A Special Edition PQI Profile

"The lessons of Little House on the Prairie are not relics of a bygone era. We are invited to forgive where bitterness tempts us, to show patience in the face of provocation, and to extend kindness even when cruelty feels easier. We are called to stand for what is right, even when others remain silent, and to let love of neighbor guide us above all else.”

Clifton J. Kenon, DNP, MSN, RN, FAAN, FAWHONN, IBCLC, wrote the following message that he posted on Facebook. His message resonated with the PQI team and so, with Dr. Kenon’s permission, we very pleased to share his message of compassion and neighborly love that binds us together. 

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Where is Walnut Grove Today…..

Modern life often feels like a storm of noise—social media shouting matches, endless headlines stoking division, and communities pulled apart by suspicion and mistrust. The issues dominating our conversations—freedom of speech, political violence, racism, ableism, elitism, and more—seem overwhelming, even unprecedented. Yet they are not new. Our society has faced these challenges before, and the question has always been the same: how will we respond?

One unlikely but enduring guide is Little House on the Prairie. Though remembered as a frontier drama, the series carried a deeper message: how ordinary people can live with integrity in extraordinary times. Through its gentle storytelling, it offered lessons about forgiveness, neighborly love, patience, humility, and moral courage. These are the very virtues that can help us face today’s storms.

For the Ingalls family and their neighbors, survival was never guaranteed. They endured crop failures, illness, discrimination, and harsh winters—obstacles that demanded resilience and cooperation. Communities survived because they leaned on one another, even across lines of difference. Our challenges may look different, but the parallels are striking. Instead of prairie fires, we face the flames of political division. Instead of a plague of locusts, we face epidemics of loneliness and mistrust. Just as pioneers could not endure without solidarity, we cannot navigate modern crises without rediscovering the values that bind us together.

One of the show’s most powerful themes was the Ingalls family’s willingness to stand against prejudice, cruelty, or injustice—even when neighbors or church members chose silence, or worse, opposition. Time and again, Charles and Caroline Ingalls showed that conscience must not be surrendered to comfort. They reminded us that moral clarity is often uncomfortable and rarely popular. In these moments, Rev. Alden served as a steady moral compass. His sermons and counsel consistently returned to one central truth: love your neighbor above all. He was not preoccupied with rigid rules or ritual; he called the community back to compassion, reconciliation, and the dignity of every person. His voice was a quiet but unwavering reminder that true morality requires action, not avoidance.

The series also illustrated that forgiveness was not weakness but strength. On the frontier, grudges could isolate families, and isolation could mean ruin. Reconciliation was not optional—it was necessary for survival. Equally essential was the ethic of neighborly love. Neighbors brought food during famine, rebuilt barns after fires, and tended children during illness. This ethic of care was not sentimental—it was practical. Without it, Walnut Grove could not exist. Today, survival may not depend on a neighbor’s sack of grain, but it does depend on trust, compassion, and shared responsibility.

The moral compass of Little House on the Prairie was not abstract—it was lived out in stories that still speak to us. In one memorable storyline, Walnut Grove was divided by outside pressures, and the question became whether the town would remain united under both their shared faith and the ideals of the country they loved. The Ingalls and Rev. Alden reminded the community that honoring both God and nation required them to set aside selfish quarrels and embrace sacrifice for the common good. It was a reminder that patriotism without compassion is hollow, and that true faith demands service to others. In another powerful episode, when children of color were barred from attending the local school, Charles and Caroline Ingalls stood firmly for inclusion. They faced scorn from neighbors and resistance within their own church, but they chose justice over silence. Rev. Alden underscored the point: loving your neighbor meant standing with the vulnerable, even when it was unpopular.

And yet, even as the Ingalls stood for what was right, they also modeled something harder: empathy for those on the other side. Time after time, the very neighbors who spread gossip, stirred division, or acted out of fear and prejudice were not written off forever. They were met with patience, compassion, and, when possible, forgiveness. This is perhaps the hardest lesson for us today—that loving our neighbor means not only defending the vulnerable, but also extending grace to those who have caused harm. It does not excuse their actions, but it refuses to abandon their humanity. And in the face of death, the lesson was clearest of all: loss of life is never to be celebrated. Even those who caused pain left behind families, often widows and children, who deserved compassion, care, and love. The show echoed what is also a biblical truth—that to honor life means to tend to the grieving, and that our highest calling is to comfort the brokenhearted.

The struggles of our time—whether around speech, violence, racism, or inequity—may feel unique, but they are part of a long human story. Little House on the Prairie reminds us that every generation faces moments when fear, prejudice, and selfishness tempt communities to fracture. And every generation must choose: division or unity, bitterness or forgiveness, silence or courage. The enduring gift of the show is its reminder that communities flourish only when people commit to one another, even at personal cost. To love a neighbor is not to agree with them on every issue—it is to treat them with dignity, extend generosity, stand with them when others turn away, and care for the wounded left behind.

The lessons of Little House on the Prairie are not relics of a bygone era. They are guideposts for today. The call is not to retreat into nostalgia, but to live these principles in the present. We are invited to forgive where bitterness tempts us, to show patience in the face of provocation, and to extend kindness even when cruelty feels easier. We are called to stand for what is right, even when others remain silent, and to let love of neighbor guide us above all else.

Perhaps the answer is not to dream of returning to Walnut Grove, but to create Walnut Groves in our own communities—places where compassion outweighs anger, courage replaces silence, and neighborly love binds us together. Let’s not only remember Walnut Grove. Let’s build them, all around us.

Learn more about Dr. Kenon

By: Kate Bennion

“I always go back to asking that question of ourselves: How do we want to be seen? How do we want people to recognize us and the qualities that we’re bringing into the spaces we go into? How can we further support everyone that comes into our spaces?”

Kristen O’Brien is a director of a WIC program in Western Massachusetts and has a master’s in public health.

What started as a graduate school project developed into larger changes for WIC in the state of Massachusetts when Kristen O’Brien sought to better understand how the LGBTQIA+ community experienced pregnancy care and services at her organization.

“I really wanted to explore where [WIC] staff were across the state, and how comfortable they felt working with LGBTQIA+ families,” said Kristen. As part of her master’s in public health, she developed a ten-question survey for WIC staff in Massachusetts, including questions such as, "Have you knowingly served trans or non-binary individuals? What do you feel like your learning needs are?"

With the results of that survey data, Kristen partnered with Massachusetts WIC and the Fenway Institute to develop a training for staff on basic language and terminology to better support the LGBTQIA+ community. “It was optional for staff to attend,” said Kristen. “But we did end up training over 250 staff across the state.”

From there, Massachusetts WIC also made changes to their training materials. Starting in 2021, they will use gender-neutral or inclusive language. The organization is also working on a data system update that will allow for important information, such as pronouns and chosen names.

Now a director of WIC in western Massachusetts, Kristen continues to better understand and improve the experience of gender-expansive folks at WIC. Trans and non-binary people need health and reproductive care, and face serious barriers that impact their health and well-being. “Trans people are twice as likely as the general population to experience poverty,” said Kristen. “WIC is an anti-poverty organization. This is the population we need to serve… and reach them in a way that is really providing care, that’s safe and affirming, and know that we’re going to support them fully.”

Creating supportive, affirming spaces also meets a basic, essential human need. “We all want to be seen and heard for who we are, for everything that we have to offer,” said Kristen. “From our religious backgrounds, cultural or ethnic backgrounds, we want to be seen for that. And the same goes for people who identify beyond the gender binary. People want to be seen in who they are, and affirmed in that whenever they come into any type of setting… they want to feel like they belong there just as much as everyone else.”

Kristen said a big challenge to this work is people who are resistant to it, but a little conversation and education can go a long way. “It’s hard sometimes to move outside of a black-and-white mindset, because we have been socialized to believe things to be a certain way…” she said. “I think the reason we end up getting so much pushback and hate in some cases is really just for the lack of understanding and education. People fear what they don’t know… But the more that we educate people, and just really come from a compassionate standpoint of, we don’t have to fully  understand all the nuances of gender identity, but we just have to affirm them and acknowledge that they exist, and that we’re going to support them as they come to us.”

One helpful tool towards this end is the U.S. Transgender Survey, both as far as language and terminology and also acknowledging that trans and gender-expansive people exist, and face barriers to care.

Rising anti-trans legislation is also a challenge, but people in the states where there is the most transphobia need safe people and safe spaces the most. “Even when you are up against legislation, there are small things that can be done within the scope of your offices,” said Kristen. Kristen recommended reaching out to your local chapter of the American Civil Liberties Union for information on anti-trans legislation, and finding other local organizations that are LGBTQIA+-supportive to partner with. “The more people that bind together, the greater level of support you will create as a whole,” said Kristen.

The WIC organization recently celebrated its fiftieth birthday, and currently provides services to millions of pregnant people and babies in the U.S. “We [at WIC] are serving half of all babies born in this country,” said Kristen. “That’s a really big public health impact. The more that we do to expand our reach, and make sure that all vulnerable populations are served, including gender expansive people, we’re going to make a greater impact and support the health of the future.”


KEY TAKEAWAYS/LESSONS LEARNED:

• Data is valuable for many reasons. “Data is an important marker to know who’s accessing services and who’s not, and when we lack that data, it can make it more challenging to get those resources we need to serve those populations…so we can better understand and make sure we’re available to these people.” What data is available to you and your organization? What data can you create, both on a micro or a macro level?
• Even without systemic support, you can help create a supportive, affirming environment. Visible signage, asking name and pronouns, and leaving and checking notes, as well as using inclusive language such as: “people who are pregnant” can go a long way toward creating a safe space. “The more we are receptive to asking people how they identify, if things have changed for them, if they still have the same name…really having open ended questions and letting them tell us who they are instead of us assuming who they are can really make a big difference,” said Kristen.
• Collaboration is crucial, and there are many resources available for those who need training or support. Kristen recommended reaching out to other local LGBTQIA-supportive organizations in your state or region. PFLAG and GLAAD also have educational materials. “No one should be doing this work alone,” said Kristen.
  
  
  
  

Hosting the course is just one part of the work the UTMB team is doing toward birth equity

By: Kate Bennion

In February, health care professionals gathered in Galveston, Texas, for the SPEAK UP Champion Implicit and Explicit Racial Bias Course, hosted by the University of Texas Medical Branch.

This was the first time UTMB hosted a SPEAK UP conference in person, but it is not the first time that UTMB’s team members have attended the SPEAK UP Champion education. UTMB SPEAK UP Champions are optimistic about spreading the education even further among their team to expand their birth equity efforts. They also want to encourage other perinatal health professionals to join them on the SPEAK UP learning and action pathway. They know that ensuring birth equity is critically important work because this work saves lives.

“I want UTMB to move forward in these efforts,” said Olivia Owens, RN and clinical educator for the mother-baby unit and baby-friendly coordinator. “I want those that are at the workshop to spread the word so we can push forward this initiative in working to get equitable care to our patients.”

Olivia knows firsthand the importance of this work, both from her job and also from personal experience after giving birth last year. “I did have to advocate for myself when I was in the hospital,” she said. “African Americans are receiving less equal care than our counterparts that are also being treated here in the hospital.”

Olivia also knows the value of inviting friends and colleagues to participate and learn. She became familiar with SPEAK UP after her mentor, Ginny Schmahl, attended a SPEAK UP conference and brought back resources and insights for the team, encouraging the unit to get involved.

Even though Ginny has since passed away from cancer, several team members at UTMB remain committed to seeking equitable care for their patients and building momentum around such critical work that can save lives. The SPEAK UP Champions who work at UTMB continue to invite their colleagues to join them.

Deborah Mordecai, nursing leader at UTMB, highlighted some of the ways implicit bias can affect care for multiple groups. “If a call light goes off in two rooms at the same time, and you have an English-speaking couple, and a family speaking only Spanish in the other room, which room are you going to walk in first?” said Deborah. “Everything else equal, if the nurse only speaks English and is not bilingual, they’re probably going to go into the room with the English- speaking mom first. That delays care, and is an unfair bias against the Spanish-speaking-only mother and family.”

Deborah has encouraged multiple colleagues across teams to receive the training and resources from SPEAK UP in order to identify and address implicit bias, both individually and systemically. “I want to get folks from each area to become SPEAK UP Champions,” she said.

The endeavor is not without challenges. Both Olivia and Deborah spoke about lack of data as an obstacle.

“A lot of our data is not separated by race and ethnicity. We just have a common number: this is how many primary C-sections we had, but we don’t know how many African-Americans ended up having a primary C-section,” said Olivia. Without the ability to organize or examine data along racial or other demographic lines, it is then difficult to identify or quantify differences in care, or measure improvement.

“It’s so interconnected,” said Deborah. “[Without being able to extrapolate the data], it’s hard to know where to make the changes. We can cast a wide net, saying every mother should have this type of care, but are we, are our explicit or implicit biases altering the way we care for our moms, which is leading to worse outcomes in some areas? We really don’t know.”

Even without the missing data piece, team members push for ways to continue to raise awareness and improve outcomes. Olivia said she shares the February SPEAK UP Challenge on social media and emails it out to the staff every year. She likened the yearly challenge to an annual checkup for implicit bias: a chance to check in, recommit, and bring more alertness and awareness. “This isn’t a one-and-done,” Olivia said. “This is a continual process.”

Hosting the conference is also a way to raise awareness, further the conversation, and give more team members and colleagues tools and resources for countering bias. Based on feedback from some of the thirty-seven attendees, it was effective. “You facilitated one of the best conferences I have attended,” said one participant. “Have more of them.”

Another participant came away with this takeaway: “As a leader, I will educate and lead my team to do everything we can to listen, provide care, and support the individuality of humanity.”

“You’ve got to start the discussions,” said Deborah. “Sometimes they’re not always easy to have. But it’s important to get started.”

“We can’t do this alone,” said Olivia. “We need more support from everyone involved in the patient’s care to make a change.”

Takeaways and advice from the UTMB SPEAK UP team:

• Invite friends, bring colleagues. The more people from your teams and organizations you can get on board, the farther you will go. A systemic, collective effort will be most effective.
• Data is critical to both identifying issues and tracking successes. Find out what data is being collected, by whom, and if it is extrapolatable by race and ethnicity. It is also important to track social determinants of health data.
• Identify patients who are marginalized and possible biases specific to your patient population and community. Develop action plans that outline how you will work to overcome or mitigate barriers to equitable care, such as language barriers or education barriers.
• “Don’t be afraid, just start.” It may be a difficult or painful conversation to begin, but there are mentors to learn from and with, and resources to benefit you and your teams.

Facilitators (L to R) Renee Byfield and Debra Bingham at the February 2024 SPEAK UP Champion Course hosted by the University of Texas Medical Branch.

“I was shocked that with such staggering statistics more had not been done to improve upon the health outcomes of Black birthing people. As a Black woman of childbearing age, I could not help but to also see myself in these patients and shared in the fear that other women of color feel when family planning.”

For NICU nurse practitioner Kelly Miles, MS, NNP-BC, in Albany, New York, the journey to improve care for all patients stemmed from both a professional obligation and a personal one.

“I was shocked that with such staggering statistics more had not been done to improve upon the health outcomes of Black birthing people,” said Kelly. “As a Black woman of childbearing age, I could not help but to also see myself in these patients and shared in the fear that other women of color feel when family planning.”

Kelly searched for resources for both her and her department at Albany Medical Center (AMC) to help address the U.S. maternal mortality crisis. After hearing SPEAK UP Program Director Renée Byfield speak about perinatal health disparities at a NICU nursing conference, Kelly looked into the SPEAK UP program further and knew she had found what she was looking for.

“I knew our NICU at AMC could benefit from incorporating SPEAK UP’s practices,” said Kelly. She brought the idea to her division chief and then introduced the program at a department meeting.

Though it started with just one individual, using the SPEAK UP acronym, mnemonic, and resources to seek birth equity has become a growing team effort for the AMC NICU. Kelly became the Chair, and with co-chair, Kate Tauber, MD, the AMC NICU SPEAK UP multi-disciplinary committee was born, comprised of a variety of healthcare professionals including  neonatologists, nurse practitioners, bedside nurses, a nurse case manager, and a nurse clinician. Kate also leads the Mom’s Own Milk committee that supports mothers of color to provide breast milk to their babies.

“In an environment where there is comparatively minimal diversity amongst staff, the intention of this group is to provide more culturally informed care to a diverse population of patients,” said Kelly. The group uses resources from the Institute of Perinatal Quality Improvement (PQI) and elsewhere to promote diversity, equity, and inclusion in perinatal healthcare.

Since incorporating SPEAK UP, the group has supported and initiated a variety of initiatives toward birth equity at AMC. For the past two years, the group has participated in PQI’s 28-Day Anti-Racism Challenge. Its members have also partnered with the Office of Health Equity Diversity and Inclusion at AMC to support diversity, equity, and inclusion-related community events, been involved in the NYS Birth Equity Improvement Project, and become allies to other AMC efforts to support patients from marginalized groups.

Kelly said SPEAK UP has been such a success at the AMC NICU that more units, such as labor and delivery, are planning on participating in the future.

“To say that we are grateful for the SPEAK UP program at AMC is an understatement,” said Kelly. “Your work is so needed, and has helped your partners here in Albany, New York take one more actionable step in improving care for all patients.”

Kelly Miles’s advice to others who want to work towards birth equity:

• Learn about the SPEAK UP Program and resources.
• Create a multi-disciplinary SPEAK UP committee.
• Partner with hospital-wide efforts and leaders in other perinatal units.
• Find action-oriented resources that will save you time.
• Invite your hospital care team to participate in the 28-Day Anti-Racism Challenge

“We are asking healthcare providers to see us as part of their code team and reach out to us when they believe they may have an AFE case so we can walk them through the specimens we need to draw from that patient–it’s actually not very much, it’s two vials of blood–before that patient receives blood transfusion.”

Miranda Klassen is the Executive Director of the Amniotic Fluid Embolism (AFE) Foundation, an organization she founded in 2008 just a few months after she herself survived an AFE during the birth of her first child. Shortly after starting her non-profit organization, she recognized a need for more research to be conducted into the rare and often life-threatening condition of AFE and developed the Amniotic Fluid Embolism Registry with the help of AFE experts and maternal-fetal medicine experts at Baylor College of Medicine (it has since been moved to University of Texas Health Services at the McGovern Medical School in Houston). Today, this registry is the world’s largest database of AFE cases, making it possible to investigate the genes and mechanisms involved in AFE. 

Fourteen years after the birth of her organization, Klassen is on a mission to end AFE. Rows of portraits hang on the wall behind her desk, each of them featuring a woman who lost her life to AFE. As Klassen put it, “This is our wall of angels, it is women we have lost to this condition, and I do this work on behalf of them. For them and for all the babies we’ve lost and all the families that have been impacted. We really won’t be able to move the needle until we understand the etiology, so that is the key to all of this work.”

The exact cause of AFE is still unknown, and for Klassen, the primary driver behind her efforts is to understand the initiating event that sets off a catastrophic cascade of symptoms. For that, she needs everyone impacted by AFE–survivors and families grieving the loss of a loved one–to band together and provide cases and bio-specimens for researchers to study. She also needs the collaboration of healthcare providers. 

“Our biggest key initiative is our research registry and biorepository. We’re trying to identify cases as they’re happening. So we are asking healthcare providers to see us as part of their code team. We’re asking that someone in their facility reach out to us when they believe they may have a case and then we can walk them through some of the specimens we need to draw from that patient–it’s actually not very much, it’s two vials of blood–before that patient receives blood transfusion. We believe that the blood tells us what’s happening biologically with this patient. We’re looking at what inflammatory markers are being expressed, what immune systems and cytokines are being expressed, and we hope that by taking these specimens when the patient is symptomatic and comparing them to the Type and Screen they drew when the patient arrived, we’ll be able to determine early signs that could alert us in the future that a patient is at risk for having a severe immune response.”


AFE occurs in 1 in 40,000 pregnancies and deliveries and there are 4 million deliveries a year. That means approximately 100 women in a year will have an AFE. “If we were to do a clinical study,” Klassen said, “we’d essentially have to enroll every single hospital in every single state and collect blood on 4 million people in hopes of capturing these 100 women–that’s just not going to work and it’s why we need to partner and be in this collaborative spirit with our healthcare providers. Until we understand what causes an AFE, we’ll only be left with supporting those that it happens to, and healthcare providers will only be able to treat the symptoms they see in front of them but won’t be able to treat the inciting event.” Klassen hopes that if enough cases are captured and researched, that her organization can provide more than recommendations for how to prepare for an event. She hopes that one day they can provide education on how to determine when a patient is at risk, and how an AFE can be prevented and treated, to save lives. 

Klassen’s compassion for sufferers of AFE, for survivors, and for families grieving the loss of a loved one who succumbed to this tragic complication is so clear in the wording she chooses to describe those losses. As the women in the portraits on the wall behind her remind her so often, these losses are not exclusive to these women alone, but extend outward to their communities and families. “I think of prominent people,” she said, “I imagine if there were no Mother Theresa, if there was no Beyoncé, if there was no Susan B. Anthony or Jane Goodall. I think about those contributions to our country and the world, and I think about if they were lost. I think about the women [on the wall] behind me and about their impact on just the familial structure. The loss of a mother, the loss of a family dynamic, the loss of a wife, of a daughter, of a sibling, of a best friend. And then I think about it from the community perspective…what did they contribute to their community, or their place of work, or within their social structures. I think about individuals like myself who survive this–when you give birth in a medical setting and you have a catastrophic event occur, you develop triggers that are lifelong around healthcare and having to recount your health history. And many of us suffer long term health consequences as a result of that one moment in time.”

Klassen’s laser focus on one day finding a way to end AFE has led her not only to encourage cooperation from healthcare providers in contributing to their registry and database, but also to spread awareness to the general public. “I think our projects are important because it would be astonishing if I told you that all 4 million people giving birth in this country are at risk for this. That’s not a true statement–it’s only 100, but there’s truth in it because we don’t know who the 100 will be…it’s impossible to say. I don’t expect AFE to be a household name but certainly would love for the recognition that every single person that’s giving birth is at risk for this. Because we don’t know yet who is at risk for this, everyone is at risk.”

Klassen’s mission is borne out in her day to day within her organization in meeting 3 key initiatives: education, support, and research. She works tirelessly to produce something more meaningful than a standard key performance indicator because for her, the sheer numbers are less compelling than the feedback she gets from families and from their physician colleagues. As she said, “I often say I know we’ve educated 10,000 clinicians, we have supported 1,500 families, and we have the largest, most robust registry - but do those that we’re educating…do they find what we shared with them to help them be more confident in handling cases, has our registry provided any further insight into this condition, have we scratched the surface? Do people that we support – do they feel supported?” For Klassen, the number one performance indicator is saving a life, and she knows they can only meet that objective if the people they support are as well-versed in the condition as they are. 

For more information on AFE and how you can help Miranda Klassen save lives, please visit afesupport.org to learn more or to donate to the organization. Miranda also volunteers as a member of PQI’s Executive Advisory Board.

Key Lessons Learned:
● AFE occurs in 1 in 40,000 pregnancies and deliveries and there are 4 million deliveries a year. That means approximately 100 women in a year will have an AFE. 
● Miranda Klassen almost died when giving birth. Because of her experience she formed the AFE Foundation.
● Get in touch with the AFE Foundation if you have a suspected case. You can contact them at:  afesupport.org/submit-a-case
● The AFE Foundation’s three key initiatives are focused on education, support, and research.
● The AFE Foundation is working to end AFE and save lives.

“The barrier for a lot of people in care is not their ability to get it but how they’re treated when they get there.” - Connie Clauson

Connie Clauson RN, CCRN, MEd, is a Unit Based Nurse  Educator in the Neonatal Intensive Care Unit/Special Care  Nursery at Beth Israel Deaconess Medical Center (BIDMC)  in Boston. She provides orientation for new staff and  facilitates staff development. She works with unit  leadership to meet the continued education needs of the  staff and supports health care quality improvement work at  BIDMC. She attended the Institute for Perinatal Quality  Improvement’s SPEAK UP Champion and Ambassador education. The experience led her to make positive changes on her unit. 

 
She was drawn to PQI’s SPEAK UP Program for professional and personal reasons. She grew up in the Midwest in a location that lacked diversity and went to nursing school in a small city. While in nursing school, she had her first glimpse of racism in healthcare when staff failed to adequately care for two toddlers injured in a house fire. 
 
Clauson recounted that while attempting to gain IV access, the Emergency Department team failed to recognize that bright red venous blood was a crucial sign of carbon monoxide poisoning. This failure caused a delay in the diagnosis and the toddlers’ care. Clauson recalled, “These toddlers were brought into the emergency room and the staff struggled to get IV access. I was just a student watching and later when we debriefed it, everybody realized that the reason they were struggling was because these two kids were Black. Every time they got blood it was bright red. They kept pulling out because they thought it was arterial. Well, it turns out these two kids had carbon monoxide poisoning and one of the nurses was crying and said ’had these kids been white, I would’ve known’ . . . It was a very powerful indicator for me of how important assessment is—no class in nursing school had ever talked about diversity in assessment. The nurses should have realized that the color of blood is the same regardless of the color of someone's skin. So as an educator I have always included information about how clinical signs relate to the color of a person’s skin.”
 
Clauson has had personal experiences related to being the mother of a multiracial adoptee. She spoke of the implicit bias she experienced, “I adopted a child of color through foster care. She’s now much older but the differences in the way that I was treated when people thought I was the bio mom as opposed to the foster mom; and the differences in the way I was treated when I tried to pay for something with a WIC check versus a debit card; and the differences in the way the world treated our family depending on where we were in the world really impacted my view. For a white woman who was raised in a comfortable environment to experience the implicit bias that people of color experience every day—it really reinforced for me -- that yes, we talk a lot about the social determinants of health, yes, we talk a lot about access to care and access to insurance and all of that, but really the barrier for a lot of people in care is not their ability to get it but how they’re treated when they get there.”

For Clauson, the biggest takeaway from the SPEAK UP Program has been the experience of being presented with such clear and stark data that really highlighted the importance of working to eliminate perinatal disparities. She said it’s made her much more aware of not just her own interactions with staff and patients but also the interactions of others. She noticed that physicians who have attended the training are more likely to reach out to support staff, and staff feel more empowered to talk about race and equity when addressing problems that arise.

In the SPEAK UP Program, participants are tasked to set a goal and create an Action Plan.  Clauson has used both her personal and professional experiences to develop and guide her action plans. While raising her child she has become aware of the impact of social media and the white centric images children are exposed to, especially girls. She saw how social media can negatively influence children’s self-esteem making it challenging for them to develop a positive self-identity. She used these insights to take a discerning look at the educational materials she provides for staff as well as the way she presents information. Her SPEAK UP action plan includes reviewing class content to ensure diversity in race such as multi-racial families and family types, for example, families with two moms or two dads. 

She creates and shares a series called “Nursing Hot Topics,” a one- or two-page report about an interesting or unusual case as a way to educate existing staff and introduce concepts to new nurses. Using her formative experiences as a nursing student, she ensures that accompanying images speak to the need for making assessments based on the physical characteristics of the patient, e.g., skin tone. When there is a teaching point related to physical assessment, she addresses differences in skin tone. A specific example is an online training she’s created for hyperbilirubinemia. She went through and made sure she explained how jaundice appears depending on the color of the skin and how it can be missed in darker skinned babies, sometimes up until their sclera turns orange. 

In January, Dr. Yarden Fraiman (also a PQI SPEAK UP Ambassador) formed the Neonatal Health Equity and Justice Subcommittee of the NICU Leadership Committee. Clauson co-chairs the committee with Dr. Fraiman. “JUST Babies” is a multidisciplinary committee with nurses, physicians, social workers, Neonatal Nurse Practitioners, Patient Care Assistants, and unit coordinators as members. The group is charged with all neonatal health equity and diversity, equity, and inclusion activities in the NICU. “Our unit is really looking at including roles and people that would normally not be included in QI work on this committee.”

Clauson and Fraiman also developed a class based on SPEAK UP training that is part of a QI SPEAK UP project. The class addresses racism and implicit bias in health care. It is currently taught to all new hires with the intent to roll it out to the staff at large over time. She said they will do a series of pre- and post-surveys to get feedback on content and assess retention.

Connie Clauson is an excellent example of the kind of dedicated effort, positive attitude, and curiosity that is so essential to shift existing structures and creating safe environments that provide equitable access to healthcare. PQI is honored that she is one of our SPEAK UP Ambassadors!

Materials Review 

• If you are reviewing multiple slide decks, create a checklist to help keep track of representation. Use a separate checklist as you create new materials. You will not be able to represent all demographics in every presentation. Try to keep representation level over time.
• If you are having trouble finding photos, reach out to local community organizations and nonprofits for assistance. They often have marketing materials they can share. Consider working within your organization to obtain photos from your local population.

Attend the SPEAK UP Champion Course

•  Implicit and Explicit SPEAK UP Training is a day-long interactive workshop that outlines strategies to help individuals and groups dismantle racism, provide quality equitable care, and reduce perinatal health disparities. Attend or be a host organization. Learn more
• Seek to create a space where all are comfortable speaking freely regardless of their position within your organization.
• Join the SPEAK UP movement. Learn what SPEAK UP stands for. SPEAK UP Mnemonic - Institute for Perinatal Quality Improvement (perinatalqi.org)

Form a Diverse Multidisciplinary QI Committee focused on eliminating racial and ethnic disparities

• Determine which roles need to be represented. Actively recruit participation from outside the traditional medicine plus nursing model. You may need to advocate with other departments for hourly wage staff to be provided with duty free time to allow them to participate.
• Begin your work together with a conversation about roles and hierarchy. 
  

Dr. Patricia D. Suplee is the Director of Professional Education and Research at the Central Jersey Family Health Consortium and an Associate Professor at Rutgers University, School of Nursing-Camden. As a seasoned researcher, scholar, and educator, Dr. Suplee’s career has focused on improving women’s health outcomes. Currently, her work focuses on improving maternal morbidity and mortality outcomes and translating evidence into clinical practice especially during the postpartum period. Her collaborative work as CO-PI on AWHONN’s Empowering Women to Obtain Needed Care project led to the development of Post-Birth educational tools that have received national attention. These tools are being incorporated into postpartum discharge teaching throughout the U.S. and have been cited as an exemplar by the CDC, HRSA, and the Joint Commission. In addition, she has led the mission to create additional touch points to educate birthing people about potential complications during the postpartum period including home visiting programs, doula services, and pediatric providers. “We know that most maternal deaths occur after the birthing person has delivered and has been discharged. Therefore it is vital that we get this information into the hands of families in our communities.”

Dr. Suplee was appointed to an interdisciplinary national committee that developed three AIMS Patient Safety Bundles that are currently used as best postpartum care practice models. Recently, she was appointed as a member of the HHS Office of Minority Health, Think Cultural Health team to advise the development of an e-learning program for physicians, nurses, and health care providers about culturally and linguistically appropriate services in maternal health care.

Dr. Suplee is Chair of NJ AWHONN and is a member of the NJ Maternal Mortality Review team that analyzes cases, identifies gaps in care, and makes recommendations to decrease maternal mortality rates. She publishes and presents nationally, is a reviewer for several journals, and has mentored numerous faculty colleagues, clinicians, and students over the last three decades. Dr. Suplee is a seasoned educator having taught nursing students enrolled in baccalaureate, masters and doctoral programs for over two decades. 

In 2016, Dr. Suplee became more involved with QI while working on a project with Dr. Debra Bingham which focused on types of postpartum patient education, how information was generally communicated to patients, and how this information informed decision making. As CO-PI, Dr. Suplee conducted a qualitative study in six hospitals within two states and facilitated focus groups with nurses. Findings showed that while nurses were sharing an abundance of information with patients, it was not always consistent information nor was it always accurate. A noteworthy outcome of the project’s effort included the development of the POST-BIRTH warning signs (PBWS) tool, a handout that was used not only as a patient information guide but also as a guide for nurses to provide consistent, accurate messaging. Following the development of the tool, a pilot study was then conducted at four of the original six hospitals to assess nurse satisfaction with the tool. The tool received overwhelming support by the nurses and patients as well.

Continuing this work, both researchers felt strongly that another study was warranted based on outcomes from their qualitative work. A national study was conducted with nurses to assess their knowledge and importance of sharing education on postpartum complications. The results were published and featured on a National Public Radio segment.

“Translational research can be difficult as it takes years for research to make it to practice. We realized that we had to expedite this process to improve maternal outcomes based on the rising rates of maternal morbidity and mortality in the postpartum period. As such we did a lot of educating. We used different platforms to educate nurses on the importance of their role in patient education and listening to birthing families’ voices from teaching nursing students in the classroom, to visiting hospitals and educating staff, to presenting at national conferences” says Dr. Suplee. She continues to speak on the topic of PBWS throughout NJ and has expanded her reach to community health workers and pediatric providers.

“Nurses have a small window of opportunity to educate all birthing families on self-care, infant care, and transitioning to the multifaceted role of being a parent. Some may argue that it is too much information to add to the lengthy list of information that must be taught. But the problem is that most maternal deaths occur before the traditional 6-week postpartum visit--so we have to give the information prior to discharge and build in other times when the information can be reinforced.”

Dr. Suplee believes that one key piece to engaging in QI is empowerment. According to her empowerment can be a process or an outcome. It must include mentoring of others, teaching how to become an advocate, and more importantly teaching how to take steps to making positive change. She believes the biggest barrier for some individuals to engage in QI is the fear that they do not have enough knowledge or skills to facilitate QI work. “Sometimes you have to take a step back before you take a step forward,” says Dr. Suplee. She recommends that those who feel intimidated or less confidant in QI should join a work group and tackle a small issue. “Do not be afraid to ask for help. Resources are available and you would be amazed at what you can accomplish as a group compared to working in a silo” states Dr. Suplee.

Dr. Suplee’s advice to others who are considering engaging in QI:

• Be patient with yourself and stay committed – We often want change to occur quickly; however the process is sometimes just as important as the outcome. It is vital that you consider the what, who, how, and why of the project in order to obtain the best outcome.
• Consider working with multi-disciplinary groups on projects. Representation from a diverse set of stakeholders makes for more meaningful engagement.
• Do not reinvent the wheel. Review the literature, check with your national organizations, and identify colleagues who have done similar work. There may already be solutions to your problems that you can utilize in your own practices. Be a lifelong learner and continue your educational journey. We are in a profession that cannot afford to stop learning and sharing.
• Engage with nursing students during their clinical rotations. Students are energized and eager to find role models so take them under your wing.
• And finally, realize that you have the power to improve the health outcomes of your patients – QI does SAVE LIVES!

LaShea Haynes, M.Ed, MSN, AGCNS-BC, APRN, RNC-OB/EFM is a clinical nurse specialist for labor and delivery and mother/baby for 7 birthing centers in her healthcare system and Editor of Healthy Mom&Baby magazine.

Her 25 years of clinical and educational experience and expertise span labor/delivery, antepartum and mother/baby areas. LaShea is the founder of the nursing company, Perinatal Potpourri. She is an award-winning national and international speaker, a previous Association of Women’s Health, Obstetric and Neonatal Nursing (AWHONN) section chair and serves on several national AWHONN committees.

LaShea became involved in QI by participating the AWHONN Postpartum Hemorrhage Project in Georgia led by Dr. Debra Bingham. LaShea then joined a mortality review committee that introduced her to eye-opening information. The experience inspired her to want to make a difference by improving services and ensuring mothers' voices were heard in an effort to reduce the number of severe morbidity and mortality cases.

Passionate about serving as an advocate for maternal morbidity and mortality, LaShea believe that there are many improvements needed to ensure quality care that include, using translators when needed to ensure patients have the best care and that there is a clear line of communication. LaShea emphasizes that practitioners, particularly those supporting women giving birth, should understand that their role is to do more than just assist delivery. “The job of healthcare providers is to provide quality care at ALL levels and that can sometimes include learning, understanding and applying things like language translators, literacy skills and empathy,” she says. “Providers are in healthcare to save lives. In your role you become a part of a family's birthing experience so it cannot just be a job.”

Through the Healthy Mom & Baby magazine, LaShea finds joy in appealing to a diversified audience and readership. She believes the platform offers a “happy medium” from the nursing perspective but also for the patient experience. One of the most recent series she has developed is a series on, Respectful Care,  the series offers tips and advice. on how to advocate for yourself as a patient . Her goal as the editor  is to have content that improves a birthing families experience during prenatal care visits, informational guides and checklist that can be used for discussions and dialogue with their healthcare providers, equip them with questions, develop a greater sense of what to expect leading up to a safe delivery.

As a QI leader, LaShea understands the importance of working with other “empowered leaders” to facilitate change and improve outcomes. LaShea encourages that in working in the QI space that other healthcare providers consider establishing relationships with a multidisciplinary team including cardiologist. “Improving access to resources for cardiovascular disorders in pregnancy is critical,” she says. One effort LaShea supported for cardiovascular education was the initiation of POST-BIRTH warning signs, she is also excited these are available in other languages and more accessible for the patient population.

Three key steps and advice LaShea shared she would impart on those considering engaging in QI are:

• Join PQI – be a SPEAK UP Champion. Across the nation women of color are dying, simply because they are being overlooked, unheard and are not always provided the same resources and services as others
• Get involved and be aware – that social determinants of health are contributing factors to the poor outcomes we continue to have in this country
• Play an active part in identifying real solutions
• SPEAK UP- silence is acceptance and benefits no one

Debra Pascali-Bonaro is a world-renowned inspirational speaker, filmmaker, DONA International Doula trainer, Lamaze International Childbirth Educator and author. For the last 25 years, Debra has volunteered her time nationally and internationally to create a healthy, respectful, and equitable maternity care system. She has long served as the Director of the International MotherBaby Childbirth Organization (IMBCO), which, with International Federation of Gynecology and Obstetrics (FIGO), co-created the International Childbirth Initiative (ICI): 12 Steps to Safe and Respectful MotherBaby-Family Maternity Care. Debra also serves as Co-Chair of the ICI Executive Committee and believes that the ICI sets the global gold standard for optimal maternity care.

In her varied roles as a Doula and educator, Debra witnessed consistent gaps in services and inequities in health care systems. In addressing her concerns Debra engaged with likeminded individuals and groups around the globe and truly developed a passion for serving as a volunteer leader and advocate for change in maternity care.

The International MotherBaby Childbirth Organization (IMBCO) and the International Federation of Gynecology and Obstetrics (FIGO) joined forces developing a single global initiative to provide guidance and support for safe and respectful maternity care, building upon their previous work and incorporating the most recent evidence and insights into what constitutes optimal maternal and newborn health. As an active contributor and Executive Committee Co-Chair Debra serves as a champion of the work. In 2018, she worked with the initiative to develop The International Childbirth Initiative (ICI): 12 Steps to Safe and Respectful MotherBaby-Family Maternity Care. This effort provides steps for implementing evidence-based maternity care worldwide, acknowledging the interaction between mother and baby, family and environment as well as their interactions with health providers and health systems. In 2021, ICI has entered a phase of recruitment and implementation of the 12 steps, engaging with health facilities and providers in collaborative quality improvement and providing the tools to monitor the process, effect, and engagement.

The work of ICI ensures every person receives respectful maternity care. “The child birthing experience really does take a village and with initiatives like ICI, there is assurance that the village is successful and is doing their own self-evaluation, self-reflection and staying accountable to achieve optimal Mother Baby family maternity care,” says Debra. ICI brings people together on the same beliefs and is integrated into the model and the community. Collective power of ICI efforts thrives because of its collaborative nature.

The work and mission of ICI, with support from key contributors like Debra, have made important contributions to changing systems. Debra is personally most proud that she and a global network of volunteers have translated the Initiative into 24 different languages and have significantly in-creased the number of implementation sites around the globe, including two in United States. Additionally, the 12 steps are being integrated in midwifery studies and knowledge in multiple countries and have been incorporated into national practice guidelines in Germany.

As a volunteer leader for the past 30 years Debra has remained dedicated to the creation of systems that serve everyone equitably and justly.\

“Sometimes people have asked me how I have done this for nearly 30 years now as a volunteer I say part of it is that I have a passion that I am not going to stop until we create the system that I know we can have that will serve everyone and be respectful, equitable and joyful. Secondly, I made an agreement with one my dearest friends before she passed to see this work through, and I am not  going to disappoint her! With those two things I continue to forge ahead. We still have a long way to go but I am dedicated and believe we can do this. With passion, drive, collective interest, and willingness change is possible.”

Debra’s advice for others who are working to advance quality, equitable and just care:

• Avoid separating advocacy from systems—they should be combined to ensure the most optimal care.
• Engage everyone – all people need be heard and feel valued.
• Diversify whose sitting at the tables and ensure representation from all. Multicultural and multidisciplinary expertise helps develop more meaningful and positive impacts.
• Listen and tailor information and resources to meet the needs of those being served as well as those delivering services.
• Never doubt what a small group of dedicated people can do.
• Step up and dedicate what you have to offer. Create the village and add your gifts with everyone else’s gifts to support the work.

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“My goal is to ensure that every woman can walk through any door of any hospital in Massachusetts and have the same chance for an optimal birth outcome as anyone else.” – Dr. Audra Meadows

Audra Meadows, MD, MPH, FACOG is Obstetrician/Gynecologist, health equity champion, public health professional, and Co-Chair of the Perinatal-Neonatal Quality Improvement Network of Massachusetts (PNQIN). PNQIN is the umbrella organization of the Massachusetts Perinatal Quality Collaborative (MPQC) and the Neonatal Quality Improvement Collaborative (NeoQIC) and works to improve outcomes for women and infants in Massachusetts (MA) while eliminating health inequities. Dr. Meadows explained, “What brings me to this work and what I’m passionate about is optimizing birth experiences and outcomes for all women.”  

Dr. Meadows learned about inequities in perinatal health outcomes during residency and her MPH coursework. “There were very few opportunities in residency for me to learn about disparities solutions. During my MPH training and over my career, the more I learned about quality improvement, [the more] I saw it as a disparities solution,” said Dr. Meadows. She came to see QI as an exciting opportunity to improve both quality and equity in health care delivery. Dr. Meadows explained, “We know some disparities occur because some folks aren’t receiving the same care, or the same quality of care. And when we raise that quality of care for everyone, you will still see differences in outcomes because of inequities.  Inequities are disparities due to injustice and are based on lots of factors some that are outside of the healthcare system.  They are rooted in medical and societal causes.” 

After finishing residency and a health disparities fellowship at Harvard’s TH Chan School of Public Health, Dr. Meadows joined the obstetrics practice at the Brigham and Women’s Hospital and began caring for women, training Harvard medical students and training OB/GYN residents. In 2009, her QI journey began with working to prevent preterm birth.  She said, “All too often, I would see women coming onto the labor floor and having babies who were born way too early and way too small.” Dr. Meadows explained that these moms would then spend their first weeks of motherhood caring for their babies in ICUs. She went on to say, “These realities of preterm birth are divided by racial lines.” 

In 2010, Dr. Meadows began using QI to reduce preterm birth in MA. She said, “We saw, in the city of Boston, that infant mortality rates were highest for Black populations and especially in certain zip codes. One of the contributing factors to infant death, and the main contributor to the disparity related to infant death, is… preterm birth.” To reduce preterm birth, Dr. Meadows helped to launch a QI task force in Boston. She said, “We expanded that program to the state of MA through the MPQC.” Subsequently, the MPQC developed partnerships across the state to address preterm birth rates through the national IM CoIIN Initiative. 

Dr. Meadows explained that PNQIN also works toward achieving the goals of the MA Alliance for Innovation in Maternal Health (AIM) Initiative. She said, “We convened stakeholders across MA and joined the AIM national program with a focus on improving maternal health specifically eliminating the preventable morbidity and mortality.” In addition, PNQIN strives to eliminate racial disparities in perinatal care in MA. Dr. Meadows said that the focus of the MA AIM Initiative was to “ensure that every woman can walk through any door of any hospital in Massachusetts and have the same chance for an optimal birth outcome as anyone else.”

Dr. Meadows explained the major barriers related to successfully implementing a QI effort, “Over time we have seen and recognized that there can be difficulties related to finding time for hospital staff to participate in QI, especially if it’s not something that’s already part of one’s job description. We have also seen that education, aligning our knowledge, is an important part of the beginning of our initiatives as we work within Massachusetts.”

Dr. Meadows gained experience in recognizing and overcoming QI challenges as she worked on the PNQIN Perinatal Opioid Project (POP). The PNQIN POP project is a statewide quality improvement initiative focused on improving the care of women, infants and families impacted by perinatal opioid use and neonatal abstinence syndrome.  PNQIN/MPQC staff support maternal teams to implement the AIM Opioid Use Disorder safety bundle.  Hospital teams involved in POP are provided education, technical assistance, and funding. PNQIN offers education through webinars, meetings and virtual team trainings on opioid use disorder (OUD) and the QI process to prepare providers for implementing standardized care. In addition, PNQIN provides technical assistance by meeting with hospitals, one-on-one, to support teams, help them name their clinical champions, arrange trainings and answer any questions they might have. Lastly, PNQIN procures funding to support maternal care teams implementing the safety bundles.

When asked what factors have led to the success of PNQIN, Dr. Meadows responded, “I think one of the main reasons for our success, and what I really enjoy about working with the Massachusetts PQC [Perinatal Quality Collaborative], is that it is voluntary… The experience we’ve had in Massachusetts has just been very pleasant, in that we’ve had a number of teams that have been open, willing, eager, and excited to participate.” 

Dr. Meadows explained that projects implemented by PNQIN often include the following three steps: 1) hold kick-off meetings, 2) provide webinars, trainings and other educational opportunities, and 3) collect data in a centralized data center to guide progress. Dr. Meadows said, “The kick-off meetings are really important.” During kick-off meetings, the PNQIN team explains the project, shares data to highlight the issues being tackled, and discusses how implementing best practices could accomplish the goals of the project. The next step is holding webinars on both the clinical topic and the QI process. Dr. Meadows explained, “So once you do that, then we’re speaking the same language, we’re angling toward the same goals, we're measuring in the same way, and we’re really, truly, collaborating and working together as we move forward. So that education piece is really important.” The next step is collecting data in a centralized data center. Data on quality (structure, process, or outcome) measures can be shared with teams to show progress over time. “The progress seen by process measures… that’s really what people tend to celebrate,” said Dr. Meadows. 

Two of the primary successes of POP, that Dr. Meadows observed, were an increased focus on centering women’s stories and on prioritizing equity. PNQIN centered women and families by asking them to share their perinatal care and birth experiences at state summits, townhalls, webinars and trainings. Dr. Meadows said, “I think [centering women and families] always helps to drive the human spirit that we all have towards really wanting to see the best … for moms and babies.” In addition, equity is a foundational mission of PNQIN and PNQIN staff have built an equity initiative through raising awareness, working to shift culture and sharing data stratified by race and ethnicity to help teams understand disparities on the ground. Discussions around health equity have been incited as PNQIN helped engaged hospital teams see where there are racial disparities in their own care and outcomes. Dr. Meadows explained, “We’ve been able to grow in the conversation around health equity and QI tools to achieve equity through data. We’ve been able to grow in that conversation not only as a team, internally for PNQIN, but as a state.  And as we’re working with other teams and really thinking about ‘How do we achieve equity and face the stark reality that there are racial differences among outcomes?’ it’s one thing to hear it in national media. It’s one thing to see it at another site. It’s another thing to face that within your own hospital system, and your own team, and your own site. The conversations have been pivotal.” 

When asked what she learned from the process of conducting QI projects, Dr. Meadows responded, “I think that it’s important to bring my authentic self to the work.” She went on to say, “It’s been great to work with a team of people [who] also bring their authentic selves to the work, and collectively work toward achieving equity, which is an issue in Massachusetts that we would really like to tackle.” In addition, Dr. Meadows has learned the importance of making goals and striving to accomplish them. She said, “I’ve enjoyed that we’ve been very intentional about moving our equity work forward.”

Dr. Meadows also feels that being involved in QI work has helped her reach career development goals. She said, “I’ve enjoyed working with PNQIN for my own career development because it’s given me the opportunity to master a few skills related to organizational culture.  This has helped me to support our project managers and team leads in encouraging engagement in the QI process…” When a team experiences challenges, Dr. Meadows and the PNQIN staff listen, learn and look for facilitators to ensure their success. 

Dr. Meadows’ advice for others who are considering engaging in QI: 

• “Follow your passion. If there is something that you’re passionate about achieving, and you can see the process of quality improvement as a path to help get there, go for it. And so, really bringing your authentic self to incite that passion and really finding what you find fun in the work and where you love to grow personally, as well as being able to see how the fruits of your labor are leading to the change you want to see in the world. And with that, I’d invite anyone to be a part of using quality improvement to optimize birth and to ensure that women have great birth experiences and birth outcomes.” 
• “Collaborate, collaborate, collaborate! There’s so much more that we can achieve together than we can alone. Partnerships are key to getting any QI work truly accomplished. Without our partners, none of what we’ve done at PNQIN would have happened. Partnerships are huge. It also makes it much more fun. So with that, collaborate, work together with partners, be organized, be intentional, and then continue to edit along the way so that you can find yourself successful on the other side.” 

Carla Rider, DNP, MSN, MBA, RNC-LRN, BS, works as the perinatal program director at Texas Perinatal Services, a program of Texas EMS, Trauma & Acute Care Foundation (TETAF). Dr. Rider has a critical role assessing the 233 birthing facilities in Texas to ensure they have a QI process in place. She visits hospitals to determine if they have the capability to apply for the desired level of maternal or neonatal designation. QI training prior to a survey is an important step in her process. She explained, “As the perinatal program director for Texas Perinatal Services, I have a monthly virtual forum where I bring maternal program managers and neonatal program managers together. We provide ongoing education on how to implement QI projects and how to ensure closure is happening with quality assurance process improvement projects.”

Recently, Dr. Rider supported Texas birthing facilities in implementing QI projects related to quantitative blood loss (QBL), sepsis, hypertension, and behavioral health. As part of behavioral health projects, facilities have implemented the patient health questionnaire (PH-9) or the Edinburgh Postnatal Depression Scale (EPDS). The Texas Perinatal Services website has resources and tools to support Texas facilities working to improve perinatal care.

Dr. Rider's Recommended Steps for QI Projects 

Collect Data

“Quality assurance begins with good data. Good data begins with completing concurrent chart reviews. This will guide the team to what is going well and not going well in the department. Although the focus may be on a more global concern, getting down to the nitty gritty of what needs improvement is the first step. Everybody has a different concern that needs work. The process improvement initiatives should be specific to the hospital.”

Pick Only a Few QI Projects

“Choosing QI projects should be driven by patient care. Determine which identified opportunities impact patient care the most. Whenever a team is trying to drive quality from the bottom up in a unit, it is important to remember to not take on too many projects at once. As a program manager, you should select 3 or 4 QI projects and do those well, moving the bar based on ongoing data review.  As you move the needle on your targeted projects, move those through to resolution and then add others. If you take on too many, then the team gets bogged down and won’t do anything well.”

Key points to remember – “Focus on a few projects. Get those moving in the right direction. Once a project is retired, pick up another one. Remember to spot check data periodically to ensure sustainability.”

Get Buy-In from Administrators and Staff

“I think it’s important to schedule a meeting to speak with administrators and practice an elevator speech to make sure you’re prepared. Tell them why this project will make a difference. Do some literature research before so you present concrete information. If you go back to your chart audits and you look at your personal outcomes, it’s easier to say, ‘These are our personal outcomes, and this is where we could be.’”

Gather Stakeholders

“Bring together all involved stakeholders and all ancillary departments that could help fix the issues. Patient outcomes are not achieved in a silo. A multidisciplinary approach to the quality improvement project will allow all involved in patient care to make recommendations. It’s very important to involve everyone that the issue touches. Bring them to a table. Everybody has a voice. Discuss what the problem is. Make an initial plan. That plan can change as everyone works through the project.”

Create a Logic Model

“Throughout my career, I’ve used a logic tool and I think it’s important to start with one. The Institute for Perinatal Quality Improvement (PQI) has included a logic model in each of the QI Action Brief Case Studies. Many organizations have toolkits to use and can be found on their websites. Don’t reinvent the wheel, consider using Johnson & Johnson, California Collaborative, Florida Collaborative, AWHONN, CDC, Texas Collaborative for Healthy Mothers and Babies (TCHMB), and Texas AIM as resources.”

Schedule Recurring QI Team Meetings

“Scheduling recurring quality meetings will help hold everyone accountable. Have meeting minutes of those committee meetings that show loop closure. Who is responsible for doing what? Month after month, how are you getting to your goal? Are stakeholders providing their data so the bar can really move? Make sure documentation until resolution is evident in meeting minutes.”

Use a QI Tool to Evaluate Progress

“Next is to evaluate the progress. If change is not evident, then re-evaluate. There are many models available to use such as a PDSA-cycle, logic models, or a Six Sigma model. Pick a model and stick with it. I personally like a model that is not used very often,  but one I have used in teaching leadership for Sigma Maternal Child Health Nurse Leadership Academy. It’s called, The Leadership Challenge.”

The Leadership Challenge is a book by James Kouzes and Barry Posner. It highlights the following five practices:

1. Model the way

2. Inspire a shared vision

3. Challenge the process

4. Enable others to act

5. Encourage the heart

Conduct Sustained Evaluation

“If part of the plan is an education piece, then audit and monitor for compliance. After education is complete, the project is rolled out, and it has been evaluated, then have a sustained evaluation. Develop a run chart and really look at the numbers to see if goals are being met. Once goals are met for 3 or 4 months in a row, then consider doing a spot check in 6 months. Always follow up with a spot check after there is sustainability in achieving the goal. Nurses come and go. Physicians come and go. If a spot check is not performed later, old habits may reappear because new hires may have missed that education. To prevent this, develop a sustainability plan to train new hires.”

Dr. Rider's advice for others thinking about engaging in QI:

• “Be specific and intentional to your own unit. For example, a hospital may do a thermal regulation project improvement, but your hospital may not have that problem. Look at your data. What are the data results for your department? Is that rate acceptable? Can it be improved? What could be changed? Be intentional about analyzing your own department and seeing if that project is important for the care you provide.”
• “Recognize that all hospitals have core measures that they’re measuring. Those are high level, external indicators. When driving quality in a department, look at the methods the department uses, not necessarily the external indicators that are pushed from the top down. Consider how to improve quality from the bottom up.”
• “Identify the champions, especially when people in ancillary departments are in different disciplines, so you can have a strong team. The team can get too big sometimes. Be very intentional when picking those champions. Also, look at the skillset of the champions and determine if they are influencers. ”
• “Read leadership books and change agent books. Figure out your style prior to leading a project. There are so many different theories so pick one to use. I personally use the Diffusion of Innovation (DOI) theory. Determine who are the  early adopters and get the naysayers in line before moving the project forward to avoid the project being derailed.”
• “Find a mentor to talk to as you move through the project. Find someone who can give direction and listen.”
• “Routinely report up to administration. This is key to moving the project forward. It is also the way to get added resources. When leadership sees progress, they are more likely to give additional resources.”
• “Focus on sustainability. What is the ongoing education plan? What is the plan for accountability? What can be learned from extensive chart reviews? What is the plan for ongoing data collection?”

"Texas EMS Trauma and Acute Foundation was very proud of partnering with Texas Health Resources Presbyterian Dallas and Institute Perinatal Quality Improvement to bring QI training to Texas. Many participants have reported learning so many important ways to improve their programs. I recommend participating in as many learning opportunities as possible. You will always pick up some interesting tips."

“I think the mnemonic SPEAK UP is easy to remember, easy to comprehend, and easy to disseminate. It’s simple, but it’s powerful.” – Zenobia Harris

Zenobia Harris, DNP, MPH, BSN, CPH, is the Executive Director of the Arkansas Birthing Project. In addition to being affiliated with Birthing Project USA for almost 20 years, Zenobia was involved in establishing the Arkansas Birthing Project as an independent non-profit organization about 5 years ago.

The Arkansas Birthing Project connects community volunteers (“sister friends”) with women who are pregnant (“little sisters”). Zenobia explained, “Those volunteers provide support to a woman during her pregnancy and for the first year of life of her baby. It’s a sister model. It’s a low-cost model because we use community volunteers to provide the support. We train women. We empower women to enhance the lives of other women by making them aware of resources that exist in their community and encouraging them to connect those resources with their little sisters, their mentees, when they need them.” Zenobia continued, “Our mission is to provide support to women so that they can in turn bring healthy babies into our communities. We encourage the growth of healthy families and babies.”

The sister friends are not required to attain a specific degree or level of education. Instead, they are asked to commit to being connected with a little sister for about 16 months. When asked about the responsibilities of the sister friends, Zenobia replied, “Basically, they agree that they will check in routinely with their little sister to make sure she’s getting prenatal care… and that she doesn’t have other social needs that pop up and really present a problem for women during pregnancy and create additional stress for them. And then, when the baby is born, she’s there almost as a godmother in supporting the baby and mom during that first critical year of life.” 

Zenobia works with Alice Rogers Johnson to train the sister friends. Alice, the Vice President of the Arkansas Birthing Project’s Board of Directors, is a national trainer with Birthing Project USA. Since Alice lives in Arkansas, she also trains the sister friends affiliated with the Arkansas Birthing Project. Zenobia explained, “We train local, community women in sessions that we set up with them in their community. Generally, we do a group of either 5 or 10 women, at a time, who agree to be a ‘bunch.’ And those women have regular meetings with each other for support and they report back on things that are going on with their little sisters.”

About two years ago, Zenobia decided to hold an anti-racism training. She said, “We were going to do an in-service for some of our sister friends and some of our community partners around antiracism a couple years ago. Debra Bingham came to one of our annual meetings and presented when she had first developed the SPEAK UP acronym.” Debra sent Zenobia a handout template and Zenobia had the handout printed onto a magnet so it could be easily distributed to the sister friends during trainings.

Zenobia has seen the positive impact that learning about SPEAK UP has had on the sister friends. “I think it empowers the sister friends to be more of an advocate for their little sisters. I think their advocacy is more enhanced by virtue of them being a part of SPEAK UP.”

Recently, Zenobia has reviewed the new PQI SPEAK UP Against Racism e-learning modules (Why Everyone Must SPEAK UP: Trends and Racial Disparities in Maternal Mortality and Morbidity; Pledging to SPEAK UP: Recognizing Bias, Inequities, and Racism in Perinatal Care; and How to SPEAK UP Against Racism in Perinatal Care). She is planning to incorporate the new modules into a new virtual training for the sister friends. Zenobia explained, “Now that the new materials are developed, we need to regroup and dive into the historical context of SPEAK UP. Alice and I are working on a virtual training. Because of COVID, we’ve had to change the way we do training.” Zenobia and Alice plan to include SPEAK UP in the new virtual trainings that they are developing to train the sister friends.

When asked what she has taken from the SPEAK UP program, Zenobia responded, “Initially, I was drawn to SPEAK UP because of the mnemonic in itself and how easy it was to remember.” She went on to say, “It has taken on a deeper meaning for me in that I see the application it could have in settings other than the healthcare settings. The additional materials, such as the historical context of racism and how it affects the health of women of color, give it a lot more substance and make it easier for people to understand the history and reality of the health situation of today.”

Zenobia believes the benefits of the SPEAK UP program extend far beyond perinatal care. As the President of the Association of Public Health Nurses, she is sharing information about the program with others regardless of whether they work in perinatal care or not. For example, she has added a link to the SPEAK UP program as part of the Council of Public Health Nursing in the organization's anti-racism statement. “I think it (SPEAK UP) can serve as an aha moment for many people – those within the healthcare system, the business setting, the school systems. It could be used in many settings. The implication is very broad, which is great. I think that women of color are valuable enough to be discussed this way… not necessarily only in conversations about perinatal health.”

Zenobia’s advice for others who are working to SPEAK UP Against Racism:

• “I think it’s important to educate oneself to the meaning behind racism and antiracism. It’s important to understand what those things mean and to always understand the historical contexts so that present day actions, our daily work, can be adjusted to be able to begin to undo some of those affects and move forward in a more positive light to promoting cultural health and antiracism in our society.”
• “I think the mnemonic SPEAK UP is easy to remember, easy to comprehend, and easy to disseminate. It’s simple, but it’s powerful. It can be expounded upon in many ways. It can be minimized, if necessary. I think it gives a good starting point for a person to utilize if they have a real, serious desire to do something different in terms of speaking up against racism.”
• “I think SPEAK UP is a great addition to the quality improvement process that’s geared toward undoing racism.”
  

The Institute for Perinatal Quality Improvement (PQI) held a virtual, two-day, SPEAK UP Implicit and Explicit Bias Training for healthcare providers in Georgia on Tuesday, September 1, and Tuesday, September 8, 2020. One of the attendees of this training was Dr. Deborah Taylor, MD, FACOG. Dr. Taylor is Core Faculty at the Obstetrics & Gynecology Residency Program at Wellstar Kennestone Regional Medical Center in Marietta, GA. Around the time she attended the SPEAK UP training, Dr. Taylor had two experiences that stood out to her.

Dr. Deborah Taylor

The first experience occurred on Monday, August 31, the day before the training began, while Dr. Taylor was at work. When performing the role as the attending physician in the clinic, Dr. Taylor supervises the residents who staff the clinic. After a patient is checked in, a consistent process unfolds. First, the resident goes to see the patient. Second, the resident tells Dr. Taylor what they think is happening with the patient. Third, Dr. Taylor goes in to see the patient and to see if she agrees with the resident. Fourth, Dr. Taylor works with the resident and patient to develop a treatment plan.

While Dr. Taylor was working, the front desk informed her that there was a patient who was upset. Dr. Taylor explained, “The patient had been told, in the Emergency Room (ER), that she was going to get an ultrasound and I had made the decision, after reviewing her chart, that she didn’t need an ultrasound. She was very upset. I went up to the front desk to explain why I didn’t think she needed an ultrasound.”

During the conversation, Dr. Taylor repeatedly heard the patient say, “I just want to make sure there’s nothing wrong.” Dr. Taylor responded, “Well, I reviewed your chart. I know you were in the ER yesterday because you had some bleeding, but they were able to see the baby in your uterus, so they’ve already confirmed the pregnancy.” The patient explained, “They told me I have bleeding inside my uterus, and I just want to make sure there’s no problem.” Dr. Taylor replied, “Okay, well, that’s not what’s written in the ER notes. Let’s have you see the doctor. Once we see you, we’ll decide if you need an ultrasound.”

Dr. Taylor let the resident know about her conversation with the patient. After seeing the patient, the resident came out to talk with Dr. Taylor and review the images from the ER. Dr. Taylor went back in to talk with the patient and said that they were going to do an ultrasound. She also thanked the patient for telling her about the bleeding inside her uterus and apologized for the confusion. Whenever Dr. Taylor talked with the patient, the patient would say, “I just want to make sure there’s nothing wrong. I just want to make sure I’m okay. I just want to make sure that this isn’t an emergency.” Dr. Taylor assured the patient that the technician would be there soon to do an ultrasound. After stepping outside of the patient’s room, Dr. Taylor said to the resident, “I don’t really understand why she’s so worried. I don’t really understand why she’s saying this.”

The next day was Tuesday, September 1st. Dr. Taylor attended the first day of the virtual SPEAK UP training. Throughout the training, Dr. Taylor kept thinking of the patient she had seen the day before. Because of her position, Dr. Taylor teaches residents about racial and ethnic disparities in maternal morbidity and mortality. She understands that the majority of these disparities are the result of healthcare providers dismissing black women’s experiences. While sharing this story, Dr. Taylor explained, “None of that triggered me on Monday. But on Tuesday, when I was sitting in this room listening to the online training, I had this moment when I realized that what the patient was saying to me was that she wanted to make sure that I heard her.”

As she reflected on her experience with the patient, Dr. Taylor felt a little conflicted. On the one hand, Dr. Taylor knew that first trimester bleeding occurred in about one in four pregnancies. After reviewing the patient’s chart, Dr. Taylor did not feel concerned about the small amount of bleeding that they saw around the baby. On the other hand, Dr. Taylor was aware that the patient may not have understood the prevalence of first trimester bleeding. In addition, Dr. Taylor knew that disparities in maternal health result from providers not listening to black women.

Dr. Taylor continued, “The training was Tuesday. I couldn’t get this patient out of my mind. The first thing I did on Wednesday, when I got back into the office, was I pulled my schedule to get her name and I pulled her chart and I called her.” Once she was on the phone with the patient, Dr. Taylor said, “It’s Dr. Taylor. I just wanted to call and check on you and make you’re doing okay from yesterday. I just wanted to make sure your pain hadn’t gotten any worse and your bleeding hadn’t gotten any worse and that you felt like we were taking good care of you.” The patient said she felt fine and thanked Dr. Taylor for calling her. Dr. Taylor asked the patient to let her know if anything changed before her next appointment.

After calling the patient, Dr. Taylor felt a little better. She explained, “I felt like I had done a better job of listening to her and hearing her concerns. Imagine my surprise when I got a message from her on Friday, through the electronic system, that said ‘I just wanted to say thank you because I don’t think that anyone has ever listened to me like you did.’ And while I’m grateful for the training, I wish I had done a better job the first time around. She’s fine by the way, the pregnancy is continuing well.”

The second experience began on Thursday, August 27, when Dr. Taylor saw a 16-year-old patient who was about 20 weeks into her first pregnancy. This was the patient’s 7th visit to the hospital system. On each visit, the patient complained of a horrible pain in her abdomen. During previous visits, labs and urine tests has been conducted. The patient had been told that she was suffering from round ligament pain and had been sent home with pain medicine.

On the patient’s 7th visit to the hospital, a 3rd year resident did the patient’s initial evaluation. Then the resident spoke with Dr. Taylor. The resident explained, “The patient says the pain is terrible, but she doesn’t look like the pain is terrible and, in her chart, it says that this is round ligament pain.” Dr. Taylor responded, “You know, round ligament pain doesn’t wake you up in the middle of the night and make you cry. It doesn’t make you throw up. We know that we don’t listen well to Black women and their concerns. Are you sure that we’re not just dismissing this lady?” The resident said she was sure. Then the resident added, “You know, she’s 16. She got pregnant in juvey. The father of the baby is not with her. I think she might be homeless. I think this is probably just psychosocial.” Dr. Taylor asked the resident to tell her about the results of all the tests she ran. The resident shared the results. “Everything was normal,” Dr. Taylor recalled.

While examining the patient, Dr. Taylor didn’t see anything out of the ordinary. The patient was resting comfortably and stated her pain had gotten much better. She asked the patient, “Do you feel comfortable going home?” The patient confirmed that she did. Dr. Taylor explained what round ligament pain typically feels like and asked the patient if this was the type of pain she had been experiencing. The patient asked, “Well, does that hurt for three hours?” Dr. Taylor said, “No, not typically.” They talked a little more before the patient went home.

A week and a half later, on Tuesday, September 8, Dr. Taylor attended the second day of the SPEAK UP training. On the next Saturday, September 12, Dr. Taylor was on call at the hospital. When Dr. Taylor arrived at work, the patient was back on the labor unit for her 8th visit. Dr. Taylor said, “Once again, there was a conversation between the team that was leaving (an attending and two residents) and the team that was coming on (myself and two residents). And they said ‘She says she’s got this terrible pain. She looks really comfortable. We don’t understand.’” Dr. Taylor replied, “Okay, here’s the deal. The data says we don’t listen. I don’t know what’s going on. This isn’t round ligament pain. If the blood work and the urine that you’re doing today is normal, we’re going to image her. She has bought herself all the workup I can do. Let’s start with the ultrasound and if the ultrasound isn’t helpful, then we’re going to CT her abdomen and pelvis because I don’t know what’s going on, but something is going on.” That conversation took place around 8 am.

At 9:30 am, Dr. Taylor received a phone call from the nurse in triage. The nurse said, “You know this patient hasn’t seen a resident since 4 am and she is writhing in pain. I think somebody needs to come right now.” Dr. Taylor said the resident would be there within 15 minutes. When Dr. Taylor called the resident, the resident said, “I just wanted to let you know that radiology just called and the patient has a completely torsed ovary.” Dr. Taylor explained, “Ovarian torsion in pregnancy is uncommon and hadn’t at all been on our differential, but this young lady was in the OR within 30 minutes so that we could untwist and hopefully save her ovary. And we untwisted it and it was fine.”

When the patient was going to sleep for surgery, she kept saying how grateful she was. The patient said, “Thank you for listening to me. No one has listened to me.” As soon as the patient woke up, she told Dr. Taylor that the pain was gone. Dr. Taylor called the patient’s mom to let her know that the surgery went well. The patient’s mom told Dr. Taylor, “I really don’t feel like anyone’s been taking care of her and I just wanted to say thank you for listening.”

Dr. Taylor shared these experiences to help illustrate how important it is to listen and believe women, in particular Black, Indigenous, and people of color.

For more information on speaking up for Black women, please visit the PQI SPEAK UP Program website and the CDC Hear Her Campaign website.

“As a result of implementing QBL at our facility, we are able to better recognize and plan preemptively for patients that are at significant risk for severe blood loss.” –Dr. Jessica McNeil

Dr. Jessica McNeil, DNP, APRN, CNM, RNC-OB, C-EFM, is a certified nurse midwife and clinical educator in Dallas, Texas. Dr. McNeil conducts QI projects, implements evidence-based practices, and oversees research projects. In addition, Dr. McNeil implements maternal safety initiatives mandated by the Texas Alliance for Innovation on Maternal Health (TexasAIM).

Dr. Jessica McNeil

In 2019, TexasAIM asked participating hospitals to implement Quantitative Blood Loss (QBL). Dr. McNeil explained, “QBL has been recognized as a best practice to improve maternal outcomes. When you have a better understanding of how much blood a woman has truly lost then you can preemptively respond appropriately.” The goals of the QI project were to use QBL on all vaginal and cesarean deliveries, conduct a risk assessment on each patient, and institute interventions for patients at high-risk of hemorrhage at Texas Health Presbyterian Hospital Flower Mound.

Before starting the project, Dr. McNeil along with Loren Blair, MSN, RN conducted an assessment to make sure all the necessary equipment was available. They also got buy-in from staff. During her meetings with staff, they shared national, state, and hospital level data. They provided staff with resources and e-learning materials developed by TexasAIM.

Loren Blair

Next, they gathered a group of stakeholders together. Dr. McNeil explained, “We started off with a narrow viewpoint of who our stakeholders were. We had to go back and say, ‘Wait a minute. We need help from IT. The nurses can’t chart this. It's not in our electronic medical record. We need blood bank at the table. We need the midwives at the table.’” The stakeholders started meeting together twice a month. They used materials provided by TexasAIM to track their progress. 

The stakeholders selected individuals to be change champions for the project. Dr. McNeil said, “The individuals that were selected were recognized leaders within the department who voiced support for the change and believed in what we were doing. They were also respected by their peers and in good standing within the unit so they could model good behavior.”

As soon as the project started, the stakeholders began running Plan-Do-Study-Act (PDSA) cycles. “After each PDSA cycle, we would evaluate what went right and what went wrong. Then we would go back to the drawing table and run another one,” said Dr. McNeil. During project implementation, they realized that many of the staff did not have a strong understanding of QI. Dr. McNeil stated, “As educators, it’s our job to continually reinforce QI concepts. What is a PDSA cycle? Why are we doing that? What does it mean to continually reevaluate and improve? What does that look like tangibly?” Throughout the project, they educated staff at Texas Health Presbyterian Hospital Flower Mound on the importance of QI.

When asked what parts of the project went well, Dr. McNeil replied, “I think actually performing the QBL, weighing the items, went well. Once they understood and they had the tools in place, I think they adapted to that really well and were able to very easily get that number.” One of the challenges they faced with implementing QBL was getting all the doctors onboard. While reviewing audits, Dr. McNeil would see notes saying certain doctors did not want to perform or chart QBL. Dr. McNeil said, “Before we started our PDSA cycles we told the doctors we would be implementing QBL, but I don’t think it truly got across. That set us back a little bit. We had other providers that really championed the change, and were instrumental in moving things forward. I think as a team we were able to change course and get on track.”

As a result of the project, staff are better able to recognize patients who are at risk for hemorrhage and respond appropriately when hemorrhage occurs. Staff are implementing QBL in about 96-100% of vaginal and cesarean deliveries. Dr. McNeil explained, “A lot of months we’re at 100%. We’ve seen some really positive rapid improvement. Hopefully that decreases our severe morbidity and mortality rates overall.”

Dr. McNeil's advice for others considering engaging in QI:

• “I think that every single team that is going into a QI project really should start with the education. What is QI? Why do we care? Why do we do it? How does it differ from research?”
• “IHI does a really good job of explaining QI and starting with the why. Their open school modules are free.”
• “Get your stakeholders. Get provider input. Make sure nursing has a voice as well.”
• “Sit down and really think about every single person that you interact with when your patient is bleeding (or even before). For every action, there is a reaction. Think about how these actions will impact the service line.”
• “Evaluate your EMR. Make sure you have the tools to chart things and run reports. If you have a data analyst, use them. They become your best friend. If you don’t have a data analyst, consider making a proposal for your hospital to get one.”
• “Attend PQI’s Implementing Perinatal Quality Improvement Conference, PQI Champions Webinars, and review PQI’s Obstetric Hemorrhage Action Brief to help get more insights into how to use QI tools and methods.”
• “Don’t be afraid to reach out to other facilities to get feedback and ideas from them. Ultimately, it’s about safe outcomes for patients. It’s not a competition between hospitals. If one hospital has a really great system, then why not reach out and share that information instead of recreating the wheel?”

Dawn Brown BSN, RN is the clinical program director for the Perinatal Outcomes Workgroup through Education and Research (POWER) at the University of Arkansas for Medical Sciences (UAMS) in the UAMS Institute for Digital Health & Innovation (IDHI). She is also the Institute for Perinatal Quality Improvement’s (PQI) Arkansas State Coordinator.

She recently spoke at and helped develop POWER’s annual spring workshop, an event that had to be completely reimagined due to the COVID-19 lockdown. “Normally it’s a two-day workshop where everyone comes together and gets away from work. We have the opportunity to network and gain information through speakers and breakout sessions, but due to COVID we were unable to do that this year. However, since we are a digital health institute, it only made sense to move forward with a virtual event. We made adjustments, surveyed all the hospitals on how they would like to hold the workshop and we were able to still have both keynote speakers participate. The feedback we’ve received has been very positive, which makes us excited that this format worked,” said Ms. Brown.

She said she and her colleagues worried that the shift to a virtual workshop would result in less engagement because participants wouldn’t physically be present, but by the end of day two, it was clear people were involved. “We were really happy to see how many people attended and asked questions which showed us they were tuned in. Even when we had technical difficulties on our end, the participants showed patience, remained interested, and continued to join us. I’m glad they embraced the new format and our use of technology.”

According to Ms. Brown, they had 94 in attendance, joining from the comfort of their offices or homes over two half-day workshops. Her department was encouraged by the high participation rate, as one of their goals is to increase the use of this technology with clinicians in birthing hospitals across Arkansas. They’re hoping not to just offset the inconveniences created by social distancing, but to aid hospitals during an emergency as well as provide smaller rural hospitals with 24/7 access to a specialist. “It’ll help us change our footprint by being there in a more real way, whether it’s providing additional virtual education, simulation or resources--there’s a lot of options. I think COVID-19 has shown us that it can be done,” Brown said.

UAMS developed a toolkit designed to help providers transition from an in-person clinical practice to a virtual practice, which benefits both moms and babies. The virtual platform had no negative impact on the topics they were able to cover. They addressed obstetrical emergencies, statewide programs impacting and improving patient care, and POWER’s mission to reduce the maternal mortality rate in Arkansas, which is the fifth highest in the nation.

“Through the UAMS POWER program we do both an outreach and educational piece with the delivering hospitals throughout the state. We help them roll out safety bundles such as the Hypertension and Postpartum Hemorrhage bundles. We provide education to hospitals that don’t have a Neonatal Resuscitation Program (NRP), S.T.A.B.L.E. instructor or the ability to access the AWHONN fetal monitoring courses so they can stay current in their certifications. We also provide simulation drills to help OB staff have a robust education program, especially in small hospitals where budgets are too small to fund such programs. We’re trying to bring everyone to the same level playing field,” Brown said.

In her talk, Ms. Brown opened with sobering “state of their state” data, noting that it is more unsafe to give birth in the U.S. than it is in any other advanced nation. Arkansas, with a preterm birth rate of 11.6%, received an F on the March of Dimes report card. Brown went on to emphasize the racial disparity among black women who are at a 47% higher risk of preterm birth than all other women in Arkansas. After highlighting the social determinants causing these numbers such as maternal circumstances, maternal health systems and post birth care, Brown outlined state recommendations as well as what UAMS is doing to address current gaps in care. The work Ms. Brown and her colleagues are doing in POWER is good news for Arkansas. Through their outreach and education efforts, results have been promising, including fewer complications for high-risk mothers and babies.

“What I, along with the other presenters tried to highlight was that the UAMS Institute for Digital Health and its high-risk pregnancy program are helping hospitals and clinicians provide better care and improve outcomes,” said Brown. “And it can be done remotely.”

Dawn Brown’s advice to other perinatal healthcare providers adapting to technology during COVID-19:

• Find creative ways to continue to work to reduce perinatal morbidity and mortality. We can’t let the pandemic stop dissemination of needed information.
• Engage nurses from all over the state in virtual education sessions.
• Partner with telehealth programs that offer 24/7 support to provide more consistent care to women and babies throughout the state.
• Support education among clinicians working in rural areas by providing them with instructors and virtual education
• Push perinatal leaders to continue efforts to ensure all women and newborns receive high-quality, safe, evidence-based, and equitable perinatal care regardless of their race and ethnicity.

This Q&A is a follow-up to the PQI Champions webinar titled “Using Nurse-Level Cesarean Rates for Quality Improvement” by Dr. Joyce Edmonds, PhD, MPH, RN.

Dr. Edmonds is an Associate Professor at Boston College's WF Connell School of Nursing. She has over fifteen years’ experience in nursing and public health practice and research focused on maternal health outcomes. Dr. Edmonds has a research appointment with the Munn Center for Nursing Research at Massachusetts General Hospital and is an Affiliate at Ariadne Labs leading the Nurse Impact Portfolio with the Delivery Decisions Initiative team. She teaches public health and population health courses at Boston College, is an Editorial Board Member of JOGNN, and is Chair-elect of the American Public Health Association Public Health Nursing Section.

Can you briefly describe your research related to using nurse-level cesarean rates for quality improvement?

“I have been investigating how to measure the influence of labor and delivery nurses on birth outcomes and factors that shape Registered Nurses’ practice patterns. The goals of my program of research is to support physiological childbirth to improve quality and equity of maternity care services.”

Why does measuring RN cesarean birth rates matter?

“Widespread variation in clinical practices are routinely observed in health care and obstetrics is no exception. We also know that nursing care is essential to ensuring patient safety and quality. As a self-governing profession, we need to monitor our practice in ways that are meaningful particularly in light of the increased demand from the public and payers for accountability and transparency about clinical processes that affect patient outcomes at the hospital-level. Nurse-level cesarean birth rates is a particularly meaningful metric because it aligns with national as well as provider unit level initiatives across the United States.”

What are the primary challenges of measuring RN cesarean birth rates?

“There are a few measurement considerations inherent in calculating and interpreting cesarean birth rates. The effort is dependent on hospital specific context such as the composition of the nursing staff, the model care delivery, birth volume and nurse documentation systems need to be considered.

Despite the challenges, it’s a worthwhile endeavor. While we do operate in a team environment, and that’s critical, nurses aren’t interchangeable. They have unique strengths and skill sets, even within a team. To have knowledge of the effect of each individual RN means you’re your care matters. This can be really empowering with the potential of impacting decisions about patient assignments, for example.”

What are the pros and cons of measuring RN cesarean birth rates?

“I think measuring RN practices can promote individual and team accountability and increase data literacy among nurses. I think there is the potential to stimulate engagement and inquiry into continuous quality improvement and it aligns nurses with national and department QI initiatives.

I think the information must be contextualized. While it’s important to think about the individual level practices of RNs, the goal is not only to target specific changes in individual practices but also to improve the systems that support high-quality safe nursing care. Measuring RN practices is a potential gateway to having additional insights into the broader context in which nurses are working. The practice environment or context is very influential on nursing behaviors. For example, environments that lack resources like adequate nurse staff and equipment will be faced with more stressors and less time to be with their patients.”

The following questions were asked by participants during the Q&A session of the PQI Champions Webinar.

What criteria do you use to determine which nurse owns the outcome for a cesarean birth?

“Attribution is the method of assigning responsibility for patient outcomes to a specific health care provider. Across the board, in all specialties with all types of providers, this is a challenge. There have been several ways that we have approached attribution. The most readily accessible nurse identity timepoint in the labor and delivery is the nurse who supported the birth. But that is commonly criticized because it doesn’t reflect the complexity of patterns or intensity of nursing care over the course of a woman’s labor. The concern is that the nurse attributed to the mode of birth may not be the nurse who most influenced whether there was a cesarean or vaginal birth. An ideal standard for attribution would include length of nursing care and quality of care.

In the webinar, I presented a few studies. We looked at the nurse at admission, the nurse during labor management (defined as the nurse who spent the greatest amount of time with the patient – what they call the “majority of care rule”) and then, the nurse at the point of delivery. In the future, we would like to explore at multiple attributions.

When considering the tradeoffs of different attribution methods, it is important to remember that we are not suggesting that nurses are solely responsible. They are part of a much bigger picture. It’s really about bringing them into that conversation and empowering them with their own data to stimulate inquiry into practice. We are not establishing cause and effect.”

In your research, are you using balancing measures, such as Apgar scores?

“Balancing measures are important in terms of maternal and fetal outcomes. Adverse events are rare so you can often cannot drill down to the individual level in any meaningful way. At the unit level you can look at the Joint Commission’s PC-06 Measure or Unexpected Complication in Term Newborns, which is the recommended balancing measure to PC-02. We have not yet looked at balancing measures. I think it’s an important next step.”

Would some nurses work for a vaginal birth in situations where a cesarean births might be indicated?

“Cesarean births are a critical lifesaving procedure. A very unintended consequence of working to reduce cesarean births would be that nurses would delay responding to a life-threatening situation or a difficult labor or fetal heart rate pattern because they didn’t want their cesarean birth rates to increase. I don’t see that happening. Within the context of really good leadership and management, that positive environment and management structure that’s really fostering a culture of continuous quality inquiry is what’s important.”

What impact does shift working have on cesarean birth rates? Some hospitals have fewer cesarean deliveries called at night than during day.

“That’s really interesting. That would be one dimension that you could look at. You could calculate individual-level nurse rates and aggregate them at the shift level to look at means, or the distribution, between day and night shift.”

During the webinar, you mentioned that physicians have said, “If the hospital is going to publish my cesarean rates, then I want to pick my nurses.” Could you give a reference for this quote?

“There’s anecdotal feedback from our physician colleagues that there are some nurses that are better at facilitating safe vaginal births in certain types of patients than others. Physicians are aware of the influence that nurses have and that some are better at supporting vaginal birth than others. Just like, nurses have insight into physician practice patterns.”

Is there anything else you would like to add?

“I would love to hear from hospital-leaders currently calculating nurse-level rates about their experience. I would also love to hear from hospital leaders who are interested in measuring RN cesarean birth levels for quality improvement purposes. I’ve been thinking about coming up with a one-page self-assessment questionnaire to determine hospital readiness to abstract and use the data needed for this metric for QI purposes.”

Over the past month, healthcare providers and hospital administrators across this country have taken daily stock of the ever evolving data models that predict the curve of the Covid-19 pandemic and have done their best to prepare and respond. In some states and cities, Covid-19 has now reached its predicted peak or surpassed it while others still await their area’s surge. But, everywhere, every medical professional is meeting a challenge unlike any they’ve faced before. In the midst of this challenge, maternal health care workers find themselves discovering what it means to support women giving birth during a deadly pandemic, while they, and the mothers they serve feel the most vulnerable they have ever felt. To help guide maternity healthcare workers as efficiently as possible, PQI has teamed up with Michele Kulhanek MSN, RNC-OB, C-EFM, Director of Safety and Quality, Maternal Infant Health at Washington State Hospital Association, to deliver a quick list of accessible resources. She includes resources specific to the disparities in Covid-19 cases in the African American community which many health experts say is likely due to deeply rooted economic and healthcare inequities. 

Michele Kulhanek’s Preferred Resources and Recommendations: 

·      Centers for Disease Control & Prevention (CDC)

o   Specifically, the CDC’s Considerations for Infection Prevention and Control of Coronavirus Disease 2019 (COVID-19) in Inpatient Obstetric Healthcare Settings, which originally was posted back in February and was recently revised on April 4^th. The update provides clarification to the following:

§  The determination of whether or not to separate a mother with known or suspected COVID-19 and her infant should be made on a case-by-case basis using shared decision-making between the mother and the clinical team

§  Prioritized testing of pregnant women with suspected COVID-19 at admission or who develop symptoms of COVID-19 during admission

§  Considerations related to visitors and essential support persons to pregnant women who have known or suspected COVID-19 infection

§  Isolation of infants with suspected COVID-19 from other healthy infants

o   CDC’s guidance on pregnancy and breastfeeding found here

·      The World Health Organization (WHO) Q&A on COVID-19 in pregnancy, childbirth, and breastfeeding found here

·      The American College of Obstetricians and Gynecologists (ACOG) website. I scan for any new tools, Q&As, or articles.

·      The Society of Maternal Fetal Medicine (SMFM) website for updates and education -which are free until June 30, 2020.

·      American Journal of Obstetrics and Gynecology (AJOG) Guidance and the latest COVID-19 articles can be accessed here at no charge during the pandemic.

·      American Academy of Pediatrics (AAP) issued INITIAL GUIDANCE: Management of Infants Born to Mothers with COVID-19 on April 2^nd, 2020.

·      California Maternal Quality Care Collaborative (CMQCC) & California Perinatal Quality Care Collaborative (CPQCC) COVID-19 Resources for Maternal Infant Health https://caperinatalprograms.org/

o   This website is a one-stop shopping experience, with the latest updates and recommendations from several organizations, data registries, sample resources for hospitals, webinars, as well as resources for caregivers and patients. There are some days where I don’t have enough time to hit every single website. On those days, I look at this one.

·      Washington State Department of Health to keep a pulse on the current status of COVID 19 cases and deaths. I also look at demographics here, as WA is tracking and reporting COVID 19 data by race and ethnicity. I recommend checking your state’s Department of Health website to learn more about the number of positive cases in each county

• Minority Health Month (April)
  • NICHQ has a social media toolkit. We are using this toolkit to raise awareness on our social media sites with the following:  
    • Black women are dying from pregnancy-related deaths at over four times the rate of white women. This article shares seven strategies for reducing maternal mortality and promoting #equity: https://www.nichq.org/insight/using-equity-lens-reduce-maternal-mortality-louisiana #healthequity #NMHM20
    • Black and American Indian/Alaska Native babies are dying at more than twice the rate of white babies. Learn from these promising practices that aim to eliminate #disparities in sleep-related infant deaths: https://www.nichq.org/insight/promising-practices-eliminating-disparities-sleep-related-infant-deaths #NMHM20 #healthequity #safesleep #sids
• Black Maternal Health Week has just ended, but we must continue to elevate and amplify the voices and experiences of Black women’s birthing experiences and focus on eliminating racism, bias, and disparities in maternal care.
  • COVID-19 brings to light more inequities for Black women, American Indian women, immigrants/non-English speaking, LGBTQ people, and other vulnerable populations. It is important to remember that disparities were present before the pandemic and will continue afterwards.
    • Many of the above mentioned have low-wage, but essential jobs, such as in grocery stores, as caregivers, or in our health care systems. People may decide to go to work when they don’t feel well due to inability to take time off or fear of losing their jobs.
    • Unemployment is rising and livelihoods of the lower income workers are in even more jeopardy than before the pandemic.
    • Social determinants of health (lack of transportation, food scarcity, education, etc.) are exaggerated in a crisis such as COVID-19.
    • Black women are also known to have more comorbidities than their white counterparts - diseases such as asthma, hypertension, and diabetes put them at greater risk of contracting the virus
    • There is a mistrust due to profiling. (Black) Women who have historically been undervalued and unheard are now birthing without a support person or doula. Many who have different birthing and/or cultural beliefs, lived experiences and education from the people who are providing care for them.
    • People may delay much needed care which means we may see an uptick in chronic illness severe maternal morbidities or mortalities.
    • With social distancing, isolation, and stay home orders, intimate partner violence increases. If only one person is allowed to accompany a woman to the hospital for birth, it may likely be the person whom the woman is mistreated by (father of the baby) and not a supportive person like a doula, friend or family member. It is vital that health care providers are screening for safety at every interaction throughout pregnancy and postpartum.
    • Pregnancy is often a time when more women have access to health care benefits. Consider if deferring or delaying services - like postpartum long lasting reversible contraception (LARC) may cause financial strain on the woman.
  • Resources for reducing maternal mortality and increasing health equity (my go to resources to learn more)
    • Black Mamas Matter Alliance (BMMA) Founder of Black Maternal Health Week. BMMA raises awareness and inspires activism for Black maternal health. BMMA also has educational webinars and toolkits
    • National Birth Equity Collaborative (NBEC) creating solutions that optimize Black maternal and infant health through training, policy advocacy, research, and community-centered collaboration.
    • Every Mother Counts (EMC), making pregnancy and childbirth safer for every woman, everywhere.
    • March of Dimes (MOD) Beyond Labels campaign to reduce stigma and it’s Supportive Pregnancy Care model.
    • Merck for Mothers Safer Childbirth Cities A digital report
    • The Institute for Perinatal Quality Improvement's (PQI) SPEAK UP Against Racism Program. PQI's newly released online education module titled:  Trends and Disparities in Maternal Mortality and Morbidity
      
  • Reporting data by race and ethnicity, payer status, language
    • States may not be required to collect data on race and ethnicity
    • Collecting this data is crucial in understanding the effect of COVID-19 on ALL of our communities and developing solutions.
  • Lastly, with every decision we make in health care, we must ask ourselves, How will this affect all of our population?

By Siena Davis, MPH & Cassidy Hine, MPH

Dr. Ronald Iverson, MD, MPH, is an obstetrician/gynecologist at Boston Medical Center in Massachusetts and vice-chair of obstetrics. He co-chairs the Massachusetts Perinatal Quality Collaborative (PQC) with Dr. Audra Meadows, MD. On April 7, 2020, the Perinatal Neonatal Quality Improvement Network (PNQIN) partnered with the Betsy Lehman Center to hold a virtual town hall meeting to present on developing perinatal care solutions during the COVID-19 pandemic.

Can you give me some background? How did you decide to conduct a state-wide town hall meeting with perinatal clinicians?

“We had seen the excellent presentations from the California and Illinois PQCs. We had been thinking about how to contribute to collaboration in the state and to other PQCs. When we learned that the Betsy Lehman Center (BLC) team was interested in collaborating with us, we decided that to put together some sort of town hall that could be an area for sharing and group learning.”

What was the format for the meeting you conducted?

“We basically came up with the idea of an opening remark, discussion of the state of knowledge on COVID-19, then presentations and Q&A. The six presentations would include the problem statement, any data, development of solutions, then implementation. The idea was that we didn’t want to put out just absolute solutions that you could just get in an email. We wanted to talk about how you developed those solutions collaboratively. How did you roll it out? Pilot testing? results? lessons learned? We are about implementation and sustainment, not just great ideas. I thought that’s what we could bring to the table and emphasize. Not every one of the final products would be applicable to every space, but if people saw how it was developed and implemented, that would be useful as an analogy. A way to do work in these rapidly changing times. The amazing thing is, we dreamed this up on a Wednesday afternoon, had speakers on Thursday, an agenda on Friday, slides by Monday afternoon, and the speakers presented 5-7 slides (up to 7 minutes) on Tuesday. We decided to have each speaker give a short presentation, so participants would remember the bulk of the information the speakers shared.”

What topics were discussed in the town hall meeting?

“We started the conversation around COVID-19 updates and management. We then talked specifically about multiple topics such as, how women can get blood pressure cuffs so they can take their own blood pressure for the telehealth visit, provide labor support and also keep staff safe in labor and delivery units, and communication between teams. One speaker talked about the process of conducting postpartum follow up with patients remotely, with an emphasis on supporting patients’ mental health. Two nurse leaders gave a presentation on leadership and how they are using rapid cycle quality improvement to innovate, run small tests of change, and re-adjust the processes as needed. They pointed out that what seemed like a good idea in theory did not always work out in reality.

All of the presentations were outstanding. The speakers were intentional in giving very succinct and clear presentations. We are operating in an environment where people don’t have a lot of time to keep up with all the changes.

We got really good feedback in the survey that the Betsy Lehman Center sent out to the participants. Fifty-four of the about 250 participants responded. Ninety three percent of them are ‘likely to attend’ to our next town hall. They generally liked a 60 or 90 minute duration. They seemed to appreciate the format and topics.”

How many people attended the town hall?

“We had 250 participants, including administrators, nurses, doctors, midwives. We’re holding another meeting on Tuesday April 14, again with an emphasis on process and implementation.” 

As you think back over the town hall meeting, what parts of the meeting went well?

“We were very lucky to have the Betsy Lehman Center help us run the meeting. In addition to having a lot of experience with webinars and collaborative learning, they have many staff to help with the online process. What went well was the preparation was very complete. We looked like we knew what we were doing. We had people running the meeting in the background - helping with technological difficulties, monitoring the chat box, and working with Dr. Meadows to prepare for Q&A in the last 20 minutes. Having the Q&A session based on chats was very effective. I think having somebody there to help organize the topics for the chats so she could put them in her own words then direct them to experts was helpful. We prepared ourselves. We knew there would be questions on things we didn’t present on. We knew there would be questions about COVID-19 positive mothers breastfeeding their babies. We asked some experts in the state to be ready to answer some of these questions on the during the meeting.

We also prepared the speakers. We all met the day before and showed our slides to each other so there was no repeating of information. I felt like, with them knowing what everyone else was talking about, the transitions felt very smooth. They were able to adjust their theme and angle on the presentation by seeing the common thread that we were aiming for. No matter how much you explain through email, you can’t explain the emphasis you are looking for. It was helpful to have them look at each other’s presentations, make comments, and help each other.”

What parts of the meetings did not go as well as you hoped?

“Next time, we will do a better job keeping track of who attends the meeting. I want to be able to say how many hospitals we touched. The last town hall was 90 minutes long - from 12-1:30 pm. I watched participant levels. Most people stayed on until 1 pm. I know some people had clinics and other meetings, so they had to drop off. We will try one hour for another next meeting.”

What advice do you have for other perinatal quality collaboratives (PQCs)?

“Trust yourselves. From what I’ve seen with other PQCs, they know what they are talking about when it comes to implementation and organizing care. People are hungry for information. This is an excellent time for us to remember the importance of process and evaluation in our projects. For widespread implementation within the system, you still need to be thoughtful. Don’t just say something and hope that it sticks, but evaluate it and quickly take the learning and put it back into the process you are working on. If you continue to emphasize what PQCs are really about, implementing good practices, people will respond.”

What were some key insights that were gained by having the town hall?

“I run a lot of webinars and I have to say having a single slide set going in is key. I’ve seen situations where presenters share their screen sequentially, which can be tricky. Simple technical difficulties can lose the momentum. You really need to have a smooth transition, continual material for people to digest.”

At this point, what do you think are the most pressing questions related to COVID-19 and maternal care?

“People are still struggling with what PPE to be using as they take care of mothers. Not just because of science not telling us what to do, but because resources are so stretched.

People are also struggling with the best medications to use. We still don’t know everything about transmission from mother to fetus. We are working on best practices for delivery and supporting the family immediately after delivery, but we don’t know exactly what that should look like. We continue to look to the colleges to give us suggestions. It’s always changing.”

Could you summarize recommendations for other hospital and state leaders?

“If you have the resources to put on a collaborative meeting, this is the time to do it. This is the time to reinforce good implementation and appropriate process development in all of the spaces where we are working. My recommendation would be don’t wait, get something together, bring in your experts, and those experts can include all the people working on their teams. Have them present.”

When is your next town hall meeting?

“Our next town hall meeting is Tuesday, April 14, 2020 from 12-1:30pm ET. Click here for more information and to register. Please also let people know they can visit our website for more information: Visit the PNQIN COVID-19 Response page for additional COVID-19 resources and hospital guidelines and to find out about future Town Hall Meetings. ”

“A lot of times we think, ‘Moms have to come to us. They have to come to the clinic or they have to come to the hospital.’ We should extend our support of moms to where they are.” –Dr. Sarah Rhoads

Dr. Sarah Rhoads, PhD, DNP, WHNP-BC, FAAN, is a Professor and Research Faculty Member at the University of Tennessee Health Science Center. Dr. Rhoads researches the human impact of technologies on both health care providers and their patients. “I have a passion for helping moms in rural areas. There has got to be a nationwide push to help improve connectivity, for healthcare reasons, in rural areas,” said Dr. Rhoads.

In April 2018, Dr. Rhoads was employed as an Associate Professor & Education Director with the University of Arkansas for Medical Sciences College of Medicine and Center for Distance Health. She piloted a provider-initiated lactation support program in two hospitals (an academic science center and a private hospital) in Arkansas. The goals of the project were to improve at home support for new mothers who are breastfeeding, determine whether it would be feasible to provide lactation support to mothers through phone calls and two-way audio/video calls, and assess the acceptance of virtual lactation visits with lactation consultants and mothers. Dr. Rhoads wondered, “Would mothers be receptive to this? Would the lactation consultants be receptive to it? Logistically, could we work out all the patient enrollment issues with the app and connectivity?”

Before conducting the project, Dr. Rhoads learned that some of the lactation consultants were worried about using the technology. Dr. Rhoads trained the lactation consultants to make sure they were comfortable using the HIPPA compliance software, downloading and navigating the app, and making an assessment over the virtual visit using a two-way audio/video call. Once a few lactation consultants were on board, the entire team quickly became champions for the project. Dr. Rhoads said, “They were a cohesive team, but getting one or two lactation consultants to be cheerleaders for the project was very important.”

At the start of the pilot study, Dr. Rhoads randomized mothers into a phone only group or a two-way audio/video group. During the phone call or the virtual visit with two-way audio/video, lactation consultants would ask mothers a series of questions to assess their breastfeeding status, triage any issues, and provide breastfeeding education as needed. The mothers in the virtual visit could see their lactation consultant via the app and the lactation consultants could assess conduct an assessment of the breast and view the latch-on of the infant as needed. Because Dr. Rhoads had heard from both mothers and lactation consultants that mothers were not always calling in when they had breastfeeding issues, Dr. Rhoads made sure lactation consultants were contacting mothers regularly to provide breastfeeding support. “I set the study up so that we would automatically call the mothers 24-48 hours after discharge, one week after discharge, and then 3 weeks after that,” said Dr. Rhoads. 

Dr. Rhoads included all mothers in the study, regardless of how many children they had or how many times they had breastfed. She said, “Many breastfeeding studies limit interventions to first-time mothers. I’ve had several personal experiences where I met mothers who struggled even after their first two babies because each baby is different and the mom’s health can change over time. Having that additional support even with their third baby just made a world of difference and they breastfed longer. I was very purposeful with making sure we didn’t have those restrictions.”

Before calling study participants, the lactation consultants practiced audio/video calls with a mother who was in the hospital and another mother who had recently returned home. During the first few calls, Dr. Rhoads asked an IT specialist to wait outside the rooms and help the lactation consultants if any technical issues arose.

Dr. Rhoads decided to put up a poster board to recognize the lactation consultants who were making the connections. Her research assistant suggested putting a Mardi Gras baby on the board whenever a lactation consultant completed a call. “You would be amazed how happy it made the lactation consultants when they got a Mardi Gras baby on the board,” Dr. Rhoads said.

Throughout the project, Dr. Rhoads saw that the lactation consultants were highly effective at supporting breastfeeding mothers. She explained, “Sometimes just telling a mom she’s doing everything right is just what she needs at that moment in time. Lactation consultants do such a good job with mothers in the hospital. They build connections with the mothers that they’re helping. They’re the natural people to help them once they leave the hospital.” As a result of this project, the lactation consultants have embraced a new way to support mothers after they return home.

The primary challenge of this project was related to connectivity. Dr. Rhoads said, “Any time there were IT issues, most of them surrounded around connectivity. Whether it’s Wi-Fi connectivity or cellular connectivity in the mother’s home, it’s just not great in some areas of our nation, especially in rural areas. To have a poor connection was very frustrating for the lactation consultants and for the mothers.”

As Dr. Rhoads evaluated the qualitative data from the project, she discovered that many women in either group would not have called for lactation assistance on their own and they appreciated the scheduled calls. They would have waited until their breastfeeding issue became worse to reach out for help or would have just stopped breastfeeding altogether. A theme that was also found in both groups was reassurance. Many of the mothers needed reassurance during the first few weeks of breastfeeding. They also voiced that the convenience of having the breastfeeding assistance at home was very helpful. Dr. Rhoads is currently evaluating the quantitative data to determine whether the women in the study breastfed longer compared to other women at 12 weeks after delivery.

Dr. Sarah Dr. Rhoads’ advice to others who are thinking about engaging in QI:

• “We wouldn’t be in healthcare and helping moms and babies if we didn’t want the best type of care for them. Keep that in mind when you’re thinking of a QI project.”
• “Everybody has to start somewhere. Start small.”
• “Find a partner.”
• “Engage the people who are going to participate, get them comfortable, get them to be a cheerleader, and then recognize them throughout the process.”
• “Strive to provide better care for moms and babies.”
  

Across the country, maternal healthcare workers are attempting to stay informed as hospitals rapidly change their protocols to match the ever-escalating threat of COVID-19. In a time when so much is still unknown about the virus and its effect on pregnant people and their babies, PQI has partnered with Michele Kulhanek, MSN, RNC-OB, C-EFM, Director of Safety and Quality, Maternal Infant Health at Washington State Hospital Association, to provide frequent updates from Washington State that offer guidance and resources to all maternity care providers navigating this crisis.

Michele, in a matter of days, New York hospitals went from instituting a controversial ban on partners and birth support from the labor and delivery room to overturning that policy when the NY State Health Department intervened. Can you give us your thoughts on changes to labor support policies across the country?

“It is a horrible place to be – trying to protect our hospital staff and do the right thing for every patient every time. We know the evidence for continuous labor support – Shorter duration of labor and birth, fewer medical interventions during labor and birth, including instrumental vaginal births, increased spontaneous vaginal birth, and more positive feelings about the birthing experience. With the known benefits of support during labor and delivery, WSHA recommends obstetric patients may have one partner and one birth support person accompany them. We do realize that there are other considerations for hospitals and they are making the best decisions based on the current information and the supplies at hand. I think the variation we see between our hospital’s visitation policies are based on community spread, supplies available, and the data we have about this virus. All of these factors change day-to-day, with each new patient, each situation, each new case we hear about. Does the hospital have enough supply to give to partners and birthing support people their own Personal Protective Equipment (PPE)? How do we keep doing what is proven to be best and what women deserve and keep everyone safe; these are extraordinary circumstances we are caring for people in. Hospital staff are leaving their families to show up and care for patients and they need to be protected. If we don’t find ways to keep our staff safe, we are in bigger trouble than we are right now.

If limiting visitors to your units, especially for COVID-19 positive or PUI, how can we help people feel supported, connected, and less afraid? We may need to get creative and offer iPads, video conference platforms, or other forms of communication to support birthing people through these unprecedented times. Is this as comforting or effective as having support in-person? Most likely not, but as hospitals are making individual considerations for who and how many can be present during labor and delivery, we must try everything we can to continue to provide evidence-based, respectful, and equitable patient-centered care.

One of the things I hear from doulas in Washington is that their clients are very understanding. They just want to know the policy ahead of time. It is crucial that hospitals communicate temporary restrictions on visitors and/or support persons to pregnant people and their support networks early and often -finding more than one outlet to share updates so people can prepare as much as possible. Communication should be culturally specific to the people served and available in other languages. People are afraid that they will be going through birth alone; it is important for nurses and providers to remember that they are coming to us feeling this way. We must find every opportunity for transparency and clarity in our decisions.” 

How are hospitals in Washington dealing with the uncertainty around asymptomatic patients who seem healthy but are still able to infect others?

“With news of COVID positive asymptomatic cases, it is likely staff and patients are coming to work or the hospital and unknowingly exposing others. We are now seeing some hospitals go to universal masking to care for all patients. Some are asking patients to don surgical masks. Again, this may greatly depend on their supply and it is unfortunate that not all hospitals have that as an option. Also, wearing masks may not be tolerable for patients at all times, especially during the second stage of labor, but may help prevent further spread of the virus. Some hospitals are starting to assign staff a stash of masks and eyewear for all patients and this will surely impact supplies but could be considered to keep staff healthy and at work. The main worry is keeping staff safe and from exposing one another. I am watching closely for stronger evidence and guidance on this practice.

Most hospitals are screening visitors at hospital points of entry and every 12 hours. We are counting on people coming into the hospitals to disclose if they have symptoms or have been in contact with others who are sick. This is imperative in minimizing the spread within the hospital. Staff are also being screened. Leaders at one Washington hospital said they send home, on average, 5 staff per shift. Staff may not realize they have a temperature, or they are coming to work out of obligation to their colleagues.

One hospital system in Washington is providing rapid testing to all patients admitted to labor and delivery, as well as testing patients scheduled for cesarean section or medical induction of labor in advance. This helps determine exactly where to place these patients and what equipment is needed. This isn’t available state-wide, but it is exactly what we need.”

Speaking of masks and testing...what are your thoughts about the dwindling supply of both?

“The national shortage of PPE is infuriating. Not having enough PPE to protect staff is one of the reasons hospitals are restricting partners and birth support persons. Fortunately, our state government and communities are working hard to increase production – from the Department of Corrections making gowns to a local furniture manufacturing company making thousands of masks daily (organizations can learn more about connecting factories with health care services here). There is a lot of variation in what is available depending on resources on hand at each facility-each hospital is optimizing its supply of PPE during the shortage. That may mean extending use beyond manufacturers guidelines. Some hospitals are sterilizing N95 masks in-house for reuse, provided they are not soiled with makeup or other debris.

We are also finding that many staff are confused about when to wear what. Per guidance from the Centers for Disease Control and Prevention (CDC), surgical facemasks can be used when N95, Powered Air Purifier Respirators (PAPR/CAPR) are not available. The CDC has a checklist of strategies for optimizing the current supply of N95 respirators during the response to COVID-19. It can be found here. Multiple professional organizations, including the Society for Maternal Fetal Medicine, American College of Obstetricians and Gynecologists, the Association of Women’s Health, Obstetric and Neonatal Nurses, and the American College of Nurse Midwives have submitted an open letter to the CDC outlining their concern that the CDC’s statement on PPE needs to be revised because it is being interpreted to mean that clinicians caring for women in labor do not need to wear PPE.

The CDC’s advice can be unsettling; we are seeing more and more health care workers fearful and anxious about the current situation. The reality is that in facing PPE shortages, we do the best we can with what we have--no one likes this reality. Some staff are bringing homemade masks to wear over their surgical masks. Recommendations from the CDC, Departments of Health, etc. vary on this practice. My hope would be that if staff are wearing home masks that there is a communicated process about how to store, transport, and launder these masks. Once the normal supply chain is restored, the CDC says to resume the use of appropriate PPE for all PUI and COVID 19 positive patients. Everyone agrees that clinicians need to continue to use N-95 or Powered Air Purifier Respirators (PAPR) for all aerosol-generating procedures. The challenge is what to do if there are not enough PPE supplies.

At a minimum, all patients having a vaginal birth who are persons under investigation (PUI) or COVID-19 positive should include appropriate PPE of a surgical mask, eye or face shield, gown, and gloves. Many OB providers and staff are using N-95 masks or Powered Air Purifier Respirators (PARR) for other occasions, from rounding on patients to the second stage labor (pushing), not only of PUI or COVID 19 positive patients but negative patients as well. Again, we need to ensure we are optimizing supplies. While birthing has not consistently been defined as an aerosolizing procedure, it is a time of prolonged contact with a patient and the possibility of producing droplets during deep exhalation and pushing. The American Journal of Obstetrics and Gynecology published labor and delivery guidelines authored by Dr. Boelig, et al. These authors state that since “second stage of labor is likely high risk for aerosolization and N-95 mask should be used.”

As we learn more about how the virus can (or may) be transmitted, it is important to consider enteric contact precautions with potential for fecal exposure, as well as asymptomatic spread. In addition, there are other questions being raised, such as, whether administering oxygen via facemask or via nasal cannula increases the amount of aerosolization of the virus and whether the use of nitrous oxide increases the risk of aerosolizing the virus. There is much that is still unknown at this time.”

When are you testing perinatal patients and staff?

“The lack of testing also continues to be problematic. Even for hospitals that have enough tests, the turn-a-round time for results can be up to 8 days. Using in-state laboratories can decrease the time to wait for results, as well as rapid testing options. I spoke to one nurse colleague who told me they had more than a dozen nurses out as PUI. These kinds of situations can be devastating-another example of why we need point of care rapid testing.

Appropriate PPE and rapid testing availability are two things we all need right now - these two things would allow hospitals to loosen birthing support person restrictions, lessen the time of separation from baby, and get PUI staff back to work sooner.”

Have you seen any creative staffing models emerge as a way to help healthcare providers fill whatever gaps may be left by PUI staff?

“There have been some suggestions recently about creating alternating health care workers and OB clinical teams (one or two weeks on, then off for one or two weeks) in order to help limit exposure and keep hospitals staffed appropriately. I am a bit skeptical of this working--first of all, there were staffing shortages prior to the pandemic but also I think about our rural and critical access hospitals whose labor, delivery, postpartum and nursery nurses who usually wear several other hats – maybe they are a L&D nurse, but they also float to the emergency department or are a part of another specialized team within the hospital. There isn’t a one size fits all answer to this, but I think there are things hospitals can do to help keep staff healthy and on the frontlines:

• If your unit has 8-hour shifts, move to 12-hour shifts if possible
• Consider training OR/PACU and short-stay nurses since elective surgeries are canceled
• Start an “on-call” group to assist in covering when other staff need to leave
• Use everyone to their highest-level scope of practice to decrease the burden on doctors and nurses – have nurse practitioners or certified nurse-midwives help with triaging or postpartum discharges
• Have staff practice social distancing in the break room and at the nurses’ stations
• Consider universal masking for staff for all patients, all shift
• Begin call-in huddles, if you haven’t done so already, to limit the number of people in gathering in one area together
• Ensure only essential personnel respond to emergencies, attend deliveries, and limit the trips in and out of PUI and COVID positive patients’ rooms by clustering care
• Are there low-risk patients who could have intermittent auscultation of fetal heart rate instead of continuous fetal monitoring? This may free up a nurse to do other tasks instead of watching a fetal heart monitoring screen, as well as equipment if the unit were to experience a surge in patients.
• Are there alternate locations for giving birth – for low-risk patients?”

Michele Kulhanek's Additional Recommendations:

1. Considerations Regarding Separation of Mothers and Babies

• There is insufficient data and conflicting recommendations on whether to routinely separate mom from baby.
  • The CDC guidelines do not categorically recommend separation - the language reads “consider” temporary separation.
  • This conflicts with the World Health Organization’s recommendation to keep the dyad together, including skin to skin, kangaroo care, and supports breastfeeding. The WHO recommends these activities to be done along with proper infection prevention, such as wearing a mask and completing proper hand hygiene.
  • It is essential that providers are engaging patients in conversations about the risks of separation and the benefits of separation so pregnant and birthing people have what they need to make an informed decision.
  • The decision should be made with the mother, not to the mother.
  • Separation should depend on the following
    • Clinical condition of the mother or newborn (ICU/NICU admission)
    • Mother’s choice/preference based on evidence and risks/benefits
    • Unit limitation or configuration
  • If the dyad is separated and the mother intends to breastfeed, support pumping to help establish a milk supply. Offer lactation consultation.”

2. Work to Eliminate Inequities

• This pandemic will have huge implications on our most vulnerable communities. People who have less access to resources and who may be more likely to feel uncomfortable expressing their wishes or concerns. We cannot forget why we brought in doulas into hospitals in the first place – because they have improved outcomes for low income and communities of color. Historically, we have not done a good job listening to women, especially women of color. We need to give people the opportunity to be heard.
• We need to track data by race/ethnicity.

3. Keep Up-to-Date

• The CDC and professional organizations are posting regular updates. It is important to frequently review the recommendations from the CDC and from the professional organizations.
  

COVID-19 has had a major impact on hospital labor and delivery units, but community birth settings such as freestanding birth centers face unique challenges. Margaret Buxton is the Lead Midwife and Angela Graham is the Director of Education and Programs at Baby and Company, a busy birth center in Nashville, TN affiliated with Vanderbilt Health. They shared how they have transformed their service model to keep patients and staff safe during the COVID-19 crisis.

Before the crisis: a model rooted in social connection

Social distancing has been a particular challenge for Baby and Company because, before the crisis hit, the care model focused on being socially connected, and the center itself was a hub of activity. “On any day, you would see families waiting in the great room for babies to be born, women having long face-to-face prenatal visits with their other children in tow, couples taking wellness and childbirth classes, and lots of staff moving around between births and visits at the center, births and patient rounds at Vanderbilt, and postpartum home visits to check in on mom and baby,” wrote Graham.

Angela Graham

Within a week of the first case of COVID-19 in the United States, the Baby and Company team had altered almost every part of this model.

A task force to nimbly adapt as the crisis evolved 

As news came that COVID-19 was in the United States, the birth center formed a task force aimed at keeping the birth center a safe and controlled environment to have a baby. “There were a couple members of the team who really turned out to be early adopters, urging us to take the spread of the virus seriously,” said Buxton. “We stay nimble, follow the evidence as it evolves, and implement plans in nearly real-time every day.”

Margaret Buxton

“When you’re in midwifery care, you’re all about hands-on, and this virus has forced us all to be the exact opposite of that!”

Baby and Company’s COVID-19 task force has made multiple changes to reduce contact between staff and patients—changes that impact the full spectrum of care, from prenatal visits to births, postpartum care, and gynecological care. Buxton and Graham shared some of the changes that have been implemented:

• We are doing nearly all visits, unless they require an in-person evaluation, via HIPAA compliant telehealth platforms. We immediately moved to one entrance to the building for our clients so we could more easily control the flow of traffic. Before they enter, they have a verbal screening and a temperature check, and once cleared, they are directed to either wash their hands or are given hand sanitizer before entering. No one with signs of illness may enter the building.
• We are encouraging clients to limit visitors during in-person appointments, and optimally, have visitors wait in the car. We're asking that they do not bring children.
• We've instituted a drive-up lab. The client texts when they arrive, then an RN or MA meets the client at their car in our open parking garage, takes their temp, and then proceeds with any lab needs. The nurses have moved rugs and some of our patio furniture out to the garage so that it looks homey and comforting.
• We're asking that clients limit their labor support to one support person or partner, and one doula. If they do not have a doula, then we're asking that they restrict their support to one person.
• We're asking that siblings meet the baby at home.
• Midwives previously floated between the birth center and the hospital and followed clients into the hospital when transfer was necessary, but now there is a hospital team and a birth center team. If a client needs to transfer care to the hospital, they will still get midwifery care, but from the hospital-based team.
• All GYN appointments and procedures have been postponed unless they are deemed critical, and we are referring out all ultrasound services.
• All of our postpartum home visits have been moved to in-center visits for the time being so that we can better control the environment for the exam. 

Buxton writes, “When you’re in midwifery care, you’re all about hands-on, and this virus has forced us all to be the exact opposite of that! We just keep reiterating to our clients that none of us want it to be like this, and one day, it won't be. But right now, we're doing everything we can to keep them safe.”

Moving education programs online 

Graham leads the education program for the center’s 500+ clients, the majority of whom are enrolled in classes. “Just as we got the news that there was a first COVID case in Tennessee, I remember being in a leadership meeting and saying, ‘You know, I think we should move our classes online’ At the time, I thought we might receive pushback from folks, but within 3 days of that decision, the world was socially isolating.”

For people planning birth center birth, Baby and Company requires participation in the education program. “So we had no choice but to make the switch quickly,” Graham writes. “Luckily, our education team is fast on its feet, and after a little tweaking, we moved the entire model online. The classes are still live with an educator but delivered remotely via Zoom.”

“One of our center's core values is ‘community,’ and we have spent the last five years fostering it at every turn. I refuse to let this virus put a stop to it.”

Baby and Company’s care model put a large emphasis on support, but with classes moved online and group visits cancelled, the team needed a new model. “We quickly sent out a survey on what kind of support new moms and pregnant women would like, and we now have implemented free, online support groups at several times during the week. We are offering support groups for newly-postpartum moms, general pregnancy, and for wellness topics like stress-reduction during this time, and even cooking with what's in your pantry.”

“One of our center's core values is ‘community,’ and we have spent the last five years fostering it at every turn. I refuse to let this virus put a stop to it,” says Graham. Buxton adds, “It's been interesting to see that the thing that drives anyone who does this for a living - the love of helping others and making a difference - has only intensified during this time. And since the touchpoints can't be physical ones, we seem to be growing around the obstacle of physical distance to find other ways to do those things.”

Increased demand for out-of-hospital birth amid the COVID-19 crisis

Changes in hospital policies and practices and rising concerns about the safety and capacity of the hospital system during a pandemic has led to an increased interest in birth center and home birth in Nashville and around the country. Buxton writes, “We have seen an increase volume of calls from women in the community seeking information about community-based birth. While we are excited to introduce them to our care model, we want to emphasize that all women in our care are screened carefully and continuously to make sure they remain low-risk, and planned hospital birth may be needed if risk factors develop. We are seamlessly integrated with Vanderbilt University Medical Center, and they have gone to extraordinary measures to prevent the labor unit from being a source of viral exposure.”

Graham adds, “Since we've opened in 2015, we've been working hard to introduce our birth center to the community. In a strange way, this difficult situation has brought fresh attention to the birth options in our community and we are grateful for that.”

Supporting staff and keeping them safe and well

The COVID-19 pandemic has made front-line health workers vulnerable to both getting and spreading the virus. Buxton share, “Like the rest of the country, our biggest physical needs are PPE supplies. Every day is a new discussion on how best to preserve and prolong the supplies we have.”

The risk of infection is not the only vulnerability, however. The crisis has also added stress for the team. Graham writes, “We have quickly realized that we miss each other on a social level! We started a staff Facebook group so that we could interact, keep in touch, and feel a little normal. And each meeting we have (and there are many meetings these days) begins with individual check-ins to see how everyone is coping.” She adds, “We are so lucky that most of us at the birth center are health-oriented anyway. Even though the days are longer and more stressful right now, I think we've all doubled down on finding time to care for ourselves physically and mentally. Without that self-care, we wouldn't be able to sustain the energy it takes to flex and change daily and continue to serve the women who need us more than ever.”

Summary of Margaret Buxton and Angela Graham's advice to perinatal healthcare workers during the COVID-19 pandemic:

1. General Recommendations

• Create an interdisciplinary task force that meets frequently to review new information and adapt to evolving information
• Communicate frequently with patients and offer extra support through web-based methods
• Organize staffing to reduce the number of possible exposures, for instance creating a hospital team and a birth center team.

2. Prenatal Visits

• Conduct as many of the routine prenatal visits via Telehealth if possible
• Reduce the length of in-person visits, and screen people prior to visits
• Ask patients to come by themselves to visits, and use technology such as FaceTime to loop partners or children in to the visits, if desired
• Add signage to help people navigate new processes when they arrive for visits

3. Education and Support

• Conduct classes via Zoom and provide other web-based resources to teach important pregnancy, childbirth and postpartum topics
• Provide additional opportunities for support and connection, since patients will not be able to socialize as much through classes, and will be seeking extra support and reassurance

4. Intrapartum

• Reduce the number of labor support people
• Update cleaning guidance and re-train staff in proper disinfecting procedures
• Make a plan for the process of transferring a patient if they are symptomatic for COVID-19

5. Postpartum

• Monitor mother-baby dyads in the center for longer than usual, and provide additional guidance on home monitoring for COVID-19 symptoms in both the mother and newborn
• Replace home visits with clinic visits
• Provide additional opportunities for support and screening for mood disorders

Michele Kulhanek, MSN, RN-C, C-EFM, is a QI leader on the front lines of the COVID-19 pandemic in Washington state. Her work as the Director of Safety and Quality, Maternal Infant Health at Washington State Hospital Association is to improve outcomes and promote quality improvement throughout her state, work that has looked dramatically different in this crisis.

“You almost want to beat your head against the wall sometimes because the changes are happening so rapidly-by the minute-and I think that we really are in new waters. We’re trying to balance between finding out more information, learning what our sources of truth are, and being able to collate these and get it out to the hospitals. It can be overwhelming and it can be frustrating because we just don’t know how this virus really affects pregnant women or newborns.”

ACOG has released a statement that although it does not appear from the evidence available that pregnant women are at greater risk of complications with COVID-19, pregnant women do need to be placed in a higher risk category because the natural state of pregnancy carries greater risk for respiratory infections such as influenza. For Kulhanek and her team, the lack of evidence so far means there are no clear answers to questions of preparedness in their hospital’s L&D units. Kulhanek stated that the limited number of cases reported from China and elsewhere indicate no vertical transmission of the virus, as the babies were not found to be born with COVID-19. However, we don’t know if the cases of women in China (where there is a higher c-section rate than the US) experienced skin-to-skin after delivery or were separated, and whether that will impact the data on birthing outcomes.

“Culturally, birth in China may be different than birth in the US. They may not do ‘golden hour’ like we do in the United States, where we’re keeping moms and babies together--we’re not comparing apples to apples. And what’s frustrating, is there’s a lag...a waiting period to see what will happen, if anything, with pregnant people and newborns,” Kulhanek said.

“We have a lot still to learn and unfortunately we won’t know until we know.”

While Kulhanek can confirm there have been COVID-19 cases among the pregnant population in Washington, these have so far been mild, with symptoms like fever and a cough. What still isn’t known is whether COVID-19 poses a greater risk to pregnant women with co-morbidities, such as diabetes, asthma, preeclampsia, and hypertensive disorders. “We have a lot still to learn and unfortunately we won’t know until we know,” she said.

Despite the lack of evidence and the ever-changing landscape Kulhanek finds herself navigating, she has gained some wisdom through her experience dealing with the spread of COVID-19 a couple weeks ahead of the rest of the country. Kulhanek said the first thing perinatal healthcare workers across the country should consider is shifting as much as possible from face-to-face to online appointments with patients, and to cancel events and restrict travel among staff. “We’re seeing some hospitals saying no to elective inductions of labor, and on the flip side of that we’re seeing some hospitals leaders saying let’s get these low-risk women in and delivered as soon as possible so if we do have a surge we’re better prepared,” Kulhanek said.

A Focus on Communication

A possible surge is the greatest concern hospital workers in any department are facing. In order to generate solutions to this evolving crisis, Kulhanek suggested that centralized communication be a focus. She emphasized the need for hospital perinatal leaders to network with other hospitals during this time to learn from each other and keep information flowing to staff and from staff on the front-lines. These frequent updates to their staff and community should include “current as of” that day’s date because things are changing so rapidly. “Staff and patients need to make sure they’re not looking at something that came out 5 days ago,” she said.

She stated that her organization has created a model visitor policy that can be found on its website www.wsha.org. She advised other organizations across the country to do the same. She noted that most labor and delivery units are restricting visitors to one support person, and acknowledged that this limitation might be uncomfortable for patients. She said she’s seeing that some women are choosing to give birth at home or in a birthing center instead. For healthy, low-risk pregnant women this is an option to discuss with a provider and may reduce bottlenecking in hospitals should we see a surge in capacity on labor and delivery units. She suggested that hospitals strengthen their communication with freestanding birthing centers and midwives and doulas as a way to standardize care as much as possible for patients who wish to transfer.

Adjustments to Care

As far as changes that have been made to adjust how women are cared for before, during, and after pregnancy during the pandemic, Kulhanek said she is seeing providers move the first prenatal visit from 6 or 8 weeks to 10 or 11 weeks, and they’re also looking at how often each person needs to be seen to try and space out prenatal visits. If telehealth isn’t an option, Kulhanek said providers are trying phone visits as an alternative. She said it was important to include information as it develops in these appointments since there are so many new fears surrounding the pandemic. Part of that advice should include encouraging patients to do more laboring at home before leaving for the hospital, so there’s less chance to be exposed to the virus.

She also suggested that hospitals keep their shift huddles to essential personnel only, and said the whiteboard in a patient’s room is more important than ever to keep patients, family and the health care team informed. “Finding new ways to communicate,” she said, “there’s been an adjustment there.” She said there’s been a lot of discussion in labor and delivery units on where to put patients who are COVID-19 positive. “Most units only have a couple of negative air pressure rooms, if any,” she said and emphasized the importance of establishing that protocol now. The Centers for Disease Prevention and Control (CDC) recommends that PUI (patients under investigation for COVID-19) need two negative swabs before being taken off isolation but acknowledged that lack of testing and slow turn around on results might lengthen their stay. 

“Just kind of thinking ahead, in [a provider’s] workflow, and how we can mitigate any issues ahead of time” 

Kulhanek said another consideration in looking at the possibility of a surge, is placing epidurals earlier-even if you’re not starting the epidural pump-to help free up the anesthesiologists to be available if there’s an emergency. “Just kind of thinking ahead, in [a provider’s] workflow and how we can mitigate any issues ahead of time, and making sure everyone is taken care of and everything is going smoothly if a crisis does occur,” she said. Another key adjustment Kulhanek suggested is making sure the door stays closed during any aerosolizing procedure for a suspected or positive COVID-19 patient, and for 30 minutes afterward. “It’s what the CDC recommends for the safety of the patient but that really ties up your staff so thinking about this ahead of time and realizing even beforehand; do you have signage on the OR door, some sort of symbol that lets people know this isn’t a routine C-section?” She also acknowledged that all aerosolizing procedures require N95 masks, a rare commodity right now and warned that hospitals and clinics need to think about where these as well as other PPE are kept and remove them from areas where the public can access them. “These [PPE] are walking away...it really is unfortunate...people are not their best selves when they’re experiencing fear.” She also emphasized that now is the time to start practicing safety protocols, as she said, “as L&D nurses, if you have someone who needs an emergency c-section seconds count. Staff may have the mentality of ‘you know what, I’ll throw on my hat on my way to the operating room because the patient is more important than donning my safety equipment.’ So, staff need to practice how to quickly and correctly put on their personal protective equipment before there is an emergency. Simulation training sessions will help staff practice how to keep themselves safe while responding quickly during an emergency.”

Rethinking Postpartum Support

She said another intrapartum adjustment might be co-location; deciding whether mom and baby are rooming in together if you have a suspected or confirmed COVID positive mom. “Some hospitals, depending on their configuration and the staffing of their unit and the mother’s choice, are keeping the mother and baby together, some are separating them and swabbing the baby at 24 hours of age and waiting for the results to come back.” She suggested that providers and hospitals make sure to inform their patients on whatever the protocol is, to decrease their fears and increase their knowledge, so they’re able to partner in their care during this time. She said hospitals are also rethinking their discharge instructions, and what moms really need to know before being sent home about warning signs and proper hygiene should they become symptomatic, and how to get these patients out of the hospital as soon as possible with as much information as they need, in order to increase capacity and limit the amount of exposure for the mother and baby. “I think hospitals are already thinking about newborn re-admissions for conditions like jaundice and how that may impact hospital capacity; here in Washington, the Washington State Health Care Authority has given the directive for all Medicaid managed care organizations to include home phototherapy as a covered benefit.” She also suggested hospitals rethink lactation support, whether it’s possible to have pediatricians step in to offer that support during their visits or if it’s possible to conduct sessions via telehealth.

Women also need to be fully aware of POST-BIRTH warning signs so that they do not ignore potentially life-threatening symptoms that are unrelated to COVID-19. “We need to help women now more than ever be aware of the POST-BIRTH warning signs so that they get treated if they experience symptoms. This information is particularly important to women who may be discharged from the hospital early. If a woman has a POST-BIRTH warning sign they need to ensure they know how and where they can go to be evaluated and treated.

“Don’t re-invent the wheel...share with each other--now is the time more than ever for multi-disciplinary and multi-organizational collaboration…”

The advice Kulhanek offered perinatal health leaders across the country is to think about who they’re screening and what their symptoms are; “we don’t want to be testing everyone, in order to conserve our tests.” She also recommended that as hospitals are developing new protocols: “don’t reinvent the wheel...share with each other--now is the time more than ever for multi-disciplinary and multi-organizational collaboration, and so look to those who have these in place and then adjust them to your own needs and the nuances of your unit.” She also suggested that units walk through their procedures first by considering what steps to take when a COVID-19 positive patient is admitted in labor, and creating a checklist. “It really is important to keep track of what is first, what is second, because this isn’t rote yet.” She also said your state’s Department of Health and Infectious Disease Departments are your new best friends. “Make sure you’re communicating with them and keeping on top of what’s new and latest to help you make decisions, and make sure you’re talking to clinics that feed into your labor and delivery unit and what their role is in triaging patients because that is critical to help with a surge that could overwhelm our healthcare systems.”

Planning for the Unexpected

When asked what she wished she would have known at the start of the pandemic, Kulhanek said, “We’re so used to thinking about what’s happening within the four walls of our hospital unit and preparing for emergencies there that we forget about what happens when a crisis has a ripple effect in our community,” and noted the effect school closures had on the availability of staff who suddenly needed childcare or the problem of certain staff being forced into quarantine after coming into contact with COVID-19. “We needed to think about how to keep our staff coming to work and how to keep their kids safe and how to best support them,” she said. She noted that in Washington, they’re seeing an amazing response from teachers and other individuals who are stepping in to solve this problem by starting day programs to care for the children of first responders and essential hospital personnel. “These are things nobody thought about before, but we’re seeing our community help each other and we’re seeing healthcare workers consider how they can help each other if they’re working opposite shifts; they’re connecting with each other in online forums to make child swapping arrangements.”

As a final thought, Kulhanek emphasized that as this pandemic sweeps across the country, people need to take it seriously. “This is much more dire than we thought it was in the early days and you need to shelter in place as much as you can, even if your state is not recommending it at this time. Stay home. This really needs to be a ‘we over me’ response. Without that approach, situations will become worse.”

Summary of Michele Kulhanek’s advice to perinatal healthcare workers during the COVID-19 pandemic:

1. General Recommendations

• Leadership needs to communicate with front-line staff, pregnant women, and the community often. Date each document and keep the communications as updated as possible based on the most recent news and recommendations from the CDC.
• Strengthen communications with other hospitals in the area, as well as local birthing centers, midwives, and doulas
• Partner closely with your state’s Department of Health and Infectious Disease Departments and check websites frequently
• Move PPE to a location that is inaccessible to the public
• Update yourself frequently on information coming from the WHO, CDC, ACOG, AWHONN, and SMFM

2. Prenatal Visits

• Shift as much face-to-face care to virtual or telehealth forums and give patients clear and updated information to make sure their questions are answered and they know what to expect
• Consider co-location and separation of suspected or confirmed COVID positive mothers and their babies prior to being admitted to the hospital
• Postpone elective or non-medically necessary inductions

3. Intrapartum

• Conduct trainings now on the correct methods of donning and doffing safety equipment
• Create a checklist for new procedures and protocols implemented to respond to COVID-19; none of it is rote yet
• Limit shift shift huddles and rounding to essential personnel only
• Signage on the OR door and the whiteboard in patients’ rooms is more important than ever
• Consider your workflow; ask yourself, “if an emergency occurs, is staff available to handle it?”
• Decide where suspected or confirmed COVID-19 patients will go when they’re admitted in labor

4. Postpartum

• Rethink infant re-admittance for conditions like jaundice
• Rethink discharge instructions for mothers to include information pertinent to COVID-19
• Make sure all women are taught the POST-BIRTH warning signs and know where and how they will be evaluated and treated if they have a postpartum complication

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.”

“...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.”
  

“You don’t have to have a DNP or a PhD… You don’t have to be the attending physician... All perinatal health professionals with these tools can successfully implement a practice change.” -Lucy Davidoff

Lucy Davidoff, BA/BSN, RN, works in the Neonatal Intensive Care Unit the at the University of Maryland Medical Center. She is pursuing a Doctorate of Nursing Practice in the Neonatal Specialty at the University of Maryland School of Nursing. Lucy co-authored QI Action Brief 4.1: Delayed Cord Clamping, which was released in June of 2019.

 Can you tell me a few reasons why delayed cord clamping is important?

“Delayed cord clamping is important for a lot of reasons. It’s a really simple practice change… Oftentimes, when we think about practice changes, they are expensive and complicated. It’s nice when you get a practice change that, in some ways, is walking back our medical practices and connecting with much older obstetric/midwifery practices. To be able to have a very huge impact on such a vulnerable patient population, just by waiting a few seconds to act, is pretty powerful. Coming from the nursing world, I really appreciate how interdisciplinary the practice change is. It requires small, but significant changes on the part of every person on the team.”

Can you describe the process you went through in selecting this topic?

“I started just thinking about my patient population and what are some practice changes that have good evidence behind them that a small, dedicated team can be successful in accomplishing. Delayed cord clamping fit all of those objectives.”

How would you explain a QI Action Brief to someone who hasn’t used one before?

“It’s a learning tool, or guide, on how to think through effectively making actionable clinical changes... It helps a team create a driver diagram, or a logic model, and think through potential barriers and how to mitigate those barriers, potential facilitators and how you might enable those facilitators to help with your practice change.”

What do you see as the value of using a QI Action Brief?

“Utilizing the Action Brief helps guide you through the research and process that informs the best way to implement delayed cord clamping. Especially if you haven’t been academically trained in this area, these are a great short cut to helping you succeed.”

Can you briefly describe the main sections of the Action Brief?

Section 1: Case Study

“The case study takes you step-by-step through a scenario… I think the case study gives a really good, real-life, example of why and how you would use these tools.”

Section 2: Education on the Topic

“The education [section] is basically a quick walkthrough of the given case study topic, pathophysiology, protocols, guidelines, and some tips on why it’s important and how to implement it.”

Section 3: Education on QI Concepts, Methods, & Tools

“This last set of slides really pulls it all together and gives education on… the importance of quality improvement and implementation science. How best to use the tools? How best to get an interdisciplinary team together? How to motivate a group?”

Templates

“It’s really helpful to have [the templates], especially if you can print them out ahead of listening to the Action Brief. Give them a look over as your listening through. Think about how you would fill them out. Obviously, if you’re implementing practice change at your own setting, having those blank diagrams to work through on your own, or with a small workgroup, is helpful.”

What do you hope subscribers will learn from the QI Action Brief you co-authored?

“We all talk about how we struggle to translate evidence into practice. There’s that missing link. I think these tools, these Action Briefs, can really help to bridge that divide… I think it helps you lay out a clear process for improvement.”

What did you learn from the process of co-authoring this QI Action Brief?

“I learned a lot. For me, being in the middle of my doctorate, we are touching on a lot of these topics in my academic setting. I see the other side of it in my clinical practice. I think actually doing the Action Brief was, in many ways, one of the first time I started from the beginning and connected the academic world to my clinical practice… I feel a lot more confident about developing and implementing quality improvement practice changes in the future.”

Which QI tool do you find the most useful?

“Definitely the force field analysis. One of the things I find most helpful is that assessment of what could possibly come up. It’s so great if you can, before that problem arises, figure out a way around it so you don’t have it in the first place. Sort of an acknowledgement of ‘We might have this problem and when we do, we have a plan for how to approach it.’”

Is there anything else you would like to add?

“When Dr. Bingham first asked me if I would be interested in writing an Action Brief, I definitely felt hesitant and nervous. ‘I don’t know if I’m qualified to do that.’ I think it’s such a good reminder that anyone can do these! It’s one step at a time... one foot in front of the other. Walk through the tools and I think you come out really successful on the other side.”

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“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.”