11/26/2012
L22
These presenters have
nothing to disclose
The Right Start:
Eliminate OB
Adverse Events
Sunday,December9,20121:00pm‐4:30pm
PeterCherouny,MD
CheriJohnson,RN
SueGullo.RN
Session Objectives
Discuss the definition of an OB adverse event.
Define the current evidence to support an
obstetrical care delivery system that focuses on
getting it right- starting with the determination of
gestational dating.
Describe solutions that support collaborative
care with all stakeholders having a voice.
Learn from an organization who has applied the
work to achieve results.
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IHI uses a three-step model for applying
principles of reliability to health care systems:
Prevent failure (a breakdown in operations or
functions).
Identify and Mitigate failure: Identify failure
when it occurs and intercede before harm is
caused, or mitigate the harm caused by failures
that are not detected and intercepted.
Redesign the process based on the critical
failures identified.
US National Cesarean Rate- 32.8%
Prevent-Mitigate-Redesign
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The nulliparous measure
This measure seeks to focus attention on
the most variable portion of the CS
epidemic, the term labor CS in nulliparous
women. This population segment accounts
for the large majority of the variable
portion of the CS rate, and is the area
most affected by subjectivity.
The nulliparous measure
As compared to other CS measures, what is
different about nulliparous term singleton vertex
(NTSV) CS rate (Low-risk Primary CS in first
births) is that there are clear cut quality
improvement activities that can be done to address
the differences. Main et al. (2006) found that over
60% of the variation among hospitals can be
attributed to first birth labor induction rates and first
birth early labor admission rates.
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EFFICIENCY
International Comparison of Spending on
Health, 1980–2009
Average spending on health
per capita ($US PPP*)
Total expenditures on health
as percent of GDP
* PPP=Purchasing Power Parity.
Data: OECD Health Data 2011 (database), version 6/2011.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
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HEALTHY LIVES
Infant Mortality Rate
$50 Billion
Infant deaths per 1,000 live births
National average and state distribution
International comparison, 2007
7.7
^ Denotes years in 2006 and 2008 National Scorecards.
Data: National and state—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2003–2008; Mathews
and MacDorman, 2011); international comparison—OECD Health Data 2011 (database), Version 06/2011.
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Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2011.
National Statistics
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4.3 million births per year in the United States
Care of childbearing women and their newborns
was by far the most common reason for
hospitalization ($98 billion)
Six of the ten most common hospital procedures
in 2008 were maternity-related
In 2008, 41% of all maternal childbirth-related
hospital stays were billed to Medicaid
http://www.childbirthconnection.org/article.asp?ck
=10621
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Cost and Quality
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"Mother's pregnancy and delivery" and "newborn infants"
were the two most expensive conditions billed to private
insurance in 2008, involving 14% of hospital charges to
private insurers, or $50 billion.
Childbirth Connection, United States Maternity Care
Facts and Figures December 2010.
www.childbirthconnection.org
Induction of labor and cesarean delivery rates among late preterm births:
United States, 1990-2006
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http://www.cdc.gov/nchs/data/databriefs/db24_fig5.png
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Vaginal Induced
Vaginal not induced
Cesarean induced
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16
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Change vs. Improvement
Of all changes I’ve observed, about 5%
were improvements, the rest, at best,
were illusions of progress.
W. Edwards Deming
– We must become masters of improvement
– We must learn how to improve rapidly
– We must learn to discern the difference between
improvement and illusions of progress
“The First Law of Improvement”
“Every system is perfectly
designed to achieve exactly
the results it gets.”
Paul Batalden
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Infant Mortality Rate in 2011
(Total Deaths per 1,000 Live Births)
Infant mortality rates United States, 2007
IHI Perinatal is currently is working
with the state of Louisiana to improve
birth outcomes for mothers and babies
IHI is also working with HRSA on the
national Infant Mortality CoIN for
Regions IV and VI
An infant death occurs within the first year of life. Source: National Center for Health Statistics, final mortality data, 1990‐1994 and period linked birth/infant death data, 1995‐present. Retrieved January 10, 2012, from www.marchofdimes.com/peristats.
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United States 1990-2006
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Maternal Mortality Rate per 100,000
live births, 2003-2007
United States leading causes
Between 1999 and 2007, the maternal mortality rate increased more than 28% in the United States (MOD Peristats)
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OB Adverse Event
IHI defines an adverse event as
any noxious or unintended event
occurring in association with
medical care.
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Normalization of Deviance
Peter Cherouny, M.D.
Emeritus Professor, Obstetrics, Gynecology and
Reproductive Sciences, University of Vermont
College of Medicine, Burlington, Vermont, USA
Normalization of Deviance
What’s normal
From what are we deviating
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Normalization of Deviance
Normalization of Deviance
Who wrote the rules anyway
Rules are made to be broken
The exceptions make the rules
We need to break rules for the good of the
patient
Our knowledge is imperfect and poorly spread
Rules are Stupid-I don’t need them
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Normalization of Deviance
Space Shuttle Rules
– Any damage to the O-rings was
considered a criticality I event
– O-rings are only certified to work at 59oF
or higher
– Requirement was to prove safety
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Normalization of Deviance
Space Shuttle Findings
– 14/24 flights revealed O-Rings damaged
by fire
– February 1984- 2 burned O-Rings
– July 1985- Failure of all O-Rings
– Progressively higher “near-failures” as
launch temperatures decreased
Normalization of Deviance
Space Shuttle Rules
– Any damage to the O-rings was
considered a criticality I event
– O-rings are only certified to work at 59oF
or higher
– Requirement was to prove safety
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Normalization of Deviance
Space Shuttle Rules
– What damage level to the O-rings was
acceptable and safe
– O-rings are only certified to work at 59oF
or higher
– Requirement was to prove safety
Normalization of Deviance
Space Shuttle Rules
– What damage level to the O-rings was
acceptable and safe
– Successful launches at progressively
lower temperatures were deemed
successful
– Requirement was to prove safety
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Normalization of Deviance
Space Shuttle Rules
– What damage level to the O-rings was
acceptable and safe
– Successful launches at progressively
lower temperatures were deemed
successful
– Requirement was to prove unsafe/risk
Normalization of Deviance
New Space Shuttle Rules
– Norm was reset with subsequent
successes
– Nothing bad happened with prior
violations
– Change from proof of safety to proof of
risk
– Under pressure to continue
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Normalization of Deviance
Other examples:
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Normalization of Deviance
Other examples:
– Deepwater Horizon
– Titanic
– Exxon Valdez
– Banks and leveraging
– Others?
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Normalization of Deviance
Standards vs Tolerance
– Standards are fixed, developed by
consensus
– Tolerance is variable
Normalization of Deviance
Necessary clinical variation
-Clinical and biologic variation
Unexplained clinical variation
-PC-02, the highest variation among
hospitals and practitioners
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Normalization of Deviance
Standards vs Risk Tolerance
– In our private lives
– In our public lives
If the posted speed limit is 60 mph, do
you usually drive 60 mph?
1. Yes
2. No
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If the posted speed limit is 60 mph,
would you drive 64 mph?
If the posted speed limit is 60 mph,
would you drive 75 mph?
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If the posted speed limit is 60 mph,
would you drive 120 mph?
For those of you who drove 60 mphwhy did you?
1. 60 mph is the
law.
2. You believe
driving 60 mph is
safest.
3. Afraid that you
might receive
traffic violation.
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For those of you who drove 64 mphwhy did you?
1. No significant safety
risk incurred by
driving 64 mph
2. Traffic violations at 64
mph are unlikely
3. Driving 64 mph
reduces traveling time
4. All of the above
For those of you who drove 75 mph
why did you?
1. You drive just a safely
at 75 as 60 mph.
2. Traffic planners don’t
use realistic scientific
data to establish speed
limits.
3. 75 mph reduces
traveling time.
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For those of you who didn’t drive 75
mph why didn’t you?
1. The risk of a traffic
accident at 75 mph
is unacceptable
1. The risk of a traffic
violation is
unacceptable
Normalization of Deviance
BTCU
– Borderline tolerated conditions of use
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Individual Autonomy
VERY UNSAFE SPACE
Forbidden
behavior except
under extreme
circumstances
Safety regs
Collective
& good practices
120 in memory of
Certification/
experiences
accreditation
a 60 75 in a standards
65 in a 60
60 in a
60
Usual space
the ‘illegalof action
60
illegal’ space
(for almost all
Forbiddenof us!)
by all
<1%
Illegal-normal
space
5%
50%
80%
Guidelines
as defined by
professional
standards
Legal space
Individual
Pressures
Perceived
Vulnerability
Belief in
Systemsguidelines
100% percent of staff
PERFORMANCE
Normalization of Deviance
Pressures
– Market
– Individual
Belief in guidelines
– Experiences
– Individual
– Collective
Perceived vulnerability
– Adverse outcome
– Detection and punishment
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Normalization of Deviance
Fudge factor management
1) Fudging increases when we are part
of a group that fudges
2) Fudging increases when the
distance to the desired object/outcome
increases
3) Fudging decreases when we’re
reminded of our own morality
Normalization of Deviance
Standards vs Tolerance in Obstetric Care
– Drive to get delivered
– Low-dose regimens of pitocin increase
cesarean sections
– Elective delivery prevents fetal death
– Cesarean section is not a failure
– Don’t want to miss anything
Crane JMG, Young DC. Metanalysis of low-dose vs high-dose oxytocin for labor induction. J Obstet Gynecol Can.1998;20:1215.
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Normalization of Deviance
Standards vs Tolerance in Obstetric Care
– Risks associated with unfavorable cervix
– Low-dose regimens of pitocin increase
cesarean sections
– Elective delivery prevents fetal death
– Cesarean section is not a failure
– Don’t want to miss anything
Crane JMG, Young DC. Metanalysis of low-dose vs high-dose oxytocin for labor induction. J Obstet Gynecol Can.1998;20:1215.
Normalization of Deviance
Standards vs Tolerance in Obstetric Care
– Risks associated with unfavorable cervix
– Higher dose regimens increase maternal
and fetal risks
– Elective delivery prevents fetal death
– Cesarean section is not a failure
– Don’t want to miss anything
Crane JMG, Young DC. Metanalysis of low-dose vs high-dose oxytocin for labor induction. J Obstet Gynecol Can.1998;20:1215.
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Normalization of Deviance
Standards vs Tolerance in Obstetric Care
– Risks associated with unfavorable cervix
– Higher dose regimens increase maternal
and fetal risks
– Early elective deliveries increase
morbidity and death
– Cesarean section is not a failure
– Don’t want to miss anything
Crane JMG, Young DC. Metanalysis of low-dose vs high-dose oxytocin for labor induction. J Obstet Gynecol Can.1998;20:1215.
Normalization of Deviance
Standards vs Tolerance in Obstetric Care
– Risks associated with unfavorable cervix
– Higher dose regimens increase maternal and
fetal risks
– Early elective deliveries increase morbidity
and death
– Cesarean section increase subsequent risks
– Don’t want to miss anything
Crane JMG, Young DC. Metanalysis of low-dose vs high-dose oxytocin for labor induction. J Obstet Gynecol Can.1998;20:1215.
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Normalization of Deviance
Standards vs Tolerance in Obstetric care
– Risks associated with unfavorable cervix
– Higher dose regimens increase maternal and
fetal risks
– Early elective deliveries increase morbidity
and death
– Cesarean section increase subsequent risks
– Errors of commission can be costly
Crane JMG, Young DC. Metanalysis of low-dose vs high-dose oxytocin for labor induction. J Obstet Gynecol Can.1998;20:1215.
Normalization of Deviance
Standards vs Tolerance in Obstetric care
– Would you give a potentially dangerous
drug to hasten the completion of a
physiologic process that, if left alone,
would usually complete itself without
incurring the risk of medication
administration?
Clark SL et al. Oxytocin: New perspectives on an old drug. AJOG 2009;200:35.
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Normalization of Deviance
The PC-02 measure
– Cesarean section rate for Nulliparous,
Term, Cephalic presenting patients.
– This is where there is the highest
variability of cesarean section rates
between providers and hospitals
Normalization of Deviance
The PC-02 measure
– Has your norm been reset due to
nonevents?
– Are you influenced by GroupThink?
– Is your main driver patient safety or are
you accepting of care just because it
hasn’t been shown unsafe?
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Normalization of Deviance
The PC-02 measure
– Do you recognize your own
vulnerability?
– Do you execute to meet standards?
– Do you Plan the Work?
Work the Plan?
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