11/29/2016

1

Nulliparous Cesarean Section Reduction Initiative

(PC-02)—Implementation across the System—

Keeping Normal, Normal!

Carolinas HealthCare System

Why are cesarean deliveries a concern?

• Current method of delivery for over 30% of babies born in the United

States

• Higher associated morbidity compared to vaginal deliveries with the

current pregnancy as well as future pregnancies

• Higher incidences of intraoperative complications

• Longer lengths of stay in the facility

• Consume higher health care dollars.

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CESAREAN RATE REDUCTION

Reduction in the first-time cesarean delivery rate is the main strategy

PC-02—What is this?

• Joint Commission Perinatal Core Measure

– Publicly reported for facilities >300 deliveries effective January 2015

• Included patients:

– Nulliparous patients (first baby)

– Term pregnancy (37 completed weeks of pregnancy)

– Singleton gestation (one baby)

– Vertex presentation (head down)

• Numerator: Patients meeting above criteria delivered by cesarean

section

• Denominator: All patients meeting the above criteria

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National C/S Rates—What Does the Variation Tell Us?

• National data for the nulliparous CS rates vary between hospitals,

physician groups, and individual physician providers within the

groups

• Significant national hospital-level variation in the rates

– 2.4%-70% PC-02 rates for these low-risk women—quite the variation!!

• Contemporary patterns show that labor may progress more gradually

than previously believed and result in a vaginal delivery—we need to

allow more time for labor progression

• Nationally, we do not have a standard approach to managing labor

What Did We Need To Do?

• Standardize the approach for labor management to reduce variation

in the practice

• Contemporary labor patterns show the following:

– it may take more than 6 hours to progress from 4 to 5 cm and more than 3 hours to

progress from 5 to 6 cm of dilation

– active phase of labor often does not start until the patient is 6 cm or more dilated

• Allow patients more time to progress through the stages of labor

before diagnosing labor dystocia in contemporary women

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How did we start?

• Multidisciplinary team formed as part of the IHI Perinatal

Improvement Community (PIC) representing our health care system

(OBGYN providers, nursing, and administrative representatives)

• Goal was to develop a plan for PC-02 rate reduction

Role of the Leadership Team

• Attended IHI PIC face-to-face meetings

• Reviewed the evidence presented by the IHI faculty

– Obstetrical governing societies

– Society for Maternal Fetal Medicine (SMFM)

– American College of Obstetricians and Gynecologists (ACOG)

• Presented the evidence to the system-wide perinatal collaborative for

approval and eventual adoption

• Identified a pilot site—CHS NorthEast

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Steps for Implementation of PC-02 Initiative

• Presentation of evidence based guidelines for the pilot site

• Education for providers, leadership, and nursing staff on practice

changes that needed to occur

• Communication of baseline data by facility rates, individual practice

rates, and provider specific rates to system-level leaders, facility

leaders, providers, and nursing staff

• Creation of a toolkit for system spread

Steps for Initiative

• Each facility emphasized transparency and published individual

provider and group/practice PC-02 rates

• Group rates shared within the Ambulatory Medical Group

• Pilot site began initiative 1/1/14—CHS NorthEast

• Two facilities were early adopters—went live 4/1/14—CHS Lincoln,

CHS University

• Initiative go-live across CHS occurred 7/1/14

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Challenges with Reducing the C/S Rate

• Providers and nursing staff did not understand exactly what PC-02

measured—this is not a primary cesarean section rate—education

was required

• Individual rates and practice rates were provided—required time to

review the data

• Providers were often surprised with their individual rate and some

questioned the validity of the data

• Some providers challenged the new ACOG/SMFM

guidelines/recommendations for managing labor

Success Story with Reducing the PC-02 Rate

• Overall Carolinas HealthCare System’s rate decreased from 27.02%

in 2013 to 21.79% in 2015

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What Does This Success Story Really Say?

• In 2013, our system had 30,509 deliveries

– 8,416 women in the PC-02 population

– 2,274 had cesarean deliveries

– 27.02% PC-02 rate

• In 2015, our system had 30,872 deliveries

– 10,322 women in the PC-02 population

– 2,249 had cesarean deliveries

– 21.79% PC-02 rate

How Many Lives Have Been Changed???

What Does This Really Mean??

• If our PC-02 rate in 2015 had been 27.02%, 2,790 women would

have had a cesarean delivery compared with 2,249 that actually had

a cesarean delivery

• That is 541 women that did not have a cesarean delivery in 2015 that

would have had if performance had not improved from 2 years ago

• If we count both Mom and Baby…..

1,082 lives were changed in our

system in one year!!

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Cost Avoidance

• Cesarean deliveries are estimated to cost $7,000 MORE than

vaginal deliveries

• In 2015, 541 women avoided a cesarean delivery with our new

practice

Cost avoidance for one year for this quality improvement project

$3,787,000!

The Joint Commission PC-02 Rate

29.6%28.1% 27.9% 27.0%

23.8%21.7%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

2010 2011 2012 2013 2014 2015

CHS PC-02 Rate by Year

**In 2011-2012, the Perinatal Quality Collaborative of North Carolina (PQCNC)

had a Supporting Intended Vaginal Birth (SIVB) Initiative where many of our

facilities participated in the work

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The Joint Commission PC-02 Rate

UCL 0.305

CL 0.263

LCL 0.221

20.0%

22.0%

24.0%

26.0%

28.0%

30.0%

32.0%

2010 2011 2012 2013 2014 2015

Perc

en

t

Year

CHS PC-02 Rate Reduction by Year

The Joint Commission PC-02 Rate

27.9

%

27.0

%

27.5

%

25.7

%

25.3

%

22.6

%

23.4

%

22.4

%

22.5

%

22.4

%

20.7

%

21.0

%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

CHS PC-02 Rate by Quarter 2013-2015

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27.6

%

24.3

%

24.1

%

24.4

%

22.7

%

20.8

%

23.9

%

23.2

%

23.2

%

21.5

% 24.1

0%

21.9

%

21.1

%

24.1

%

22.1

%

21.5

%

24.7

%

23.1

%

20.3

% 22.6

%

21.4

%

20.5

%

20.8

%

21.9

%

10.0%

15.0%

20.0%

25.0%

30.0%

Jan

-14

Fe

b-1

4

Ma

r-14

Ap

r-14

Ma

y-1

4

Ju

n-1

4

Ju

l-14

Au

g-1

4

Se

p-1

4

Oct-

14

No

v-1

4

Dec-1

4

Jan

-15

Feb

-15

Ma

r-15

Ap

r-15

Ma

y-1

5

Ju

n-1

5

Ju

l-15

Au

g-1

5

Se

p-1

5

Oct-

15

No

v-1

5

Dec-1

5

CHS PC-02 Rate by Month 2014-2015

1st shift Median 23.552nd Median 21.7

Pilot site started

2 Early Adopter sites

go live 4/2014Go Live

Everyone

Baseline 27.02%

PC-02 Rate by Month

Median

0

5

10

15

20

25

30

Jan

'14

Fe

b '1

4

Marc

h'1

4

Ap

ril '1

4

May '14

Jun

e '14

July

'14

Au

g '14

Se

pt

'14

Oct '1

4

No

v '14

De

c '14

Jan

'15

Fe

b '1

5

Marc

h'1

5

Ap

ril '15

May '15

Jun

e '15

Jun

e '15

Au

g '15

Se

pt

'15

Oct '1

5

No

v '15

De

c '15

PC-02

Percentage

23.55

Signal= Shift –

7 points below the median

Run Charts Rules Summary

Signals of non-random patterns:

1. Shift - 6 or more consecutive points either all

above or all below the median

2. Trend - 5 or more consecutive points all going

up or all going down.

3. Runs - Too few or too many runs.

4. Astronomical point - A point obviously different

from the rest, "everyone agrees." This rule is

subjective, unlike rules 1-3, which are

probability based.

1/3/2015 3

See Perla et al. (2010) for further explanation and details

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Sustainability of PC-02 Improvement

• Transparency of data is reported by facility, practice, and provider

quarterly

• Practice level and provider level trends are reviewed

• Engagement and collaboration of Acute Care and Ambulatory

Leadership– PC-02 performance is part of Acute care and Ambulatory Leader goals (including

physician leaders)—Alignment of goals across the service line

• Peer review and case study development is occurring for cesarean

cases not meeting criteria

Sustainability of PC-02 Improvement

• What you measure, you improve!

• Communicate, communicate, communicate!!

• Don’t take your eyes off the ball!

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Next Steps

• Continue with goal alignment across the system

• Determine what each facility needs in terms of support—

individualize

• Focus on the facilities that have not shown improvement or have had

rate increase—though we’re a system of One, we have different

challenges– Continue to support those facilities with good results and work with others to improve

results

Learning Design/Collaborative Structure

• Monthly collaborative Perinatal Quality system-level meetings

– Nursing Leadership—each facility represented

– Provider Leadership—each facility represented

• Reporting of Perinatal Core Measures and other Perinatal Quality

initiatives

• Sharing of best practices, success stories and opportunities

identified/lessons learned

• Peer review/peer discussions for providers with a higher than

average rate for PC-02 using case studies

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TIPS FOR QUALITY IMPROVEMENT

IMPLEMENTATION

PDSA MODEL FOR IMPROVEMENT

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Plan—Where to Begin??

• Do you have high performers that can be identified as champions

for your improvement project?

• Establish best practice protocols/guidelines for the change

needed

• Educate teammates on these new best practices

Plan—Next Steps

• Important to know what exactly it is that you are measuring—gain

understanding

• Gain trust with the data—data integrity is essential

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Do—Implement Improvement Strategies

• Once trust is gained, then you can work on improvement strategies

Study—Where to Focus the Work

• Review data variations to determine where to focus the

improvement efforts

• Discussions with facility leaders and providers with low performance

• Know your data—this will require case reviews and deep dives

into the reasons for the variation in performance

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Study—Show Them the Data!!

• Competition is a great driver for improvement!

• Be transparent with the data

• Have peer to peer conversations regarding following evidence-

based practice—engage your provider champions

Act—Successful Approaches for Addressing Variation

• Transparency with the data and accountability for performance

– Consider including in the Ongoing Professional Practice Evaluation (OPPE)

– Peer review for cases not following guidelines

– Link performance to provider and leader compensation

• Goal alignment across the system is key—all working together for

success!

• Outside sources may force improvement for facility viability—let’s

have great performance without this “stick”

– Medicaid payment plans

– Private payers

– Blue Cross Blue Shield Blue Distinction for Maternity Care

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Take Aways

• This work has a meaningful impact to both mom and baby

• Goal alignment with stakeholders across the system is key to

success

• Standardization of care utilizing evidence based practice is needed

to reduce variation in care delivery

Questions??

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Toolkit Elements for PC-02 Initiative

• Data collection tool

• Algorithm

• Clinical Practice Guidelines

• PC-02 Scorecard

• Deep dives into numerator cases (cesarean sections)

CHS PC-02 Algorithm

Scheduled Admission

C-Section

Patient delivers via C-Section(Will be included in Numerator &

Denominator)

YesIs there a medical

indication for induction?

Document the Bishop Score

Place Cervical Ripening Agent

Is the Bishop Score <8?

Induction of Labor

Yes

Continue with Induction of Labor

See Page 2

No

Is the pt between39-

39+6 weeks?

NoNot a candidate for

induction or admission; d/c to home

Yes

Is the pt 40-40+6

weeks?

No

Document the Bishop Score

Yes

Is the Bishop Score <8?

Not a candidate for induction or admission;

d/c to homeYes

Patient meets criteria for induction

No

YesIs the

pt >41 weeks?

NoYes

PC-02 Algorithm

F:\IHI information\Perinatal Improvement Community\CHS Leadership Team\PC-02 project\algorithm\PC-02 Algorithm For Admission-Modified by PI vsd revised 3-3-14 (2).vsd

PC-02 Patient Population is defined as:· Nulliparous· Term (>37 weeks)· Singleton gestation· Vertex presentation· Live fetus

Elective primary c-sections do not need OB Department Chair review· Pt must be > 39

weeks· Risk/benefits of

trial of labor vs. primary c-section have been reviewed/explained

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CHS PC-02 Algorithm (page 2)

From Page 1

Discharge Home with F/U

Information

Once the patient is in labor

Does the Patient meet criteria for C-

Section?

If any one of these apply:-- NonReassuring FHR-- Failed Induction (see definition to left)-- Active Phase Arrest 6cm Dilated w/ ROM & No Cervical Change * > 4 Hrs of Adequate Ctx w/ IUPC > 200 MVUs * > 6Hrs of Inadequate Ctx-- Second Stage Arrest *3 Hrs in Nulliparous W/O Epidural *4Hrs in Nulliparous W Epidural

Unscheduled Admission

(Evaluate patient for admission criteria)Meets Admission Criteria

(Laboring, SROM, or Medical Reason)

Doesn’t meet Admission Criteria

Patient Delivers Vaginally

Pt will be in Denominator

Use Labor Support

Techniques, Monitor Pt and

Fetus Per Policy

No

Pt will be in Numerator and Denominator

Patient Delivers Via C-Section

Yes

“Failed Induction”

defined as:Failure to generate regular (e.g. every 3 min) contractions and cervical change after > 24 hours of oxytocin administration with AROM (if feasible).

PC-02 Algorithm

F:\IHI information\Perinatal Improvement Community\CHS Leadership Team\PC-02 project\algorithm\PC-02 Algorithm For Admission-Modified by PI vsd revised 3-3-14 (2).vsd

Data Collection Tool

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PC-02 Scorecard2015 (Baseline) Jan-14 Feb-14 Mar-14 Q1 Apr-14 May-14 Jun-14 Q2 Jul-14 Aug-14 Sep-14 Q3 Oct-14 Nov-14 Dec-14 Q4 2014 YTD

PC-02 Rate

Expected PC-02 Rate (target goal) 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7% 21.7%

Expected PC-02 Rate (stretch goal) 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0%PC-02 Rate #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Numerator 0 0 0 0 0

Denominator 0 0 0 0 0Number of vaginal deliveries 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

Balancing Measures (PC-02 Population Only)Operative Deliveries

Rate of Vacuum Deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Number of Vacuum deliveries 0 0 0 0 0

Rate of Forceps Deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Forceps delivery 0 0 0 0 0

Rate of Vacuum and Forceps Used Together #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Vacuum and Forceps Used Together 0 0 0 0 0

3rd Degree LacerationsRate of 3rd degree lacerations with vaginal deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Number of 3rd degree lacerations 0 0 0 0 04th Degree Lacerations

Rate of 4th degree lacerations with vaginal deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Number of 4th degree lacerations 0 0 0 0 0

Shoulder DystociasRate of shoulder dystocias with vaginal deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Number of patients with Shoulder Dystocias 0 0 0 0 0Chorioamnionitis

Rate of chorioamnionitis with total deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Number of patients with chorioamnionitis 0 0 0 0 0

MeconiumRate of meconium with total deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

Number of patients with meconium 0 0 0 0 0Postpartum Hemorrhage

Rate of OB Hemorrhage with total deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Number of patients with an OB Hemorrhage 0 0 0 0 0

Apgar <7 at 5 minutesRate of Apgars <7 at 5 minutes with total deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Number of patients with an Apgar <7 at 5 minutes 0 0 0 0 0

Unplanned Admission to the NICU/SCN 0.00%Rate of unplanned NICU admissions with total deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!Number of patients with an unplanned NICU admission 0 0 0 0 0