Perinatal High Reliability: Doing the Right Thing for Every Patient, Every Time

Sunday, June 16, 2013

Title: Perinatal High Reliability: Doing the Right Thing for Every Patient, Every Time

Ryman Hall B4 (Gaylord Opryland)
Charmaine L. Kyle, MSN, RN, EFM-C , Quality, Spectrum Health, Grand Rapids, MI
Erin Keenan Nulf, BSN, RN , Women Infant Services, Spectrum Health, Grand Rapids, MI

Discipline: Childbearing (CB), Newborn Care (N), Professional Issues (PI), Women’s Health (WH)

Learning Objectives:
  1. Summarize the importance of the High Reliability Unit (HRU) in the obstetric department.
  2. Analyze High Reliability Unit (HRU) components and examine how to begin the journey to becoming a HRU.
  3. Formulate plans to implement High Reliability Unit (HRU) principles in the perinatal setting.
Submission Description:
Purpose for the program: High reliability organizations operate highly complex and hazardous systems, essentially without mistakes.  Safety is the hallmark of a high reliability unit (HRU) and is understood to be the responsibility and duty of every team member.  The purpose of this project is to implement the clinical and cultural changes required to establish our Women Infant Services units as HRU’s.

Proposed change: All clinicians have an obligation to speak up for safety.  This project creates the environment and mechanisms supporting team efforts to achieve safety. Activities are geared toward ensuring quality issues are exposed to provide opportunities for prevention. Project activities include daily check-in meetings, increased leadership presence, implementing a process for timely and open review of safety incidents, and communicating findings and solutions to team members.

Implementation, outcomes and evaluation:

Daily Check In (DCI):  DCI reviews the past 24 hours looking ahead 24 hours asking, “Are there any safety concerns?”  The team includes charge nurses from L&D, M/B, GYN, Antepartum, and NICU; nurse management; physicians; social work; pharmacy; and anesthesia.  In the first 10 weeks of DCI, 55 safety concerns were verbalized; 66% resolved the same day and 88% within 5 days. 

Rounding to influence:  Obstetric leaders round twice per month.  Bedside nurses verbalize safety concerns and safety behaviors.  STAR (Stop, Think, Act, Review) and ARCC (Ask a question, Make a Request, Voice a Concern and use the Chain of Command) behaviors are reinforced.  Patient interviews give further opportunity to verbalize safety concerns. 

High Reliability Committee Structure:

  • High Reliability Committee:  Accountability and transparency of safety, quality and patient satisfaction measures
  • Incident Report Committee (ISIS):  Monthly meetings; bedside nurses review incident reports and make action plans.

Debrief/Cause Analysis:  Critical safety events are brought within a week of occurrence.  Participants assess the event from every angle looking for opportunities to improve and make action plans.

Safety Newsletter:  Monthly updates on action plans and safety concerns close the loop of communication. 

Evaluation:  Fall 2012 safety culture survey

Implications for nursing practice: Within the safe culture of a HRU, the authority gradient is lessened and nurses experience decreased stress and increased respect for their contribution to the team. When unusual or unexpected events occur, nurses are empowered to improve bedside practice through the debriefing process and support from the team.  Job satisfaction is increased on units where practice is based on evidence and professional standards. 

Keywords: High Reliability Unit; Safety; Communication

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