Unit Transformation Improves Safety for Mothers and Newborns

September / October 2009

Unit Transformation Improves Safety
for Mothers and Newborns

In “Delivering System Transformation: Respect, Communication, and Best Practices” (Dougherty et al., 2007), we described what we found when we looked closely into patient safety at the Maternity and Newborn Care Center (MNCC) at our organization, Hunterdon Medical Center. We found problems that included some identified as common root causes of perinatal death and injury by The Joint Commission in its Sentinel Event Alert Issue #30, “Preventing Infant Death and Injury During Delivery”: poor communication, unavailable physician staff, hierarchy and intimidation, and inadequate staff competence and fetal monitoring training.


Hunterdon Medical Center (HMC) is a 178-bed, non-profit community hospital in New Jersey, approximately 46 miles west of New York City. HMC provides a full range of services: preventive, diagnostic, and therapeutic; inpatient and outpatient; hospital and community health. HMC includes a regional cancer center affiliated with Fox Chase Cancer Center, a cardiac catheterization suite, a sleep disorders center, and an active diabetes center, among many other services. HMC has recently been awarded Magnet and NICHE status.


In this article, we discuss how we have addressed those problems and the progress we have made. In a future article we will discuss roadblocks we encountered and how we have arrived at a culture that truly supports on-going, sustainable excellence in patient safety.

Culture of Safety Survey
To “make the unacceptable impossible to ignore,” one must first find the deviance that has been normalized.

Our first formal step was to survey the nursing staff, physicians, and nurse midwives by using the Agency for Healthcare Research & Quality (AHRQ) Culture of Safety Survey. We knew we needed quantifiable data to establish a baseline for current practices so we could track changes in patient safety over time using defined metrics to measure the impact of our interventions. Our goal was to help the entire team embrace a common vision of safety and commit to their part in assuring that patient safety is our first priority.

The AHRQ survey measures 13 unit-level aspects of safety culture:

  • Teamwork
  • Staffing
  • Compliance with procedures
  • Training and skills
  • Nonpunitive response to mistakes
  • Hand-offs
  • Feedback and communication about incidents
  • Communication openness
  • Supervisor expectations and actions promoting safety
  • Overall perceptions of unit safety
  • Management support for safety
  • Organizational learning
  • Overall ratings

The AHRQ survey and an article by Simpson (2006) confirmed our instincts that we needed to look at safety across various measures. Simpson identifies the following aspects of safety:

  • Structure measures, which cover the organizational context of care such as an interdisciplinary practice committee and strong key clinical protocols for areas of care known to be associated with patient risk (for example neonatal resuscitation). Our Perinatal Committee was inactive. During our safety improvement program, the MNCC Safety Steering Committee, headed by the chief medical officer (CMO) and the director of patient safety, became the precursor to a revitalized Perinatal Committee.
  • Process measures evaluate how care is provided, including adherence to science and standards-based clinical protocols (for example, decision-to-incision within 30 minutes for emergent cesarean birth).
  • Outcome measures should be tracked for complication rates, morbidity, and mortality. These are included in AHRQ’s patient safety indicators (PSIs), the Joint Commission core measures, and the NQF performance measurement set for nursing-sensitive care. We collected qualitative information via assessment methods, which provided rich actionable data (Simpson 2006). Qualitative data was obtained on our unit by storytelling, staff interviews, the AHRQ Safety Survey, administrative safety walk-arounds, and shadowing of nurses by the chief nursing officer (CNO).

The initial survey results confirmed that we “had work to do” with staff perceptions of safety, both for patient safety and indeed their own safety, if they dared to speak up. We had a response rate of 68.3% (82 out of 120); 58% of the respondents had worked at Hunterdon between 1 and 10 years; and 99% had direct interaction with patients. The survey confirmed much of what we had heard through stories and informal surveys. It also alerted us to constraints that were very difficult for nursing leadership to face: we learned that staff didn’t feel as supported by management as we would have hoped.

The following is a brief summary of results from our initial safety survey:

  • 30% disagreed that patient safety never was sacrificed to get more work done.
  • 45% indicated that serious mistakes don’t just happen by chance in labor and delivery.
  • 38% indicated that there were safety problems and concerns that need attention within labor and delivery.
  • Near misses and close calls were reported only 30% of the time, and harmful events only 60% of the time.
  • The overall reporting of incidents by staff was low: almost 50% of staff reported they had never filled an incident report.
  • 43% indicated our patient safety grade was “acceptable” or “poor,” while only 11% said “excellent,” and 46% said “very good.”

Management expectations and actions promoting patient safety:

  • 48% indicated that supervisors and managers of the labor and delivery department are supportive of patient safety concerns; 39% felt they were supportive of suggestions by staff and colleagues.
  • 61% indicated that work pressure in the majority of situations did not compromise safety, but recurring events were actively addressed by management only 60% of the time.
  • 80% of the MNCC nurses and physicians felt that the organization as a whole was actively working to resolve patient safety issues.
  • 57% agree that learning and making positive changes in response to mistakes has been important.
  • 70% feel that colleagues were supportive of each other.

Communication environment:
While staff were willing to speak out regarding safety concerns 72% of the time, they did not feel free to question decisions of those in authority 44% of the time:

  • 47% of the time, they were afraid to ask questions when something did not seem right.
  • 32% of respondents indicated that the staff worked in crisis mode, trying to do too much too quickly
  • 38% of respondents indicated that patient information got lost during transfers and hand-offs.

Improvement Strategies
These survey results verified that we had many issues to address. To avoid becoming overwhelmed and make the most of the momentum generated by the survey, we analyzed the results with the administration and chose to tackle issues on several fronts at once. Our strategy was to set up a collaborative system with our provider colleagues to garner their support and cooperation in avoiding problems rather than reacting to bad outcomes.

Since the survey indicated that the staff did not feel adequately supported by management, we made sure unit management was visibly present to support and affirm the staff in all safety issues, including those with providers. The director of patient safety rounded almost daily, attended special meetings with staff and teams, co-chaired the MNCC Safety Committee, trained staff to use incident reports to generate data for change, empowered staff to use incident reporting and strengthen their “voice,” assisted in developing performance improvement measures and spent a significant amount of time responding quickly to staff and management concerns negotiating solutions.

The CNO and CMO made themselves very present, visible, and available through regular executive patient safety rounds, attendance at staff meetings, following up on reported issues, and providing courageous, strong support at the MNCC Safety Steering Committee. The CNO also spent time shadowing a staff nurse on labor and delivery and in the special-care nursery to better understand the unique work challenges at the sharp end.

We started medical team training soon after viewing the survey results: 44% of staff members did not feeling comfortable questioning their superiors, 47% were afraid to question even when something didn’t feel right. Those were red flags. Our training focused on team communication skills, understanding human error, and human factors skills such as teamwork, assertion, advocacy, situational awareness/red flags, decision-making, briefings, and debriefings. The 4-hour training was interactive, interdisciplinary, and very well received, even by those who were not enthusiastic initially. The training emphasized the universal and effective use of SBAR (situation, background, assessment, and recommendations) for communication. These team skill sets were first developed by the military and aviation to reduce error in their high-risk environments. Aviation had a history of communication failures that led to significant loss of life with root causes similar to those at work in healthcare. The Joint Commission, Leapfrog Group, and various patient safety organizations recommend team training for healthcare organizations.

As we implemented team training at our hospital, we had a strong expectation, supported by leadership, that all who cared for patients on our unit would participate. We included all of our obstetrical care providers: physicians in obstetrics and family practice, family practice residents, and certified nurse midwives; anesthesia; neonatologists/pediatricians; nurses; environmental care workers; and unit coordinators (unit secretaries). They all attended and learned how to communicate, assert, and take action to be a safer team.

We formed multidisciplinary groups to work on key safety issues by developing policies for high-risk protocols and procedures. These groups included:

The SBAR Group, which developed tools to help with safe communication and hand-offs. They developed a labor communication tool as well as hand-off tools for situations including change of shift and transition to social work/psychology.

The Standards Committee worked hard to bring our policies into strict alignment with standards from the American College of Obstetricians and Gynecologists (ACOG) and Association of Women’s Health, Obstetrical, and Neonatal Nurses (AWHONN). This group also wrote a policy that allows the bedside nurse to call for an immediate consultation if she is concerned about the management of a patient. This was before rapid response teams were a national expectation.

The Fetal Monitoring Group developed definitions for fetal well-being that are in line with ACOG and AWHONN standards. We taught the NICHD (National Institute of Child Health and Development) terminology to all providers and staff. This group also decided to have all who take care of laboring women take the same fetal monitoring class together so they can communicate using the same knowledge base and terminology in caring for our patients. This is still a fairly vanguard expectation, but is gaining in popularity because of improved outcomes. We used the AWHONN Principles & Practices Fetal Heart Monitoring Course. Everyone heard the strong message of patient safety advocacy and use of chain of command that this course emphasizes.

The new central surveillance system promoted group ownership of every patient on the monitor and facilitated collaboration on all fetal monitor strips. This system also made it possible for staff to view more than one strip at a time in any patient’s room so they can watch more than one fetus at a time as a team from anywhere in the unit. This system makes it possible to observe fetal heart rate (FHR) and uterine activity traces for every patient on the floor at a central location as well as at the bedside. Also, to identify and retrieve FHR tracings from locations other than the individual bedside fetal monitors, including the possibility for physicians to observe the tracings via a secure web-based system from their offices or home and it has an alert system to increase ability to identify and respond to potential problems quickly.

The Briefings/Debriefings Group developed a tool for pre-delivery briefings about complicated patients so that all anticipated “what ifs” are clearly understood by the entire team and the team can have everything and everyone in place to keep those patients safe. They also developed a tool for post-delivery debriefing on every delivery, surgery, and admission to the special-care nursery. Over time, the debriefing tool has been narrowed down to three questions: What did we do well? Were there additional resources needed? What could have been done better? There is also a place for comments. All debreifing recommendations are catalogued for action and then reviewed for organizational learning at staff meetings and the Perinatal Committee. We capture 100% of debriefings in writing.

Throughout this transformation, MNCC Safety Steering Committee (now called the Perinatal Committee), headed by the CMO and director of patient safety, exercised ongoing, visible oversight. All providers who want to deliver at HMC are expected to attend at least 50% of the committee meetings.


To improve the safety of care in its Maternity and Newborn Care Center, Hunterdon Medical Center used products and services available from Quantros, The Patient Safety Group, and Safer Healthcare.


We also initiated a unit-based patient safety reporting system to help us track our patient safety issues in a very transparent way. We encouraged everyone to use the web-based program to report near misses and potential or actual unsafe situations, as well as issues for future improvement projects. The system was developed at a leading healthcare organization in collaboration with the King family, as a result of their child’s death from medical error. The child’s mother, Sorrel King, formed the Josie King Foundation, which is a driving force in helping hospitals provide safer, more transparent care, using on-line tracking tools and on-going education. Because the vendor has been designated by AHRQ as a patient safety organization (PSO), reported information is protected from discovery.

With the strong support of management and reassurance of confidentiality, we saw an increase in incident reporting, which helps us identify and address on-going issues.

Although change isn’t easy, patient safety is too important not to follow through to consistent respect, communication, and best practices. The steps we have taken are replicable by any organization and demonstrate authentic action. We take inspiration from Ralph Waldo Emerson, who wrote:

What lies behind us and what lies before us are small matters compared to what lies within us.

Stephanie Dougherty is director of patient safety and risk management at Hunterdon Medical Center. She has been certified in critical care nursing, gastroenterology, and has completed ASHRM’s Healthcare Risk Management Module Certificate Program. She is past president of the New Jersey Society of Healthcare Risk Managers, and has presented patient safety topics at conferences in New Jersey, at the VIPCS annual conference in Virginia, and at the Quantros User Group Meeting in Las Vegas. Dougherty holds a bachelor’s degree in nursing from William Paterson University in New Jersey, is a graduate of the Patient Safety Fellowship program at Virginia Commonwealth University, is a masters-of-science candidate in patient safety leadership at the University of Illinois, Chicago, and teaches patient safety at The College of New Jersey. She also is a member of the New Jersey Maternal Mortality Review Committee. She may be contacted at dougherty.stephanie@hunterdonhealthcare.org.

Jeanne Whaley is director of the Maternity and Newborn Care Center at Hunterdon Medical Center. She has chaired the Nursing Management Council and sits on the Medical Staff Performance Improvement Committee. She also sits on a Multifacility Continuous Quality Improvement Council for the Central NJ Maternal Childhealth Consortium. She is an AWHONN Fetal Monitoring Principles and Practices instructor. She is certified by NCC in in-patient obstetrics, by ANCC in nursing administration, and is a member of AWHONN and NANN. Whaley holds a bachelor’s degree in nursing from Rutgers University in New Jersey.

Ardath Youngblood is co-leader of the interdisciplinary maternal child health safety initiative in the Maternity and Newborn Care Center at Hunterdon Medical Center. She is a NRP, S.T.A.B.L.E., and AWHONN Fetal Monitoring Principles and Practices instructor and is certified as an International Board Certified Lactation Consultant. Youngblood is a member of AWHONN, NANN, Sigma Theta Tau, and sits on the Central NJ Maternal Child Health Consortium’s Education Council. She received her BSN and MN from Emory University School of Nursing in Atlanta.

Robert Pickoff is chief medical officer of Hunterdon Healthcare System. After graduating from the Mount Sinai School of Medicine in New York, he completed an internal medicine internship and residency at Beth Israel Medical Center in New York and a Fellowship in Cardiovascular Diseases at The Saint Vincent’s Medical Center, where he was the Dr. William J. Grace Fellow. He practiced cardiology in New Jersey for 14 years. Pickoff holds a master’s degree in medical management from Tulane University in New Orleans.

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