A Systems Investigation of Maternal Care

项目总结 尽管拥有世界上最昂贵的产妇保健，但美国的孕产妇死亡率(MMR) 2017年，每10万名活产儿中有16.9人死亡，2015年估计高达26.4人。对于每个 孕产妇死亡有50-100例严重孕产妇发病率(SMM)，这一比率也在上升 2006至2015年间大幅增长了45%。有色人种女性更容易患上死亡率和SMM； 黑人女性死于妊娠相关原因的可能性是白人女性的3到4倍。母性 死亡率和SMM每年造成数十亿美元的损失。然而，45%-60%的产妇死亡和SMM是 如果及时和适当的护理，是可以预防的。因此，死亡率和SMM的差异不仅与 个人级别的变量，也包括多级别的贡献者，这表明有机会 提高健康服务质量。对护理结构和过程的检查将有助于揭示 临床系统中造成产妇保健不佳和差异的挑战，并确定 护理系统的特点是可以接受干预的。尽管有20年的系统研究， 在医疗保健方面，很少有研究研究临床系统对不良结果和差异的贡献 在产妇护理方面。产妇护理单元的初步观察-产前、分娩和分娩(L和D)，以及 产后-对患者安全事件的审查发现了一系列系统问题，如 人员编制不足，大量使用缺乏经验的合同制护士，缺少设备和用品 设备故障，影响了病人的护理。19个月行政管理数据的初步分析 发现该院L诊疗科接诊病人4,057人次，平均每月接诊225.39人次， 剖宫产率为38%。在此期间，有45人再次入院，其中15人记录有SMM病例 (出血、子宫切除和脓肿)和一名产妇死亡。这一数据没有按种族分列。 这项研究提出了一种混合方法来调查系统的安全性和公平性，方法是进行 预后风险评估和检查事件的分布作为对不同事件的初步评估 关心。这项研究将比以往任何时候都更详细地描述临床医生如何 通过工作系统的设计，提供产妇护理容易成功或失败，并提供 卫生系统中不同护理质量的合理近似值。具体地说，以下三个 将开展以下目标：目标1：利用一项工作开发产妇护理的社会技术系统模式 系统分析；目标2：使用病人安全事件报告检查产妇护理单位的风险；目标3： 确定造成产妇护理不良事件差异的社会技术因素。这项研究 将患者安全和差异努力结合起来，以生成和测试最终将导致多个 可为当地实施量身定做的干预措施，并可扩展以供广泛采用。

PROJECT SUMMARY Despite having the most expensive maternity care in the world, the maternal mortality rate (MMR) in the US increased to 16.9 deaths per 100,000 live births in 2017, with estimates as high as 26.4 in 2015. For every maternal death there are 50 - 100 cases of severe maternal morbidity (SMM) and this rate has also increased sharply – rising 45% between 2006 and 2015. Women of color are more likely to suffer mortality and SMM; Black women are 3 to 4 times more likely to die from pregnancy-related causes than white women. Maternal mortality and SMM cost billions of dollars each year. However, 45 – 60% of all maternal deaths and SMM are preventable with timely and appropriate care. Thus, disparities in mortality and SMM are not only related to individual-level variables but also to multilevel contributors, which suggests that there are opportunities to improve health service quality. Examination of the structures and processes of care would help uncover challenges in the clinical systems that contribute to poor maternal care and disparities and identify also features of the system of care that are amenable to interventions. Despite 20 years of systems research in healthcare, few studies have examined the contribution of clinical systems to adverse outcomes and disparities in maternal care. Initial observations in the maternal care units - antepartum, labor and delivery (L&D), and postpartum - and review of patient safety incidences identified a range of systems issues such as understaffing, extensive use of inexperienced contract nurses, missing equipment and supplies, and malfunctioning equipment, that impacted patient care. Preliminary analysis of 19 months of administrative data found that the hospital’s L&D unit delivered 4,057 patients, an average of 225.39 patients each month, and the cesarean delivery rate was 38%. There were 45 readmissions during this period, 15 recorded cases of SMM (hemorrhage, hysterectomy, and abscess) and one maternal death. This data was not disaggregated by race. This research proposes a mixed methods approach to investigate systems safety and equity by conducting a prognostic risk assessment and examining distributions of incidents as a preliminary assessment of disparate care. This research will describe, in more detail than has ever been available before, how the clinicians delivering maternal care are predisposed to success or failure by the design of the work system and offer a reasonable approximations of disparate quality of care in the health system. Specifically, the following three aims will be conducted: AIM 1: Develop a sociotechnical systems model of maternal care using a work systems analysis; AIM 2: Examine risks in maternal care units using patient safety incident reports; and AIM 3: Identify sociotechnical factors contributing to disparities in adverse events in maternal care. This research coalesce patient safety and disparities efforts to generate and test hypotheses that will ultimately lead to multi- level interventions that can be tailored for local implementation and scaled for widespread adoption.