Healthy Birth Initiative

Reducing Primary Cesareans Collaborative

Our Team for Jan. 8th Webinar

Elliot Main Leslie Cragin Cathy Emeis Ana Delgado Kate Chenok

Agenda for Reducing Primary Cesareans Webinar

Jan 8th 20161-2:30 p.m. Eastern (12 Central, 11 Mountain, 10 Pacific)

Intro 2Bundle Implementation Process 10Unwarranted variation/drivers 20Discussion 10Data collection process 20Questions 15Reflections on barriers/facilitators 5Wrap up 2

Objectives for Call

• Understand the overall process of implementing a bundle

• Discuss unwarranted variation in the drivers of NTSV Cesarean Birth

• Review the variables and process for collecting QI data

BUNDLE IMPLEMENTATION PROCESS

Leslie Cragin

Plan- Big PictureWhat are you trying to accomplish? Reduce NTSV

cesarean section rate– What is your target amount and time frame (1 year?)

Team: content experts, leaders• Predictions: what drives your NTSV cesarean birth

rate? What decrease do you want to seeData: what and how are you going to measure?

Initial Work

Identify your patient/target population

Analyze your drivers and contributing factors for the NTSV rate

Choose your bundle

Become familiar with what will be measured and how, including outcomes and processes

Develop a preliminary picture about how all the elements work together to get the desired result, and note the most important elements (could be a driver diagram or other visual tool)

Describe an ideal system: How will care be delivered? Identify major gaps between this and the current system.

Tackle an “easy” part of the system first.

Structure and Process

MAP-IT• Mobilize people and resources• Assess• Implement• Track

Two hospitals (data from RPC member institutions)

• University Affiliated Medical Center (UAMC)

• 4800 births annually• 38% Primary CesareanBarrier• Lack of consensus among

care providers that C/S rate needs to be decreased

• Community Hospital (CH)

• 1250 births annually • 31% Primary Cesarean

Barrier• RN staffing models that make

bundle implementation difficult

Planning- AssessUAMC StrengthsInstitutional commitment to lowering the C/S rateCommitment to evidence based practiceUAMC BarrierLack of consensus among care providers that C/S rate needs to be decreased

CH Strengths• Culture of change in our

workplace• Commitment to evidence-based

practiceCH Barrier• RN staffing models that make

bundle implementation difficult

Other AssessmentsDeliverables• Drivers

Key bundle elements• Develop guidelines and policies in support of

change• Training for everyone who is part of the care

team• All needed resources are reliably available • Shared decision making is a part each

conversation about an intervention or procedure• Data is gathered to support the QI process

UAMC Bundle interestPromoting spontaneous progress in labor

CH Bundle interest• Promoting comfort in

labor• Promoting spontaneous

progress in labor

Rapid cycle improvementsUAMC

• Goal: All providers educated about importance of reducing NTSV– Champions for reduction of

rate mobilized, – Grand Rounds “debate” held– Existing policies reviewed for

consistency with the evidence

CH• Goal: All women who

desire an unmedicated birth will have access to comfort measures– Inventory of current

supplies– Lunch time trainings in

care practices

Study • Data analysis• Compare results to predictions• What was learned?

Act• How can you get closer to your goal?• What changes can you make to be more

successful?

• Jan – Logistics, Train in data collection, and Implement– Assess drivers and select bundle

• Feb– Begin first PDSA cycle

• March– First cycle completed?

NTSV: UNWARRANTED VARIATION AND DRIVERS

Dr. Elliot Main

METRICSCathy Emeis

Metrics

• Outcome Measure: NTSV cesarean rate• Balancing Measure: Apgars less than 7 at 5 min.• Variables for all NTSV patients: 13• Variables per bundle: 4-7

Before Data Collection Begins:

Before data collection begins, have an Information Technology Specialist at your hospital ensure :1. the monthly data collection spreadsheet is located

in a secure location on your network, accessible to all the individuals who will be using it.

2. a current version of Microsoft Excel is installed at the workstations that will be used to input the data.

Step 1: Determine if the patient case was NTSV:

1. Nulliparous (no prior pregnancies beyond 20 weeks)2. Term (37+0 weeks gestational age)3. Singleton4. Vertex presentation

After Every Delivery:

Step 2 Open the spreadsheet

Step 3: Answer using drop down• Answer all the questions from left to right

using the available drop-down options. Please DO NOT populate any of the questions with manually typed responses.

PLANNING DATA Ana Delgado

Planning Survey: Top Ranked AssetsResponses % Who Ranked in Top 3

Commitment to evidence-based practice 95%

Institutional commitment to lowering the C/S rate 67%

Front-line staff commitment to lowering the C/S rate

67%

Significant in-house QI expertise 42%

Culture of change in our workplace 35%

Consumer interest in lowering the C/S rate 29%

Adequate funding to procure needed supplies and equipment

21%

Planning Survey: Top Ranked BarriersResponses % Who Ranked in Top 3

Lack of consensus among care providers that C/S rate needs to be decreased

62%

Skepticism about specific bundle items 54%

RN staffing models that make bundle implementation difficult

43%

Lack of funding for necessary staff time. supplies or equipment

32%

Overly bureaucratic processes that make change very slow 32%

Workplace culture is not receptive to change 30%

Technical difficulties related to data collection 25%

Resistance to protocol or bundle-driven care 24%

Lack of staff champions 20%

Problems with collecting the raw data 13%

Lack of shared decision-making between providers and patients

4%

Planning Survey: Priorities for Jan. 28 Meeting

Topics % who ranked as priority (top 5)

Review of the evidence behind each bundle 84%

More information about the structure and timeline of the collaborative itself

60%

Specific QI techniques (fishbone diagrams, rapid cycle PDSA, etc)

56%

How to facilitate difficult conversations 56%

Tips for creating a culture of change 48%

Support for leadership development for my collaborative team

48%

Hands-on data collection tech support 44%

How to identify and cultivate stakeholders 36%

Opportunity for making peer/regional connections 20%