Wednesday, February 27, 2013

Hold the presses: Clinicians jointly decide and act!

I did a double-take after glancing at this chart posted on the wall in the obstetrics department at Contra Costa Regional Medical Center in Martinez, CA.  What were those terrible peaks in the record of pre-39 week elective induced deliveries?  Then I looked more closely and realized what the scale was on the vertical axis.  Each of the two peaks represented only one such delivery! The rate during those two months remained below 1%.  And one of the two deliveries was only one day short of 39 weeks.  For the rest of the three years shown, the statistic stayed resolutely at zero.

I immediately spun around to the chief nurse on the floor, "How'd you do that?"  I had in mind the experience of so many other hospitals, including those in Massachusetts, which have had much higher rates and only recently have focused attention on this issue.  (The problem being that pre-39 week babies suffer distress and problems much more often than full term babies.  This puts them at risk and sometimes requires visits to the intensive care unit.)

Her response was way too simple:  "We collectively agreed that this was a serious issue and that we would religiously follow the criteria for early induction laid out by ACOG (the American College of Obstetricians and Gynecologists.) If a doctor shows up wanting to induce an earlier delivery, any person on the staff is empowered to question the decision. In case of conflicting opinion, we jointly discuss it."

For those who want to follow the lead of this public hospital in California, check out the ACOG Practice Bulletin, "Clinical Management Guidelines for Obstetrician-Gynecologists:  Induction of Labor," Number 107, August 2009.

Oh, by the way, did you notice that I said that the chart above was on the wall for all to see?  That's the kind of transparency that helps an organization hold itself accountable to the high standards it has set for itself.  Notice, too, that the goal is zero, not some national benchmark.  As I have said before, there is no virtue in benchmarking yourself to a substandard norm.  Bravo on all fronts to CCRMC.


Barry Carol said...

Congratulations to everyone at Contra Costa Regional Medical Center. Keep up the good work. When I think about the potential to replicate this general approach elsewhere, I wonder about three things. First, what was the role of the hospital’s senior management in providing leadership and encouragement? Second, how were doctors brought on board? Are they culturally more collegial and team oriented in the SF metro area than elsewhere? Finally, to what extent did the presence of Kaiser and its dominant healthcare market position in the region influence the effort and ultimate result at this hospital?

Kaiser is very successful in Northern CA but it has failed to gain traction in some other geographies. HMO’s are very unpopular in some markets. However, physician practice patterns are more culturally conservative in the upper Midwest than in the Northeast and the Sunbelt. Physician buy-in is critical to the success of all process improvement efforts and I just think it’s an easier sell in some places than others mainly due to differences in culture.

This is why I think we need to continue to enhance efforts to structure financial incentives so the most cost-effective doctors and hospitals are rewarded with more patients. Patients, for their part, need to be rewarded with higher wages and/or enhanced other fringe benefits if they make cost-effective healthcare and health insurance choices that save employers money and they need access to good cost and provider quality information to help them do that.

Unknown said...

Eureka! It had been so long ago that I'd forgotten! As Oncology Medical Director I held "Discussion Rounds" 6 days/week. All staff attended, although folks were in and out except when their cases were being discussed. All members of the treatment team were given the power to contramand ANY order in the chart, if they were able to defend it adequately.

If all were in agreement, I'd call the patient's physician and present our case.

This was not just transparency. This was collective commitment. We did it at no extra cost to the hospital or the patients. Our motives included excellence of care, continuity, commitment and pride as coequals, each with his own perspective.

Thanks for bringing that back to me. In the final analysis, I think we were better than just "transparent". Our buy in was that we all bought in.

Most of all, it was a kick! A way to combat our individual sorrow and burn-out.

Peter Kennedy, M.S., M.D.

Christine Morton said...

Thanks for highlighting how this one hospital in NorCal addressed this issue. In response to Barry Carol, I would note that there has been a statewide effort by many stakeholders to bring this to hospitals' attention. CMQCC and CPDH as toolkit author/funders were involved, as was the March of Dimes, which licensed and rebranded the Toolkit and took it statewide and nationally, in concert with ACOG. Anthem/Blue Cross funded a "Patient Safety First" initiative that was administered through three Hospital Associations in CA. Certainly the Kaiser influence was a factor, but also other major systems, like Sutter which implemented this guideline before the Toolkit release. Barry's comment raises another really critical question for me and my colleagues at CMQCC, which is, how to identify and analyze the relative influence of a variety of structural and contextual factors in determining the impact/influence of QI implementation efforts at any one facility? Would LOVE to have some discussion and/or pointers to good literature on that.

Mike said...

The graph reminds me that when we have rare events, it is sometimes better to plot the time between events rather than the number of events themselves.