Utilizing the MOREOB Program to Spread the Culture of Safety to All Maternal-Child Units
We began our MOREOB journey in 2005 with a careful review of program content, as well as an evaluation of the current climate and culture of our Labor and Delivery unit. Our primary goal was to improve safety for our patients and families. We also saw, as a very important and integral part of this MOREOB journey, the importance of inter-professional communication in our day-to-day operations. Realizing that the success of the program would depend heavily on this last goal of communication, we utilized and relied heavily on the insight and direction of our consultant, especially in the early learning phase of the program. On a few occasions we even needed her redirection in defining our goals. We learned it was a three-year program that would build on previous modules of knowledge. As such, we developed a very stringent timeline and committed to strict adherence to this schedule. We sought and received participation of all personnel on our unit, from nurses to practitioners to administration. We utilized all the excellent online tools, such as the environmental survey, culture assessments and re-assessments, and audits, to name a few. It was exciting for us to see that we were able to demonstrate great success and continued improvement in all measures. This was especially true in the arena of communication, which, as stated, was the critical component upon which we felt success of the program hinged. We continue to practice the lessons learned and look forward to continued improvement and development of our environment and culture of safety.
Our initial three years spanned 2005 through 2008. There was a short hiatus during which we managed to maintain the program initiatives and actually build upon our successes and even developed a new emergency drill. However, in 2011 we began to see a small waning of enthusiasm on the unit. Some of this was due to several of the initial Core Members leaving for various reasons and being replaced by new ones who were not present for the initial program and/or did not have the advantage of being involved in a leadership role in our Core Group. Because we saw the value of a more structured program, we talked with our hospital administration and, in 2012, we were given approval to begin MOREOB Plus.
From the outset in 2005, we began primarily with staff from labor and delivery, as this is the unit most affected by management of safety in the field of obstetrics. Our Core Group was, and still is, composed of all disciplines - obstetricians, midwives, family practitioners and nursing. Administrative personnel were also incorporated, including the Director of Maternal-Child Services and the Chief Medical Officer of the hospital. The Vice President of Nursing has also been intimately involved with the progress of each initiative. All have endorsed and encouraged our participation in MOREOB. Some of the obstetricians and family practitioners were, and still are, those actively involved in leadership roles in their respective departments. From the beginning, we all saw the value in a strong commitment to the program, and vowed to make it a priority. As such, we had strong and consistent participation in all Core Group activities. Attendance at monthly meetings was a priority. Everyone was expected to participate in planning, and did so in earnest. It required a great time commitment and all of the Core Group members sacrificed a certain degree of both personal and professional time in order to complete our goals, adhere to the timeline we had set and guarantee success of the program. We were very determined.
As previously stated, we have always encouraged and received full participation from all personnel on our labor and delivery unit. This includes involvement in and attendance at workshops, emergency drills, online assessments and post-tests, as well as reporting of no harm and harm events. Our workshops have always been multidisciplinary in makeup. Careful attention is given to assigning Core Group members and other staff to each session so as to ensure that there is equal distribution and representation of all disciplines. This includes obstetricians, family practice physicians, nurse midwives, labor and delivery nurses, and more recently personnel from the Mother-Baby unit (post partum and nursery), Intensive Care nursery, and College of Nursing instructors. We have received very positive feedback about this arrangement from all participants.
As we moved through the modules and began to accumulate data we realized we needed the tools with which to analyze and disseminate this information. We also wanted to develop more fully some components of the program. The online tools were indispensable in this area. The auditing forms, No Harm Event reporting sheets, culture assessments and environmental surveys have all been utilized to varying degrees throughout the different phases of our program. At each Core Group meeting we review the no harm events, perform an abbreviated root cause analysis and formulate corrective actions. Our Core Team actually made a specific change to the No Harm Event tool, so that we can glean even more information from it. We wanted to determine how many no harm events were a result of a Take 5. For more significant events, we utilize a more formal Root Cause Analysis to help formulate new policies and procedures or make revisions and updates to the current ones in place. Always asking the question "Why" helps us get to the root of the problem. This information is then shared with the Labor and Delivery department. Posttests and culture assessments have also been used extensively and have helped us target areas of weakness, which have then helped us focus our efforts. However, we have also been diligent in recognizing the strengths demonstrated and make sure to share this positive feedback with the participants on our unit. We have begun to utilize the "Take 5" tool after every delivery, both vaginal and cesarean. This more "informal" tool allows a quick discussion and analysis of events surrounding the delivery to address things that went well, as well as any concerns. More recently we have begun including the ICN personnel and Anesthesia department in attendance to improve further the effectiveness of this tool and to, of course, strengthen communication among us. With the specific change to the Take 5 tool, we can further investigate those Take 5 issues that may need more attention. Early on, we also developed a multidisciplinary morning report to review all current patients on the unit, as well as those that were scheduled to undergo outpatient testing with us later in the day. These discussions are centered on the plan for that day, and this "huddle" time is also utilized for mini didactic sessions for all those in attendance. Again, participation and feedback has been positive, and changes have occurred to our process such that this report has remained very informative, and we feel is another example of how we have improved safety on our unit. Huddles have also begun at 830pm for the evening and night shifts of all three OB units-L&D, Mother-Baby, and ICN. Last year we successfully developed emergency drills for Eclamptic Seizures which was incorporated into the formal MOREOB module. This year again we have developed two new emergency drills Anaphylaxis and Malignant Hyperthermia.
As stated, we have committed to share all data with our unit personnel on a regular basis. We modified our newsletter and strive to publish this monthly, and do so at least quarterly. Included in the newsletter are results of our no harm event analyses, upcoming emergency drills, new policy changes, audit results and many other pieces of information. We encourage feedback and have had very positive responses and comments. A bulletin board is prominently displayed on the unit and is constantly updated with emergency drills for the month, didactic sessions, reminders about skills drills participation and any awards or accolades we have received in recognition of all of our hard work and commitment to the program.
Because of the huge success of our program over the last 7 years, it only made sense to incorporate other units of our Maternal Child Department and share our knowledge and experiences. The Mother-Baby Unit, Intensive Care nursery, Anesthesia department, surgical techs, Laboratory, Family Medicine residents and College of Nursing instructors and students have enthusiastically joined our program by attending our workshops. We have made small modifications to the content to make the programs more appropriate to the units we have added. We have, however, been very careful to make every attempt to share all content that would be beneficial to understanding the safety practices that are common to all units. As an example, our most recent workshop included 160 participants from all the disciplines noted above, spread over 8 workshops, and the response was overwhelmingly positive. Because this was our first attempt at including all other areas of OB, we included such topics as Communication/Working Together, and updates to Hypertensive Disorders of Pregnancy and its potential relationship to the neonate. We also included a joint Neonatal Resuscitation emergency drill in that workshop. Recently, we have begun collaborating with our Emergency Department, which sees over 250 patients a day and is one of the busiest in New York State. We are in the process of developing protocols surrounding Imminent Delivery and care of patients presenting to the ED with Eclamptic Seizures.
We are slowly but surely beginning to see the fruits of our labor as reflected in cost savings. This is a hard measure to quantify for various reasons but there clearly has been a favorable cost impact. To that end, we have developed a policy surrounding length of stay, which has included both patient and staff education. The education begins in the provider office and continues on admission to the hospital. Again, this has required participation of various disciplines, and is beginning to show positive results. Ultimately we expect this to favorably result in more significant cost savings, which is more and more important in the current healthcare climate.
As we continue through this process I am confident we will recognize other areas of potential improvement and develop initiatives that will certainly be shown to be beneficial to all units involved. Because of our obvious successes throughout our journey, and the sharing of the MOREOB program philosophy, we have become the model of patient safety for the entire hospital, and have indirectly facilitated, in one way or another, the incorporation of various safety programs in other specialties. We look forward to, and are excited about, our continued growth, both from an inter-professional perspective, as well as patient safety perspective. Ultimately this will continue to result in improved patient care outcomes, a deeper appreciation for what we do, and an understanding of the demands of our specialty. Although this is a job, it is also a vocation that we all take very seriously. We are dedicated to providing a culture and atmosphere that is the safest possible. All of our initiatives can only result in more patient and practitioner satisfaction, which will go a long way to helping all of us appreciate more fully the experience of pregnancy and childbirth. What a great beginning in this long and fulfilling journey for our patients and families!
Dr. Chris LaRussa,
St. Joseph Hospital Health Center,
Syracuse, New York