -Asante Three Rivers Medical Center-Holy Rosary Hospital-Kaiser Sunnyside Medical Center-Legacy Health System-Legacy Emmanuel-McKenzie Willamette Mercy Medical Center-Oregon Health &Science U.( OHSU)-Peace Health Corporation-Peace Health Sacred Heart-Peace Health Harbor Hospital-Providence Health System-Providence St. Vincent-Salem Hospital -Samaritan Albany General-Willamette Falls Hospital -Willamette Valley Medical. Center-Kootenai Medical Center- 17 hospitals

Experts: Consumers Advancing Patient Safety( CAPS) ,Parents of Infants & children w/ Kernicterus( PICK)

Hospital Corp. of America (HCA)-Kaiser Permanente: Perinatal Patient Safety Project,Partnership for Patient Safety -Physician Insurers Association of America (PIAA)

OB Emergency Team Response

EFM CommonNomenclature

Communication SBAR+R

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Current Collaborative Structure

Northwest Physicians Insurance Company OB Collaborative (NPIC)

VP Patient SafetyD.Zimmer

Program DirectorM. Constable

Chairman OB Task ForceL. Marzano

Participating Hospitals Oregon/Idaho

Experts: Consumers Advancing Patient Safety( CAPS) ,Parents of Infants & children w/ Kernicterus( PICK)

Hospital Corp. of America (HCA)-Kaiser Permanente: Perinatal Patient Safety Project,Partnership for Patient Safety -Physician Insurers Association of America (PIAA)

OB Emergency Team

Response Workgroup

Simulation BasedTraining

Workgroup

25 Hospitals 3 Health Systems

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Collaborative Structure

Work GroupCoach/Facilitator

Content Experts

Monthly Conference

Call

Collaborative Member Hospital Teams

Annual Patient Safety Symposium

Quarterly Topic of interest

Webinar

Collaborative Learning

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EFM Common Nomenclature-2006 Established need for standardized language in the interpretation,

description & discussion of EFM tracings. NICHD selected, ACOG endorsed

Researched options for training

Advanced Practice Strategies Advanced Electronic Fetal Monitoring e-learning courseware reviewed & offered to collaborative members.

2,500+ seats purchased

Single contract avoid legal fees

>40% volume discount

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Perinatal Bundle-2008

Second collaborative initiative Perinatal e-learning bundle

Shoulder Dystocia

Operative Vaginal Delivery

Structured Communication

2,800+ seats purchased

38% volume discount

Communication Workgroup

The group developed a “SBAR+R Toolkit” Consisting of 26 educational aids designed to facilitate the implementation.

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OB Emergencies Team Response

Evaluate perceptions about the value of team training to improve preparedness for OB emergencies.

Anonymous survey administered to all staff who respond to obstetric emergencies in 7 Oregon Collaborative hospitals from June 2006-August 2006.

614 (74.5%) staff responded

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Teamwork

90% felt confident the appropriate staff would respond to an OB emergency.

50-70% reported that other staff were confused about their role in an OB emergency.

84% were confident that emergency drills or simulation-based team training would improve team performance.

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TeamworkFigure 2. Rating of Teamwork Effectiveness(1=least effective versus 10=most effective)

7.3

7.7

8.1

6

6.5

7

7.5

8

8.5

9

Deliveries/Year

< 100 100-399 > 400

P for trend < 0.0001T

eam

Eff

ecti

vene

ss S

core

*

* Adjusted for team, delivery and OB emergency experience, training to work as a team,

length of training and working in same institute

By Hospital Delivery Volume

STORC Safety Initiative: A Multicenter Survey on Preparedness & Confidence in Obstetric EmergenciesJeanne-Marie GUISE, MD, MPH123, Sally Y. SEGEL, MD1, Kristine LARISON RN4, Sarah M. JUMP MD, MPH1, Marion CONSTABLE, RN, MSN,

CNM4, Hong LI MD2, Patricia OSTERWEIL BS1, Dieter ZIMMER FAAMA4

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TeamworkFigure 2. Rating of Teamwork Effectiveness(1=least effective versus 10=most effective)

STORC Safety Initiative: A Multicenter Survey on Preparedness & Confidence in Obstetric EmergenciesJeanne-Marie GUISE, MD, MPH123, Sally Y. SEGEL, MD1, Kristine LARISON RN4, Sarah M. JUMP MD, MPH1, Marion CONSTABLE, RN, MSN,

CNM4, Hong LI MD2, Patricia OSTERWEIL BS1, Dieter ZIMMER FAAMA4

7.67.9

6.6

8.2 8.3

5

6

7

8

9

10

OB

Tea

m E

ffec

tive

ness

Sco

re*

* Adjusted for hospital size, delivery and OB emergency experience, training to work as a team,

length of training and working in the same institute

RN L&D

Anesthesia

Pediatric

Other

P=0.06P<0.0001

P=0.004P=0.001

By Team

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Teamwork: Simulation

Established network to support hospitals

Develop a sustainable simulation program.

Develop Simulation Specialists

Access to simulation training opportunities

15 hospitals in the NPIC Simulation program attend training sessions, network, share ideas and information as they develop simulation programs in their organizations.

Simulation focus group

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Collaborative Structure

Work GroupCoach/Facilitator

Content Experts

Monthly Conference

Call

Collaborative Member Hospital Teams

Annual Patient Safety Symposium

Quarterly Topic of interest

Webinar

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Collaborative Learning: Webinars

Team Stepps

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Collaborative Structure

Work GroupCoach/Facilitator

Content Experts

Monthly Conference

Call

Collaborative Member Hospital Teams

Annual Patient Safety Symposium

Quarterly Topic of interest

Webinar

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Collaborative Learning: Annual Symposium

Collaborative Results

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Results

Variables Impacting reduction in claims frequency-

National impact-Tort reform

Increase awareness

Local patient safety efforts

Frequency & Severity by Injury Year for OB Providers

1

5 4

18

23

8

2426

33

25

33 3436

34

38

41

36 35

3234

20

11 10

3 20

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

0

5

10

15

20

25

30

35

40

45

DIRECT LOSS.... CLAIM_CNT

Oregon Rates 1983-2008

Northwest Physicians InsuranceOregon Rates by Year for OBG (Class 7/6), 1M/3M limits

0

10000

20000

30000

40000

50000

60000

70000

80000

90000

83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08

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Physician Incentive 10% Premium Credit

Partnering with Harvard’s Risk Management Foundation and Advanced Practice Strategies, The Doctors Company is offering its physician members free of charge the online bundle of Perinatal courses. To qualify for the premium credit, physicians must complete the courses and implement a patient safety communication protocol plan in a 12-month period.

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Collaborative Funding

Annual Cost-2005 Consulting Costs—Includes all facilitation activities)            $65,000

Includes travel, lodging and meals expenses, etc.

Conference call telephone and webinar charges                 $5,000

Annual OB Symposium (includes faculty/speaker fees)      $17,000

Printed materials and mailings                                             $2500

                                                                                       ______

Total Annual Cost:                                    $89,500

Total cost underwritten by NPIC

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Collaborative Funding

Annual Cost-2006-2007 2006 2007 Consulting Costs—Includes all facilitation activities)            $65,000 $65,000

Includes travel, lodging and meals expenses, etc.

Conference call telephone and webinar charges                 $5,000 $ 5,000

Annual OB Symposium (includes faculty/speaker fees)      $17,000 $17,000

Printed materials and mailings                                             $2500 $ 2,000

Simulation Program $50,000 $ 38,000

                                                                                ______ ______

Annual Cost:                                    $139,500 $127,500

Simulation Program offset by

Voluntary Sponsorship Support (-) $ 50,000 $30,000

Total Annual Cost _______ _______

$ 89,000 $ 97,500

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Collaborative Sustainability

Moving toward a sustainable funding model for the future. Hospitals are being asked to participate in a shared fee structure based on staffed beds according to the American Hospital Association annual report.

NPIC will continue to fund 50% of the collaborative costs with hospitals funding the remaining 50%.

Thank you

Questions

Contact Information

Marion Constable marconstable@cox.net

Kristine Larison kristine.larison@comcast.net

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