the health roundtable maternity improvement group: improving care for women with obesity 10-11 march...

The Health Roundtable

Maternity Improvement Group: Improving care for women with obesity

10-11 March 2011

HRT1104b– MaternityMelbourne, Vibe Savoy


The Health Roundtable …… An Innovation Clearinghouse

Non-profit membership group

70+ Members 130+ Facilities Founded 1995 Share problems Share solutions Provides

informal network2

HealthRoundtable

HealthRoundtable

The Health Roundtable 3

Our Role: Help members answer basic questions

Are our results different? Why are we different? Who can we learn from? How do they do it? How can we make it

happen here? “How to change things, when change is hard”•Direct the Rider•Motivate the Elephant•Shape the Path

Switch – Chip & Dan Heath, 2010


Focus on Benchmarking for Innovation…

Voluntary comparisons

Search for differences Data Methods Clinical Practices

No “right or wrong” Opportunity focus Gradual fine-tuning


…Not Benchmarking for Accountability

Mandated Uniform Tightly defined Score – “win/lose” Denial “by losers” Gaming the system “Inspectors”

needed


Program/Calendar for 2011

Casemix/ED Comparisons 2-4 March

KPI Comparisons Webcasts

CEO Meetings 24 March / 25 Nov

S1. “Stranded” Patient Care Program May - October

S2. Lean Healthcare Program On site

S3. Online Staff Improvement Surveys Online

S4. Adverse Event Trigger Tool Program Online / 9-10 June

R1. Improving Outpatient Care Models 26-27 May

R2. Meeting Workforce Needs for 2015 11-12 August

R3. Preventing & Rescuing Long-stayers 20-21 October

B1. Clinical Costing Group 2-3 March

B2. Allied Health Group 27-28 October

B3. Imaging Journey Group 17-18 February

B4. Nursing Workforce Group 15-16 September

B5. Maternity KPI Group 10-11 March

B6. Mental Health KPI Group 23-24 June

B7. Patient Safety Group 9-10 June

B8. New Zealand Benchmarking Group 11-12 May / 2-3 Nov

B9. Victorian Benchmarking Group 19-20 May / 24 Nov

B10. Operating Theatre Group 7 April / 9 Nov

Core

Optional

6


2010 AIM Statements

How are you going with last year’s goals?


What hospitals were planning to improveTitan Improve mother and baby outcomes by implementing

rounding – Improve breast feeding and pt satisfaction and link LOS with breast feeding at discharge and readmission rates

Hera Improve normal birth rate by implementing practices (workshops and policy statements) and raise awareness of staff including clinical room environment

Fox Reduce caesarean rates (32% to 28%) by auditing using Robson classification and feeding back to staff; education about benefits of normal birth and other strategies

Lynx Improve staff pride and understanding in what they are doing by producing and presenting a maternity annual report within 6 months to promoting success; use Robson classification; promote use of maternity data within NZ

Fury Evaluate the role of the breast feeding advocate in maternity ward – aiming to improve women’s confidence in breast feeding prior to discharge.


What hospitals were planning to improveApollo Increase VBAC rates for Robson classification group 5 by

20% using comparison with NZ for maternal requests eg Say NO and knee replacement analogy; develop policy, education and ?VBAC group; video successes; immediate debrief after 1st caesarean to manage expectations

Cougar Reduce caesarean rate to 30% from 36% (20% reduction); identify priority groups within Robson; developing plan with stakeholders by using data

Scorpio Reducing caesarean rate by promoting normal birth; improving VBAC programme; increasing VBAC from 60% to 70%

Gemma Improve access to women’s health clinics by streamlining clinic processes; reduce wait times

Jaguar Increase normal birth rate for Robson Grp 1


Team Presentations


Survey Data

Improving the management of women with obesity


Survey Review - Purpose

To identify innovations and hot topics that help you learn from each other NOT for judgement!

To assess your progress against other hospitals but/ hospitals are different sizes and have different resources available (inpatient reports use levels 1- 6 depending on patient volume and complexity)

There maybe more variation in how the survey is completed than in actual performance


Additional services offered ……


Small Groups Survey Review

What have you learnt?


Maternity Reports

Overview


Inpatient Episodes

•Length of Stay•Complications•Readmissions•Mortality

Health Roundtable Data Collections

Emergency Presentations•Time to be Seen•Time to Disposition

OptionalData Collections•Inpatient Costing•Allied Health Activity•Imaging Activity•Community Mental Health•NZ Chapter•Victorian Chapter

Optional Inpatient Extracts

•Maternity•Safety Indicators•Nursing Sensitive•Paediatric

Hospital KPIS•Emergency •Cancellations•Clinical Care•Workforce•Casemix


My Data tab or Compare Performance tabs


Short questionnaire......have you

Implemented a service improvement because of The Health Roundtable data?

Disseminated The Health Roundtable data to Nurse leaders Medical leaders Senior executive Other?

Displayed the data somewhere in your maternity unit?


Have you......

Tabled and discussed the data at a management meeting

Tabled and discussed the data at a multi-disciplinary clinical meeting

Tabled and discussed the data at a MDM meeting

Incorporated benchmarks into a quality strategy for your maternity service


Question Health service Count

Implemented a service improvement because of The Health Roundtable data?

5

Disseminated The Health Roundtable data toNurse leaders

7

Disseminated The Health Roundtable data toMedical leaders

4

Disseminated The Health Roundtable data toSenior executive

4

Disseminated The Health Roundtable data toOther?

1 (Board level)

Displayed the data somewhere in your maternity unit? 2 (Annual Report)


Question Health service Count

Tabled and discussed the data at a management meeting 6

Tabled and discussed the data at a multi-disciplinary clinical meeting

4

Tabled and discussed the data at a MDM meeting 2

Incorporated benchmarks into a quality strategy for your maternity service

4


The Hawthorne effect is a form of reactivity whereby subjects improve or modify an aspect of their behavior being experimentally measured simply in response to the fact that they are being studied


“What matters more than raw data is our ability to place these facts in context and deliver them with emotional impact”

Daniel Pink: A whole new mind


Turning information into action!

How can you improve?


Variation in clinical practice

Reviewed all indicators where

Greater than two fold variation between health services

No reason to think that coding differences have major impact on rates (eg excluded complications of care)

Note that some differences due to mix of patients and level of hospital

Please choose an indicator for your hospital


“Knowing-Doing Gap”

Although difficult to quantify, there is known widespread variation in the way that best available evidence is applied in clinical practice.

The reasons for gaps between evidence and practice are complex, and efforts to improve uptake are unlikely to be successful if they are one-dimensional or focus on individual health professionals.

Kennedy et al, MJA 2010


Barriers impeding best practice

the guidelines themselves — whether they are considered feasible, credible, accessible and attractive;

professionals’ individual levels of awareness, knowledge, attitude, motivation to change and behavioural routines;

patients’ knowledge, skills, attitude and compliance;

professionals’ social context — opinion of colleagues, culture of the network, and level of collaboration and leadership;

organisational context — infrastructural elements supporting or inhibiting uptake (eg, staff, processes, capacities, resources and structures;

economic and political context — broader influences supporting or inhibiting uptake, such as financial arrangements, regulations and policies.


ALOS varies from 1.3 to 3 days for vaginal deliveries…….


RSI varies from 75% to 115% days for vaginal deliveries…….


Variables used for Relative Stay Index 20,000 subgroups based on combinations of:

Diagnosis Related Group: now DRG Version 6 Patient Age Group: expanded to 8 groupings

A = 0 years, B = 1-16 years, C = 17-34 years, D = 35-49 years, E = 50-64 years, F = 65-79 years, G = 80+ years

Admission Type: - Sameday Emergency (S) / Overnight Emergency (L) / Elective (P)

Arrival Source: Transferred in (X) / Normal Admit (4) Discharge Destination: transfers refined

Discharged home (H) / Dead (D) / Statistical Discharge (X)

Transfer by major hospital (T), Transfer by regional hospital (U)

Comorbidity Level: High (True) / Low (False) High means three or more co-morbidities from separate ICD10

Chapters Average LOS for 2007-2009 forms the ‘expected’

LOS


ALOS varies from 2.6 to 5.9 days for caesarean deliveries…….


RSI varies from 75% to 110% days for caesarean deliveries…….


Rate of emergency readmissions within 28 days varies from 0.3% to >5%


Rate of deliveries with induction +epidural +instrument use vary from 0.5% to 4.5%


Rate of emergency readmission for diseases of pregnancy, childbirth varies from 0.3% to 2.1%


Rate of VBAC varies from 27% to 4%


Rate of 3rd of 4th degree tears in vaginal deliveries varies from 1% to 4%


Rate of episiotomy in instrument, vaginal deliveries from 22% to 78%


Induction methods also vary from predominantly prostaglandin to oxytocin and rate of ARM varies from 6% to 28%


Rate of episiotomy in vaginal deliveries varies from 5% to 28%


Rate of instrument use in deliveries varies from 5% to 18%


Rate of failed induction of labour varies from 3% to 10%


Rate of epidural incidence in all deliveries varies from 21% to 45%


Caesarean deliveries vary from 15 to 32%


Rate of induced delivery varies from 15% to 29%


Rate of deliveries with obese women varies from 4% to 0%

E66* - Obesity


Review of data on women coded with obesity

E66* (Obesity) is not coded every time If ‘obesity’ hasn't been specifically documented the

coders can’t code it There is no rule or criteria that the coders use

(eg. BMI > 30)

Unless ‘obesity’ affects the patient’s stay at the hospital it isn’t coded e.g. special diet, drugs etc.

Because of this sometimes you may see it coded for one episode but not other for the same patient.


Customised briefing data also available...


Review of data on women coded with obesity

For any patient only complications that need to managed, assessed or monitored are coded.

Need to document ‘obesity’ for it to be coded BMI > 30 = Obesity? Ethnicity?


Very few obese women have lactation disorder or supervision of lactation coded


Rate of induced deliveries varies up to 100%(non-obese 15-29%)


Improving Data Quality:

Talk to your coders……………………………………..


Small Groups Data Review

Debrief in your hospital team and choose an indicator that is important for your service

In groups (based on indicator):

Discuss how to use the data plus experience-based design in service improvement

Start: with brainstorming


You are going to do a series of idea generation exercises

AND....will only have one minute for each


The way to get good ideas is to get lots of ideas and throw the bad ones away.

Linus Pauling, Nobel Prize winning chemist


1:00



Now think of how Virgin or McDonalds would improve service delivery



1:00



Now think of how you could approach improving your performance a indicator


1:00



Count up your ideas......

How many did you have.......?

Be prepared to feedback on what you think is the most creative in each section


Other Innovations


Hot Topics


Hot TopicsClinical ManagementHow to manage intrapartum and post partum care e.g. epidural etc in high BMI patients.

Manual handling procedures in emergencies:•Shoulder dystocia.•Cord prolapsed.•PPH.•Breech presentation.

How do centres manage the obese patient with the suboptimal views on morphology scan performed in the community?

What is the effect of bariatric surgery?

CPAP management of sleep apnoea following surgery

What is the impact of rising BMI on other risk factors?


Hot Topics

Psycho-social support for obese womenHow is pre-conception information best provided to obese women e.g. benefits of weight loss and high dose folic acid?

What is the best way to address the opportunity for education about complications related to obesity post partum?

How do you manage the stigma of clinics purely for women with a high BMI?Psychology of morbid obesity.

Operational TopicsHow do level 2 hospitals categorise c/s urgency where operating theatres are shared?

Operational TopicsHow do your services manage the increasing number of women being referred to tertiary centres on the basis of weight when most maternity units have reached and exceeded their booking numbers?


Hot Topics

Caesarean SectionsHow is Vaginal Birth after Caesarean Section managed?

How are women supported following primary c/s?

How is CT pelvimetry used to guide decision making in VBAC?


Small Groups Review


AIM Statements

Setting your 2011 goals


Idea Screening Does it work elsewhere?

Credible evidence? Personal network / connection to innovators?

Is it worth it? Enough patients / activity / value? Big potential improvement?

Can we do it? Someone to champion? Resources potentially available? No major resistance expected?


Aim Statement

25 words or less – specifying goal, improvement, and deadline – from patient perspective

To improve / reduce what ________ (for patients)By what amount ________By when __________In what area ___________

To reduce waiting time for Emergency X-ray by 80% by September 2010 for category 1-2 patients


Involving Key Stakeholders

Who are the stakeholders? What are their concerns? How to engage them in the improvement process? When to engage them? Where to engage them?

What’s in it for me?


2012 AIM Statements


Inpatient Report Update: Complication of Care Analysis

Previous- Home-grown system- 269 “complication” codes

identified- Episodes flagged if found

anywhere other than as principal diagnosis

- Frequent “false alarms” with pre-existing conditions flagged

New “CHADx” system- Commissioned by Australian

Safety Commission (T Jackson research)

- 4000 codes in 17 chapters identified as “hospital acquired”

- Requires new “onset flag” to be recorded for better accuracy

- More detailed reporting available

- Fewer “false alarms”


What does this mean for maternity? Most common complications coded for “deliveries”


Most common complication for any maternity patient


Able to drill down by principle diagnosis


Inconsistent coding eg Only half of second degree perineal lacerations were coded as ‘hospital acquired’ for some hospital

the health roundtable maternity improvement group: improving care for women with obesity 10-11 march...

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