Patient safety in women's health-care: professional colleges can make a difference. The Society of Obstetricians and Gynaecologists of Canada MOREOB program

doi:10.1016/j.bpobgyn.2007.01.013

Best Practice & Research Clinical Obstetrics & Gynaecology

Volume 21, Issue 4, August 2007, Pages 565-579

https://doi.org/10.1016/j.bpobgyn.2007.01.013 Get rights and content

The Society of Obstetricians and Gynaecologists of Canada has played a leadership role in advancing patient safety at the national level with the launching of their obstetric patient safety program ‘Managing Obstetric Risks Efficiently’ (MORE^OB). Developed over a 2-year period and launched as a pilot in 2002, the program has extended to 126 hospitals in five provinces that provide care for 48% of the births in Canada. The end-point for the program is to change the culture of blame to a focused and sustained patient safety culture, where patient safety is everyone's responsibility, with observed reductions in events and improved quality of care. The program has integrated the principles of high reliability organizations (HROs), systems error theory, team function, and communities of practice (CoPs) as values for the work environment. In this chapter we describe how the program was developed, the role of the national specialty society in the development, and the funding, structure and implementation of the program, and we report on the impact of the program over the first 3 years. In these first 3 years, knowledge enhancement in all disciplines and in all practice environments, with a significant reduction in variance among the disciplines, has been demonstrated. Culture change has occurred in all practice settings and has continued to improve over time. Using liability claims information from the hospitals, a reduction trend has been observed in liability carrier (hospital) incurred costs.

Section snippets

How managing obstetric risk efficiently (MORE^OB) was developed

The development of Managing Obstetric Risk Efficiently (MORE^OB) evolved out of an earlier educational risk management course that the Society of Obstetricians and Gynaecologists of Canada (SOGC) had developed for physicians. In the early 1990s, the SOGC developed the successful Advances in Labour Management and Risk course (ALARM) to address the concerns of managing obstetric risk. The courses were in demand and were well regarded, but the training was available to only a relatively small

The structure of the program

The MORE^OB program is a collaborative relationship between the Society of Obstetricians and Gynaecologists of Canada (SOGC), a hospital insurance provider, and/or the provincial government and the participating hospital. MORE^OB is implemented with three modules provided in sequence. This starts the hospital's obstetric program on its patient-safety journey. These modules are building blocks and include:

•
Module 1: learning together;
•
Module 2: working together;
•
Module 3: changing the culture.

Upon

How the program is implemented in the hospital environment

The implementation process in each hospital's obstetric unit is led by an inter-professional core team that includes family physicians, obstetricians, midwives, nurses, risk managers, senior hospital administrators, and a hospital board member. Each member of the core team is required to provide a signed commitment form indicating that they have read the mandate and understand their responsibilities. The SOGC has developed a core team selection guide to assist in this process.

The mandate of the

The funding business model for the program

To create a level playing field for all participants it was proposed that that the program be marketed as a subscription program for all health-care providers funded by participating hospitals and their liability insurance providers. Several insurance liability providers were approached for their support. The Health Insurance Reciprocal of Canada (HIROC) led the way and joined in a cooperative venture for a pilot program with the SOGC by introducing us to a number of their client hospitals and

The pilot phase: a catalyst for change

In July 2002, the SOGC launched the pilot phase of the program in Ontario, and by May of 2004 the program had been implemented in 33 pilot sites, with 2500 participants. Participation in MORE^OB has proved to be not only a valuable educational experience for pilot hospitals but also a powerful catalyst for making constructive changes in policies, practices, and workplace culture to improve patient safety.

How clients perceive the program

St Michael's Hospital has a fast-growing obstetrics program that delivers 30% more babies today than 8 years ago. It was the first academic hospital in Canada to participate in the MORE^OB program. The focus on finding the cause of unexpected events and not assigning blame struck the right chord. Dr Guylaine Lefebvre, chief of obstetrics and gynaecology, reports that she was impressed with the concept of bringing members of the department together as a team and evaluating processes of care as

The national launch

In June 2004, the Alberta Ministry of Health and Wellness agreed to provide funding to help support the implementation of the program across the province. In the fall of 2004, the national launch of MORE^OB began in Alberta, the first province to embrace the program on a province-wide basis.

The rapid rollout of the MORE^OB program in Alberta was a remarkable feat and a major step toward advancing the commitment to patient safety. The SOGC, in partnership with the Alberta Perinatal Health Program

The expansion continues

Alberta's leadership has provided direction for other provinces in undertaking to support the program in a similar manner. This year the British Columbia government has provided funding to support the launch of MORE^OB in a regional group of hospitals. Surrey was the first hospital in BC to join in September of last year, and another 18 hospitals in the northern interior region implemented the program between January and April of 2006. Following the pilot phase, the MORE^OB program has continued

What are the payoffs?

Today, more than 6000 obstetrics professionals in 126 hospitals in five provinces are involved in MORE^OB. Any hospital that wishes to participate must have at least 80% of obstetrics staff enrolled in the program. Of all births in Canada, 48% now take place in hospitals enrolled in the MORE^OB program.

National test results show that MORE^OB clinical core knowledge has increased significantly for all disciplines in primary, secondary and tertiary hospitals (Figure 3). Pre-training test scores

Fewer events and claims

The Health-care Insurance Reciprocal of Canada (HIROC) has provided claims information for 28 of their hospitals participating in the program. All services have shown a reduction in the frequency of claims. HIROC has used a polynomial trending process and separated obstetrics from all of the other hospital services to look at their incurred costs, which includes payouts to HIROC lawyers, adjusters, expert opinion expenditures and claimant's legal costs, and ultimate probable costs reserves

References (17)

L. Kohn et al.
To err is human, building a safer health system
(2000)
An organization with a memory Report of an Expert Group on Learning From Adverse Events in the NHS
(2000)
Vincent C. Presentation at CMA Forum on Risk Management, May 1998. Quoted in: Canadian Medical Association...
Personal communication of shared information from the education division of the Canadian Medical Protective Association...
P. McLean
Liability trends in nursing
Can Nurse
(2002)
J.T. Reason
Managing the risks of organizational accidents
(1997)
M. Garbowski et al.
Risk mitigation in large-scale systems: lessons from high reliability organizations. California management review
Summer
(1997)
K.H. Roberts
Some characteristics of one type of high reliability organization
Organ Sci
(1990)

There are more references available in the full text version of this article.

Cited by (19)

The Medico-Legal Climate in Canada: A Reflection on 75 Years for Obstetrics and Gynaecology
2019, Journal of Obstetrics and Gynaecology Canada
Le climat médico-juridique au Canada : un regard sur 75 années d'histoire de l'obstétrique et la gynécologie
2019, Journal of Obstetrics and Gynaecology Canada
The co-learning process in healthcare professionals: Assessing user satisfaction in virtual communities of practice
2015, Computers in Human Behavior
Communities of practice are nowadays an important concept in the healthcare sector. Particularly, the intensive use of ICT has allowed their creation into a virtual environment – Virtual Communities of Practice (VCoPs) developing optimal conditions to make possible the collaborative learning process. The VCoPs antecedents can be situated on social network phenomenon, where individuals with different traits but a common interest/objective are linked, use ICT potency (especially social media) to interchange information, experiences and contents among them. And as a result, people create and share knowledge, and learn collaboratively. VCoP users have a higher satisfaction level in the collaborative learning process when they can: (1) Achieve benefits related to patient diagnosis and treatment (cost reductions, faster management, quality and accuracy of diagnosis, etc.); (2) Increase the share capital of participants and creating networks of trusted individuals. Given the interest in this topic, the objective of this work is to identify the factors that determine user satisfaction in relation to Community Practice (CoP) and the process of building shared knowledge. For this, a sample of 130 Spanish health professionals participating in an online community, and developed in a virtual community of practice, is discussed. The results obtained from an analysis of logistic regression show evidence of the perception of efficiency and effectiveness in collaboration with the members of the VCoP as positively influencing the perceived satisfaction with the CoP. Also, the degree of individual participation in the community affects the degree of perceived satisfaction. The conclusions provide interesting strategic recommendations in the management process of the CoP.
Reflections on the Canadian MORE<sup>OB</sup> obstetrical risk management programme
2013, Best Practice and Research: Clinical Obstetrics and Gynaecology
Citation Excerpt :
The modules teach core obstetric content to ensure all members of an obstetric unit (e.g. nurses, midwives, family physicians, and obstetricians) have a similar foundation of clinical knowledge. Learning activities include the following: review of evidence-based guidelines; knowledge testing; inter-professional workshops; emergency drill simulation; culture assessment; and objective structured clinical examinations among others.1,2 These activities focus on establishing characteristics of high-reliability organisations3,4 within obstetric units, such as, safety being the first priority and everyone's responsibility, teamwork, communication and risk-management proficiency.2
In, 2001, the Patient Safety Division of the Society of Obstetricians and Gynaecologists of Canada initiated and championed a new program to improve patient safety performance in Canadian hospital obstetric units. This new program was developed under the banner of Managing Obstetrical Risk Efficiently and called the MORE^OB Programme The MORE^OB Programme was first piloted in Canadian hospitals at the beginning of May 2002 and, by mid 2004, 33 pilot sites had been implemented. In autumn 2004, this program embarked on a national launch. In 2007, the Society of Obstetricians and Gynaecologists of Canada collaborated with the Healthcare Insurance Reciprocal of Canada to form Salus Global Corporation. The birth of this corporate entity embraced the support of rapid expansion of the program within and outside of Canada. This collaboration also enabled innovation and implementation of safety programs beyond the obstetric discipline.
Models of maternity care in rural environments: Barriers and attributes of interprofessional collaboration with midwives
2013, Midwifery
Citation Excerpt :
We have commented elsewhere on the need for an alternative payment scheme for midwives and physicians working in shared care practice (Kornelsen, 2009), as well as on-call funding for maternity care for rural physicians to mitigate burn-out (Kornelsen and Grzybowski, 2010). With regard to resolving differences in models of care, decision makers may consider expanding and adapting interprofessional education programs that instill maternity provider students with the benefits and tools of collaboration, such as the Collaboration for Maternal and Newborn Health developed in British Columbia (Saxell et al., 2009) and the MOREOB (Managing Obstetrical Risk Efficiently) professional development programme, which strives to develop a focused and sustained patient safety culture among disciplines (Milne and Lalonde, 2007). This study highlights that barriers to interprofessional collaboration are more than professional ‘turf battles’ and reflect genuine concerns for professional sustainability and safety in low-resource, low-volume rural practice environments.
interprofessional primary maternity care has emerged as one potential solution to the current health human resource shortage in many developed nations. This study explores the barriers to and facilitators of interprofessional models of maternity care between physicians, nurses, and midwives in rural British Columbia, Canada, and the changes that need to occur to facilitate such models.
a qualitative, exploratory framework guided data collection and analysis.
four rural communities in British Columbia, Canada. Two rural communities had highly functional and collaborative interprofessional relationships between midwives and physicians, and two communities lacked interprofessional activities.
55 participants were interviewed and 18 focus groups were conducted with midwives, physicians, labour and delivery nurses, public health nurses, community-based providers, birthing women, administrators, and decision makers.
in models of interprofessional collaboration, primary maternity care providers – physicians, midwives, nurses – work together to meet the needs of birthing women in their community. There are significant barriers to such collaboration given the disciplinary differences between care provider groups including skill sets, professional orientation, and funding models. Data analysis confirmed that interprofessional tensions are exacerbated in geographically isolated rural communities, due to the stress of practicing maternity care in a fee-for-service model with limited health resources and a small patient caseload. The participants we spoke with identified specific barriers to interprofessional collaboration, including physician and nurses' negative perceptions of midwifery and homebirth, inequities in payment between physicians and midwives, differences in scopes of practice, confusion about roles and responsibilities, and a lack of formal structures for supporting shared care practice. Participants expressed that successful interprofessional collaboration hinged on strong, mutually respectful relationships between the care providers and a clear understanding of team members' roles and responsibilities.
interpersonal conflicts between primary maternity care providers in rural communities were underpinned by macro-level, systemic barriers to interprofessional practice. Financial, legal, and regulatory barriers to interprofessional collaboration must be resolved if there is to be increased collaboration between rural midwives and physicians. Key recommendations include policy changes to resolve differences in scope of practice and inequitable funding between rural midwives and physicians.
Simulation: Improving patient outcomes
2013, Seminars in Perinatology
Citation Excerpt :
Simulation-based training can provide teams with increasing confidence to manage emergency situations. Importantly, if teams train within their own environment, they identify local solutions to local problems, facilitating a more productive working environment.25,33 Providing staff with feedback on patient outcomes following training can also enhance motivation.26,43
Effective training has been shown to improve perinatal care and outcome, decrease litigation claims and reduce midwifery sick leave. To be effective, training should be incentivised, in a realistic context, and delivered to inter-professional teams similar to those delivering actual care. Teamwork training is a useful addition, but it should be based on the characteristics of effective teamwork as derived from the study of frontline teams. Implementation of simulation and teamwork training is challenging, with constraints on staff time, facilities and finances. Local adoption and adaptation of effective programmes can help keep costs down, and make them locally relevant whilst maintaining effectiveness. Training programmes need to evolve continually in line with new evidence. To do this, it is vital to monitor outcomes and robustly evaluate programmes for their impact on patient care and outcome, not just on participants.

View all citing articles on Scopus

View full text

4Patient safety in women's health-care: professional colleges can make a difference. The Society of Obstetricians and Gynaecologists of Canada MOREOB program

Section snippets

How managing obstetric risk efficiently (MOREOB) was developed

The structure of the program

How the program is implemented in the hospital environment

The funding business model for the program

The pilot phase: a catalyst for change

How clients perceive the program

The national launch

The expansion continues

What are the payoffs?

Fewer events and claims

To err is human, building a safer health system

An organization with a memory Report of an Expert Group on Learning From Adverse Events in the NHS

Liability trends in nursing

Can Nurse

Managing the risks of organizational accidents

Risk mitigation in large-scale systems: lessons from high reliability organizations. California management review

Summer

Some characteristics of one type of high reliability organization

Organ Sci

4
Patient safety in women's health-care: professional colleges can make a difference. The Society of Obstetricians and Gynaecologists of Canada MORE^OB program

How managing obstetric risk efficiently (MORE^OB) was developed