Transcript A Note to the Speaker DELETE THIS SLIDE BEFORE PRESENTATION The following slides have been developed to support presentations on the elimination of.

A Note to the Speaker
DELETE THIS SLIDE BEFORE PRESENTATION
The following slides have been developed to support presentations on
the elimination of non-medically indicated deliveries <39 weeks
gestational age and should be tailored to meet the needs of the
audience.
When adapting the slide deck, the following guidelines must be
considered:
 The slide deck is copyrighted by the State of California.
 Slides contained in this deck should not be changed or amended.
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 Additional slides can be added, but new slides must not contain the
CMQCC logo, March of Dimes logo or the State of California
copyright.
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1
Elimination of Non-medically Indicated
(Elective) Deliveries Before 39 Weeks
Gestational Age
An Implementation Strategy
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Funding for the development of this toolkit was provided by:
Federal Title V block grant funding from the California Department of Public Health; Maternal, Child and Adolescent Health Division was
used by the California Maternal Quality Care Collaborative to develop the toolkit; and March of Dimes.
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A Daunting Task
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Objectives
1. Learn the step-by-step process necessary for
successful implementation of the elimination of elective
deliveries before 39 weeks project
2. Gain a deeper understanding of the importance of the
following implementation components:
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•
•
•
•
•
3.
Who to involve
Tools needed (i.e. policy, scheduling guidelines)
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Engaging
to drive
and sustain
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How to overcome barriers
Tracking outcomes
Describe the common barriers to full implementation
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Key Points
1. Education provided to obstetricians and patients
regarding ACOG guidelines and best practices is
important
2. Nursing support and medical leadership are crucial
3. Modest change at most, until physicians were held
accountable, nurses were empowered, and guidelines
were enforced (“Hard Stop”)
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4. One Grand
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5. Data reporting helps facilitate change
6. Patient education can also drive change
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Overview: Critical Elements for Successful Implementation
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What Do We Need to Get Started?
MAP-IT
• Mobilize
• Assess
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• Plan
• Implement
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• Track
Source: Guidry, M., et. al. Healthy people in healthy comamunities: A community planning guide using healthy people 2010.
Washington, D.C. U.S. Dept. of Health and Human Services. The Office of Disease Prevention and Health Promotion.
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Mobilize the Team
• Identify physician champion
• Involve all stakeholders
needed to change culture:
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Obstetricians,
Practice Physicians8, Nurses,
Schedulers, Quality Improvement
Team, Analysts, Hospital
Administration, Service Line
Directors, Public Relations, Public
Health, Payers, Business, Others
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• Involve people early
Image: renjith krishnan / FreeDigitalPhotos.net
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Mobilize the Team
Getting Stakeholders to be Stakeholders
• Effective communication strategy
• Stakeholders must be able to express their
concerns
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• Motivation
• We’re part of a team
• Win-Win
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• Data presentation (local)
Image: renjith krishnan / FreeDigitalPhotos.net
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Assess the Situation
Determine Your Starting Point
• What is your induction and cesarean section rate?
(Baseline assessment)
• Elective vs. indicated
• Before 39 weeks and between 370/7 and 386/7 weeks
• What are your NICU admission rates and trends?
• Assess your scheduling process
• Who schedules inductions and cesarean sections?
• Do you know the Estimated Gestational Age and
indication
at the
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• Who are the champions, adopters and resisters?
• What is the process for referring a case?
• What are the barriers to change?
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Assess the Situation
Communication: Data are Local!
Distribution of births by gestational age
United States, 1990 and 2009
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What is your
local hospital
data?
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37-38 weeks
Gestational age is calculated in completed weeks.
Source: National Center for Health Statistics, 1990 and 2009 final natality data.
Prepared by March of Dimes Perinatal Data Center, August 2012
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Plan Change Tactics
Overview
• Develop revised scheduling process and guidelines
• Establish an appeal process for deliveries that don’t meet
scheduling guidelines (“Hard Stop”)
• Appoint physician leader(s) to enforce scheduling process and
approve exceptions
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•
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Revise scheduling forms, policy and procedure
Develop data collection plans and forms
Formalize change in hospital policy
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Determine
which
clinician
and patient
education
materials
are needed
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Plan Change Tactics
A Tool to Educate Patients
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© 2007 Bonnie Hofkin Illustration
marchofdimes.com
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Plan Change Tactics
Develop a Scheduling Process
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Plan Change Tactics
• Establish
professional
consensus on
indications for
early delivery
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• These are not
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exhaustive lists!
But close… (e.g.
prior classical CS)
Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age
Spong et al. Obstet Gynecol. 2011 Aug;118(2 Pt 1):323-33.
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Plan Change Tactics
Caveats About the Indication Lists
• The Joint Commission list was developed for ease of
data collection utilizing ICD-9 codes.
• Two additional indications that do not have ICD-9 codes
are now accepted by The Joint Commission - prior
classical CS and prior myomectomy.
• Everyone understands that there are cases in which
earlier delivery is indicated and but the indication is NOT
on theClick
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• No one is expecting a ZERO rate.
• Off-list indications should be prospectively scrutinized.
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Plan Change Tactics
• Develop and adopt a
scheduling form and
process
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style
Scheduling Form
Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks
Gestational Age
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Plan Change Tactics
Overview of Changes to the Scheduling Process
• Patient is NOT scheduled and is allowed to go into labor
spontaneously.
• Accurate gestational dating.
• Appropriate indication for induction or cesarean section for
gestational age.
• Patients scheduled either by calling the scheduler,
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electronic
submission
or faxing insubtitle
the request.
• Elective deliveries - including repeat scheduled cesarean
sections - must be at least 39 weeks gestation based
upon ACOG criteria.
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Plan Change Tactics
Scheduling Process (continued)
• Any scheduling conflicts will be directed to the OB Chair
or Director of L&D for resolution.
• Ongoing problems that are identified will either be
resolved as soon as possible or discussed at future
department meetings.
• Data will be reported on a regular basis to inform
everyone about how the project is going.
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Plan Change Tactics
Confirmation of Term Gestation
• Early ultrasound, < 20 weeks gestation, is more accurate
than an ultrasound after 20 weeks gestation at
determining gestational age and benchmarking < 39
weeks gestation.
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• Ultrasound-established dates should only take precedence over
LMP-established dates when the discrepancy is greater than 7
days in the first trimester and 10 days in the second trimester
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ACOG Practice Bulletin: Ultrasonography in Pregnancy
Number 101, February 2008
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Plan Change Tactics
• Create or rewrite
hospital policy
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Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks
Gestational Age
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Plan Change Tactics
• Identify strong physician
and nursing leadership
• Empower
nurses
to
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handle “appeals” for
exceptions
• Establish
“Hard
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styleStop”
process
Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks
Gestational Age
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Plan Change Tactics
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• Develop data collection plans and forms
Sample Data
Collection Form
Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks
Gestational Age
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Implement
• Convene department and staff meetings to educate
physicians and staff
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•
•
•
Baseline assessment
Ongoing data collection plan
Policy and procedure with Approved Indications
New scheduling process and forms
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• Provide educational materials for physicians, staff,
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and patients
• Choose start date and begin data collection and
reporting on a regular basis
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Track Progress
• Use data and audit tools to track
the number of non-medically
indicated deliveries <39 weeks
• Develop trend charts and report
back to staff and providers on a
regular basis
• Address issues and concerns as
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soonClick
as possible
• Tracking data secures buy-in and
sustains results
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style
Track Progress
• Data Collection Resources
• Elimination of Non-medically Indicated Deliveries
Before 39 Weeks Toolkit
• March of Dimes Perinatal Quality Improvement portal
(PQIp)
• California Maternal Quality Care Collaborative
(CMQCC)
Website
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• The Joint Commission
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Understanding Barriers to Change:
It’s All About People
• It is important to consider how people will personally be
affected by the change process.
• Uncertainty can evoke a wide range of emotions:
frustration, anger, despair, acceptance, enthusiasm and
elation.
• Which emotion is encountered will depend on whether
people make the change willingly or unwillingly.
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Source: NHS Modernisation Agency 2005. ‘Improvement Leaders Guide, Managing the human dimensions of change’.
Department of Health Publications, London www.modern.nhs.uk
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“People” Barriers
• Not aware why change is necessary
• Feel that there are other more important issues.
• Don’t agree with the proposed change, or feel that change
is harmful.
• Disagree about how the change should be implemented.
• Feel criticized by the change process.
• Feel that they have done this before and nothing changed.
• Feel that there will be extra work.
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Source: NHS Modernisation Agency 2005. ‘Improvement Leaders Guide, Managing the human dimensions of change’.
Department of Health Publications, London www.modern.nhs.uk
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Readdress Concerns
• The “UNKNOWN” is scary. Educate as much as
possible to decrease uncertainty before implementation.
• Continue to communicate throughout the implementation
process and listen to people’s concerns.
• Addressing concerns engages people and makes them
part of the team and part of the solution.
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Less than 39 weeks (%)
Success Breeds Success
Review progress
serially and
provide feedback
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Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks
Gestational Age
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Implementation Summary
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•
•
•
Need a motivated QI Team
Leadership is critical
RNs need to be empowered
Develop the necessary tools (hospital policy, scheduling
guidelines, process and form)
• People need to be engaged
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• Data collection
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essential for
success
• Sustained improvements will be realized through culture
change
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Questions?
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For More Information, Contact:
Barbara Murphy
[email protected]
Leslie Kowalewski
[email protected]
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