News: PQI Profiles

How One NYC Team Implemented Quantification of Blood Loss

Wednesday, December 11, 2019  
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By Siena Davis, MPH, Project Manager, PQI

“You don’t have to have a maternal death from hemorrhage to improve on what you’re doing and begin to quantify blood loss.” -Elizabeth Igboechi

Elizabeth Igboechi, RN, NEA-BC, FNP, CPPS, is the Administrative Director for Patient Safety and Quality Improvement in Obstetrics and Gynecology at the Montefiore Medical Center in the Bronx, New York. She covers the five facilities with gynecology outpatient services and the two facilities with maternity services.



In April 2018, Elizabeth started working with the nurses, OB safety team, and physicians at Montefiore Medical Center to implement quantification of blood loss (QBL). “The reason being that hemorrhage in obstetrics is still one of the leading causes of maternal mortality,” said Elizabeth. At first, the providers and nurses felt they did not have enough time to implement QBL. Elizabeth said, “In the end, we had an event that made it hit home and made it clear that it needs to be done because blood loss was only estimated in that incident.”


To help staff move from estimating to quantifying blood loss, they used the book Influencer: The New Science of Leading Change by Joseph Grenny, Kerry Patterson, David Maxfield, Ron McMillan, and Al Switzler. The authors explain that you can influence behavior change using the following six sources of influence: (1) Personal Motivation, (2) Personal Ability, (3) Social Motivation, (4) Social Ability, (5) Structural Motivation, and (6) Structural Ability.


Personal Motivation


To increase personal motivation, Elizabeth would play YouTube videos that told stories of women who had died from hemorrhage. Elizabeth said, “Play it and then listen to that person who lost their loved one from blood loss. These are young people. Educated people. Highly achieving people. When you make it personal, people begin to think ‘It could have been me. It could have been my neighbor. It could have been my coworker.’” This motivated the nurses and physicians to perform QBL.


Personal Ability


Whenever she saw an opportunity, Elizabeth showed nurses how to perform QBL. Once, Elizabeth was in a room with a nurse who said, “Oh no, we cannot weigh all of these.” Elizabeth responded, “Yes, we can.” She weighed the gowns soaked with blood and then weighed the same number of dry gowns. Elizabeth subtracted the weight of the dry gowns from the wet gowns to determine the amount of blood lost. She heard someone say, ‘If she can do it, why can’t we?” These teaching moments gave staff the skills they needed to perform QBL.


Social Motivation


Peer pressure can be a powerful tool in behavior change. Elizabeth said, “You always have to know who the key players are.” She got buy-in from both nurse and physician leaders. These leaders became change champions for the project. Once the change champions were on board, everyone else followed. The change champions encouraged others to quantify blood loss. They used peer pressure to motivate staff to perform QBL.


Social Ability


“Everybody got into their scrubs – myself, the physician champions, the safety nurse – and we were in the operating room showing people how to do it,” said Elizabeth. Change occurred as more nurses and doctors committed to implementing QBL. Those who had committed to using QBL shared their knowledge and skills with those who were hesitant about the change.


Structural Motivation


Elizabeth noticed that the staff liked to be praised for performing QBL. She said, “Everyone wanted to be part of it and be congratulated for doing the right thing.” In the end, their hard work paid off. “Our goal was to quantify blood loss 85% of the time. We ended up quantifying blood loss 100% of the time,” said Elizabeth. She promised to provide a breakfast or lunch to congratulate staff for exceeding their target.


Structural Ability


For long term change to occur, Elizabeth knew that the structural environment had to support the shift from EBL to QBL. “We bought calculators. We bought scales… We gave them the tools to do it,” said Elizabeth. She made sure every room had a calculator and so that the nurses would have the tools they needed to perform QBL.




 Lessons Learned


Using the six sources of influence to implement QBL has changed the culture at Montefiore Medical Center. Elizabeth said, “We weigh everything and it has become our norm. Nobody talks about EBL now. We talk about QBL.” In addition, the nurses and doctors are more prepared to recognize and respond to blood loss. “We now have timely recognition of blood loss. It’s no longer a huge emergency for us because we are on top of it,” said Elizabeth.


Elizabeth's suggestions for people who are thinking about engaging in QI:


  • “Be the change. You cannot do QI in a vacuum. You have to be part of it.”
  • “Start small. Pick something that people will be passionate about. Start by checking the charts to find out what things you want to improve. Or use your incident reports.”
  • “Ask the people on the unit… ‘give me three things that you want improvement on.’ Find out which one is mentioned most often and pick it. Say ‘You asked for this. What do you want done? Who is going to champion with me?’ It must be actionable and measurable.”
  • “Then be there! Don’t do it from your office.”
  • “Raise awareness. Audit. Post your numbers. And celebrate it.”
  • “Give all the credit to the frontline staff.”

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