reducing primary cesareans collaborative december 8, · pdf filesupport moving forward. ......

Copyright ©American College of Nurse-Midwives Inc. All Rights Reserved

HealthyBirthInitiativeâ

Reducing Primary Cesareans Collaborative

December 8, 2017 Webinar


Goalsfortoday’swebinar

• Review how to hold gains and sustain change

• Get an overview of simplifications and changes to the data center for 2018


Sustaining Change

Diana R. Jolles PhD, CNMFaculty Frontier Nursing University


ObjectivesSustainability, Standardization, Spread and Scale

• Distinguish clearly how testing, implementing, and spreading a change are all different steps in the sequence of improvement

• Build communication strategies that foster and support spread

• How do you hardwire the new processes, methods, systems to create the "new norm"?

• Explore next steps in sustainability, standardization, and spread.


• Expect huge improvements and spread right away

• Don’t bother testing- do a large pilot

• Check huge mountains of data just once every quarter

SEVENSPREADLYSINS


• Give one person the responsibility to do it all

• Rely solely on vigilance and hard work

• Spread success unchanged• Require the person and team

who drove initial improvements to be responsible for spread

SEVENSPREADLYSINS


CaseStudies

• 5 million lives• Denver Health • Kolter• IHI Sustaining

Improvement


CaseStudy:5MillionLives§ Sustainability: Locking in the progress that hospitals have made already and continually building upon it; and § Spread: Actively disseminating best practice and knowledge about every intervention and implementing each intervention in every available care setting.


Sustainability:HoldingtheGains

1. Supportive Management Structure2. Structures to “Foolproof” Change 3. Robust, Transparent Feedback Systems 4. Shared Sense of the Systems to Be

Improved 5. Culture of Improvement and a Deeply

Engaged Staff6. Formal Capacity-Building Programs


DenverHealthMedicalCenter


DHMCHoldingtheGainsNationalRates

N=1,573

DenverHealth2005N=269

DenverHealth2010

N=1,064

DenverHealth2015

N=1253

Continuouslaborsupport ------- 2% 67% 55%

Ambulation 24% 12% 75% 64%

Hydrotherapy 6% 3% 61% 38%

Intermittentauscultation 15% 2% 67% 58%

Intermittentauscultationonly

3% 0% 29% 21%


DHMCHoldingtheGainsNationalRates

N=1,573

DenverHealth2005N=269

DenverHealth2010

N=1,064

DenverHealth2015

N=1253

Successwithpainreliefintention

------- 50% 76% 75%

Physiologicpushing 21% ….. 59% 79%

Non-lithotomybirthposition

43% 1% 98% 98%

Delayedcordclamping ------ ……. 58% 67%

Breastfeedinginitiationinthebirthroom

------ 45% 75% 74%


MaintainingTransformation• HARDWIRE TEAM • Extremely important looking to the future - strong physician

support moving forward. Strong support throughout hospital administration and with other departments.

• Participation in executive committees - i.e. medical staff.• What happens when there is new physician leadership?

• Ensure strength of the service - (many things involved in this - trust, integrity, credibility, stable staff, excellent outcomes)

• Be very active when interviewing/selecting new physician leadership

• Develop reliable, trusting relationships beyond the OB service - director of ambulatory care, etc.


MaintainingTransformation• HARDWIRE TEAM• How to maintain a happy team that is adhering to the

mission and providing quality care.• work/life balance• Fostering strenths• Building trust, credibility

• Developing leaders• Formal• Informal


MaintainingTransformation• HARDWIRETEAM:• Constantvigilancetomaintainhighly-functioningcollaborativeteam.

• BuildingandmaintainingTrust,credibility,integrityvital• Continuingtolearnfromeachother- MDs,RNs,etc.Supportingourdifferencesandsimilarities.

• Participatingincollaborativegroups- QI,P&P• Beingavoiceinbroaderhospitalgroupsandinitiatives- Priv/cred,MSEC,communityhealth


MaintainingTransformation

• HARDWIRE ACCOUNTABILITY AND DATA DRIVEN DECISIONS • Ongoing self-assessment, data collection and analysis

• Data collection over 10 years.• Peer review - chart audits, formal CNM review of cases,

QI • IPE - informal to formal - constant education despite

formality.• OBs, FPs, med students, RNs


DISCUSSIONChange: It is the Only Constant


HealthyBirthInitiativeâ2018 Revision of the ACNM DATA CENTER

FiscalSponsor:TheA.C.N.M.Foundation,Inc.


GoalsforThisPresentation

• Learn about the new, streamlined

ACNM DATA CENTER

• Be familiar with the revised measures

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Process• Steering Committee reviewed use of data

center by participants, including comments from coaching sessions (3/17)

• Sub committee and staff held 3 meetings to analyze patterns and make decisions (4/17-7/17)

• Meetings with vendor to confirm principles of revision and decisions (8/17)

• Revision completed and tested early 10/17

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Principles• Reduce data collection burden• Keep most relevant and useful

measures• Make “deep-dives” and analysis easier• Allow large institutions to use sampling

methodology• Keep a few “optional” variables to allow

a more robust analysis of bundle implementation for those who want it.– Can be used for audits

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GeneralMeasuresDeleted

• Cesarean Rate Among Epidurals < 5cm• Cesarean Rate Among Epidurals at 5cm

or Greater• C Section Among Independent

Midwifery Management• Physiologic Birth

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https://www.dropbox.com/s/jr4erkbiae0dtwo/9_29_17%20master_patient_worksheet_1.4%20tracking%20changes%20.xlsx?dl=0


GeneralVariablesDeleted• Any Pitocin before 3rd stage of labor• Did the woman have nitrous oxide in the

first or second stage of labor?• Did the woman have opiates in the first

or second stage of labor? • At what dilation did the woman receive

her epidural?• Did the woman have an episiotomy?• Independent Midwifery Management in

labor and birth

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IAMeasuresDeleted• 5-minute Apgar Below 7 Among Women

Eligible for IA• Rate of First Stage IA Among Women

Eligible for IA• Rate of IA Throughout Labor Among

Women Ordered to Receive IA• 5-minute Apgar Below 7 Among Women

Eligible for IA• Change from IA to EFM due to staffing

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IAVariablesDeleted

• Eligible for I/A• Mode of fetal monitoring ordered• Was the requirement for 1:1 staffing in

order to perform intermittent auscultation THE reason for changing from IA to EFM?

29


ComfortMeasureDeleted

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• Hydrotherapy• Percentage of NTSV women using

water immersion (tub) or shower during labor. Nitrous Oxide

• Opioid• Coping Scale• Cesarean Rate Among Epidurals <

5cm• Cesarean Rate Among Epidurals at

5cm or Greater


ComfortVariablesDeleted• Was 1:1 continuous labor support

provided:§ by a physician or midwife?§ by a registered nurse?§ by doula?

Replaced by: • Was 1: 1 continuous labor support

provided?• Did the woman use a tub or shower

for comfort during labor31


ProgressMeasureDeleted

NoneHowever:• Spontaneous labor and birth will be

displayed as a general measure

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ProgressVariablesDeleted• Was 1:1 continuous labor support

provided:§ by a physician or midwife?§ by a registered nurse?§ by doula?

Replaced by: • Was 1: 1 continuous labor support

provided?

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OptionalMeasures

General Measures:Rate of First Stage IA Among NTSV

Comfort:Continuous Labor Support

Labor ProgressRate of using graphing tool for labor progress.

34


OptionalMeasures

For IA: • Rate of First Stage IA Among NTSV• Rate of Second Stage IA Among NTSV• Rate of IA Throughout Labor Among

NTSV• IA Throughout Labor and Apgar Below

Seven Among NTSV

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ThesechangeswillstartwiththeJan,2018datacollection

• This means that you begin using the new data collection forms Jan 1, 2018

• You will download them from the website from this page:

https://datacenter.acnm.org/response_set_worksheets

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37


Newinstructionshere

39

Clickherefromanyscreen

Clickheretodownloaduserguide


Thenewportalgoes“live”onFeb15th,2018

• You must have completed all data uploads for 2017 by then. If there is any chance you cannot do that, please let us know ASAP.

• If you want to have access to all of the historical variables, you must download all charts and spreadsheets for 2017 by mid Feb. They will not be available to you after that.

40


Actionsyoumusttake

• Schedule a team meeting to discuss this change with all members, especially those who are involved in collection activities.

• COMPLETE (i.e. completely finish all months data collection and uploading) for 2017 by Feb. 15th 2018.

• Download a full set of your 2017 datafor futher analysis by Feb. 15th 2018– This will be your last opportunity for you

to access the older data set.41


FORQUESTIONS,EMAIL:[email protected]

Thank you!

reducing primary cesareans collaborative december 8, · pdf filesupport moving forward. ......

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