By Stephanie Dougherty, BSN;

Jeanne Whaley, RN;

Ardath Youngblood, BSN, MN;

Robert M. Pickoff, MD, MMM

In a series of articles in Patient Safety and Quality Healthcare, we will describe the replicable process we have used at Hunterdon Medical Center to improve patient safety and create high reliability throughout the system, focusing first on maternity care. On this journey, we discovered that maternity physicians and nurses, unit coordinators, midwives, technicians, and administrators are caring, dedicated professionals truly committed to improving the safety of care. They have devoted themselves to developing excellent communication skills, high-reliability characteristics, evidence-based practice, and healthy professional relationships, enhancing the safety net for our patients.

Behind the Scenes
Hunterdon Medical Center (HMC) is a 178-bed, non-profit community hospital in New Jersey, approximately 40 miles west of New York City. HMC provides a full range of services: preventive, diagnostic, and therapeutic; inpatient and outpatient; hospital and community health. HMC includes a regional cancer center affiliated with Fox Chase Cancer Center, a cardiac catheterization suite, a sleep disorders center, and an active diabetes center, among many other services. Our shared-governance nursing model encourages active participation of staff nurses in the development of policy, education, and other important issues affecting nursing practice. Nurses are eligible for tuition reimbursement and are rewarded financially for continuing their education, for specialty certification, and for participation in unit- and hospital-based projects. Nursing satisfaction is high, and our turnover rate is low. We are a teaching hospital with one of the oldest accredited family practice residencies in the country.

In 2004, our administrative staff initiated patient safety rounds on our patient care units in response to Joint Commission recommendations and published literature, for example, To Err Is Human, the seminal publication by the Institute of Medicine (2000). Through the use of rounds and root cause analysis, our patient safety officer and members of the senior administrative team could see the role that dysfunctional communication and relationships among healthcare workers played in adverse events, even in our tight-knit community hospital. Stories of chronic disruptive behavior, intimidation, lack of respect, practice based on old models of care, and retaliatory behavior came to light in conversations with staff, as administrative staff built trust that they really were there to listen and respond with authentic action. We learned that you won't get substantive answers if you don't ask tough questions. The key "wicked question" we asked nurses, doctors, technicians, pharmacists, and all healthcare workers was, "What keeps you up at night about the way we deliver care?" a word of caution: Be prepared for a deluge of issues to come forth, if you are there to listen. We heard about well meaning, highly trained, advanced-degree professionals exhibiting behaviors that were perhaps adaptive, but deviated far from what you would expect, all in an effort to deal with abnormal, hierarchical relationships, and faulty systems.

It is one thing to read that communication is a leading cause of sentinel events; it is quite another to see for yourself the impact it has on delivery of care in your own hospital.

The Choice: Begin in Maternity
A convergence of events — published literature on causation of adverse events in maternal newborn care, claims analysis, a Joint Commission Sentinel Event Alert, and a lawsuit — galvanized Hunterdon's resolve to discover and address anything that was compromising the safety of its patients. This has become our passion: To prevent adverse events and foster a patient-safety-first culture based on healthy professional relationships, high reliability characteristics, and evidence-based best practices.

Despite the fact that Hunterdon had already started a journey toward improved safety, in 2004 a patient in the 20-bed Maternity and Newborn Care Center at HMC suffered a preventable adverse event that obligated us to look even more closely and urgently at the care we provide. a wise person once said, "There is always more to the story," and as we delved into the causative factors behind this incident, we found that was the case.

We were familiar with the Joint Commission's Sentinel Event Alert Issue #30, Preventing Infant Death and Injury During Delivery (2004), which lists the issues most commonly involved in adverse perinatal outcomes — often several of these contribute to a specific adverse outcome. Table 1 lists some of the most common root causes found by the Joint Commission.

Table 1. Root Causes of Perinatal Death and Injury* Root cause % of time problem affected outcome Communication issues 72% Culture issues (i.e., intimidation, hierarchy) 55% Staff competency 47% Orientation & training 40% Inadequate fetal monitoring 34% Credentialing/privileging/supervision of physicians & certified nurse midwives 24% Physician delayed or unavailable 21% Prenatal chart unavailable 11% *Most injury and death cases had more than one cause. Data from Joint Commission Sentinel Event Alert Issue #30

We decided to start with this list as we began to evaluate the culture of safety in our Maternity and Newborn Care Center.

Communication
Communication patterns between team members on our perinatal unit provided many opportunities for improvement. Nurses, obstetricians, midwives, pediatricians, neonatologists, and family practice physicians did not see themselves as a team. The concept of team had to be developed and promoted. While the physicians and staff shared a common goal — healthy mothers and babies — the processes leading to that goal were fraught with communication pitfalls. Adverse outcomes were rare, but near misses were not. Communication between nurses and physicians suffered from lack of respect, disruptive behavior, intimidation, production pressures, environmental limitations, and other stressors.

Physician Delayed or Unavailable
Our care providers are often in the office building or the operating room while patients are laboring, and nurses often speak with office or operating room staff rather than directly to the physician. Nurses are not always assertive when attempting to contact physicians with concerns, nor are telephone conversations consistently satisfactory for the nurse or the physician. Office staff may say the physician is "in with a patient," and instead of insisting on speaking to him or her immediately, the nurse may ask for the physician to call back as soon as possible. The urgency of the message may be lost by the time the physician receives it. On other occasions, physicians say it was not clear to them that they were being asked to come to labor and delivery right away, but nurses thought they had described the emergency well enough that the physician would rush to the unit. When additional calls to the physician become necessary, irritation and a perception of conflict often develops among the physicians, their office staff, and the maternity nurses. Ultimately, if nurses don't make critical messages clear, the hospital and the nurse will be held accountable.

Hierarchy and Intimidation
Several approaches were used to uncover staff concerns about poor communication patterns, ingrained behaviors of intimidation by providers, and an inability to confront these behaviors. Nurses were reluctant to act for patient safety or to activate the chain of command, because of tolerated or "normalized" patterns of perceived and actual intimidation from physicians and midwives. The nurse manager interviewed each nurse about her perception of intimidation on the unit. Every nurse but one said she had either experienced intimidation or witnessed it.

Further conversations with the nurses indicated that most of the intimidation was related to the management of oxytocin for induction or augmentation, interpretation of fetal heart patterns, and issues in the operating room. Experienced labor and delivery nurses described the conflict avoidance techniques they had adopted with physicians, expressing weariness about frequently facing adversarial communication.

These maladaptive communication patterns were very similar to those described by Simpson et al. (2006). For example, nurses reported being aware of the physician's order for increasing oxytocin, but actually increased the rate less frequently due to concerns about the fetal heart patterns, contraction patterns, or because other demands on their time made adequate supervision of the patient impossible. Nurses did not always report these decisions immediately to the physician, anticipating that they would not be pleased. Nurses felt that physicians were not responsive to their concerns, and assumed physicians would become angry and ask for "experienced nurses who were not afraid to increase the oxytocin."

Staff Competence and Fetal Monitoring Training
Many nurses and other staff participated in formal continuing education on fetal monitoring, which Hunterdon Medical Center encouraged by providing funds for conferences. However, the expectation that all nurses and all physicians would participate in a joint, standardized fetal heart monitoring course had not been established. Due to normalized deviance and no formal requirement for all nurses, physicians, and midwives to use standardized definitions/actions for fetal monitor strip interpretation, there was too much variation in recognition and appropriate care. This is a common issue and is well documented in the literature.

Post partum/ante partum (PP/AP) nurses, who had only received a basic fetal monitoring class and who used their skills infrequently to monitor stable ante partum patients, and the labor nurses, who have more advanced training and experience in monitoring laboring patients, were all tested using the same national sample of test questions. We were very surprised to find the PP/AP nurses scored higher on the fetal monitor exam — higher than the labor nurses who used the fetal monitoring extensively. As we thought about this finding and talked to our nursing staff, we learned that the PP/AP nurses tended to go "by the book" in interpreting the strips and choosing interventions. The labor nurses on the other hand, had "normalized deviance" in tolerating concerning fetal heart-rate (FHR) patterns. They had various explanations:

• "You often get reflex lates after epidurals."
  
  
• "How are you going to get her delivered if you always decrease or turn off the oxytocin for every little thing?"
  
  
• "Yes, there are a lot of contractions, but the baby still looks OK." (The baby hasn't "declared" himself, meaning the baby hasn't yet shown extreme signs of distress.)
  
  
• "But we're pushing; the baby's always stressed while we're pushing."

Labor nurses feared that doctors wouldn't want to work with them if they were too literal in their interpretation and management of fetal monitor strips. Some doctors would say, "I will never get my patient delivered if the nurse isn't willing to increase the oxytocin." These responses are similar to the responses Simpson encountered at other community hospitals. Simpson et al. (2006) looked at communication and interdisciplinary teamwork in the community hospital setting where labor is often largely nurse-managed — as it is at Hunterdon Medical Center — and communication with the care providers is on an "as needed" basis by phone. They found that both nurses and providers were willing to tolerate periods of a non-reassuring FHR pattern as long as they intuitively believed the fetus was doing well overall. This intuition doesn't always hold true and isn't best-practice (Knox et al., 2003). It was noted by Simpson that the physicians in community hospitals depended almost exclusively on nurses to manage labor while they are off-site. Physicians want to be in control but not if that means being contacted often or being on-site unless there is really a need (Simpson et al., 2006). We found these issues to be in effect in our system.

At our facility, physicians and nurses did not have a common nomenclature to describe fetal heart rate patterns and had not agreed on a common definition of fetal well-being. Most of the nurses used terminology from the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN) Fetal Monitoring Principles and Practice Workshop current at that time, as this course was part of their orientation process. The physicians did not have a standardized language, and their interpretation of fetal heart-rate patterns depended to a large degree on where they had trained. We had not all been trained in the new National Institutes of Child Health & Development language, and had not all taken a standardized fetal monitoring course.

Fetal Monitoring Issues
We did not have central surveillance for fetal heart-rate monitoring because we feared it might take labor nurses away from the bedside. The unanticipated result was no team oversight of non-reassuring fetal heart patterns. Our nurses did not have anyone else looking at their strips unless they asked for backup opinions, and if they had more than one labor patient at a time, the nurses had to move from room to room, monitoring patients the best they could.

The Solutions
As the complexity of the issues became apparent, we realized the situation was beyond an easy fix. Transforming our culture could not be accomplished within or by the unit itself and not without strong administrative leadership and support.

Some of the first problems we identified and the easiest to remedy were technology issues. As each piece of old equipment was discovered, it was replaced. One interesting part of healthcare culture is to "make do the best you can with what you've got." Budget constraints and a lack of appreciation for the impact of using work arounds for old equipment contributed to the complex roots that needed to be pulled. Rapidly reassessing the technology and equipment issues with our new patient safety eyes led us to purchase centralized monitoring and replace older equipment.

Time Spent to Uncover Truth:
A Wise Investment
Our experience demonstrated the value of being present on the unit on a daily basis. We discovered that the only way to see and hear what is really going on is to spend time and show presence in the unit. We became familiar with the day-to-day work of the unit, developed trust with the staff, established a daily review of issues that surfaced, and cataloged issues that need a solution. Proximity is reality. This allowed us to analyze critical issues that have been around so long they had become "normal." Administrative patient safety walk rounds brought authority and accountability face to face with the challenges that our committed and caring providers had "known all along" but had not the ability or the clarity with which to take action.

We trust this first article explains how we exposed and analyzed safety problems on one of our units, how we used patient safety walk rounds throughout the organization and why we decided to focus our patient safety improvement efforts first in maternity. In future articles, we will describe in more detail the leadership, training, and technology we used to accomplish significant, replicable, and sustainable patient safety improvements.

Technology Overview To improve the safety of care in its Maternity and Newborn Center, Hunterdon Medical Center used products and services available from Quantros, SaferHealthcare, OBIX, and the Patient Safety Group.

Stephanie Dougherty is the director of patient safety and risk management. She has been certified in critical care nursing, gastroenterology, and has completed ASHRM's Healthcare Risk Management Certificate Program. She is past president of the New Jersey Society of Healthcare Risk Managers, and has presented patient safety topics at conferences in New Jersey, at the VIPCS annual conference in Virginia, and at the Quantros User Group Meeting in Las Vegas. Dougherty holds a bachelor's degree in nursing from William Paterson University in New Jersey and is a graduate of the Patient Safety Fellowship program at Virginia Commonwealth University. She may be contacted at dougherty.stephanie@hunterdonhealthcare.org.

Jeanne Whaley is director of the Maternal Newborn Care Center. She has chaired the Nursing Management Council and sits on the Medical Service Performance Improvement Committee. She also sits on a multi-facility Continuous Quality Improvement Council for the Central NJ Maternal Childhealth Consortium and is on the Steering Committee for Hunterdon Medical Center's quest for Magnet designation. She is an AWHONN Fetal Monitoring Principles and Practices instructor. She is certified by NCC in in-patient obstetrics, by ANCC in nursing administration, and is a member of AWHONN, and NANN. Whaley has a bachelor's degree in nursing from Rutgers University in New Jersey.

Ardath Youngblood is co-leader of the interdisciplinary maternal child health safety initiative in the Maternity & Newborn Care Center. She is a NRP, S.T.A.B.L.E. and AWHONN Fetal Monitoring Principles and Practices Instructor and is certified as an International Board Certified Lactation Consultant. Youngblood is a member of AWHONN, NANN, Sigma Theta Tau, and sits on the Central NJ Maternal Child Health Consortium's Education Council. She received her BSN and MN from Emory University School of Nursing in Atlanta.

Robert Pickoff is chief medical officer of Hunterdon Healthcare System. After graduating from the Mount Sinai School of Medicine in New York, he completed an internal medicine internship and residency at Beth Israel Medical Center in New York and a Fellowship in Cardiovascular Diseases at The Saint Vincent's Medical Center, where he was the Dr. William J. Grace Fellow. He practiced cardiology in New Jersey for 14 years. Pickoff holds a master's degree in medical management from Tulane University in New Orleans.

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