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Maternity Watch Workbook: Improving Patient Outcomes by Creating Cultures of Early Detection and Response*

This workbook and the companion guide are designed to serve as a resource to Project Team Leaders in implementing the Maternity Watch program and Maternal Early Warning Trigger (MEWT) tool at their facility.

The Maternal Early Warning Trigger Implementation Workbook includes:

• Practice Change Success Assessment: Assesses a maternity unit’s strengths and opportunities as they relate to successful practice change.

• Change Impact Assessment: Assesses the impact of the planned practice change so obstacles can be addressed before you embark on your change initiative.

• Anticipating and Addressing Challenges Worksheet: Provides spaces to write down the challenges you anticipate from implementing the MEWT protocol and your plans for addressing them.

• Project Team Member Worksheet: Provides spaces to write down your selected project team members. • Communication Plan Worksheet: Provides space to write down your communication plan you will use to engage

your stakeholders. • Planning for Sustainability Checklist: Identifies components for sustainability that are in place and those that

need to be developed. • Maternal Early Warning Trigger Tool Algorithm: Outlines the work flow for activities necessary for early

identification, response and intervention for sepsis, cardiopulmonary disorders, hypertension and hemorrhage. • Maternal Early Warning Trigger Tool Parameters: Describes the parameters for early identification, response

and intervention for sepsis, cardiopulmonary disorders, hypertension and hemorrhage. • Escalation Algorithms: Sets out the organizational response required to address different levels of abnormal

physiological measurements and observations. • Tests of Change Worksheet: Provides spaces to write out plans for your small tests of change.

*Developed in collaboration with Conscious HealthCare Designs

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GETTING STARTED EVALUATING READINESS Along with stakeholder representatives, complete the Practice Change Success Assessment below and identify where your maternity unit fits on the success/failure spectrum for each factor outlined in the assessment.

Our department has a strong history of regular and successful change

We have not implemented much change in our department

Our providers and staff are motivated to make improvements

Our providers and staff are not interested in making changes

Our hospital provides us with the resources we need to succeed with our department’s QI efforts

Our hospital expects us to make changes but doesn’t provide the needed resources

Our leaders communicate a strong vision for QI and reinforce and reward behaviors associated with it

Our leaders reinforce behaviors that conflict with successful QI (e.g. ignore non-engagement with change efforts)

QI data/results are regularly shared and discussed with everyone in our department

Only select/few people in our department are privy to our QI data/results

People in our department feel comfortable to disagree and raise difficult issues and problems

People are judged negatively if they disagree or raise difficult issues and problems

People in our department feel safe talking about their mistakes

People are hesitant to talk about their mistakes because they are held against them

The different disciplines in our unit work well together

There are on-going conflicts between the different disciplines in our unit

All disciplines/roles are valued/treated equally

Disciplines/roles with more power are valued/treated better than others

Workers are generally happy at work

Workers are generally unhappy at work

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After completing the assessment, answer the questions below:

1. What are our strengths?

2. Where are our opportunities?

3. What stands out as most important for success?

4. What makes sense to address, first, second, next?

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Along with stakeholder representatives, answer the questions in the Change Impact Assessment, below.

CHANGE IMPACT ASSESSMENT Cultural Dimensions Questions

Nature of behaviors • Who needs to do what differently, when, where, how often and with whom? • How will clinicians know whether the behavior has happened?

Beliefs about capability • How difficult or easy is it to do the practice? • What problems are likely to be encountered? • How confident will clinicians be performing the practice despite the difficulties?

Beliefs about consequences

• What do clinicians think will be the short and long-term consequences if they do the practice?

• What do clinicians believe are the benefits of doing the practice? • What do clinicians believe are the costs of doing the practice? • Do clinicians believe the benefits outweigh the costs? • How will clinicians feel if they don’t do the practice?

Beliefs about social influences and identity

• What do clinicians think about the credibility of the source(s) recommending the practice?

• To what extent do social influences facilitate or hinder carrying out the practice? (peers, managers, other professional groups, patients)

• Will clinicians observe others doing the practice? (are there role models?) • Will adopting the practice conflict with professional values/standards/identity?

(limits to autonomy/moral or ethical issues)

Knowledge and skills • How does the practice change align with what clinicians already know? • How does the practice change align with how clinicians have been trained? • How does the practice change align with what clinicians already do?

Motivation and goals

• How much interest will there be to adopt the practice? • Are there other things clinicians want to do or achieve that may interfere with

doing the practice? • Are there incentives to do the practice? • Why will clinicians decide not to do the practice? (e.g., competing commitments)

Emotion • Does doing the practice evoke an emotional response? If so, what? • To what extent do emotional factors facilitate or hinder doing the practices?

Behavioral regulation • What preparatory steps are needed to do the practice? • Are there procedures or ways of working that will encourage doing the practice?

Environmental context

• To what extent do physical or resource factors facilitate or hinder doing the practice?

• Are there competing tasks and time constraints? • Are the necessary resources available to carry out the practice? • Can the context be used to prompt the new behavior? (layout, reminders,

equipment) • Are there systems for maintaining long term change?

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After completing the assessment, answer the questions below:

1. What are our strengths?

2. Where are our opportunities?

3. What stands out as most important for success?

4. What makes sense to address, first, second, next?

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ANTICIPATING AND ADDRESSING CHALLENGES: Fill in the table below with your anticipated challenges and plans to address them. Refer to the examples in the implementation guide.

Anticipated Challenges Plan Challenge #1:

Challenge #2:

Challenge #3:

Challenge #4:

Challenge #5:

Challenge #6:

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ENGAGING STAKEHOLDERS CONFIGURE THE PROJECT TEAM: Refer to the implementation guide for characteristics to consider when selecting your team members and then fill in the table below.

Roles Names

Project Lead

Project Sponsor

Physician Champion

Project Team Member

Project Team Member

Project Team Member

Project Team Member

Project Team Member

Project Team Member

Project Team Member

Project Team Member

Project Team Member

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COMMUNICATION PLAN WORKSHEET: Refer to the implementation guide for strategies to engage your stakeholders and then fill in the table below.

Who (Presenter) Audience When

(Date/time or Frequency) Plan

PLANNING FOR SUSTAINABILITY Using the table below, think through these components and determine those you have in place and those which are in need additional support and development.

Component Examples Y/N Supportive Management Structure Leadership buy-in and support; accountability for improvement.

Structures to “Foolproof” Change

Structures that make it difficult to revert to previous habits; “hardwiring” processes and tools to support sustained implementation of the intervention.

Feedback Systems Measurement systems, data reports and transparency across the organization.

Shared Sense of Improvement

All stakeholders share an understanding of the program goals and structure, how they contribute and hold each other accountable.

Culture of Improvement/Engaged Staff

Staff are broadly aware of the program and feel invested in program outcomes. See also “Creating Cultures of Change” section in Implementation Guide.

Formal Capacity-Building Programs

Give staff the training and skills they need to be successful in achieving and sustaining program goals. Team Leaders consider the composition and skill base of their teams, working to enhance confidence and competency.

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APPLYING THE PRACTICES Use the tools listed below to implement the MEWT protocol, and answer the corresponding questions Maternal Early Warning Trigger Algorithm:

Answer the following questions:

1. How will we implement the tool?

2. How will we know we’ve been successful?

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Maternal Early Warning Trigger Parameters: Review the parameters below and the pathway-specific parameters within the Implementation Guide.

Answer the following questions:

1. How will we implement the parameters?

2. How will we know we’ve been successful?

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Select an Escalation Plan from option A or B that best suits your department and answer the questions on the next page:

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Answer the following questions:

1. How will we implement the tool?

2. How will we know we’ve been successful?

TESTS OF CHANGE - PLAN DO STUDY ACT (PDSA) WORKSHEETS Refer to the Plan Do Study Act model for change on the left and then use the worksheet below for each of your tests of change.

Plan: Describe plan: What change are you testing? What do you predict will happen and why? Who will be involved in this PDSA? How long will the test last? What resources are needed? What data need to be collected?

Do: Describe what actually happened when you ran the test:

Carry out the test on a small scale. Document observations, including any problems and unexpected findings. Collect data you identified as needed during the “plan” stage.

Study: Compare the measured results vs. the predictions:

Study and analyze the data. Determine if the change resulted in the expected outcome. Summarize what was learned. Look for: unintended consequences, surprises, successes, failures.

Act: Describe modifications for the next cycle:

Based on what was learned from the test, make modifications and plan your next cycle of change.

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MEASUREMENT AND DATA SUBMISSION Coming soon.