In, 2001, the Patient Safety Division of the Society of Obstetricians and Gynaecologists of Canada initiated and championed a new program to improve patient safety performance in Canadian hospital obstetric units. This new program was developed under the banner of Managing Obstetrical Risk Efficiently and called the MORE OB Programme The MORE OB Programme was first piloted in Canadian hospitals at the beginning of May 2002 and, by mid 2004, 33 pilot sites had been implemented. In autumn 2004, this program embarked on a national launch. In 2007, the Society of Obstetricians and Gynaecologists of Canada collaborated with the Healthcare Insurance Reciprocal of Canada to form Salus Global Corporation. The birth of this corporate entity embraced the support of rapid expansion of the program within and outside of Canada. This collaboration also enabled innovation and implementation of safety programs beyond the obstetric discipline.
Introduction
Over the past 10 years, the MORE OB Programme has been progressively rolled out in a total of 258 hospitals, and over 13,000 obstetric healthcare practitioners have been trained across Canada ( Fig. 1 ). More recently, 13 hospitals in the USA have implemented the MORE OB Programme, demonstrating the immense potential to expand the program and also propagate the culture of patient safety in obstetric units in the USA.
From the beginning, the vision of the program was to make patient safety the guiding principle. The mission of the program was to create and sustain a culture where (1) patient safety is everyone’s first priority; (2) there is trust and respect for all health care workers; (3) effective communication is highly valued; (4) the model of care is focused on inter-professional collaboration and teamwork; (5) reflective learning is an everyday practice; and (6) tacit and explicit knowledge is shared.
The MORE OB Programme consists of three educational modules, each about 12 months in length: ‘Learning together’, ‘Working together’ and ‘Changing culture’. The modules teach core obstetric content to ensure all members of an obstetric unit (e.g. nurses, midwives, family physicians, and obstetricians) have a similar foundation of clinical knowledge. Learning activities include the following: review of evidence-based guidelines; knowledge testing; inter-professional workshops; emergency drill simulation; culture assessment; and objective structured clinical examinations among others. These activities focus on establishing characteristics of high-reliability organisations within obstetric units, such as, safety being the first priority and everyone’s responsibility, teamwork, communication and risk-management proficiency.
The program is delivered partly on site and partly on-line, and uses a ‘train the trainer’ structure. A hospital-selected multidisciplinary healthcare practitioner team is first trained by Salus MORE OB facilitators and then supported by Salus program consultants.
The end goal for the program was to change the culture of blame to a culture of patient safety. To reach this, the program has integrated principles and practices that have been successfully used in other HRO industries (1) processes that create open communication, teamwork and multidisciplinary problem-solving; (2) communities of practice that value each team member, integrated across all hierarchies; (3) ownership of patient safety as everyone’s responsibly at all levels; (4) after 10 years, the program has made a difference in clinical outcomes for mother and baby and in the way healthcare teams function.
In 2004, the Alberta Ministry of Health and Wellness made the MORE OB Programme available to all obstetric units in Alberta, Canada, and it was implemented in 64 facilities in the province. Program implementation on a provincial basis, and at roughly the same time, provided a unique opportunity to study the effect of the MORE OB Programme on obstetric care quality. In 2010, Thanh et al. conducted multivariate regression analyses of the MORE OB Programme’s effect on specific maternal and neonatal health outcomes in Alberta. The study used retrospective outcome data from the Alberta Health and Wellness Discharge Abstract Database, which is maintained by the Canadian Institute for Health Info rmation.
Thanh et al. found that the MORE OB Programme produced a significant improvement in rates of key maternal and neonatal outcomes. For example, a decrease was reported in the number of third- and fourth-degree perineal tears and in patient length of stay successively after the implementation of each MORE OB Programme module. Furthermore, a significant decrease was observed in the risk of severe neonatal morbidity after the implementation of the second and third modules. The findings of the study were possibly limited to a slight degree in that not all facilities had completed the third learning module at the time of data collection. Although not directly studied, these outcomes in maternal and neonatal outcomes likely translate into decreased costs for healthcare systems and suggest a positive return on investment for hospitals implementing the program. Observations from our own data are discussed below.
Learning
A key objective of the program was to provide and measure the ability for all disciplines within the program to achieve the same core knowledge base. The expectation was that an equivalent, cross-professional core knowledge level would provide the initial foundation for building respect and trust, and lead to improved communication. All disciplines within the program (e.g. nurses, obstetricians, family physicians and midwives) were provided with the same core knowledge contained in 16 online chapters.
A standardised knowledge-base assessment tool consisting of 75 criterion-referenced multiple choice questions was developed to test important MORE OB Programme clinical core content knowledge. Each year, a multidisciplinary evaluation team carefully selected questions to make assessments balanced, equivalent, and fair to all disciplines. As an example, one-third of questions were chosen to test knowledge felt to be critical to safe practice. All disciplines were tested with the same assessment tool under the same conditions. Participants were evaluated before the program (pre-test) and after completion of each module (post-test 1, 2 and 3). On the pre-test, the average test result by profession showed differences among nurses, midwives, family physicians and obstetricians. These differences were relatively consistent regardless of the hospital level of obstetrical care (e.g. primary, secondary and tertiary).
All participants were required to take part in the assessments to continue in the program. The average score for each discipline was calculated after each assessment ( Table 1 ). The same participants in the same site were assessed in three different time periods (132 Canadian sites).
| Discipline | Sample size | Average score (%) Based on 99% confidence interval | |||
|---|---|---|---|---|---|
| Pre-test | Post-test 1 | Post-test 2 | Post-test 3 | ||
| Family doctor | 337 | 68.15 | 80.22 | 80.98 | 81.97 |
| (66.86–69.44) | (79.08–81.36) | (79.67–82.29) | (80.73–83.22) | ||
| Nurse | 2719 | 58.24 | 74.41 | 77.26 | 79.55 |
| (57.78–58.7) | (73.88–74.95) | (76.72–77.81) | (79.03–80.06) | ||
| Obstetrician | 298 | 75.72 | 83.68 | 83.24 | 84.65 |
| (74.6–76.85) | (82.43–84.94) | (82.07–84.42) | (83.46–85.84) | ||
| Midwife | 180 | 69.39 | 80.22 | 80.95 | 82.83 |
| (67.74–71.04) | (78.68–81.75) | (79.3–82.6) | (81.2–84.47) | ||
| Inter-disciplinary range (highest to lowest) | 17.48 | 9.27 | 5.98 | 5.10 | |
a On the basis of a similar sample size, if this process were repeated, the mean (average scores) would be expected to fall between the values of the CI 99% of the time. The same participants were assessed in the same site at three different time periods.
Learning
A key objective of the program was to provide and measure the ability for all disciplines within the program to achieve the same core knowledge base. The expectation was that an equivalent, cross-professional core knowledge level would provide the initial foundation for building respect and trust, and lead to improved communication. All disciplines within the program (e.g. nurses, obstetricians, family physicians and midwives) were provided with the same core knowledge contained in 16 online chapters.
A standardised knowledge-base assessment tool consisting of 75 criterion-referenced multiple choice questions was developed to test important MORE OB Programme clinical core content knowledge. Each year, a multidisciplinary evaluation team carefully selected questions to make assessments balanced, equivalent, and fair to all disciplines. As an example, one-third of questions were chosen to test knowledge felt to be critical to safe practice. All disciplines were tested with the same assessment tool under the same conditions. Participants were evaluated before the program (pre-test) and after completion of each module (post-test 1, 2 and 3). On the pre-test, the average test result by profession showed differences among nurses, midwives, family physicians and obstetricians. These differences were relatively consistent regardless of the hospital level of obstetrical care (e.g. primary, secondary and tertiary).
All participants were required to take part in the assessments to continue in the program. The average score for each discipline was calculated after each assessment ( Table 1 ). The same participants in the same site were assessed in three different time periods (132 Canadian sites).
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