In reviewing outcomes that are associated with the implementation of a series of labor and delivery patient safety efforts from 2004-2009, we requested data on the number of related professional liability claims that were reserved by our insurance companies that are established with the specific objective of financing risks that emanate from their parent group or groups. While we restructured the manner in which we give care, required training modules, and provided simulations to our providers, our legal risk continued to be monitored independently and in parallel. Retrospective review of the number of cases for which money was held in reserve for claims demonstrated a 20% decrease per year, which was adjusted for delivery volume, over this time period. We believe that the improved care that resulted from our safety projects has led to this decreased legal risk.
Patient care may be defined in terms of both patient safety and satisfaction. Specific outcome data, such as cesarean rates or specific complication rates, are not necessarily indicative of the quality of care and the patient’s perceptions. Aggregated data, such as the Adverse Outcome Index (AOI), are attempts to combine data for evaluation; these collective outcome measures are not yet proven measures and do not describe the patient’s hospital experience completely. Patient perceptions of poor care or communication can lead to claims or suits, despite medically acceptable outcomes.
As we implemented patient safety improvements, we noted a concomitant decrease in the number of reserved claims. Based on the cumulative experience reported here, we believe that the number of claims for which funds are reserved by a service’s professional liability insurer is another useful reflection of safety improvements and patient care.
Materials and methods
Boston Medical Center (BMC) is an urban safety net hospital that is the primary teaching hospital for Boston University School of Medicine. Although 80% of the obstetric patients are covered by government insurance or are uninsured, the hospital and medical school staff also use the facility. English is spoken by only 62% of the women who deliver at BMC; the center has regionally recognized programs for human immunodeficiency virus–infected and substance-abusing pregnant women. The annual delivery volume averages 2400.
The labor and delivery staff at BMC is comprised of nurses, midwives, obstetricians, family medicine physicians, and residents in obstetrics and gynecology and family and emergency medicine. Third- and fourth-year medical students typically are involved in patient care. The labor and delivery staff is “closed,” in that all providers are full-time employees of either the hospital or the faculty practice plan. BMC is self-insured through a captive insurance company (an insurance company that is established with the specific objective of financing risks that emanate from their parent group or groups) that was incorporated in 2002.
In 2004, we began a series of interventions (described in detail later) to improve patient safety and satisfaction on labor and delivery. We have collected cases with poor outcomes and patient complaints through a variety of sources. We have an active risk management group, which is contacted immediately when unexpected poor outcomes occur. There is an anonymous online reporting system that is available to all BMC employees to report patient safety concerns; these reports are followed up by the risk management group and our quality improvement committee. We have a “complications reporting section” on discharge summaries that flags cases for further review. Finally, we communicate with our patient advocates when patient concerns arise. All of the identified cases are reviewed by our obstetric quality-improvement committee and the risk management team. Obstetric cases with poor outcomes are evaluated by legal and medical experts within the insurance captive, independent of the providers, and the quality-improvement committee, because it is a common practice to reserve funds for cases that may require legal defense. Specifically, the risk management team reviews events with the insurance captive to decide which cases may result in a professional liability claim. When there is believed to be significant risk of a claim or suit, money is set in reserve for defense or settlement. Because the amount of money that is reserved is determined by the captive insurance company using regionally specific data, we believed that it would be more useful to measure the number of reserved claims rather than the amount of dollars that are held.
We conducted a retrospective observational study that compared the number of reserved claims per policy year, which was adjusted for the annual number of deliveries, over the 5 policy years from July 1, 2004, to June 30, 2009. Mantel-Haenszel statistics were used to evaluate the data on the 11,931 deliveries that were included in the analyses. Poisson regression analysis was performed. Because no specific identifiable patient information was used in this study, it was exempt from institutional review board approval.
Safety Improvement Steps
2004–Provider call schedule revision
Beginning in 2004, providers were no longer permitted to do clinical work after overnight call in labor and delivery. Scheduled clinical activities on the day after overnight call in labor and delivery pose a potential conflict to the covering providers in that a decision may need to be made as to which activity is more pressing, tonight’s or tomorrow’s. The negative impact of sleep deprivation on clinical care has been well documented and discussed.
2005–Obstetric drills
Obstetric drills are used to prepare providers for specific technical improvement and to improve teamwork and communication. Medical emergency preparedness has become a recommended activity for all departments. The benefits of shoulder dystocia (SD) drills have been documented. Because birth injuries that are associated with SD are a major source of obstetric liability, an SD drill was developed to standardize and improve teamwork and documentation. These drills focused on the anticipation of SD, communication both within and outside the room when SD occurred, demonstration of appropriate delivery techniques, and accurate documentation of the events. All providers, which included nurses, midwives, and physicians who worked in labor and delivery, were required to participate in the drills, which were carried out over a 2-month period. Subsequently, we have performed postpartum hemorrhage drills and repeated the SD drill.
2006–Collaborative practice model
Before 2006, there was minimal collaboration between providers in labor and delivery. Typical coverage was by an attending obstetrician, 2 obstetrics and gynecology residents, and a midwife. The family medicine attending physicians and residents took calls from home and attended only the 200 or so deliveries whose prenatal care was provided by their service. To improve care, a collaborative committee that included the medical disciplines and nursing, was formed and met monthly to develop a new model of care. Compensation was changed to reflect work shifts, not deliveries; family medicine physicians began participating full-time in labor and delivery coverage. A consultative structure was defined. Patients were assigned to providers by acuity, with attention to the patients’ prenatal provider group whenever possible. A cap of 3 was placed on the number of patients for whom an individual provider was responsible. Rules for respectful and helpful behavior were delineated. The collaborative committee continues to meet to evaluate new evidence-based obstetric practices and to initiate projects. Recent examples include nonpharmacologic labor pain relief, standardization of requirements and counseling of patients who are interested in a trial of labor after cesarean delivery, a breastfeeding initiation, and newborn skin-to-skin care.
2006–Electronic fetal heart rate monitoring course
To standardize fetal heart rate interpretation and documentation, all providers of labor and delivery were required to complete an online 12-credit continuing medical education course that focused on the up-to-date criteria for fetal heart rate description. Participation in the course is required of all providers as part of retaining privileges and must be renewed every 2 years by labor and delivery staff physicians, midwives, and nurses.
2008–Dedicated obstetric quality assessment and improvement committee
Although quality assessment and improvement had been an integral activity in the department since 2004, obstetric and gynecologic review was performed by the same team. To focus on obstetric improvement, the obstetric and gynecologic sections of the departmental quality assessment and improvement committee were separated. Standard obstetric quality indicators (such as infections, blood transfusion, return to the operating room, readmission, and other serious rare events) are collected, as noted earlier. A dedicated quality assessment nurse begins incident investigations, and peer committee members complete the investigations when necessary. Monthly meetings include case review, data evaluation, and quality-improvement project development. Feedback is given in “real time” to the providers from the investigating committee member or from the quality improvement director after committee consideration. Examples of identified issues include provider-to-provider communication, surgical planning, and errors in medical knowledge.
2008–Cultural competency training
The patient population at BMC is unusually economically, geographically, and socially diverse. To better communicate our recommendations and meet the needs of our patients, the hospital staff underwent cultural competency training that was produced by Manhattan Cross Cultural Group of Quality Interactions (North Pembroke, MA). This computer-based training has an emphasis on individual patient assessment and treatment. All providers are required to undergo this training.
2008–Teams training
Pratt et al demonstrated the improvements in patient safety after a structured teams training process based on Crew Resource Management (CRM). We used a teams training program that was based on their model. Twelve leaders from the nursing, obstetric, family medicine, and anesthesia groups were trained in the process of labor and delivery teamwork using the CRM model. After the 3-day intense “train the trainers” sessions, a 4-hour presentation directed at our providers was developed to reflect the CRM ideas in our setting. The customized presentation was then delivered to everyone who worked in labor and delivery. We emphasize the importance of a shared consciousness of patients and resources, communication techniques, and conflict resolution. We modified our twice daily common board rounds, instituted pre- and postprocedure briefings, and actively resolve conflicts and miscommunication. New providers receive instruction when they begin working in labor and delivery.
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