Integrating Change to the Bedside

Integrating change to the bedside can be difficult for many reasons including a lack of the following resources to effectively drive change: quality support staff, data, leadership, time, adequate mentoring, knowledge of quality improvement (QI) techniques, and a culture that does not support change. The culture piece includes hanging on to old practices because of the mentality of “this is the way it’s always been done”, also referred to as sacred cows (Kelly et al, 2018). Simply because it’s the way it’s always been done does not mean it’s the best way of doing something. Shifting this mindset through the use of a QI approach includes evaluating if current processes can be done better, or if research supports integrating specific changes into practice.  Unfortunately, this is a slow process, with the average length of time to integrate national guidelines into clinical practice being cited as 17 years (Markow & Main, 2019). There are, however, many tools and strategies that can help reduce this time to adoption and bridge the gap to the bedside. 

Tools to help integrate change to the bedside 

There are a variety of ways to incorporate change to the bedside, these include the use of evidence-based safety bundles, guidelines and protocols, and electronic medical record optimization.  The following table defines these tools along with examples.

Tool	Definition	Example(s)
Bundle	An organized way of improving care processes and patient outcomes, derived from evidence-based practices. These practices, when used as a whole, have been shown to improve patient outcomes. (IHI, n.d.)	IHI Elective Induction Bundle (Oxytocin), IHI Augmentation Bundle (Oxytocin), and the IHI Vacuum Bundle California Maternal Quality Care Collaborative Obstetric Hemorrhage Safety Bundle: including hemorrhage cart, order sets, risk assessment, quantitative blood loss, teamwork training including simulation and systems learning through debriefings and case reviews (Markow & Main, 2019).
Guidelines	Documents based on literature review, that include recommendations for patient care	AWHONN Nursing Care and Management of the Second Stage of Labor Evidence-Based Clinical Practice Guideline
Protocols	More prescriptive includes detailed steps to be followed pertaining to select patient populations or diagnoses.	Oxytocin Checklist Protocol. Details assessment parameters prior to initiating oxytocin and in-use. Ensures adequate fetal and maternal well-being are assessed and met, the patient is a good candidate for induction/augmentation and adequate safety measures are in place.
Electronic Medical Record (EMR) Optimization: Flowsheets	Rows within the EMR may include required documentation, assessment parameters, or action items to be completed. Can serve as reminders or visual cues.	The second stage of labor flowsheet row containing pushing technique, maternal position, position aids, maternal response to pushing
EMR Optimization: Clinical Decision Support	Embedded alerts or reminders for correct next steps to be followed, compliance with best practice or documentation requirements	Best practice alerts (BPA’s) for emergency room providers that (a) alert providers when pregnant or postpartum patients have Blood Pressures that reach severe range (b) list next step interventions for treatment/management
EMR Optimization: Order Sets	A group of orders designed for specific patient diagnoses with the goal of standardizing practice	Order sets for management of severe hypertension in pregnant/postpartum patients for emergency room providers that include: medications, lab work, fetal monitoring, obstetric consult, blood pressure monitoring parameters

(Kelly et.al., 2018)

Toolkits

In addition to the above-described tools, a more comprehensive strategy is a toolkit. Toolkits are defined as collections of evidence-based articles, resources, guidelines, protocols, implementation guides, and education slide decks (Markow & Main, 2019). The California Maternal Quality Care Collaborative (CMQCC) has developed several tool kits including (but not limited to) obstetric hemorrhage, hypertensive disorders of pregnancy, sepsis, and cardiovascular disease.

The Power of Collaboratives

Perinatal Quality Collaboratives are state or multi-state networks of teams working to improve the quality of care and outcomes for mothers and babies. They offer a greater level of support for quality improvement efforts through sharing of information and resources, as well as data support. The CMQCC is one example of a highly successful collaborative that has served as a role model for other states. To increase leverage with their efforts, the CMQCC engaged private and public partners including the California Department of Public Health, health plans, purchasers, and major professional societies such as the American College of Obstetricians and Gynecologists (ACOG) and the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN). 

Their work has stimulated change at a national level, leading to the development of quality measures supported by the National Quality Forum including the primary cesarean rate for low-risk first births, infants under 1500g delivered at an appropriate site, exclusive breastfeeding at hospital discharge, and unexpected newborn complications (CMQCC, n.d.). Lastly, their approach also involves data support for both hospital and provider levels, along with QI support to help mentor hospital teams in tool kit implementation strategies including change management and QI techniques (Markow & Main, 2019). 

In summary, QI efforts, whether it’s making a small change to improve a process, implementing evidence-based practice, or a larger QI initiative, require effective ways to drive change to the bedside. A comprehensive approach includes use of toolkits and safety bundles that are adapted to individual environments. If available, state collaboratives can also offer support for these efforts. 

*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide

References

Evidence-Based Care Bundles: IHI. (n.d.). Retrieved from http://www.ihi.org/Topics/Bundles/Pages/default.aspx#:~:text=Page Content, proven to improve patient outcomes.

Kelly, P., Vottero, B. A., & Christie-McAuliffe, C. A. (2018). Introduction to quality and safety education for nurses core competencies for nursing leadership and management. Springer Publishing Company.

California Maternal Quality Care Collaborative (CMQCC) (n.d.). What We Do.Retrieved from https://www.cmqcc.org/about-cmqcc/what-we-do

Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS