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Perinatal Collaborative Stories


St. Agnes Hospital

For the team at St. Agnes Hospital, participation and leadership in the Maryland Patient Safety Center Perinatal Collaborative seemed like the “logical next step” in their ongoing patient care enhancement efforts. They were already actively participating in a highly successful collaborative with the Institute for Healthcare Improvement (IHI), Kaiser Permanente, Ascension Health, and Premier, Inc, charged with looking at an optimal design for perinatal care.

“It was clear to our team that we could play a leadership role in Maryland’s efforts, drawing upon and sharing the best practices we had derived through our work with the other collaborative,” said Raymond Cox, MD, Chair, Obstetrics & Gynecology, St. Agnes Hospital. 

A major focus of the St. Agnes team has been enforcing the “39-week minimum” rule for inductions and augmentations. According to the American College of Obstetricians and Gynecologists (ACOG), elective inductions under 39 weeks are not appropriate except under extenuating circumstances.

“With regard to enforcing this policy, it’s all about effective and continued communication with physicians,” notes Dr. Cox. “I can characterize it in two words: relentless persistence.”

Obstetricians, in the past, often have been too lenient about scheduling inductions, in an effort to accommodate a patient’s wishes – but, unless there is a legitimate clinical reason for inducing earlier, this is a potentially dangerous practice.

“The risks are much higher for an infant less than 39 weeks old, and it is absolutely in the best interest of both mother and baby to delay the procedure until the baby is more fully developed. It’s a matter of reminding physicians of this again and again, until it becomes second nature to them,” continued Dr. Cox.

Through participation in the Collaborative, St. Agnes Hospital has also reinforced its focus on teamwork and communication. Dr. Cox and his team are very enthusiastic about the outcomes so far.

In the area of Labor and Delivery, the team was looking for ways to work more efficiently. “The incorporation of ‘huddles’ before each procedure – taking time to check in with everyone to make sure you are all on the same page regarding what is to follow – has been highly effective in improving communication among all members of the team,” said Dr. Cox.

“Equally important, as well as exciting, has been our use of simulation drills,” he continued. Early on in the process, some of our physicians were leery of the idea, but once they became engaged they have been our most ardent supporters.”

As a result of improved communication and preparedness through simulations, St. Agnes Hospital experienced a 16-month period of zero birth traumas, a significant achievement of which the entire team is very proud.

“But our work continues,” Dr. Cox stressed. “This by no means implies the work is over – rather it infers that we are on the right track, and we’ll continue making improvements and learning more as we go along.”

Dr. Cox provided a classic and real-life example of improved communications, involving a patient who required an emergency hysterectomy following a cesarean section. “This event required the immediate and undivided engagement of the whole team – anesthesiology, physician groups, nursing, techs, etc – who were literally saving this woman’s life.”

Had the scenario occurred before the improved communication and simulation training, Dr. Cox believes they probably would have lost the patient. “People develop a higher comfort level in communicating with one another so that in a time of urgency, they aren’t inhibited – they are fully engaged and feeling confident about their role and relating to others on the team. It saves lives.”

Dr. Cox also noted that as a result of their participation in the Collaborative, St. Agnes’ OB/GYN unit is much calmer, which helps to reduce error. Members of the care team are much more confident in their skills and abilities and less inclined to get frazzled at critical times.

Apparently, the enthusiasm for these positive outcomes is catching. Dr. Cox reported that, following in the footsteps of the OB/GYN unit, St. Agnes’ GYN Surgery unit is now performing simulation exercises. “As people see what we are doing and how effective it has been, they are now competing for time in the simulation room. It’s both remarkable and thrilling.”

Looking ahead, Dr. Cox said his team plans to spread these improvements to other areas of the hospital, as well as to other hospitals. They also plan to focus on improving transparency, focusing on two major areas: removing silos that restrict interaction and communication among the care team; and communicating more clearly with patients.