At St. Thomas Elgin General Hospital (STEGH) the BORN Maternal Newborn Dashboard (MND) is a living breathing report that is actively discussed during morning “huddles” (quality improvement rounds). Continuous quality improvement (CQI) initiatives related to the MND KPIs are identified and tracked daily.
The MND is also a standing item at the Clinical Care Team meeting where CQIs initiatives are discussed. One of four KPIs selected by this committee as a CQI priority was KPI 6: Proportion of women who were induced with any indication of post‐dates and were less than 41 weeks’ gestation at delivery. The provincial benchmark target was
Tailored strategies were developed to address this issue: the clinical care team reviewed best practices, literature and made recommendations for practice change. Policies were reviewed and revised, education for both physicians and front line staff were provided and staff were enabled and supported to respectfully challenge reasons for induction. Every induction was reviewed by the Clinical Resource Nurse and if it did not meet the SOGC criteria it was brought to the attention of the Manager who then discussed the case with the physician. Within 6 months the target benchmark was achieved and the STEGH team has been able to sustain this performance, now maintaining a 0% in this metric for a year and a half.
Empowering staff with knowledge and resources, and physician support for the initiative led to practice-changing results and improved care. STEGH continues to monitor KPIs on the “huddle board” daily. Weekly reports to the Quality, Risk and Safety Committee and the Board Quality Committee keeps leadership within the organization informed of the changes made and sustained within the Women and Children’s Program. Engaging, enabling and empowering staff through practice change keeps the team focused on quality, patient outcomes, and a positive patient experience.
The BORN Maternal Newborn Dashboard has been a pivotal resource to support this initiative.