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Recommendations From a National Panel on Quality Improvement in Obstetrics

Open AccessPublished:March 11, 2019DOI:https://doi.org/10.1016/j.jogc.2019.02.011

      Abstract

      This paper describes the recommendations of a national panel on quality improvement in obstetrics to identify priorities for action among five areas of greatest medico-legal risk. Using previously conducted medico-legal data analyses and a systematic literature review, the panel reviewed existing data and developed recommendations for areas of focus in quality improvement in five obstetrical high-risk areas. The panel recommended clarification of definitions in some areas, identified needs for data collection and standardization of practices in others. The most promising interventions to improve care in the five areas were grouped into: standardized processes (such as protocols and communication tools), checklists, audit and feedback, mentoring and coaching, inter-professional communication, simulation and training, and shared decision making guides. This national panel of experts created 18 action-oriented recommendations focused on quality improvement to reduce medico-legal risk and improve the safety of care for Canadian mothers and babies.

      Résumé

      Cet article décrit les recommandations d'un groupe national d'experts sur l'amélioration de la qualité en obstétrique pour définir les priorités d'action dans cinq domaines présentant un risque médico-légal particulièrement élevé. Le groupe s'est servi d'une revue systématique de la littérature et d'analyses de données médico-légales antérieures pour examiner les données existantes et formuler des recommandations quant aux priorités d'amélioration de la qualité dans cinq domaines obstétricaux à risque élevé. Il a recommandé de clarifier les définitions dans certains domaines, et a relevé des besoins de collecte de données et de normalisation des pratiques dans d'autres. Les interventions les plus prometteuses pour améliorer les soins dans les cinq domaines ont été regroupées dans les catégories suivantes : processus normalisés (p. ex., protocoles, outils de communication), listes de vérification, vérification et rétroaction, mentorat et encadrement, communication interprofessionnelle, simulation et formation, et aides à la prise de décisions conjointe. Ce groupe national d'experts a créé 18 recommandations pragmatiques sur l'amélioration de la qualité visant à réduire le risque médico-légal et à améliorer la sécurité des soins pour les mères et les bébés du Canada.

      Key Words

      Maternity care has been identified by many organizations as a significant medicolegal concern for health care providers.

      Obstetrics services in Canada: advancing quality and strengthening safety. Ottawa: Accreditation Canada, the Healthcare Insurance Reciprocal of Canada, the Canadian Medical Protective Association, Salus Global Corporation; 2016.

      According to an extract from the Healthcare Insurance Reciprocal of Canada (HIROC) claims database, for every 1000 births there was one claim reported.

      Obstetrics services in Canada: advancing quality and strengthening safety. Ottawa: Accreditation Canada, the Healthcare Insurance Reciprocal of Canada, the Canadian Medical Protective Association, Salus Global Corporation; 2016.

      Medicolegal matters reported by physicians to the Canadian Medical Protective Association (CMPA) occurred in approximately one of every 5275 Canadian births; 20% of these resulted in a patient's death, and a further 50% of patients had a catastrophic or major disability.

      Obstetrics services in Canada: advancing quality and strengthening safety. Ottawa: Accreditation Canada, the Healthcare Insurance Reciprocal of Canada, the Canadian Medical Protective Association, Salus Global Corporation; 2016.

      These figures highlight that safety incidents reflected in medicolegal events are associated with significant harm to patients.
      Members of the National Panel on Quality Improvement in Obstetrics:
      •Jon Barrett MBBch – Head of Maternal-Fetal Medicine at Sunnybrook Health Sciences Centre, Toronto, ON Ontario Regional Representative, Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON; Chair of Southern Ontario Obstetrical Network, Toronto, ON
      •Howard Berger MD – Head of Maternal Fetal Medicine and Obstetric Ultrasound, St Michael's Hospital, Toronto, ON
      •Jennifer Blake MD – Chief Executive Officer, Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON
      •Kim Campbell RN, RM, MN – Midwife, Instructor Midwifery Program, Department of Family Practice, The University of British Columbia, Vancouver, BC; Lead, Midwifery CPD Program, Division of Continuing Professional Development, Faculty of Medicine, The University of British Columbia, Vancouver, BC
      •Jocelynn Cook PhD, MBA – Chief Scientific Officer, Society of Obstetricians and Gynaecologists of Canada, Ottawa, ON
      •William Ehman MD – Chair of Maternity & Newborn Care Program Committee of the College of Family Physicians Canada, Mississauga, ON
      •Jeremy M. Grimshaw MBChB, PhD – Senior Scientist, Clinical Epidemiology Program, Ottawa Hospital Research Institute and Professor, Department of Medicine, University of Ottawa, Ottawa, ON
      •Liisa Honey MD – Chief of Obstetrics & Gynecology, Queensway Carleton Hospital, Ottawa, ON
      •France Morin RN, MScN – Perinatal Consultant, Registered Nurse, Champlain Maternal Newborn Regional Program, Ottawa, ON
      •Joanna Noble RN, CRM, CPPS – Supervisor, Knowledge Transfer Healthcare Risk Management, Healthcare Insurance Reciprocal of Canada, Toronto, ON
      •Heather Scott MD – Obstetrician, Dalhousie University, Halifax, NS; Obstetrical Director of the Reproductive Care Program of Nova Scotia; Chair of the External Advisory Committee for the Canadian Perinatal Surveillance System, Ottawa, ON
      •Gareth Seaward MBBch, MMed(O&G), MSc(CE), MSc(QIPS), Dip Mid COG(SA) – Vice Chair, Quality Improvement and Patient Safety, Obstetrics and Gynecology, University of Toronto, Toronto, ON; Vice Chair, Provincial Council of Maternal Child Health of Ontario, Toronto, ON
      •Dorothy Shaw MBChB – Vice President, Medical Affairs, British Columbia Women's Hospital & Health Centre, Vancouver, BC
      •Kirsten Smith MD – Obstetrician, North York General Hospital, Toronto, ON
      •Jordan Tarshis MD – Anesthesiologist Director of Sunnybrook Canadian Simulation Centre, Sunnybrook Health Sciences Centre, Toronto, ON
      •Mark Walker MD, MSc, MHCM – Scientific Director and co-director of Better Outcomes Registry and Network, Ottawa, Ontario; Maternal Fetal Medicine, Clinician Scientist, The Ottawa Hospital, Ottawa, ON
      From 2015 to 2016, the CMPA, a not-for-profit organization that provides medicolegal protection to physicians, and HIROC, a not-for-profit insurance reciprocal owned and governed by over 700 Canadian health care organizations, conducted a collaborative retrospective analysis of 1688 medicolegal matters over 10years involving obstetrical care. In their joint report, the authors identified five key areas of medicolegal risk for Canadian obstetrical care: induction and augmentation of labour, assisted vaginal delivery, shoulder dystocia, decision to delivery time for Caesarean section, and fetal surveillance.

      Obstetrics services in Canada: advancing quality and strengthening safety. Ottawa: Accreditation Canada, the Healthcare Insurance Reciprocal of Canada, the Canadian Medical Protective Association, Salus Global Corporation; 2016.

      Collaborative care was a common theme featured throughout these cases. To build on this work, the CMPA partnered with the Society of Obstetricians and Gynaecologists of Canada (SOGC) in the fall of 2017 to create a national panel tasked with examining opportunities for quality improvement in obstetrical care.
      These organizations identified a need for prioritization, coordination, and implementation of quality improvement initiatives. The burden on patients, families, and providers when patient safety incidents occur can feel magnified when applied against front-line practitioners’ heavy clinical loads and limited quality improvement resources. Although there are multiple quality improvement projects in maternity care across the country, to date national focus or coordination of efforts is lacking. In this paper, we describe the recommendations of a national panel on quality improvement in obstetrics to define priority areas for action among the five areas of greatest medicolegal risk.
      The national panel was created using a modified snowball technique with the aim of identifying opinion leaders, quality improvement leaders, health services researchers, and front-line clinicians. The intent was to represent the breadth of maternity health care professionals in Canada. The panel included members of the CMPA, SOGC, HIROC, College of Family Physicians of Canada, Canadian Association of Perinatal and Women's Health Nurses, Canadian Association of Midwives, Champlain Maternal Newborn Regional Program, Southern Ontario Obstetrical Network, Better Outcomes Registry and Network (BORN Ontario), Provincial Council of Maternal Child Health of Ontario, Reproductive Care Program of Nova Scotia, and the Canadian Anesthesiologists Society, as well as family physicians, midwives, nurses, and implementation science experts. The panel convened during a 1-day in-person meeting in Toronto on December 2, 2017.
      Before this meeting, the CMPA conducted a systematic review to identify Canadian and American studies describing quality improvement interventions involving in-hospital obstetrical care.
      • Calder L
      • Bowman C
      • De Gorter R
      • et al.
      A systematic review of quality improvement interventions in labour and delivery.
      This review included randomized and prospective controlled trials and cohort studies describing interventions designed to improve the quality of care in hospital-based labour and delivery unit. The results of this systematic review were used to inform the panel.
      The panel's discussion is summarized for each of the five chosen high-risk topics in Table1, Table2, Table3, Table4, Table5, and the final recommendations are presented in Table6. The topic of intrapartum fetal surveillance featured prominently in many of the discussions and was felt by the panel to be relevant to many of the drafted recommendations. This topic and several key overarching themes are described further here.
      Table1Induction and augmentation of labour
      Knowledge gapsPromising interventionsBarriers to spreadOpportunities for spread
      • Lack of national and provincial-level data

      • Lack of high-level evidence for which aspects of processes are most closely linked to morbidity or mortality
      • Standardized booking processes

      • Evidence-based oxytocin protocols and checklists

      • Checklist and protocol adherence audits and feedback relating to quality clinical and process outcomes
      • Perceived wide variation in practice across and within institutions

      • Lack of appropriate standardization, including appropriate incentives, could affect success

      • Lack of a network within and between provinces to facilitate uptake of accepted national protocols
      • SOGC could coordinate a national approach for protocols to standardize booking processes and oxytocin usage

      • Regional best practices exist for standardized oxytocin protocols and checklists

      SOGC: Society of Obstetricians and Gynaecologists of Canada.
      Table2Assisted vaginal delivery
      Knowledge gapsPromising interventionsBarriers to spreadOpportunities for spread
      • Lack of clear evidence on when to use vacuum versus forceps

      • Lack of standardized protocols for the “double set-up” allowing access to prompt Caesarean section
      • Procedural and team checklists

      • Simulation of assisted vaginal delivery technical and non-technical skills

      • Checklist and protocol adherence audits and feedback relating to quality clinical and process outcomes

      • Mentoring and coaching of less experienced providers
      • Regional variation in uptake of MOREOB and ALARM

      • Lack of consistent training on vacuum and forceps across health care providers
      • Competence by Design could evaluate the adequacy of current training and create continuing professional development curricula for infrequently performed skills beyond residency
      ALARM: Advances in Labour and Risk Management; MOREOB: Managing Obstetrical Risk Efficiently.
      Table3Shoulder dystocia
      Knowledge gapsPromising interventionsBarriers to spreadOpportunities for spread
      • Lack of standard definition of shoulder dystocia

      • Lack of common language to identify priorities and urgency of Caesarean section

      • Lack of consistent anticipation and management of this clinical event

      • Lack of consistent documentation

      • Lack of national clinical practice guidelines
      • Simulation of shoulder dystocia management including emergency team responses

      • Procedural and team communication checklists

      • Debriefing skills for use in clinical practice

      • Antenatal patient education tools and shared decision-making guides
      • Lack of mechanisms such as communities of practice to enable high-level knowledge sharing

      • Lack of appropriate incentives for broad interprofessional participation in training and/or drills

      • Variable access to effective simulation models that provide real-time skills feedback

      • Lack of consistent learning culture to facilitate knowledge sharing, reflective practice, and critical incident debriefing
      • SOGC could facilitate broader acceptance of national clinical practice guidelines
      SOGC: Society of Obstetricians and Gynaecologists of Canada.
      Table4Decision to delivery time for Caesarean section
      Knowledge gapsPromising interventionsBarriers to spreadOpportunities for spread
      • Lack of standardized terminology for processes and outcomes

      • Lack of communication protocols clearly identifying the level of urgency of Caesarean section to the necessary physician, staff, and support teams

      • Lack of meaningful measures
      • Structured emergency team response systems

      • Interprofessional communication training

      • Standardizing nomenclature, measuring and reporting on process adherence
      • Perceived lack of trust among disciplines

      • Lack of effective structured communication mechanisms

      • Conflicting priorities for management of urgent surgical cases in each institution
      • Best practices currently existfor operating room prioritization and team communication
      Table5Collaborative care
      Knowledge gapsPromising interventionsBarriers to spreadOpportunities for spread
      • Lack of appropriate definitions

      • Lack of meaningful measures
      • Interprofessional team communication simulation training

      • Structured handover communication processes

      • Shared care roles including most responsible provider clearly defined and documented

      • Structured morbidity and mortality rounds and/or patient safety rounds

      • Team communication audit and feedback
      • Electronic and paper health record hybrids can impede effective collaborative care

      • Workplace culture issues affecting shared team situational awareness and speaking up

      • Current privacy legislation can inhibit information sharing across teams
      • Best practices currently exist for structured handover tools

      • Experienced sites could share positive implementation experiences
      Table6National Panel on Quality Improvement in Obstetrics recommendations
      TopicRecommendations and strategies
      Induction and augmentation of labour• Regional health systems should enable the collection of data on current practices to identify the most impactful parts of induction processes on the quality of care.

      • Create a national oxytocin protocol and implementation package to ensure appropriate patients are induced and appropriate oxytocin doses are used. Implementation should include education of patients, families, and providers.

      • Link implementation efforts in this area to quality improvement initiatives targeting fetal health surveillance training, labour support, and structured handover processes.

      • Use audit and feedback to measure impact of implementation at local and regional levels.
      Assisted vaginal delivery• Standardize continuing professional development goals beyond residency at a national level.

      • Encourage implementation of assisted vaginal delivery checklists and use of simulation to practise technical and non-technical skills, including acquisition and maintenance of situational awareness.

      • Implement plans with attention to workplace culture, engagement of opinion leaders, and appropriate incentives.

      • Develop mentorship models to facilitate consistency in approaches to assisted vaginal delivery.

      • Develop benchmarking tools to measure impact of implementation of assisted vaginal delivery checklists.
      Shoulder dystocia• Develop a clear definition of shoulder dystocia and consensus on unsafe acts.

      • Emphasize consistent drills, especially in the first 5years of practice.

      • Engage in simulation as a tool to clarify team roles and responsibilities when managing shoulder dystocia.

      • Develop methods of creating mobile simulation units that can facilitate shoulder dystocia training by sharing tools and scenarios.
      Decision to delivery time for Caesarean section• Develop standardized terminology and measures for high quality decisions to delivery time for Caesarean section.

      • Set a national standard that all institutions have a plan and policy for emergency response to Caesarean section.

      • Incorporate structured team communication tools into implementation plans to enhance team situational awareness for improving decisions to delivery time for Caesarean section (e.g., team huddles, structured handover).
      Collaborative care• Create national guidelines on a clearly defined most responsible provider role, consultation standards, and structured team communication tools to support collaborative care in obstetrics.

      • Engage in shared interprofessional fetal health surveillance training, and use the opportunity to address safety culture issues and practise speaking up.

      INTRAPARTUM FETAL SURVEILLANCE

      Although it was not singled out as an isolated theme at the national panel, intrapartum fetal surveillance was noted to be an essential component of obstetrical patient safety, validated by current national initiatives. As a result, it featured prominently in many of the discussions and was felt by the panel to be relevant to many of the drafted recommendations. Although several educational and team training interventions have been successful, the panel recognized that there were gaps in consistent and reliable training for physicians, nurses, and midwives in intrapartum fetal surveillance across the country. The SOGC has recognized theimportance of this issue and has issued a statement urging further work in this area.
      • Bow MR
      Perinatal death and hypoxic injury in Canada: can we reduce the incidence?.
      In particular, standardized interprofessional training has been provided as a key opportunity for strengthening collaboration in maternity care.

      OVERARCHING THEMES

      During the panel discussion, it became evident that several themes were represented across all five high-risk areas. They related to the design of training programs, engagement of health care professionals, and the role of existing training and maintenance of competence programs aimed at improving the quality of obstetrical care. The panel indicated there was variability across regions in how health care professionals are trained to address some of the high-risk areas; in particular, not all continuing professional development programs are evidence-based in design. The panel articulated an awareness of how challenging it can be to engage busy clinicians with high-volume workloads; this applies both to continuing professional development programs and to quality improvement efforts. The panel suggested that there is currently a lack of appropriate incentives for participation in continuing professional development. Panel members provided examples of incentives such as Doctors BC, which has provided funding for physicians in each health authority to engage in quality improvement activities. Québec similarly has offered provincial funding for physicians to participate in continuous professional development activities, such as the programs offered by l'Approche multidisciplinaire en prévention des risques obstétricaux (AMPRO).
      Panel members also debated the obstetrical community's readiness to adopt standardized processes such as the consistent use of checklists. The panel noted that checklists have been successfully implemented at some sites but that cultural resistance has prevented their adoption in other regions.
      Finally, the panel commended the SOGC for supporting the Managing Obstetrical Risk Efficiently and Advances in Labour and Risk Management training programs, but it was noted that uptake was variable across the country. Nonetheless, these programs are examples of system-wide initiatives with the potential to broadly improve quality of care in some or all high-risk areas.
      By focusing and coordinating quality improvement efforts across the country, this national panel believes that obstetrical care can move beyond incremental local changes to system-wide enhancements that will benefit Canadian mothers, babies, and families, as well as health care providers. Members of the panel recognized some commonality between their discussions and the recent U.K. report, “Each Baby Counts,”

      Each baby counts: 2015 full report. London: Royal College of Obstetricians and Gynaecologists; 2017.

      including effective interprofessional communication, timing of clinical decisions, and technical skills-based issues. These three high-level concepts influenced the recommendations of the U.K. report and are also reflected in a second joint report on obstetrical care published by the CMPA and HIROC.

      Delivery in focus: strengthening obstetrical care in Canada. Ottawa: Healthcare Insurance Reciprocal of Canada and the Canadian Medical Protective Association; 2018.

      Communication issues within and across health care teams were a leading contributing factor to obstetric medicolegal cases in this latter report and are reflected across the recommendations by the national panel. Practising the acquisition, retention, and recovery of situational awareness is a fundamental concept linked to this theme and was also a focus of the U.K. report. One of the main challenges to maintaining situational awareness in intrapartum care is the sensitivity to time for clinical decisions and resulting actions. Thus, attention to improving individual and team situational awareness is warranted. Finally, several medicolegal cases featured gaps in technical skills, particularly in the interpretation of intrapartum fetal health surveillance data. The panel endeavoured to capture this latter concept in its recommendations.
      Given that these common safety issues have been broadly and consistently identified, the panel supported the fact that quality improvement efforts are essential tools to help address the current implementation gap. These efforts can facilitate rapid evaluation and adoption of evidence-based solutions customized to local needs. Panel members also noted that quality improvement is one approach in the implementation tool box and recommended that health care providers leverage local and national expertise in implementation science to facilitate their efforts. In discussing the implications of implementation, the panel noted that it is important to consider in each setting whether the problem being solved is a knowledge gap, a skills gap, or another determinant of clinician behaviour. Health care providers seeking solutions to these gaps should tailor their approaches accordingly. Similarly, panel members generated several examples of local best practices, and currently evolving regional networks could facilitate the sharing of these potential solutions.
      As the panel reflected on the recommendations generated for the five high-risk areas, challenges were recognized. Some of the high-risk areas had a body of evidence supporting promising interventions (see Figure) that are ready for dissemination. Others lacked clarity in fundamental definitions or measures, and although they had a dearth of evidence, they may still offer opportunities to standardize aspects of care according to available best practices. Furthermore, for some of the high-risk areas, there exist clear standards of care; in others, none are available. Panel members also highlighted that even in cases where standards exist, these require operational adaptation at a unit level that is based on the level of care available and the accessibility of specialized staff. The panel also recognized that checklists featured prominently among the promising interventions. It is important to emphasize that checklists are solutions that need to be applied to the appropriate prioritized problem. The panel recommends that close attention be paid to training, implementation planning, and evaluation of checklists. Finally, because audit and feedback tools feature prominently among the recommendations, it is important to acknowledge that standards for optimization of tools are available in the literature.
      • Brehaut JC
      • Colquhoun HL
      • Eva KW
      • et al.
      Practice feedback interventions: 15 suggestions for optimizing effectiveness.
      Figure
      FigurePromising interventions to improve the quality of care in five high-risk areas.
      The panel wished to convey in this paper a call to action to the Canadian maternity care community. Engaged stakeholders need to work collectively to bring these recommendations to fruition: front-line clinicians, hospital administrators, provincial and territorial medical associations, regional networks, and national bodies (e.g., SOGC, CMPA, CFPC, HIROC, Health Standards Organization, Canadian Anesthesiologists Society, Royal College of Physicians and Surgeons of Canada, Canadian Association of Midwives), as well as provincial governments, provincial perinatal programs, and regional health authorities. Provincial quality councils could also be tremendously helpful in facilitating some of the panel's recommendations. The panel also recognized that accreditation standards and clinical practice guidelines could be powerful levers for change.

      CONCLUSION

      This was a novel experience in Canada to bring together multiple partners in obstetrical care to create action-oriented recommendations focused on quality improvement. We believe that future focused, coordinated efforts will not only reduce medicolegal risk but, more importantly, will also improve the safety of care for Canadian mothers and babies.

      Acknowledgements

      The panel wishes to thank Monique Lafrance for meeting coordination.

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