Better Outcomes Start with Better Education

Patients who are engaged with their health care, experience better health outcomes (Miller, 2016). " Better outcomes start with better education" (Customized Communications Inc, n.d., para 1). Prenatal education comes in a variety of forms. Multiple studies have shown that pregnant women are turning to the internet to gather information due to the prenatal visit not fulfilling that need (Kraschnewski et al., 2014; Lagan, Sinclair, Kernohan, 2011; Vamos, Merrell, and Detman 2019; Lima-Pereira, Bermúdez-Tamayo, & Jasienska, 2011). Further research reported that the majority of fathers to be are also searching for information on the internet. They concluded that providers need to be recommending credible websites during antenatal care (Oscarsson, Medin, Holmström, & Lendahls, 2018). According to Marcia Pugh, "the web offers some excellent resources, but it is imperative to know the good, the bad and the ugly of online information if patients are to retrieve quality educational experiences" (Pugh, 2011, p. 13). In 2016, an article published in BMC Pregnancy and Childbirth, reported women search the internet at least once a month during pregnancy. Most of the women did not discuss the information they retrieved with their provider (Sayakhot & Carolan-Olah, 2016). Another study reported that almost all the women in their study used the internet as a source of pregnancy-related information (Bjelke, Martinsson, Lendahls, & Oscarsson, 2016). However, that information caused feelings of worry. It was suggested that provider recommendations are needed to guide women to suitable web pages (Bjelke, Martinsson, Lendahls, & Oscarsson, 2016). As healthcare providers, we have the opportunity and duty to provide prenatal education that is current, evidence-based, easily accessible, and meets the needs of the patient. University of Utah Women's Health Services has identified a need for improvement in prenatal education materials. The project started approximately four years ago. A small focus group was done to survey patients about current prenatal education materials and identify the gaps. The patient feedback included a preference for digital, searchable, and easily accessible material, including links to hospital and clinic websites. Similar results were found in a study exploring pregnant women's experiences in accessing, understanding, evaluating, communicating, and using health information and services during pregnancy (Vamos, Merrell, Detman, Louis, & Daley, 2019). Currently, each clinic has created its own packet of education materials. The packet contains the book Great Expectations: A guide for prenatal care. As well as copies of copies of information they have deemed as relevant information for patients. Materials vary widely across the OB community clinics. A team of stakeholders came together to review the current materials and propose moving to a digital format. The purpose of this project is to improve the prenatal education materials for the patients receiving care at the University of Utah Health.

BETTER OUTCOMES 1 Better Outcomes Start with Better Education Nikole Ihler BSN, RNC University of Utah April 30, 2020 In partial fulfillment of a Master of Science Degree College of Nursing Major: Nursing Specialty: Nursing Education BETTER OUTCOMES 2 Introduction Patients who are engaged with their health care, experience better health outcomes (Miller, 2016). "Better outcomes start with better education" (Customized Communications Inc, n.d., para 1). Prenatal education comes in a variety of forms. Multiple studies have shown that pregnant women are turning to the internet to gather information due to the prenatal visit not fulfilling that need (Kraschnewski et al., 2014; Lagan, Sinclair, Kernohan, 2011; Vamos, Merrell, and Detman 2019; Lima-Pereira, Bermúdez-Tamayo, & Jasienska, 2011). Further research reported that the majority of fathers to be are also searching for information on the internet. They concluded that providers need to be recommending credible websites during antenatal care (Oscarsson, Medin, Holmström, & Lendahls, 2018). Problem According to Marcia Pugh, "the web offers some excellent resources, but it is imperative to know the good, the bad and the ugly of online information if patients are to retrieve quality educational experiences" (Pugh, 2011, p. 13). In 2016, an article published in BMC Pregnancy and Childbirth, reported women search the internet at least once a month during pregnancy. Most of the women did not discuss the information they retrieved with their provider (Sayakhot & Carolan-Olah, 2016). Another study reported that almost all the women in their study used the internet as a source of pregnancy-related information (Bjelke, Martinsson, Lendahls, & Oscarsson, 2016). However, that information caused feelings of worry. It was suggested that provider recommendations are needed to guide women to suitable web pages (Bjelke, Martinsson, Lendahls, & Oscarsson, 2016). As healthcare providers, we have the opportunity BETTER OUTCOMES 3 and duty to provide prenatal education that is current, evidence-based, easily accessible, and meets the needs of the patient. University of Utah Women's Health Services has identified a need for improvement in prenatal education materials. The project started approximately four years ago. A small focus group was done to survey patients about current prenatal education materials and identify the gaps. The patient feedback included a preference for digital, searchable, and easily accessible material, including links to hospital and clinic websites. Similar results were found in a study exploring pregnant women's experiences in accessing, understanding, evaluating, communicating, and using health information and services during pregnancy (Vamos, Merrell, Detman, Louis, & Daley, 2019). Currently, each clinic has created its own packet of education materials. The packet contains the book Great Expectations: A guide for prenatal care. As well as copies of copies of information they have deemed as relevant information for patients. Materials vary widely across the OB community clinics. A team of stakeholders came together to review the current materials and propose moving to a digital format. Available Knowledge In one study, a mobile app was compared to traditional mode of paper as a patient education and engagement tool in the clinical setting. The results concluded that patients used the app more frequently than using the paper as well as greater patient activation (Ledford, Canzona, Cafferty, & Hodge, 2016). In another study, 55% of participants were using mobile apps related to pregnancy, birth, and/or childcare. (Lee & Moon, 2016). BETTER OUTCOMES 4 An additional study surveyed the quality of information found on the internet specific to cesarean section. One hundred and seventy-six websites were sampled. Results showed 30% of the pages were poor or very poor quality, and 47% were moderate quality. The study concluded that "pending improvement of these resources, obstetricians should warn pregnant women about these facts and encourage them to discuss what they have read on the internet about caesarean section" (Fioretti, Reiter, Betran, Torloni, 2014, p. 731). The Safe Reduction of Primary Cesarean Section safety bundle created by the National Partnership for Maternal Safety lists patient education as one component of supporting intended vaginal birth and reducing cesarean birth ((Lagrew, et al., 2018). Poor quality information obtained on the internet could have an effect on patient's decision and outcomes. One study specific to labor epidural education demonstrated that that education on epidural analgesia could influence women's decisions (Alakeely, et al.,2018). Rationale "Effective patient education results in empowering patients and improving their selfefficacy and self-knowledge" (Sanchez & Cooknell, 2017, p. 17). Using the adult learning theory, prenatal education should be self-directed and allow patients to review the information when they are ready and at their own pace (Sanchez & Cooknell, 2017). As well as providing a space for patients to reflect on life experiences and relate to new information. The adult learning theory also allows for learning to happen on a need to know basis (Twaddell, 2019). Patient's learning preferences should also be taken into consideration when providing education. Learning styles affect a patient's ability to comprehend information (Sanchez & BETTER OUTCOMES 5 Cooknell, 2017). The VARK learning style metrics are visual, auditory, reading/writing, and kinesthetic. A digital education platform can provide tools to cover all learning styles. Age is also an essential factor in learning. The pregnant population expands across multiple generations, including but not limited to, Generation X, Millennials, and Generation Z. Generation X prefers delivery methods that include on the job, e-learning, and active learning. Millennials prefer delivery methods that include e-learning, blogs, wikis, mobile apps, and hands-on learning. Generation Z dislikes the traditional classroom format and wants learning to be fun (Oermann, De Gagne, & Phillips, 2018). Specific Aims The purpose of this project is to improve the prenatal education materials for the patients receiving care at the University of Utah Health. Methods The University of Utah Health combines Lean, Six Sigma, and PDSA methodologies for process improvement. The steps are as follows: Project Definition, Baseline Analysis, Investigation, Improvement Design, Improvement Implementation, and Monitoring. This methodology was used to guide this quality improvement project. Context University of Utah Women's Health Services incorporates eight community clinics in the Salt Lake Valley and surrounding areas. Over one hundred providers, including Maternal-Fetal Medicine, Obstetrics, Family Practice, Certified Nurse Midwives, and OBGYN residents, BETTER OUTCOMES 6 provide high-quality pregnancy care. The professional nursing team is also committed to quality family-centered care. In 2019, 4584 patients gave birth at the University of Utah Health. Interventions Staff members of the OBGYN department initiated the prenatal education improvement project. A focus group was organized, and patient feedback was collected regarding the current state of prenatal education. With the help of the Perinatal Education Department, an inventory of prenatal education materials was obtained. This data was presented to key stakeholders within Women's Health Services at the University of Utah Health. At that meeting, a quality improvement project was launched to improve patient education. A working group was formed. The group attended demonstrations of several digital education platforms. Next, a crosswalk was created to compare current resources, and a gap analysis was completed. A consensus was obtained to move forward with the Customized Communications digital education platform called YoMingo. Access was obtained from YoMingo to begin demonstrations of the digital platform to stakeholders within the Women's and Children's Service Line. As well as creating a buzz by demonstrating the app at staff meetings throughout the OB community clinics. The project proposal was written by the community clinic nursing director and presented to the general council. After approval, the YoMingo app was presented to the education steering committee for recommendation. Once the recommendation was received, the purchase of YoMingo was completed. Once the University of Utah Health YoMingo app was live, the hospital started collaborating with the marketing department and Customized Communication INC to brand the app for the University of Utah Health. As well as planning for the "go live." Taking direction from Customized Communication Inc., the hospital started marketing and spreading the word BETTER OUTCOMES 7 about YoMingo in staff meetings throughout the organization. The YoMingo "go live" will be announced on the University of Utah Women's Health website as well as featured on social media accounts associated with the University of Utah Health. Posters will be displayed in high traffic areas as well as flyers handed out in the clinic. The perinatal education department will also refer to YoMingo in prenatal education classes. An email with a link to access the app will go out to patients and staff. The University of Utah Health will be using the auto registration tool provided by YoMingo. Study of the Interventions/Measures/Analysis Qualitative data was gathered from a patient focus group regarding prenatal education materials. This focus group will be repeated one year after the YoMingo launch to provide a comparison. Immediately after launching YoMingo, the hospital will be able to start gathering quantitative data. YoMingo provides administrators of the app access to metrics about usage at any time. The metrics available include the number of users, number of registrations, high usage leaners, low usage learners, popular overall category, popular overall module, popular overall article, popular overall tool, number of logins, and popular times. The University of Utah Health will also have the ability to filter the metrics and create reports. Ethical Considerations The most significant barrier encountered thus far in this project is providing education in multiple languages. YoMingo is available in sixteen languages via Google translation. A readaloud feature is also available within YoMingo. The education steering committee only recommended the app in the English language. Concerns regarding the Google translation of BETTER OUTCOMES 8 medical information were raised by the steering committee. At this time, the plan is to move forward with YoMingo with the translation tool turned off. The hospital will address education for non-English speaking patients and patients without access to the internet in the next phase of the project. Results First, the data gathered from a patient focus group indicated that current prenatal education materials were not being utilized. Quantitative data is not able to be collected with the current process. YoMingo provides metrics including the number of users, high usage learners, low usage learners, popular content, and the number of logins. The plan is to gather feedback with a patient focus group one year after instituting YoMingo and compare it to the feedback given by the initial focus group. Second, before launching YoMingo, data was gathered from three test patients. Patients were asked to complete a pre-survey, register for YoMingo, and participate in a demonstration. Then patients were asked to use the app for two weeks and then complete a post-survey. Two out of three test patients were currently using a pregnancy app. All three patients said that if they had a question, their primary resource would be their prenatal care provider. All three patients had viewed the current prenatal material once with the medication list being most useful. The postsurvey feedback described YoMingo as user friendly and easy to navigate. Information was quickly obtained using YoMingo. Plus, the videos and diagrams were helpful. Third, patients will be asked who their provider is when they register for YoMingo. This information will allow us to track which clinics are promoting YoMingo and which clinics may need more education. To incentivize staff to teach patients about YoMingo, a contest will be held BETTER OUTCOMES 9 between clinics. The clinic that registers the most patients for YoMingo will be rewarded. Rewards will also be given to the inpatient nurses who register the most patients per week. Discussion Improving prenatal education materials at the University of Utah Women's Health Services has required a multidisciplinary team and a phased approach. The evidence gathered supported the team's efforts to improve education materials. Results from the patient focus group guided the decision to choose YoMingo for the evidence-based digital education platform. This project successfully achieved the aims that included: providing an application that meets the patient's needs in regards to a digital platform, providing an application that will allow patients to easily search evidence based prenatal education material on all electronic devices, reducing organizational cost in prenatal materials, and standardizing all prenatal education material throughout the Women's Health Ambulatory Clinics and the Women and Children's Service Line. Summary The University of Utah Health continuously strives for better outcomes. "Better outcomes start with better education" (Customized Communications Inc, n.d., para 1). YoMingo will be the standard digital education platform used throughout Women's Health Services and the Women and Children's Service Line. All maternity patients receiving care at the University of Utah will be guided to one digital, convenient, evidence-based resource for patient education. Interpretation YoMingo improves patient education, reduces cost, and provides metrics. The hospital anticipates even more cost savings in the future as it continues to eliminate paper handouts and BETTER OUTCOMES 10 incorporate customized digital education within YoMingo. The impact of YoMingo is farreaching. Improving outcomes not only impacts the patient and family but impacts the organization, the community, and the world. Limitations A small portion of the patient population does not have internet access and, therefore, will not have access to YoMingo. The University of Utah will continue to promote community resources and encourage patients to access YoMingo through shared internet spaces like libraries and schools. Also, YoMingo is only available in English at this time. The quality improvement team will continue to seek approval to use the Google translation tool within YoMingo to gain access to other languages. Due to the Coronavirus, all in-person meetings have been canceled throughout the University of Utah Health. The plan to educate staff and providers about YoMingo changed from demonstrations at staff meetings to virtual demonstrations. As well as dissemination of information through email. Patients will also be moving from seeing providers in-person to virtual visits. This changes the way staff will introduce YoMingo to patients. Staff will be provided a script and a tip sheet to teach patients about YoMingo. The after-visit patient summary in MyChart will link patients to the YoMingo registration. To achieve a successful YoMingo launch, the hospital has enlisted the help of the inpatient nurses throughout the Women and Children's Service Line. All units will be promoting and assisting patients in registering for YoMingo. BETTER OUTCOMES 11 Conclusion On Monday, April 6th, the hospital will be launching YoMingo. Phase one of this quality improvement project will improve prenatal education. YoMingo is replacing the Great Expectations book previously given out in clinic for patient education. Phase two will be developing the University of Utah Health tile. This tile will contain customized patient education materials. The hospital also hopes to include more language options in phase two. Phase three, will identify other areas that could eliminate paper education and reduce cost. The metrics provided by YoMingo will guide the University of Utah Health in continuous efforts to improve patient education and outcomes. YoMingo is a continuous patient education improvement project for the Women's and Children's service line in collaboration with the OB community clinics. A YoMingo Steering Committee has been created and will meet every two weeks to approve custom content and prepare for the next phase of implementation. The University of Utah Health will be using social media to advertise YoMingo to help sustain the change. The data collected by using the YoMingo metric tool will drive the decisions in regards to sustainability. The plan is to circle back with staff and providers once the hospital can reinstitute in-person staff meetings. This quality improvement project could be used as a model to improve patient education in other settings and other organizations. The project could be easily adapted for any digital education platform that was purchased by an organization. BETTER OUTCOMES 12 References Alakeely, M. H., Almutari, A. K., Alhekail, G. A., Abuoliat, Z. A., Althubaiti, A., Aboitai, L. A.R., & Al-Kadri, H. (2018). The effect of epidural education on Primigravid Women's decision to request epidural analgesia: a cross-sectional study. 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