Empirical Quality Outcomes

As we move forward on our journey to becoming a Magnet-designated hospital, VIDA stands as a testament to the innovation and dedication of our Mother Baby nurses. Spearheaded by our nurses and rolled out in the NCAL region, this project marks an important milestone in our commitment to excellence. 

Planning for VIDA began in November 2022, and we proudly launched it on March 28, 2023. This initiative, conceived and executed by the Mother Baby team and nurses, is focused on efficiently discharging eligible mothers and infants before 11 a.m.  

Our vision was clear: We aim to empower new, healthy moms to return home sooner, facilitate better rest, minimize the risk of hospital-acquired infections, and enhance the overall recovery experience in a comfortable home setting. 

The mother baby workgroup began the project by determining the eligible patients and establishing a Vida tracker. After identifying the eligible patients and setting up the tracker, the work group members-initiated education sessions for the Assistant Nurse Manager/ Relief in higher class, and staffs about the changes and the GO-LIVE date. Nurses were actively involved in the project, which helped us design and evaluate processes for improvement. Throughout this process, we maintained a strong focus on patient safety and upholding the highest standards of quality care, which are our top priorities. 

VIDA has also strengthened collaboration across various departments, including OBs, pediatricians, labs, hearing screeners, and HIM, fostering a culture of teamwork that drives success. 

The results speak for themselves: from January to October 2024, we’ve achieved significant progress in our goal of 80% of discharges occurring before 11 a.m.  

This is a remarkable success story for the Mother Baby department, and we are proud of our achievements.

To ensure our patients are seen in a timely manner and align with the latest evidence-based practices, implementing the Maternal Fetal Triage Index (MFTI) is a crucial step in enhancing patient safety and optimizing obstetric care. In May 2023, we began our MFTI journey by educating staff on this evidence-based framework, highlighting its role in standardizing the assessment of maternal and fetal conditions upon admission. The core triage team was instrumental in leading and facilitating this education.

The MFTI framework prioritizes patients using exam flags, with Priority 1 marked in red and ascending numerically through 2, 3, 4, and 5. These visual cues streamline the triage process, ensuring patients are assessed and treated according to their clinical needs. To support the transition, experienced triage nurses and core triage team members provide guidance and oversight for 60 to 90 days following the go-live date.

Successful implementation of the MFTI requires collaboration among all team members, including RNs, midwives, physicians, and unit assistants, to ensure consistent application of the tool. Key strategies include establishing clear protocols, conducting simulation-based training, and integrating the MFTI framework into electronic health records to improve usability and compliance.

Continuous monitoring of outcomes, along with periodic reviews and feedback, is essential to refine the process. By prioritizing timely identification of high-risk conditions, the MFTI improves resource allocation and ensures patients receive the appropriate level of care promptly. This initiative underscores our commitment to advancing patient safety and delivering high-quality obstetric care.

At Modesto Labor and Delivery, we have successfully embedded the MFTI process into our practice. When we first began this journey, only 0.24% of our MFTI scores were recorded. Recent data reveals significant progress, with 80.85% of our scores now being documented, demonstrating our dedication to continuous improvement and excellence in patient care.

In September 2024, the Fall Prevention Rapid Improvement Event (RIE) marked a transformative milestone in patient safety at Kaiser Permanente Modesto Medical Center. Before this initiative, the Medical-Surgical Units had recorded 13 falls with injury year-to-date, underscoring the urgent need for action. Falls posed significant risks to patient recovery, impacted care quality, and highlighted the necessity for systemic improvements. Under the dedicated leadership of Lorry Quintero, MSN (Clinical Adult Nursing Director), and Sameer Khullar, DNP (Lead Quality Nurse Consultant), the RIE brought together an interdisciplinary team led by frontline nurses, to implement lasting solutions.

Through root cause analysis, the team identified key contributors, including inconsistent rounding practices, delayed responses to call lights, and environmental hazards like cluttered pathways. Using the Plan-Do-Study-Act (PDSA) framework, they introduced standardized hourly rounding to meet patient needs proactively, a “No Pass Zone” to ensure timely assistance, and targeted environmental improvements, such as decluttering and labeling mobility aids for easy access. These interventions created a culture of accountability and patient-centered care.

The results were extraordinary. Since the RIE, the Medical-Surgical Units have reported zero falls with injury, a remarkable improvement from the 13 incidents recorded earlier in the year. The accompanying graph vividly illustrates this steep decline, showcasing the sustained impact of the interventions. This success underscores the power of collaboration and innovation, led by strong, focused leadership and a dedicated team.

The Fall Prevention RIE has set a new standard for patient safety at Kaiser Permanente Modesto Medical Center and serves as a model for future initiatives. Through collaboration, data-driven strategies, and an unwavering focus on excellence, this initiative showcases that transformational change is both achievable and enduring.

Our Mother Baby department proudly ranks among the top three in the NCAL region and is recognized for delivering exceptional lactation support. On November 25, 2021, we launched the Donor Breast Milk program in the NCAL region, piloting a groundbreaking initiative that underscores our unwavering commitment to comprehensive feeding solutions for our babies. This program thrives thanks to our dedicated lactation consultants and Mother Baby nurses, whose tireless efforts significantly enhance the health and well-being of mothers and newborns alike.

Our Mother Baby Lactation Workgroup plays a crucial role in our unit’s outstanding success. We provide extensive breastfeeding support and education for new mothers, offering expert guidance to initiate and sustain lactation. Our advocacy for optimal infant nutrition addresses challenges like poor latch, sore nipples, and low milk supply with proficiency.

We take pride in offering around-the-clock lactation support, empowering mothers to navigate their breastfeeding journey confidently. Our devoted team ensures effective feeding for babies, maximizing the countless benefits of breastfeeding for both mother and child and promoting their ability to thrive.

Through strong teamwork and a steadfast commitment, we profoundly impact the families we serve, solidifying our leadership in lactation care. Our goal is to maintain an 80% success rate in lactation metrics, and from January to October, we not only achieved this goal but consistently exceeded it, showcasing our relentless pursuit of excellence in lactation support.