This blog post is taken from a recent Webinar featuring Dr. Tamika Auguste, Director of Obstetrics and Gynecology Simulation, MedStar Health, and Jeanne Mahoney, Senior Director of The College’s Provider’s Partnership, American College of Obstetricians and Gynecologists (ACOG).
Why is it important to focus on OB risk reduction education? Our problem is maternal mortality here in the United States. Our maternal mortality rate in 2007 was 12.7 and by 2013 had increased to 22.0. By 2010, the U.S. was ranked 50th among 59 developed countries according to WHO and then by 2013 the Lancet estimated that our maternal mortality rate was as high as 18.5 per 100,000, thus dropping us to 60th in the world. And when we take a closer look not only in the United States, but across the world as to what is contributing to the problem of maternal mortality, the leading preventable causes of maternal death and severe morbidity are obstetrical hemorrhage and preeclampsia. So where are the problems coming from—how are these numbers increasing?
Some investigators have pointed to the recent improvements in identification of maternal deaths and the collection of maternal death data, where others point to significant changes in population characteristics of pregnant women that make them more at risk for morbidity and mortality. And yet there's also a fraction of investigators who acknowledge that, yes there are administrative and population characteristic changes, but while they account for only some of the increase, a significant portion of the increase may be due to clinical factors under the control of a healthcare system. That's more of a reflection on the quality of care that a healthcare system may deliver. So what can we do? Continuing our maternal mortality reviews, researching and finding the primary causes of death, and sharing that data. That's the only way that we're really going to learn.
We also want to continue with our quality improvement initiatives that increase awareness. Though on a local level it may seem a small change, but often times these small changes can lead to larger change. We also want to continue to develop and utilize bundles and tool kits for education that come from organizations like AIM, the Council for Patient Safety in Women’s Health Care, CMQCC, AWHONN, SMSN, etc.
Focus on Education
The focus should be on education. To help with our maternal mortality rate, we need to improve communication and our critical thinking. Communication breakdown is the number one cause in 73% of perinatal sentinel events. When we are developing education around communication we have to focus on the tools that we have and how we deliver education around them. We need education that allows people to set the stage when they're in a tough case. Allow learners to feel confident if they see something to say something, and to go ahead and ask questions. We're talking about shared decision making—we have to allow our healthcare team and patients to discuss evidence-based options, consequences of these options, and the other ones available, and to make a decision together. It allows patients to have his or her opinions and values heard and respected by the whole healthcare team. And it's important to realize that each member of the healthcare team has an equal contribution to the decision-making process and the outcome.
We also need to be able to teach structured communication, this is what we know of specifically things like ASPAR. Its utilization needs to be improved. When you think about effective assertion, this is where we have to allow our learners to speak up and state the information they need with appropriate persistence until there's a clear resolution. We need to focus on the use of critical language, key phrases that are understood by all to mean, “Stop and listen to me, we have a potential problem here!” We also have to be able to teach our learners situational awareness. This allows us to recognize all the events that are going on around us, and to act correctly when things proceed as planned and react appropriately when they don't. It's important to realize that situational awareness is shared by the whole entire team. So what is the education that has to happen around these?
Strengthen Communication and Critical Thinking
Communication and critical thinking is where we're going in the future. What is the definition of critical thinking? The objective analysis and evaluation of an issue in order to form judgement. When you have the belief, action, conceptualizing, and judgment involved in the concept that we have to teach, that is difficult. Critical thinking is self-directed, self-disciplined, self-monitored, and self-corrective thinking.
There's a theme of communication across all the topics, in addition to specific modules on communication and disclosure. Why? Because we know how important communication is, and all the modules truly encourage critical thinking. It helps learners to truly get the most out of the education. And one of our greatest educators said, "If you have an important point to make, don't try to be subtle or clever, use a pile driver. Hit the point once, then come back and hit it again, and then hit it a third time, a tremendous whack!”
So when you think of critical thinking, it's no longer solely task-specific focused education. It's not just shoulder dystocia, breech delivery, vacuum, or forceps, but encompasses decision making. What do you do with category two tracings? What if you have prolonged stage two labor? And then it also speaks to that inner voice in us about failure to speak up. This is a significant problem in the world of safety and often due to hierarchy and intimidation. Critical thinking is a combination of those specific paths and communication and that's where we are today and what we have to teach, that's our challenge.
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