Improving Maternal Safety at Scale with the Mentor Model of Collaborative Improvement

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Background

Obstetric safety bundles, consisting of action steps shown to improve outcomes, have been developed to address the most common and preventable causes of maternal morbidity and mortality. Implementing these best practices across all birthing facilities remains an important and challenging clinical and public health priority.

Methods

The California Maternal Quality Care Collaborative (CMQCC) developed an innovative external mentor model for large-scale collaborative improvement in which participating organizations were subdivided into small teams of six to eight hospitals, led by a paired dyad of physician and nurse leaders. The mentor model preserves the active sharing that enhances improvement across a large group of facilities working on the same project while enabling individualized attention to teams. The mentor model was tested by implementing the obstetric hemorrhage safety bundle (which consists of 17 key practices in four domains) in multiple California hospitals.

Results

A total of 126 hospitals were engaged to simultaneously implement the safety bundle. The adoption rates for the recommended practices in the four action domains were (1) Readiness, 78.9%; (2) Recognition and Prevention, 76.5%; (3) Response, 63.1%; and (4) Reporting and Systems Learning, 58.7%. Mentors (31/40) and participating teams (48 responses from 39/126 hospitals) provided feedback in an exit survey. Among the respondents, 64.5% of mentors and 72.9% of participants agreed that compared to a traditional collaborative structure, the mentor model was better suited for quality improvement at scale.

Conclusion

The mentor model was successful in providing individualized support to teams and enabled implementation of the hemorrhage safety bundle across a diverse group of 126 hospitals.

Section snippets

Organization of the Collaborative

The CPMS collaborative was established by the CMQCC, in partnership and collaboration with the Merck for Mothers initiative. The CPMS collaborative began in January 2015 and lasted for 18 months. Recruitment of participating hospitals and mentors and pre-work was performed between August 2014 and December 2014. During the active phase (January 2015–June 2016), the collaborative focused on implementing maternal safety bundles for hemorrhage followed by preeclampsia. Invitation to participate in

Participating Hospitals and Bundle Elements

Characteristics of hospitals participating in the collaborative are shown in Table 1. Participating hospitals were diverse in size, ownership, neonatal intensive care level, volume of deliveries, patient payer mix, and geography. About a quarter of the participating hospitals (26.2%) had prior experience with participating in a CMQCC maternal safety collaborative.

The proportion of bundle elements completed by the participating hospitals is shown in Table 2. The overall completion rates for the

Discussion

National organizations have developed clinical safety bundles to address the most common and preventable causes of maternal morbidity and mortality, including hemorrhage, preeclampsia, and venous thromboembolism. Focus on these clinical issues has been shown to improve maternal safety and outcomes.5, 6, 32 Implementation of these safety bundles across all birthing facilities is an important step to address high rates of severe maternal morbidity and mortality in the United States. Our

Conclusion

The timely translation of national guidelines into widespread clinical practice is of paramount national importance. Although there is widespread acceptance of collaboratives as a key implementation strategy, we need to expand our understanding of the specific features and individual components of the collaborative that facilitate practice change efforts. Internal mentoring has been shown to be an effective approach for hospital QI initiatives.30, 31 However, many community hospital obstetric

Elliott K. Main, MD, is Medical Director, California Maternal Quality Care Collaborative (CMQCC), and Consulting Professor, Department of Obstetrics and Gynecology, Stanford University, Stanford, California; Member, The Joint Commission's Perinatal Care (PC) Measure Maintenance Technical Advisory Panel; and Member, Editorial Advisory Board, The Joint Commission Journal on Quality and Patient Safety.

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    Elliott K. Main, MD, is Medical Director, California Maternal Quality Care Collaborative (CMQCC), and Consulting Professor, Department of Obstetrics and Gynecology, Stanford University, Stanford, California; Member, The Joint Commission's Perinatal Care (PC) Measure Maintenance Technical Advisory Panel; and Member, Editorial Advisory Board, The Joint Commission Journal on Quality and Patient Safety.

    Ravi Dhurjati, MS, PhD, is Research Engineer, California Perinatal Quality Care Collaborative, Division of Neonatal and Developmental Medicine, Stanford University.

    Valerie Cape, BA, is Program Manager, CMQCC, Division of Neonatal and Developmental Medicine, Stanford University.

    Julie Vasher, DNP, RNC-OB, is Clinical Implementation Lead, CMQCC, Stanford University, and Perinatal Clinical Nurse Specialist, Salinas Valley Memorial Healthcare System, Salinas, California.

    Anisha Abreo, MPH, is Biostatistician, CMQCC.

    Shen-Chih Chang, MS, PhD, is Biostatistician, CMQCC.

    Jeffrey B. Gould, MD, MPH, is Robert L. Hess Professor in Pediatrics, Stanford University; Director, California Perinatal Quality Care Collaborative; and Director, Perinatal Epidemiology and Health Outcomes Research Unit, Stanford University School of Medicine and Lucile Packard Children's Hospital.

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