An L & D's Journey in Establishing a Culture of Patient Safety and Teamwork

Commitment to patient safety is a leading issue for hospitals and healthcare leaders.The 1997 publication Demanding Medical Excellence (Milesnson 1997, Chicago Tribune, University of Chicago Press) combined with the Institute of Medicine’s 2000 press release, To Err is Human, laid the groundwork for the present national movement in hospitals and healthcare facilities to improve communication and prevent patient harm.  This has required not only major adjustments in healthcare systems but also implementation of best practices and changes in the underlying culture in which patient care is provided, evaluated, implemented, and improved.

The foundation for this culture change began four years ago with a review of maternal deaths, major maternal morbidity, and birth trauma results within our unit.  This data was then used to consider methods to improve reliability and increase patient safety. The framework to create a dominant culture of high reliability and improved communication involved:

• Leveraging nurses’ skill and experience to open dialogue
• Demonstrating mutual respect among nursing and medicine
• Creating a learning environment driven by the needs and concerns of the nurses
• Creating an environment where all providers can speak freely and fearlessly
• Utilizing information obtained during rounds to create an action plan based on not only evidence-based practice but also individualized patient needs and collaborative communication
•  Developing a common language   

In an effort to enhance nurse-physician communication, routine daily patient safety rounds began on our labor and delivery unit.  Nursing and OB leadership provided the organizational structure, format, and goals, as well as demonstrating leadership concepts of commitment and mutual respect.

Each patient is presented by the primary nurse or OBCP to the care group comprised of nurses, OBCPs, OB anesthesiologists, social workers, and NICU representatives and are held twice daily. The rounds are facilitated by nursing leadership, the nurse-in-charge, as well as the attending obstetrician supervising obstetric care on the unit for that time frame.   The patient’s history is concisely presented and the nurse is given the opportunity to present any concerns.  A multidisciplinary discussion ensues and a plan is formed.  Over time, communication techniques aimed to promote clarity, mutual respect, and situational awareness were added. Staff are required to use NICHD nomenclature to describe fetal heart tracings and other communication tools such as SBAR and closed loop communication are encouraged.

Results

Decreases in poor obstetrical outcomes and sentinel events have been demonstrated since the implementation of Safety Rounds.  Results of staff satisfaction questionnaires showed improvements in:

·         Feelings of empowerment

·         Communication

·         Situational awareness

·         Commitment to patient care

·         Teamwork

·         Accountability

·         Learning/mentoring

·         Patient-centered care

·         Mindfulness

·         Culture change

Other quality improvement projects were initiated during this time frame. It is unclear whether the improved outcomes reported are attributable to any single effort, however, the safety rounds are unique in they have had a direct impact on nursing participation in the patient’s plan of care, and the nurse’s perception of the influence her knowledge and input have on the team’s effort.