News: PQI Profiles

A Successful Strategy For Texas Perinatal QI Leaders: Share The Load

Wednesday, February 26, 2020  
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By Lauren Hamilton


Dr. Amanda Wagner DNP, WHNP-BC, CPHQ, CNE is a force in the QI world.



She is unlike most of our member profiles in the scope and breadth of her work; in short, she is a Senior QI and Research Nurse supporting perinatal QI initiatives for the entire state of Texas.


Dr. Wagner, appointed through The University of Texas Health Science Center at Tyler, works for the Population Health department at The University of Texas System which is contracted with the Texas Department of State Health Services (DSHS) to facilitate the Texas Collaborative for Healthy Mothers and Babies (TCHMB). Her role supports TCHMB as their QI nurse, and as such, she works closely with the TexasAIM initiative. TexasAIM is a collaboration between the Texas Department of State Health Services, the Texas Hospital Association (THA), and the nationwide Alliance for Innovation on Maternal Health (AIM).


Dr. Wagner currently spearheads statewide efforts regarding TCHMB’s Maternal Early Warning Systems (MEWS) project. The goal of this project is to support the implementation of MEWS in all obstetrical units and for all perinatal patients admitted to non-obstetrical units. In her words, “I lead a focused effort throughout the state, with a specific cohort of 15 hospitals—to help with their implementation efforts and [get] an idea of what barriers they’re encountering. This gives us an idea of how we can better help the other hospitals in the state. Meanwhile, we’ve also been teaching about MEWS at TexasAIM Learning Sessions, and made resources available through those sessions, so while I work closely with this group of 15, I also work with, and am available to the TexasAIM hospitals…so my role in Quality Improvement is probably a little different from most people’s, since most are leading QI in their own hospital or unit.” Dr. Wagner, in contrast, is the point person for TCHMB’s maternal QI initiatives throughout the state, and does all she can to help QI project leaders statewide implement QI initiatives, or bundles, that are designed to improve maternal quality and safety. “All in a day’s work, right?” she said, laughing. She is quick to point out, however, that her work would be impossible without the direction of the co-chairs of TCHMB’s Obstetrics Committee, Dr. Carey Eppes (who is also the faculty chair for TexasAIM) and Dr. Christina Davidson.


Dr. Wagner’s interest in QI began with her education. While getting her master's degree and becoming a women’s health nurse practitioner, she participated in translating the evidence-based research on maternal health into real life practice and developed a passion for QI work. Shortly after completing her doctorate, the opportunity arose to interview for her current position and she decided to go for it. Somewhat to her surprise, she got the job, which she described as a dizzying career jump. She expected to start in QI, practicing it in her own unit, but instead, suddenly, she was leading a statewide effort.


“We chose Maternal Early Warning Signs because we feel it’s the precursor; it does the most to prevent deterioration of maternal health.”


The year before Dr. Wagner stepped into this role, the Texas State Legislature mandated an effort to reduce maternal mortality and morbidity in the state of Texas. Just prior to this, the State Health Department (DSHS) contracted with the University of Texas system, of which Dr. Wagner’s organization, Texas Collaborative for Healthy Mothers and Babies (TCHMB) is a part, and DSHS was able to launch TexasAIM as their primary effort to meet the mandate. TCHMB wanted very much to be involved and partnered with DSHS to support TexasAIM by launching a patient bundle intended to improve recognition and response to Maternal Early Warning Signs (MEWS). As Ms. Wagner puts it: “We chose Maternal Early Warning Signs because we feel it’s the precursor; it does the most to prevent deterioration of maternal health.”


As part of the foundation for this QI initiative, Dr. Wagner and her team administered a readiness survey to all hospitals who participated in TexasAIM’s first Learning Session. They wanted to assess where in the process of implementing Maternal Early Warning Signs these units were, what their capacity for change was, and whether the culture of their units was conducive to change. These results ranged from “haven’t even thought about it,” to “fully implemented; has been for a while.” They then chose their small cohort of 15 hospitals whom they call the MEWS Reinforcement Cohort-to act as a sample; about half of whom were on the lower end of the implementation, and the other half, already practicing MEWS. They hoped that by studying both ends of the spectrum in this sample, they would get a better grasp on what hospital leaders need to successfully implement MEWS, and how to help them overcome challenges.


“...all QI work is at least a full-time job, and it’s being added on the shoulders of people who already have full--time jobs.”


Dr. Wagner acknowledged that the work being done in the hospital’s perinatal units by QI project leaders can be overwhelming-often it’s difficult to know where they need to start. Then there is the problem of not having enough time. Ms Wagner said “My greatest hope and vision for the future is that each unit will eventually have their own QI person but right now, all QI work is at least a full-time job, and it’s being added on the shoulders of people who already have full-time jobs.” She has found that the units that incorporate multiple people into the role to share the load of leading a perinatal QI effort have greater successes, and that often, this collaborative effort leads to nurses learning how to more effectively do their jobs. “Some hospitals have all the new RN’s on the floor participate in auditing as a way to get it done, but also as a way to teach them how to chart, and what the expectation is for charting on that unit,” she said. She also believes that when you have more eyes on a QI problem, it’s easier to identify what needs to change.


“That’s what QI is all about; start with why, and show them why.”


Dr. Wagner recognized that another hurdle of QI projects is often the need to encourage buy in from perinatal clinicians. She described how it can be difficult for a provider (physician, nurse practitioner, or midwife) to go from getting a call when there’s a problem and ordering medication over the phone, to being expected at the bedside within 30-60 minutes. “None of us, as providers, sign up to hurt people, and I don’t think any provider would say ‘I know I’m not giving safe care,’ so I think going to people who are trying as hard as they can and saying a need to change is going to be challenging--that’s where QI data can really help,” she said. She described how seeing the numbers from audited charts and studies can be sobering and create the necessary motivation. “That’s the way to engage providers. That’s what QI is all about; start with why, and show them why. When we hear it was safer for our mothers to give birth than it is for us, that’s an eye opening statistic, and definitely motivating--we’ll see that trend reverse through this work,” she said.


Dr. Wagner is overall optimistic about the QI projects she is overseeing, and the response she is getting from hospital leaders and providers. She also sees a new fervor for QI as a response to the data and has noticed providers across the state getting inspired by each other’s results. “The enthusiasm for improving Maternal Care in Texas is phenomenal,” she said. “Of 224 birthing hospitals in the state of Texas, TexasAIM has been able to have 217 hospitals sign up to be a part of their efforts,” she said. “These hospitals have been able to do so many things in such a short time and that needs to be celebrated. We’re doing better for ourselves and our daughters and our sisters in the state and throughout the country.”


Dr. Amanda Wagner's advice for anyone engaged in QI work:


  • “My greatest takeaway is that it matters HOW people approach QI work. It’s important to start small. There are lots of tools available, the help is there when you slow down and seek it out.”
  • It’s time consuming and challenging, but I encourage people to embrace QI data. It helps to circle back to your data to reassess what you’re doing.”
  • “It always comes back to the patient.” Dr. Wagner encourages QI leaders to re-focus on the “why,” which is always to improve outcomes for patients, and create a future of maternity care that is safer.
  • “Push that boundary of what is ‘too much work’--we can do this.”
  • “Learn all you can from the QI experts.”

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