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Birth Injuries, Liability Claims Reduced by Hospitals in National Program

Initial results from one of the nation’s largest and most sophisticated perinatal improvement initiatives suggest hospitals can reduce harm to babies and mothers, and lower associated liability claims and pay-outs, through the use of high-reliability perinatal teams.

Results from Phase 1 (2008-2010) of the Premier Perinatal Safety Initiative (PPSI), a Premier healthcare alliance project, show that the 14 participating hospitals have reduced harm and liability since the program’s baseline period (2006-2007).

In relation to harm, PPSI hospitals have reduced, on average:

  • Birth hypoxia and asphyxia, which can cause infant brain damage, by 25 percent.
  • Neonatal birth trauma, which can range from minor bruising to nerve or brain damage, by 22 percent. In addition, all hospitals were below the 2008 AHRQ Provider Rate, a national comparative rate measuring perinatal harm.
  • Complications from administrating anesthesia during labor/delivery, which include cardiac arrest and other cardiac complications, by 15 percent.
  • Postpartum hemorrhage, the most common cause of perinatal maternal death in the developed world, by 5.4 percent.
  • The adverse outcome index rate, which measures the number of patients with one or more of the identified adverse events as a proportion of total deliveries, by 7.5 percent.

Because of these improvements, approximately 110 fewer mothers and babies experienced these harms.

Reduced liability claims

In addition, participants decreased the number of annual liability claims filed per delivery by 39 percent vs. 10 percent at non-participating hospitals. And whereas all PPSI hospitals averaged a total of 18 claims per year and project wide during the baseline period, that number dropped to 10 in 2009 and is trending to be at 8 in 2010.

Findings on liability claims and losses are current through November 2012. Because it typically takes two years or longer for a claim to be filed after an injury, final liability claims and losses will not be closed for some time. These results, however, provide clear insight into the trend in claims and losses.

Launched in 2008 by Premier and affiliate liability insurer American Excess Insurance Exchange, RRG (AEIX), PPSI participants are large and small, teaching and non-teaching, system-based and stand-alone, with employed and non-employed physicians. They represent 12 states, in which approximately 250,000 babies will be delivered over the collaborative’s five years (2008-2012).

“There’s no other area in a hospital where providers routinely treat two distinctly different patients at the same time,” said Susan DeVore, Premier president and CEO. “Even though childbirth is so complex and unique, serious adverse events during labor and delivery are rare. But they do occur - sometimes they’re preventable, but they’re always devastating for babies, mothers, families and care providers.”

“The PPSI seeks to better define preventable perinatal harm and identify care practices that can result in improved outcomes,” continued DeVore. “Our results to date suggest that doing so can lower the incidence of certain infrequent, though serious, birth injuries and their associated liability claims. And the diversity of the participating hospitals also lends well to possible replication of the project and its results nationwide.”

Leveraging knowledge gained from previous initiatives, including an Institute for Healthcare Improvement (IHI)/Ascension Health/Premier collaboration, PPSI hospitals use two powerful methods to create high-reliability healthcare teams: increased adherence to evidence-based care bundles and enhanced communication and teamwork.

Increased adherence to evidence-based care bundles

Research shows that grouping essential processes together in care bundles helps clinical staff remember to take all of the necessary steps to provide optimal care to every patient, every time. Although many hospitals have long followed some or all of these individual care practices to improve perinatal outcomes, the key is consistently using all of them in concert.

Care bundle adherence is scored in an “all-or-none” fashion; the care team must provide all elements of care in the bundle to be given credit for its use. For example, one care bundle is focused on reducing the risks associated with augmenting labor, particularly in using oxytocin, a drug that accelerates a slow labor. This bundle has four elements that must be practiced consistently. If a team neglects to estimate the fetal weight before administering the medication, it would not receive credit for the work, even if team members successfully implemented the three other elements of the bundle.

PPSI hospitals have significantly improved compliance with care bundles over the course of Phase I. On average:

  • Elective Induction bundle compliance increased 52 percent, from 58 percent to 88 percent.
  • Augmentation bundle compliance increased 118 percent, from 33 percent to 72 percent.
  • Vacuum bundle compliance increased 467 percent, from 9 percent to 51 percent.

These improvements led to 106,000 additional mothers receiving evidence-based care bundles.

"Over the past several years, our team has established a number of quality interventions designed to increase safety for moms and babies and reduce the incidence of already very rare perinatal injuries," said Tiffany Kenny, RN, MSN, C-EFM, OB informatics administrator at Summa Akron City Hospital in Akron, Ohio. "By following evidence-based care models, we've improved the quality of our Elective Inductions, lowered the C-section rate for low-risk first time mothers and improved overall safety."

Enhanced communications and teamwork

PPSI hospitals have implemented the following proven strategies for certain high-risk protocols:

  • TeamSTEPPS®: Developed by the U.S. Department of Defense and the Agency for Healthcare Research and Quality (AHRQ), TeamSTEPPS produces highly effective medical teams that optimize the use of information, people and resources to achieve the best clinical outcomes.
  • Situation Background Assessment Recommendation (SBAR): An effective situational briefing strategy, used by the U.S. Navy, to communicate relevant case facts in a respectful, focused and effective manner.
  • Simulation drills: Exercises featuring actresses and mannequins reacting as real patients during the birthing process.

“These principles and strategies provide a foundation of clear communications tools and close to real life scenarios for use by obstetric, NICU, anesthesia, blood bank and lab teams,” said Becky Gams, RN, MS, APNL, University of Minnesota Medical Center, Fairview, and University of Minnesota Amplatz Children’s Hospital.

According to Phillip Rauk, MD, a University of Minnesota perinatologist, “The reward is observing all of the team members transfer these skills to real life situations involving patients and their families.”

The PPSI’s Baseline Phase consisted of the retrospective collection of harm outcome data from 2006 and 2007 to establish a baseline of performance. During Phase I, healthcare teams implemented interventions and actively worked on performance and perinatal safety improvement across approximately 145,000 births.

Phase II began in January 2011 and will be completed in December 2012. In June 2010, AHRQ awarded a three-year demonstration grant to PPSI participant Fairview Health Services to extend the initiative. The grant allowed for the Phase II extension, which is examining hospital bundle compliance and associated outcomes, and the role of hospital culture in perinatal performance improvement to further reduce harm and liability. The University of Minnesota School of Public Health and the National Perinatal Information Center will continue providing specialized data and analytic services during the grant phase. Premier will begin analysis of Phase II results when the PPSI concludes. Results from the entire initiative will be made public in the summer or fall of 2013.

About the Premier healthcare alliance, Malcolm Baldrige National Quality Award recipient

Premier is a performance improvement alliance of more than 2,700 U.S. hospitals and 90,000 other sites using the power of collaboration and technology to lead the transformation to coordinated, high-quality, cost-effective care. Owned by hospitals, health systems and other providers, Premier operates a leading healthcare purchasing network with more than $4 billion in annual savings. Premier also maintains the nation's largest clinical, financial and outcomes database with information on 1 in 4 patient discharges. A world leader in delivering measurable improvements in care, Premier works with the Centers for Medicare & Medicaid Services. Headquartered in Charlotte, N.C., Premier also has an office in Washington. Stay connected on Facebook, Twitter and YouTube.

About American Excess Insurance Exchange, Risk Retention Group (AEIX)

AEIX provides excess professional and general liability insurance to not-for-profit hospitals and health systems. To qualify for participation in AEIX, an organization is required to maintain a minimum self-insured retention of $2 million and an in-house professionally staffed claims and risk management group. AEIX can provide up to $40 million in limits without the use of facultative reinsurance. AEIX is organized as a Vermont licensed reciprocal risk retention group, an insurance company authorized under federal legislation for the purpose of providing liability lines of insurance to its members.

About Premier Insurance Management Services Inc. (PIMS)

Incorporated in 1987, PIMS is an Illinois for-profit corporation wholly owned by Premier Inc. PIMS provides contracted management services for American Excess Insurance Exchange, Risk Retention Group (AEIX), and is attorney-in-fact for Premier Insurance Exchange, Risk Retention Group (PRx). PIMS also serves as program manager offering enhanced sponsored programs with leading commercial insurers through a comprehensive portfolio of property, casualty and employee benefit products. Other services include providing claims and risk management assessments and education offerings regarding medical professional liability for hospitals and their physicians. For more information, visit

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