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AIM Patient Safety

AIM Patient Safety. OB Hemorrhage Bundle Implementation. How are we doing so far?. 23 of 24 delivery facilities participating in the bundle implementation Kick-Off meeting March 25, 2018 with over 85 attendees Four years of baseline data entered into the AIM Data Portal

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AIM Patient Safety

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  1. AIM Patient Safety OB Hemorrhage Bundle Implementation

  2. How are we doing so far? • 23 of 24 delivery facilities participating in the bundle implementation • Kick-Off meeting March 25, 2018 with over 85 attendees • Four years of baseline data entered into the AIM Data Portal • Three full quarters of implementation data submitted by the participating facilities • Recognized at the AIM National level for our participation rate and progress!

  3. Bundle elements • Process, Structure and Outcome measures • Checklists and toolkits for facilities to reference and use • Resources, references, videos, webinars and electronic modules for education • Policies, forms and protocol samples for building facility specific

  4. How does wESTvIRGINIAcompare? Comparison to other state collaboratives engaged in the OB Hemorrhage Bundle Implementation

  5. SMM among all delivering WomenOutcome measure 2 – Collaborative comparison

  6. Outcome measures

  7. Outcome measure results

  8. SMM among all delivering WomenOutcome measure 2 – WV Collaborative rate

  9. Outcome measure 2WV Hospital Distribution – 2017

  10. SMM among all delivering WomenOutcome measure 2 – WV Collaborative rate

  11. SMM among Hemorrhage casesOutcome measure 4

  12. Outcome measure 4WV Hospital Distribution – 2017

  13. Process Measures

  14. Process measure – hospital distributionHemorrhage risk assessment – Q2 2018

  15. Structure measures

  16. Structure measure 4Hemorrhage cart Does your hospital have OB hemorrhage supplies readily available, typically in a cart or mobile box?

  17. Structure measure 5Unit policy and procedure Does your hospital have an OB hemorrhage policy and procedure (reviewed and updated in the last 2-3 years) that provides a unit-standard approach using a stage-based management plan with checklists?

  18. How do all the elements work together? • Outcome measures are received directly from coding and billing process • Structure measures – tangible items in place • Process measures – policies, protocols, checklists, forms etc.

  19. What issues are we working on now? • Quantitative blood loss • Education • OB Hemorrhage Staged Protocols and Policies • Continue implementing the Hemorrhage Risk Assessments

  20. Process measures – nurse and provider education

  21. Process measure – blood loss measurement

  22. Critical Elements Shift and team huddles to prepare for possible or current changes in patients Immediate debriefs – what went well? What could have gone better? Formal multi-disciplinary case reviews of outlier events and outcomes Support for family during and after event – explanations, education follow up

  23. When will we get there? Data submission for all of 2019 Complete all process and structure measures Celebrate at 2019 Perinatal Summit!

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