Audrey Lyndon, RNC, PhD, CNS is an Associate Professor and Director of the Perinatal Clinical Nurse Specialist Program in the Department of Family Health Care at the University of California San Francisco (UCSF). Her clinical background is in labor and delivery nursing and perinatal clinical nurse specialist advanced practice. Dr. Lyndon received her Master’s degree from UCSF. She also completed her PhD at UCSF addressing the question of what drives nurse agency for safety, with emphasis on communication and teamwork to avoid preventable adverse events.
In her current research she continues her focus on quality improvement and patient safety in the inpatient perinatal care setting. Dr. Lyndon is investigating the role of communication, assertion, and teamwork in safety for inpatient obstetric care in teaching and community hospital settings. She is also involved in projects analyzing the tensions and teamwork between midwives and nurses, as well as conflict resolution between nurses and physicians during labor and birth. As a perinatal clinical nurse specialist she was actively engaged in major QI initiatives in both community and tertiary care settings. She continues her QI work with CMQCC as a member of the Executive Committee and Maternal Quality Improvement Panel (MQIP), where she co-chairs the Maternal Hemorrhage Task Force.
Maternal QI is important because we have historically been fairly slow to adopt evidence-based practices in maternity care in the US. Women and their families deserve nothing less than the best quality care available. I hope that as members of CQMCC we can contribute to ensuring that all California childbearing women receive the highest quality care.
CMQCC Committee Memberships
Audrey Lyndon recognized that there was significant and generalized dissatisfaction with the induction process for physicians, patients, and nursing staff. So she and others at Anne Arundel Medical Center (Annapolis, MD) employed a systematic approach to improve the problem. As in the approach to other clinical situations, systematic assessment, followed by diagnosis, planning, intervention and evaluation were key to improvement. The Plan-Do-Check-Act (PDCA) process is an example of an improvement model with this approach. At Anne Arundel Medical Center Dr. Lyndon applied the “FOCUS” model to help define the key activities in the PDCA cycle.
“Find an opportunity for improvement.”
This first step identified that delays in induction were causing dissatisfaction and tension among patients, nurses, and physicians, and therefore the induction process was prioritized for improvement.
“Organize a team that knows the process”
A team was organized including the Chief of OB, the Women’s & Children’s Medical Director, a Clinical Administrator, Clinical Nurse Specialist, Nurse Manager, and staff nurses. Top-level administrators were selected for their ability to identify feasible solutions and to demonstrate the organizational commitment for all stakeholders. This group performed the initial steps of clarifying the mission and developing a work plan.
“Clarify current knowledge.”
In order to establish the baseline for improvement, a pilot study was developed to describe and localize the current problem. The pilot study examined variance between the scheduled time and time of admission, the indication for induction, reason for delay or rescheduling, incidence of Bishop’s score < 6 on admission, and distribution of inductions by day of the week.
“Understanding Process Variation”
This step is a root cause analysis of the problem. The pilot study demonstrated the percentage of inductions that began early, on time, and delayed. This step also identified the reasons for delay and respective percentage of delays they caused. Through the pilot study (assessment) Dr. Lyndon identified the root causes (diagnoses) for induction delays: Not enough beds, staffing, and patient lateness. A key finding was that the main problem was not “not enough nurses,” which most had identified as the source of the problem prior to the pilot study.
“Selecting Process Improvements.”
This phase is the “DO” phase of generating and evaluating the solutions, as in the planning and intervention phases of the nursing process. The team brainstormed improvements and decided which ones to pilot.
After these phases were complete, data collection was continued as various solutions to the delays in induction were implemented. This data was in preparation for the “CHECK” or evaluation phase of the process, in which the efficacy of improvements was evaluated. By repeated Plan-Do-Check-Act cycles, Dr. Lyndon and her team continued to reduce the incidence of induction delays, thereby improving patient, nurse, and physician satisfaction at Anne Arundel Medical Center.