Years of Work Helped Make Hospital Births Safer and Safer for Women
Einstein Medical Center Philadelphia has by far the lowest rate in Philadelphia of complications related to childbirth that affect the mother. We talked with David Jaspan, DO, Chairman of Obstetrics and Gynecology for Einstein Healthcare Network, about the continuing patient-safety initiatives that have made these results possible.
Perspectives: What led to the decision to make changes to reduce morbidity for mothers giving birth at Einstein?
Dr. Jaspan: It was approximately six years ago when we began to formally address the national trends. We decided that we wanted to create the safest place for patients to have care. We wanted to change the culture. We wanted to enable all people who cared for or touched a patient, in any fashion, to have the ability and opportunity to speak up and identify a problem.
And then we looked to our colleagues in patient safety and quality. There is an initiative that was started at Johns Hopkins called CUSP, and it stands for Comprehensive Unit-based Safety Project. And what it speaks to is that you ask a question of everybody and then they begin to ask that question of themselves: how can the next patient be harmed? And most importantly, what can I do to prevent it? It was a cultural change to have people open up and communicate and feel free.
What we have been able to do is create a culture and a community where everyone is singularly focused on the care of the mother and the baby.
— David Jaspan, DO
It sounds very simple, but it’s empowering and it goes to the people who clean rooms, bring food, provide the care – anybody. We wanted to create that culture and make it pervasive through our building. And so we are able to spread this CUSP program across the domain of obstetrics.
Perspectives: How did you implement that program?
Dr. Jaspan: We put a team together, and it’s very important to note that there’s no hierarchy on the team. I was a member of the team, but I wasn’t the team leader and the team was made up of nurses, residents, Environmental Services, Dietary, operating room techs, obstetrics techs. And we met and we started asking the questions, how and where can the next patient be harmed and what can I do about it? The program was implemented first on labor and delivery, then in the neonatal intensive care unit (NICU), then on postpartum.
We still use that methodology today. It’s evolved a bit and we have changed the name to a UBCL, a Unit-Based Clinical Leadership model, which is very, very similar.
What we have been able to do is create a culture and a community where everyone is singularly focused on the care of the mother and the baby. And if there’s a concern, raise it. And most importantly, from my leadership perspective, making sure that that concern is addressed.
Perspectives: Can you give an example of another important change?
Dr. Jaspan: Yes. One of my greatest concerns in obstetrics is the patients who are waiting to be seen in obstetrical triage. This is someone who comes in and says, “I’m ready to have a baby,” or “I’m contracting,” or “I have a headache or a stomachache.”
Historically, they were seen in chronological order, no different than going to a shopping center and taking a number, and that’s just not right. What we wanted to do is to come up with a proper way to triage our OB patients. So if you come in and you stubbed your toe, it should be very, very different than if you come in and have abdominal pain.
We went back and looked at all our data and came up with a scoring system so that we can properly evaluate our patients based on their chief complaint, how far along they were in their pregnancy, their initial vital signs and the initial assessment of the baby.
We see about 750 patients per month in OB triage. Roughly 250 of these patients are admitted. That means almost 500 patients have to be evaluated and discharged with a proper plan. So that’s where we wanted to look at how can we make sure the right person was in the right bed, seen by the right provider, at the right time. Our goal was to start from the moment they arrive: how can we create the safest place for them?
It has been a change in culture to do that, and it has been really successful. But it took work and understanding from nursing, residents and physicians to make the change.
Perspectives: Is the change in the triage system the most important initiative that has contributed to these low maternal morbidity rates?
Dr. Jaspan: The most important initiative is empowering everyone to say something. I’ll give you a simple example. Nurses in the triage unit said residents and providers have to move the lights between rooms. They’re pulling the lights, the lights are becoming broken, and therefore instead of six lamps we’re down to one, and it needs to be addressed. And so we addressed it.
Perspectives: Can you give an example of someone unexpected on the team who came up with a suggestion that turned out to be really significant?
Dr. Jaspan: Yes, one of the people who was in transport, moving the patients from room to room, noticed that we have some patients who are larger and we didn’t have appropriate wheelchairs to meet their needs. And there was a potential for them to fall. And so we ordered appropriate chairs to ensure that our patients were able to be accommodated in the safest way.
No matter how small the concern, it gained the same attention and we worked to correct it.
— Dr. Jaspan
Also, one of the OR techs worked at Einstein Medical Center Elkins Park before she came to OB, and she worked in bariatrics. They had a mechanism to move the patients from the stretcher to the table and it was called a HoverMatt. Traditionally we were using a slide board, which took the efforts of the entire team to move the patient to the OR table and put the patient at risk of a fall. With the HoverMatt, you can almost use your fingertips to pull the patient over, regardless of the person’s weight. And so she said, why don’t we have that here? And now we do.
Perspectives: What other steps have helped to minimize complications for new mothers?
Dr. Jaspan: Here’s a large-scale example. We worked with our IT team for years to utilize our electronic medical record to provide us with daily reports. About 18 months ago I began to notice that I was seeing, not a dramatic rise, but a rise, in readmissions for infections at the site of the incision from cesarean sections, so it’d be a surgical site infection.
I put together a team made up of our quality nurse, our infectious disease team, our surgical educators, Environmental Services, and nurses. We went back and evaluated every single step that a patient goes through from the time she’s admitted to the time she goes to the operating room, to her postoperative care, and to her care outside of the hospital after she has the baby. And we evaluated the current medical literature to ensure that we are doing best practices at each and every step.
What we identified is that we could improve, and we put 38 steps in place to create this improvement. Some of it was how patients wash themselves. Some of it was how frequently they’re seen on postpartum, and the timing of their postoperative visit to the doctor’s office.
Perspectives: What was the result of implementing those steps?
Dr. Jaspan: By doing this work, we created an almost zero infection rate. And that’s despite having a population who suffer from poor nutrition and obesity, which would create opportunities for patients to have an increased risk for surgical site infections. We were determined to make a difference for our patients, and those steps are now fully hard-wired into the work that we do.
Perspectives: What other initiatives are important to mention?
Dr. Jaspan: We initiated multidisciplinary postpartum rounds. Historically, patients who delivered and had no medical problems would be seen once by an attending physician and then they would be deemed “stable for discharge.” But we wanted to recognize that there are many things that a patient with an uncomplicated delivery has questions about.
We bring together the multidisciplinary team of the students, the residents, the nurses and the attending physician to see each and every patient after they deliver. We can answer their questions, provide them education, and ensure that they are getting the information that they need and deserve. We enable the patient and the entire family to be a part of the communications about next steps from delivery through postpartum. And it has enabled us, if there are problems in their postpartum course, to see them in real time and be able to intervene.
Perspectives: Any other initiatives you want to talk about?
Dr. Jaspan: We’ve had a lot of them. I will say this: I think that our residents are our biggest asset. And the reason is because they are a stable force on labor and delivery. Though the supervision may change every 24 hours, the OB team is constant through the month. There’s a day team and a night team, but they are the constant and they provide a level of consistency in care and communication that enhances our ability to maintain best practices.
Perspectives: One of the things that is so impressive about these results is that they’ve been achieved in a place where the population overall has above-average risks of complications in childbirth. What are the percentages of these high-risk groups, African American and low-income women, in the patient base?
Dr. Jaspan: About 56% of patients that we care for are African American, and 88% are medical assistance, Medicaid. We believe that one of the areas that we are able to make a difference is through how we provide prenatal care and education. We have a large CenteringPregnancy® program, which provides opportunities for education that far exceed traditional prenatal care. And I think that one of the areas that has been very helpful is working with the patients to improve their health-care literacy, and enabling patients to be their own best advocate and enabling patients and families to speak up.
We have brought [other medical] services into our offices so the patients don’t need to go elsewhere.
— Dr. Jaspan
I think another key component is understanding the resource availability of the patients that we care for. So simply writing a prescription isn’t good enough. We need to communicate about how they can get the prescription and, if they don’t have the funds, what opportunities could be available to them to procure the medicine that they need.
We also have been able to build bridges across departments and divisions to recognize that patients may not have accessed care until they became pregnant. And therefore, when we uncover cardiac disease, pulmonary disease, renal disease, neurological disease, we’re able to quickly coordinate care with colleagues across departments.
Perspectives: Do you take steps to make sure that people get to these other appointments?
Dr. Jaspan: Actually, we go a step further. In our high-risk clinic, we have brought those services into our offices so the patients don’t need to go elsewhere – specifically for HIV management, mental health services and cardiology. Recognizing that diabetes has a significant prevalence in our community, we created something we’re very proud of. We are one of the first in the city, probably the first, to use telemedicine to communicate with our patients. Why did we do that? Because we recognized the difficulty they were having attending appointments. It wasn’t because they didn’t want to come. It was because of transportation, child-care needs, cost of travel. And all we were really wanting to know was what were their sugar levels and what were they eating?
So our high-risk team, our dietician and our nurse practitioners now have the ability to interface with our patients through telemedicine. And it has been an unbelievably successful venture. Their sugar control is better. We have decreased admissions for diabetes-related problems and enhanced the care and compliance with the care.
Perspectives: Some believe that bias is part of the reason that black women have more serious complications in pregnancy nationwide. What has allowed you to keep the morbidity rates as low as they are for black women?
Dr. Jaspan: We treat every patient based on what her complaint is, not the color of her skin or socioeconomic class. It is our responsibility to understand the community that we serve. It’s about creating the trust between the provider and the patient and understanding the fears and concerns a patient may have, and breaking down those barriers to communication. There may be fear that something’s wrong with me, something’s wrong with my baby. And maybe there’s a distrust in medicine, that we aren’t telling the patient everything. So we need to be able to break down perceived or real barriers to care. We have had several department-wide education programs on this very topic. And when we hire people, we hire people who have trained in communities that are no different than Einstein, and they’ve made a choice to be here.
Perspectives: What about from a medical perspective? How do you avoid missing symptoms that might be important?
Dr. Jaspan: I think it’s a matter of enabling patients to feel comfortable communicating and, as I said before, being their own advocate – saying no, I don’t feel this is normal for me. And responding and giving the patient the ability to have her words heard.
Perspectives: A couple of the hospitals in the city that have higher maternal morbidity rates than Einstein say that it’s because they take the most difficult cases. Does Einstein handle high-risk pregnancies and childbirth?
Dr. Jaspan: Yes, we do. We don’t transfer a single person out. We take care of the highest-risk patients. We have patients with histories of preterm delivery, complex surgical histories, complex cardiac histories, complex medical histories. We have transplant patients. We have patients with opioid addiction. We have patients with a history of abnormal placentas. We take care of the breadth and depth of obstetrics no differently than any other hospital.
Perspectives: How did you manage to make so many changes and make them part of the culture here?
Dr. Jaspan: We started this in 2014. It’s a journey, and every day you’re responsible to continue to make sure people realize the importance of their words and their concerns. But in the beginning we needed to have big wins that were visible and dramatic.
Perspectives: So the changes became part of the culture because people saw that they were successful?
Dr. Jaspan: Yes. They saw that the team was listening and responding and closing the loop. We broke down the silos of departments. There was no nursing silo, Dietary silo, Environmental Services silo, physician silo. It’s just people saying, “This is a concern that I have.” It was really people knowing that no matter how small the concern, it gained the same attention and we worked to correct it.
Read more about how Einstein’s safety record compares with other hospitals in the city and the state.