OB program aims to cut claims, improve safety

The nation's largest Catholic and nonprofit healthcare system is launching a demonstration project to determine best methods to reduce or eliminate birth complications and at the same seeking to avoid obstetrics claims through a renewed emphasis on transparency and full disclosure.

Ascension Health, based in St. Louis, MO, has begun the Excellence in Obstetrics program within the obstetrical care units at five Ascension Health facilities. The project is made possible through a $2.9 million grant that Ascension Health received from the Agency for Healthcare Research and Quality (AHRQ) under its Patient Safety and Medical Liability initiative.

The AHRQ initiative seeks to foster better doctor-patient communication, and ensure patients are fairly and quickly compensated in a fair and timely manner for medical injuries, thus reducing the incidence of lawsuits and liability premiums. The initiative also seeks to reduce the incidence of frivolous lawsuits and liability premiums.

The Excellence in Obstetrics project is designed to determine whether and how birth complications can be reduced or eliminated altogether, says Christine K. McCoy, JD, vice president of risk management at Ascension Health. It also will evaluate medical liability models that put patient safety first and foster better communication between doctors and their patients. The project initially will focus on improving patient safety and outcomes related to obstetrical deliveries, with the long-term goal of spreading concepts and key lessons to other high-risk areas, including emergency departments and operating rooms, McCoy says. The goal is to evaluate 40,000 obstetrics patients representing uniquely diverse geographies and ethnicities.

The model being studied is based on a pilot program of team training, situation analysis, and simulation exercises that have been developed as part of a bundle with measurable outcomes, says Ann Hendrich, RN, PhD (c), FAAN, vice president of clinical excellence operations for Ascension Health. One example is a new method for responding as a clinical team to changes in electronic fetal monitoring, and evaluation of how cases of shoulder dystocia are handled.

"We believe the Excellence in Obstetrics demonstration project will help save the lives of mothers and their babies by improving safety in the birthing process," Hendrich says.

The project also will evaluate a medical liability response model based on full disclosure, transparency, and early resolution, McCoy says. The model also calls for an immediate root cause analysis when unpredictable events happen. "We want to see, when we do a uniform approach to communicating with patients, if that has an impact on their response," McCoy says. "Do they still file a claim or suit? Or when the incident is without error, can we explain to the family what happened and potentially reduce any frivolous suits?"

The five Ascension Health Ministries that will participate in the study are: Sacred Heart Hospital on the Emerald Coast (Miramar Beach, FL), St. Vincent's Birmingham (Birmingham, AL.), St. John Hospital and Medical Center (Detroit), Columbia St. Mary's (Milwaukee), and Saint Agnes Hospital (Baltimore). The sites were chosen in part because they treat patients from a wide variety of social and economic backgrounds. The patient education materials are available in 11 languages, including Arabic, Farsi, Vietnamese, Burmese, and Hmong. "The business case for patient safety has not been adequately established in health care," Hendrich says. "We anticipate that the Excellence in Obstetrics project will offer successful models of practice, and we intend to translate the anticipated success of this program to other hospitals and clinical practice areas across Ascension Health and, ultimately, to other healthcare facilities across the U.S."

The program began in January 2011. While it is too early for any results to be available, the initial response from physicians, nurses, and patients has been extremely positive, McCoy says. More than 1,000 health care professionals have been trained in electronic fetal monitoring, simulation, managing shoulder dystocia, disclosure, and cause analysis. The sites also have begun consenting patients, and more than 80% of those approached have agreed to participate in the study.

At each participating facility, the lead obstetrician acts as the principal investigator, supported by the lead nurse, risk manager, and a project manager. The sites provide education and training to all clinicians working with the OB unit, going beyond the standard competency training, McCoy says. For example, electronic fetal monitoring is a seven-module course for physicians and nurses, offered online. The shoulder dystocia training is provided in the same way, and the participants also are trained in crisis response and teamwork using simulations. Ascension Health provided all of the sites with a high-tech mannequin and new video equipment for the training.

All of the clinicians go through a three-hour course on communication and disclosure, and some leaders take additional training, McCoy says.

Ascension Health expects to see significant patient safety improvements from the Excellence in Obstetrics program, but there are no specific thresholds for success.

"If we implement a comprehensive approach to reporting, investigating, and communicating events, we will see a reduction in frequency and severity. The question is how much and how soon," McCoy says. "Obstetrical claims have a longer lag time than most claims typically do, and they're fairly rare events, even though they can be quite large claims. We're looking at our past data to benchmark our past experience, and we hypothesize that we will see significant results in the coming years."

Sources

For more information, contact:

Ann Hendrich, RN, FAAN, Vice President of Clinical Excellence Operations, Ascension Health, St. Louis, MO. Telephone: (314) 733-8207. E-mail: ahendrich@ascensionhealth.org.

Christine K. McCoy, JD, vice president of risk management, Ascension Health, St. Louis, MO. Telephone: (314) 733-8702. E-mail: Christine.McCoy@ascensionhealth.org.