obstetrics care topic - the bree collaborative 29, 2012 · obstetrics care topic recommendations...
TRANSCRIPT
March 29, 2012
BREE COLLABORATIVE
Obstetrics Care Topic
Recommendations and Plan
Table of Contents
Problem Statement .......................................................................................................................... 1
Background Information ................................................................................................................. 1
C-sections .................................................................................................................................... 1
Early Elective Deliveries ............................................................................................................. 1
Inductions .................................................................................................................................... 2
DATA ............................................................................................................................................. 3
Current Efforts .............................................................................................................................. 12
Perinatal Collaborative .............................................................................................................. 12
Washington State Hospital Association .................................................................................... 12
March of Dimes ......................................................................................................................... 12
Medicaid .................................................................................................................................... 12
Leapfrog .................................................................................................................................... 13
Case Studies of System Changes in Washington .......................................................................... 15
Case #1 Franciscan Health System (FHS) ................................................................................ 15
Other Information ...................................................................................................................... 17
Goals, Strategies and Actions ....................................................................................................... 18
Goal Statement .......................................................................................................................... 18
Areas of Focus ........................................................................................................................... 18
Five Strategy Areas and Potential Actions ................................................................................ 18
Timeline for Actions ..................................................................................................................... 20
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Problem Statement
Obstetric (OB) care practices in Washington are highly variable across facilities, and show trends
that are adverse to maternal and child health.
By encouraging the application of evidence based decision rules, where appropriate, we seek to
limit variation in care unrelated to medical necessity as a means of improving safety, quality,
access and affordability of care for mothers and infants.
Background Information
There are three distinct issues related to OB care where the Bree Collaborative might spark
improvement.
C-sections The cesarean section (C-section) rate has risen dramatically in Washington without improvement
in outcomes, and with an increase in associated costs. The C-section rate varies dramatically
within the state, and in some cases even within a city. While C-sections are sometimes necessary
for the safe delivery of mother and baby, there is evidence that decisions to perform C-sections
are not always made for medically necessary reasons.
The Bree Collaborative has an opportunity to encourage more judicious use of C-sections, in the
interest of improving mother and child health, while saving the additional costs associated with
C-Sections.
A related issue is Vaginal Births after C-section (VBAC). A successful VBAC means a mother
who previously delivered via C-section is able to deliver a later child vaginally. VBAC
availability is influenced by facility and staff factors, such as funding to have anesthesia and
surgeon on site if a problem during VBAC occurs. The VBAC rate has dropped in Washington
and shows high variation across the state. This reduction in the VBAC rate is one of many
factors contributing to the overall rise in the C-section rate.
Early Elective Deliveries The ideal time for a baby to be born is after 39 weeks or more of gestation. Births are scheduled
earlier for non-medical reasons. Babies born in the 37-39 week range are likely to have less fully
developed brains, lungs, and livers, and a small proportion will require care in the Neonatal
Intensive Care Unit. Either an induction (to try for a vaginal delivery) or a C-section may be
scheduled. The rate of births scheduled before 39 weeks for non-medical reasons (so-called
“convenience inductions” or “convenience deliveries”) varies widely across the state.
The Leapfrog group recently set a goal rate of <5% for early elective deliveries, and the overall
average for Washington is currently above that rate with a number of hospitals significantly
above 5%. Through the work of the statewide Perinatal Collaborative, the rate of early deliveries
is declining. This improvement has been uneven and not across all facilities. The Bree
Collaborative has an opportunity to support and accelerate the Perinatal Collaborative’ s work,
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and continue to reduce the statewide average and variation in early elective delivery rates among
Washington facilities.
Inductions The rate of births induced through artificial means (use of stimulating drugs to start or speed the
birth process) has risen and varies across facilities in Washington. Induced labor lasts longer
(raising costs), is more dangerous to a mother, and is more likely to end in a C-section. Labor
can be induced at any gestational age, and may be of concern even in women who are at 39
weeks or greater, due to higher costs and the higher association with C-sections. The
Collaborative has an opportunity to encourage more judicious use of inductions.
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DATA
NOTE: DRAFT ELECTIVE DELIVERY DATA/GRAPH WAS REVIEWED BY THE BREE
COLLABORATIVE ON 3/29 BUT HAS BEEN REMOVED - BECAUSE IT WAS
UNPUBLISHED DATA
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NOTE: DRAFT ELECTIVE DELIVERY DATA/GRAPH WAS REVIEWED BY THE BREE
COLLABORATIVE ON 3/29 BUT HAS BEEN REMOVED - BECAUSE IT WAS
UNPUBLISHED DATA
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The list of exclusions in the measure changed from 2010 to 2011
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Current Efforts
Perinatal Collaborative http://www.waperinatal.org/
Pre 39 week goals for 2012-2013
Celebrate Success
New Target Rate < 5% (based on data, new Leapfrog and CMS Partnership for Patients
goals)
Simplify data collection
Provide enhanced support to hospitals with greatest challenges
Assist better performing hospitals in sustaining low rates
Provide resources for hospital self data validation
July review of definition against final Joint Commission and feedback from hospitals
Adjust state goal after above evaluation
Washington State Hospital Association
WSHA has been working in partnership with the Perinatal Collaborative, Department of Health,
and Health Care Authority to reduce early elective delivery prior to 39 weeks. The result is that
rates have been cut in half.
This work is part of the Partnership for Patients and CMS push to reduce harm in ten strategic
areas including obstetrics. WSHA will continue to measure and provide support for hospitals.
That support includes:
Setting goal of < 5 percent by the end of August
Transparency on our WSHA web site
Support for hospitals to continue to improve
Offer for more intensive support for hospitals with the greatest challenges
Personalized letter to hospitals across the state on this work
Survey to advance work
WSHA requests, as part of the Bree collaborative, help from the employers, health plans, and
others around the table for a campaign including PSAs and materials sent to employees which
will help educate the public on the risks of elective deliveries and C-sections.
March of Dimes http://www.marchofdimes.com/pregnancy/getready_atleast39weeks.html
Medicaid
Goals/Strategies
Reduce the elective 37-39 week deliveries to zero state wide
Reduce NTSV deliveries to a <20% state wide average
Work toward a state wide VABC rate of 40%
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Tactics/Processes
Hospitals agree to hard stops for elective deliveries (37-39 week and NTSV) using a state
wide guideline )
Hospitals and providers agree on a standard guideline/process for:
o Labor admission and trial of labor to reduce provider/client choice of elective
non-medically necessary admissions, inductions and C-sections
FYI the OHSU guideline (coming soon and will be similar to the March of
Dimes/CA 37-39 delivery guideline and will be edited by WA providers)
Use decision aids to promote access to VBAC
Work with the Bree and OB COAP to identify and educate local leaders in each
hospital/area to:
o Promote best practices and monitor OB outcomes using feedback reports
o Address trends that deviate from best practices using feedback reports
o Transparently report quality issues at the hospital level and privately report
provider trends
o Survey hospitals and providers to demonstrate access to quality affordable health
care is improving in Washington state
Payers work toward rewarding best practices through global/bundled payment methods
o (use the Mass BCBS AQC global model for professional/facility/NICU, and/or
return the hospital quality assessment, or bundle payments to reward
professional/facility/NICU)
o Payers promote access to birthing centers and midwife care in low risk clients
Leapfrog
Leapfrog has set a priority on reducing early elective deliveries because:
Experts, including those from the American College of Obstetricians and Gynecologists
(ACOG), Childbirth Connection, the Institute for Healthcare Improvement (IHI), and the
March of Dimes, caution that a baby needs at least 39 completed weeks to fully develop.
There are medical reasons to schedule a delivery before the 39th completed week, such as
if a woman has high blood pressure at the end of pregnancy or broken membranes before
labor begins, but these are rare.
Babies born too early have more health problems at birth and later in life than full term
babies. Examples of health problems include respiratory distress, temperature instability,
increased bilirubin levels resulting in in-hospital treatment, infection, longer-hospital
stays, and a higher mortality rate. In addition to health problems, there are substantial
costs associated with early elective deliveries. One study, by Steven Clark, MD and his
colleagues at Hospital Corporation of America, found that an estimate approaching $1
billion dollars could be saved annually in the US if the rate of early term (37 to 38 weeks)
delivery were reduced to 1.7%.
Leapfrog's target for all hospitals is an early elective delivery rate of 5% or less. In 2011 average
rate of early elective deliveries for all hospitals reporting to the Leapfrog Hospital Survey was
14%, down from 17% in 2010.
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Leapfrog made these Recommendations for local action:
1. Demand transparency from all hospitals in your network - tell them to report their rate
of early elective deliveries by completing a Leapfrog Hospital Survey.
2. Help hospitals improve by connecting them to evidence-based resources.
3. Make trusted, reliable resources available to your employees and their families.
Eg: Childbirth Connection and March of Dimes
4. Examine the way you pay for maternity care and think about making a change.
5. Ask your health plan for help.
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Case Studies of System Changes in Washington
Case #1 Franciscan Health System (FHS)
Management of Early Elective Deliveries
Interview of:
Mary LaFalce, Associate Administrator, Women’s and Children’s Services
Debbie Raniero, Director of the Family Birth Center at Saint Joseph Medical Center
Interviewed by:
Steve Hill
Dr. Dale Reisner
Jason McGill
How did your System become aware of an opportunity to improve OB Care?
Elective Inductions <39 weeks - Two years ago Leapfrog data; high elective induction
rate show was due to a mix of documentation and practice issues (now estimate, rough, it
was 25% documentation and 75% lack of parameters for scheduling <39 week deliveries)
New Service Line Medical Director, Dr. Peter Andrew (Drew) Robilio serves as
champion to improve both outcomes for babies and documentation.
Debbie and other family birth center leaders at FHS are active members of the Perinatal
Collaborative and participate in many list serve and collaboration activities within CHI
and elsewhere.
Where did the leadership for changing practices come from?
Dr. Robilio, Service Line Medical Director
OB Leaders Group and Women’s and Children’s Interdisciplinary Team (IDT)
o OB Chiefs, Nursing Leaders, System Medical Director, System Quality Leader,
Neonatologists, Anesthesia, Performance Improvement, etc.
o Meets twice per quarter
What process did you follow to understand the problem and opportunity?
The same process that is used for all major quality improvement and change at FHS
o Idea Generation – From Nursing Leadership and Medical Leadership as well as
clinicians.
o Leadership Consideration / Approval
Discussion at OB Leadership Meeting / (IDT)
System Leapfrog Data
WSHA Safe Table Webinar information
Facts and experience of clinicians – impact of induction on C/S
rate and babies
Engagement of OBs by OB Chiefs at each hospital.
Quarterly OB Section Meetings @ each hospital
Mailings
o Data (covered below)
o Education (covered below)
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o Operationalize (covered below)
o Feedback and reporting – Sustain the change (covered below)
What data, research, or national standards where brought into the process?
100% chart audit to abstract data covering three months at all three hospitals-- manual
Data from WSHA Safe Table Webinar, Thomas J Benedetti, MD, & Suzan Walker, RN,
http://www.wsha.org/files/82/June_22_2011_Elective_Deliveries_Webinar.pdf
March of Dimes toolkit
How did you engage and educate Providers, Nurses and Patients?
Providers
o Quarterly OB Section meetings, mailings, and face to face at time of scheduling
Nurses
o Monthly meetings
o Training on Coding and Exception lists
Patients
o March of Dimes materials
o “Brain Card” is very effective tool to communicate risk of early delivery to
patients / families.
What was the conclusion of the process – what agreements were reached on standards and
procedures
No scheduling of pre 39 week deliveries unless clinical indicators met one of two
exclusion sets
o Joint Commission
o State of Washington
Exception process to Perinatologists if OB or midwife felt patient warranted an exception
beyond the two lists above
How was the change operationalized?
Hard Stop at scheduling (this is critical and necessary)
Exception Process to Perinatologist
Chart Audits and Feedback reports
o Manual auditing of outliers by Labor & Delivery manager, and Women’s and
Children’s Quality RN
o Key Dashboard Indicator
Was there any push back from OB’s or patients? Do you have any indication that
deliveries were scheduled at other systems because of your change in standards and
procedures?
Some OB Chiefs more enthusiastic than others.
Requires regular education and reminders to OB community
No evidence of MDs or patients moving to other systems
In discussions with another hospital where using “soft stop” has not been as effective in
reducing pre 39 week elective deliveries.
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When did FHS begin this work and how long did it take to see results?
Completed initial chart review July-Sept 2010 and then started the education and
communication. Began monthly audits in January of 2011. Due to “hard stops” results
were notable soon after the start of the program.
Other Information
System – Five Hospitals, three provide Obstetric Services service lines
o Saint Joseph – 3,800 births/yr
Laborist on duty 24/7
o Saint Francis – 1,200 births/year
o Saint Elizabeth – 300 births/year
No Electronic Medical Records (except at SEH)
o Not an impediment to doing chart review and feedback reports
Other OB QI efforts –
o Reintroduced VBACs at Saint Joseph in April ’11 and at SFH Jan ’12; (SEH has
always done VBAC).
o Used same change process: Leadership, Data, Education, Operationalize, &
Feedback
o Used standardized process and materials for patient selection, patient education,
and consent across all hospitals
o Bundle Compliance is another QI area where this process was used to effect
change. Here is a link to IHI regarding the bundle compliance.
http://www.ihi.org/knowledge/Pages/Changes/ElectiveInductionandAugmentationBundle
s.aspx
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Goals, Strategies and Actions
Goal Statement
Encourage evidence based standards of practice to increase safety, quality, access and
affordability for mothers and infants.
Areas of Focus
1. Decrease elective inductions
2. Eliminate elective pre-39 week deliveries
3. Decrease variability between hospitals in primary Cesarean Section rate
(The order of these goals strives to start with small, doable steps that support other efforts
but recognizes that to make a significant impact on outcomes and costs requires
addressing #3 – the variability in the C-section rate)
Five Strategy Areas and Potential Actions 1. Establish or endorse existing evidence-based decision rules for obstetrical care
Decrease elective inductions
Aim for zero elective inductions with unfavorable cervix
Cervical exam (Bishop score) at scheduling and confirmed on admission
o Avoid elective induction of unfavorable cervix
o Eliminate use of cervical ripening agents for elective inductions
o Promote use of detailed informed consent and PDA's (when available)
Eliminate elective pre-39 week deliveries
Support Washington State Perinatal Collaborative less than 39 week quality initiative
Ask all hospitals to institute a scheduling process with a hard stop
o Joint Commission and State of Washington definitions of elective, with appeal
to hospital’s OB QI leader.
Decrease variability between hospitals in primary C-Section rates
Encourage and support development of a community standard for labor and delivery
management
Cervical exam on admission in spontaneous labor
o Promote delayed admission of healthy patients in early labor
Avoid C-section for first stage arrest in latent phase
Promote adequate time in active phase ( 4-6 hrs.) with use of appropriate clinical
interventions before making diagnosis of active phase arrest
Allow sufficient time with appropriate clinical interventions in the 2nd
stage before
diagnosis of 2nd stage arrest or "failure to descend"
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2. Support improved data collection and analysis; utilize results in a transparent manner to
stimulate improvement
Post the facility level Birth Certificate data. Encourage others to post and
publicize this data (PSHA, WSMA, WHSA & others)
Use the Birth Certificate Data to identify the best performing systems, as well as
the systems with the greatest opportunity to improve in early deliveries,
inductions, C-Sections, low birth weight, and VBAC
Encourage all hospitals providing OB care to collect their own data by any
available means, such as manual abstraction, internal database information from
EMR or via OB COAP
Encourage greater participation in and utilization of OB COAP study results of
systems that are performing well and those that have opportunity to improve
Seek transparency in sharing the OB COAP information as a component of these
statewide quality improvement efforts in OB care
3. Promote Quality Improvement
Ask each hospital with Obstetrical services to identify a Physician Champion
(strong interest in QI)
Develop and disseminate case studies on the way Systems have improved OB
care.
o Induction/C-section scheduling parameters
o Consent for inductions (both elective and "medical")
o Minimum cervical dilation prior to Labor and Delivery admit for women
with no obstetrical or medical issues (spontaneous, uncomplicated early
labor)
o Second opinions prior to non-urgent C-section (need to verify that second
opinions prior to non-urgent C-sections are useful)
Promote the use of Toolkits or other available protocols & algorithms
Consider a pilot study through the Perinatal Collaborative involving a limited
number of hospitals that have current capability of data analysis to implement the
strategies promoted by Bree.
4. Promote public education and patient decision aid usage
March of Dimes
Partnership in Decision Making
5. Change the way OB care is paid for – Plans and Employers
Engagement with payers and hospitals – financial and non-financial incentives
and disincentives to encourage change
Help disseminate tool kits for best practice
Financial support for state authorized patient decision aids availability
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Timeline for Actions