Improvement Strategies: Step 1

These will take your time but incur little or no costs.

  • Review ALL pertinent documents that address collaborative management, consultation and transfer. Assure consistency and currency, with participation from RN, CNM, and MD colleagues, risk managers, and legal counsel. Establish an organization-wide standard for documenting collaborative management, consultation, and transfer of care.
  • Document contemporaneously and note time. Avoid making a late entry. Document accurately. Document objectively. Document completely. Document legibly. Modify sample delivery notes for shoulder dystocia and operative vaginal deliveries. Discuss facts as you understand them with other clinicians before making notes to assure completeness and accuracy. Do not argue or shift blame in the chart.
  • Adopt NICHD EFM nomenclature. Monitor compliance.
  • Put a realistic and effective chain of communication policy and plan in place.
  • Adopt across the organization, including Anesthesia and Pediatrics: Inappropriate Use of the Terms Fetal Distress and Asphyxia, ACOG Committee Opinion #326, December 2005. Monitor compliance.
  • Agree on a common definition of hyperstimulation. Use this in all clinical guidelines.
  • Adopt common terminology to be used organization-wide regarding timing of Cesarean section and agree to definitions (stat, emergent, urgent, scheduled?). Monitor compliance.
  • Adopt cord gas guidelines. Monitor compliance.
  • Adopt placenta pathology guidelines. Monitor compliance.
  • Identify the secondary influences that may be subtly affecting patient care decisions in your setting such as productivity pressure, desire to please VIP patients, unit identity to rebel against national trends, fatigue and burnout. Reach consensus about how to handle these.
  • Read your state's "apology law." Discuss this with risk management and come to an agreement on how and when this will be used in your setting.
  • Structure patient "hand-offs" as a real-time, interactive process of passing information from one clinician to another for the purpose of ensuring continuity and safety of a patient's care. Minimize interruptions (some groups post a sign on the door and have the support staff answer pages). Convey all key information (mnemonics are available to ensure complete communication). Ask and respond to questions. Confirm 'ownership' of management.
  • Have staff members complete the vocabulary exercise. Use these words in committee work and in conversations with organizational leadership.
  • Establish a mechanism to monitor, distribute, and review new documents that change current clinical guidelines, practice, or standards.
  • Create a file for archived and current clinical guidelines, a directory of past and current insurers including the type and limits of liability insurance, and a list of resources that can help when questions arise.
  • Call a time-out with the family and team during labor and agree on the time that each stage/phase begins. This is crucial for second-stage management.
  • Learn about techniques such as SBAR and closed-loop communication. Champion and implement the use of structured communication techniques in your setting.
  • Distribute and utilize an OB Pocket Guide throughout your organization once it becomes available.