At Kaiser Permanente Redwood City, the Maternal Child Health (MCH) team continued its strong focus on reducing severe maternal morbidity (SMM) through improved communication and situational awareness during postpartum hemorrhage (PPH) events. This work was driven by frontline leadership from clinical nurses Manjila Goundar, BSN, RN, RNC-OB, and Reliann Viray, BSN, RN, whose insight and persistence transformed a recognized systems gap into a practical, department-wide safety tool: the PPH board.

The idea emerged as the MCH team observed opportunities for improvement during PPH debriefs and Critical Events Team Training (CETT). With a high influx of new nurses, teams observed that there were opportunities for consistent adherence to PPH protocols. Other opportunities were identified to improve real-time communication, particularly around clarity of medications and blood products administered. Frontline nurses recognized the need for a clear, structured visual workflow that every team member could reference in real time.

Goundar, drawing on evidence-based best practices from Kaiser Permanente San Jose colleagues, began shaping what would become the PPH Board. The design evolved through several iterations to ensure accurate medication tracking, real-time quantitative blood loss updates, and clear escalation steps, addressing the communication gaps identified through the Perinatal Patient Safety Program (PPSP).

To make the tool functional and safe, Goundar partnered closely with engineering, refining board materials, sizing, and mounting options. Once approved by MCH leadership, the boards were installed and introduced through staff huddles and team education. Since implementation, the PPH boards have strengthened real-time communication and team coordination during hemorrhage events. This improvement is reflected in the PPH dashboard, which shows a reduction in severe maternal morbidity among patients that experience PPH, demonstrating the effectiveness of this frontline-led innovation.