IHI Perinatal Improvement Community: Change, Changes, and more - - PowerPoint PPT Presentation
IHI Perinatal Improvement Community: Change, Changes, and more Changes! It takes a Community! Your Perinatal Faculty Team Sue Gullo, Virginia (Ginna) Peter Cherouny, Betty Janey, PM Evan Bittel, PC Crowe, IA Faculty Chair Director Our Faculty
Change, Changes, and more Changes! It takes a Community!
Tara E. Bristol Randall J. Morgan Kim L. Armour Virginia (Ginna) Crowe, IA
Sue Gullo, Director
Deb Bell‐Polson
Evan Bittel, PC
Peter Cherouny, Faculty Chair Betty Janey, PM
Also not pictured: Cheri Johnson Martha Leighton
Our Faculty Team
(15 min) Dr. Peter Cherouny, Lead Faculty
(5 min) Sue Gullo, MS, BSN, RN IHI Director
History
– Started in 2004 – Significant unexplained variation in the system of care – Majority of errors are system driven – Communication failures drive patient risk – Lack of prospective quality assessment
IHI Improving Perinatal Care Collaborative then Community
2004‐2005 Innovation with Premier and Ascension Health. Oxytocin Bundles developed and piloted. 2006‐2013 IMPACT then Learning Community. Oxytocin Deep Dive‐ Labor Deep Dive‐Advanced Bundles‐ Gestational Age Reliability 2011‐2013 Louisiana State Effort initiated with DHHS supporting 14 hospitals. 2012 Effort expands with collaboration with LHA HEN
IHI Perinatal Care Community Measurement Strategy
Recommended Measures Optional Measures
Annual / Bi‐annual Structure Assessments Monthly Outcome & Structure Measures Initial Weekly or Monthly Process Measures Advanced Weekly or Monthly Process Measures Outcome, Balance or Process Measures Oxytocin Deep Dive* Perinatal Harm* Augmentation Bundle Composite / Compliance* (Oxytocin) Vacuum Bundle Composite/Compliance* Antenatal Steroids (TJC PC‐03) Patient and Family Centered Care (Structure/Narrative) Elective Induction Bundle Composite/ Compliance* (Oxytocin) Advanced Augmentation Bundle Composite/Compliance* Health care‐associated BSI in newborns (TJC PC‐04) Labor Deep Dive* Exclusive Breast Milk Feeding (TJC PC‐05: PC‐05a) Elective Delivery prior to 39 weeks Rate (Initial) / Time Between(Rare Event) (TJC PC‐01 ) Augmentation Induction Monthly Bundle Compliance (Oxytocin) Advanced Elective Induction Bundle Composite /Compliance* Cesarean and Elective Delivery (NQF) Prophylactic Antibiotic in C‐ section (NQF) Advanced Indicated Induction Bundle Composite /Compliance* Patient and Family Satisfaction Culture of Safety Survey Cesarean Rate for low‐risk first birth women (TJC PC‐02) Elective Induction Monthly Bundle Compliance (Oxytocin) Time Between Decision to Incision Monthly Advanced Bundle Compliance (Vacuum; Adv. Aug: Adv. EI; Adv II) (Test Measure) Transfer to Higher Level of Care: Term Delivery Neonate Transfer to Higher Level of Care: Elective Delivery (Test Measure) Gestational Age Reliability
Perinatal Leadership
Reliable Processes Effective Peer Teamwork
Perinatal Community: Reducing Harm, Improving Care, Supporting Healing
Respectful Patient Partnership
Key Outcome And Process Measures*
* See Perinatal Community Measurement Strategy
Our great challenge involves Making Systems Work
– Reliable design strategies
– Systems are designed to get exactly the results they achieve
– Improve communication – Standardize what is standardizable – Simplify where appropriate – Identify unexplained variation and work toward eliminating it
1‐3 months .. 3‐6 months… Perinatal Oxytocin Bundles Perinatal Trigger Tool
Common EFM Language and Training Reduce Variation‐ Meds, Emergencies Implement Techniques for Effective Communication
Engage Patients and Families
Establish a multi‐ disciplinary team training program Establish Huddles, Multi‐disciplinary rounds Design Interventions From Trigger Tool findings Consistent (across disciplines) Credentialing Standards Collaborative And Supportive Culture Vacuum Bundle
Supportive Leadership
Perinatal Leadership & Improvement Team
3 months to 36 months and beyond….
Deep Dive Pre‐work
3 ‐ 9 months……… 12‐24 months…….. 12‐36 months and beyond……
Patients on Improvement Teams Care is Transparent
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An evaluation of care practices intense enough to give a clear understanding of the current practices of care This includes a random sampling/evaluation so the assessment includes most (all) providers, all days and all times Structure and Process Measures
A group of clinical events that should happen every time a given process occurs Individual elements based on solid science Initial emphasis is on process rather than outcome
Members influence the content and work with faculty to stay ahead of the “next new thing” by leading to the “next new thing”.
Confirmation of fetal maturity Category I EFM Absence of tachysystole with increases in pitocin/Response to tachysystole Pelvic assessment
Gestational age > 39 completed weeks Category I EFM Absence of tachysystole with increases in pitocin/Response to tachysystole Pelvic assessment
Estimated fetal weight Category I and some Category II EFM Absence of tachysystole with increases in pitocin/Response to tachysystole Pelvic assessment
– Systems are designed to get the results they achieve
– If you want different results the system needs to be changed
– Focus on the structure and process of care
– Reliable design strategies to consistently get the care to the
bedside that we intended – Data for improvement, not for punishment – Measure, measure, measure
– The need to know that change results in improvement
– Leadership and ownership
The movement in national OB imperatives
– Elective deliveries
(PC-01)
– Primary cesarean sections (PC-02)
– Elective inductions – Admission criteria – Labor definitions
The movement in national OB imperatives
– Decreasing the hospital and provider variation – Minimizing misuse of our tools
– Increasing where underused – Avoiding overuse
– Clarifying definitions where required – Reliably delivering care
Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal‐Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181
Preventing the first cesarean section Recommendations
Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal‐Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181
Failed Induction of Labor
after at least 24 hours of oxytocin administration with AROM (if feasible)
Preventing the first cesarean section Recommendations
Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal‐Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181
Active phase arrest
cervical change for
Second stage arrest
Preventing the first cesarean section Recommendations
Spong CY et al. Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal‐Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop. Obstet Gynecol;120:1181
Are you conflicted yet?
Success is a continuous journey Openness is a start and must be fully embraced Fear the silence, not the conflict
Introducing…
– Emory Healthcare and Georgetown Hospital System!
Coaching Calls: 1 day/month 4 time blocks Open to all All Team Calls: 1 day/month 90 minutes Workgroup and/or Special Calls: Ad-hoc content specific calls Community Kick-off Call: End of September 2013 Community Wrap-up/Celebration Call: End of August 2014
Complete the enrollment form on ihi.org and send to bjaney@ihi.org by September 1, 2013 (start of collaborative year)
– All teams registered by August 1st will receive $100 discount to membership
fee
Membership Fees $15,000 per year per team A reduced rate of $7,500 per team per year applies to the following:
– Federally-qualified health centers – Physician practices comprising of fewer than 20 physicians – Hospitals with an average daily census of fewer than 50 beds
(aka how to fund your membership)
Approach underwriters and risk management. Incorporate into credentialing Work with IHI to break up payments Use these slides! Schedule a call with organizational leadership and IHI to bolster support
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Georgetown Memorial Hospital
Georgetown Hospital System
Vision Communication
Evidence Based Practice 39 Weeks Elective Delivery Initiative
Teamwork Collaboration
Patient as Active Team Member Harm Reduction
Julie Casselman, Renee Shore, Janel Moseley
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It is our AIM to be a leader in improving and providing safe, quality, family centered Perinatal Care in our communities and region. We will utilize reliable design, teamwork, and patient partnership combined with National Standards of Care and Evidence Based Practice.
Goals:
Improve reliability of documentation in the Augmentation Bundle in order to consistently have 95% compliance within 6 months (4/1/2013) Implement Advanced Induction Bundles by 4/1/2013 Continue monitoring 39 week Initiative and Induction to C/S rate to evaluate
Measure and monitor infant and maternal outcomes with the implementation of Baby Friendly (beginning 10/1/2012 and ongoing) Further address Harm Analysis: Incidence of Episiotomy, 3rd / 4th degree lacerations, and infant categories throughout the year.
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PERINATAL IMPROVEMENT PROJECT OUR PROGRESS
Significant sustained improvement in Elective Induction Bundle from 71% compliance in 2010- 2011 to 97% in 2012 Pitocin Augmentation Bundle compliance improved from 59% in 2010-2011 to 91% in 2012 Improvement in Operative Vaginal Delivery Bundle compliance from 63% in 2011 to 90% in 2012
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Our Progress – continued
GHS is among the first hospitals in South Carolina to actively address the National Initiative to Reduce/Eliminate Elective Deliveries Prior to 39 Weeks. Our rate in 2011 was 4-5% but in 2012 it was less than 1%. Analysis of C/Section following Induction of Labor
rate for 2012 was 18% compared to a national average of 53%.
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7 41% 33% 21% 83% 100% 98% 96% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Nov 2009 Dec 2009 Jan 2010 Dec 2011 Jan 2012 July 2012 Dec 2012
Induction Compliance
GOAL: 95%
56% 50% 67% 83% 100% 89% 85% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Nov 2009 Dec 2009 Jan 2010 Dec 2011 Jan 2012 July 2012 Dec 2012
Augmentation Compliance
Goal: 95% 8
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67% 83% 33% 100% 87% 93% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Jan 2011 Feb 2011 Mar 2011 Dec 2011 July 2012 Dec 2012
Operative Vaginal Delivery/Vacuum Bundle
Goal: 95%
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4.0% 7.0% 2.0% 2.0% 2.0% 2.0% 0.0% 0.0% 0.0% 1.0% 2.0% 0.0% 2.0% 0.0% 0.0% 0.0% 0.0% 0.0% 3.0% 5.0% 0.0% 0.0% 2.0% 2.0% 0.0% 0.0% 0.0%
0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% Jul-12 Aug- 12 Sep- 12 Oct-12 Nov- 12 Dec- 12 Jan-13 Feb- 13 Mar- 13 Apr-13 May- 13 Jun-13 Jul-13 Aug- 13 Sep- 13 Oct-13 Nov- 13 Dec- 13
3rd & 4th Degree Laceration Totals
% 3rd & 4th Degree Lac. % with Oper. Vag. Del. % with Spont. Vag. Del.
With Operative Vaginal Delivery National Average: 15% 3rd & 4th Degree Laceration National Average: 5.0% With Spontaneous Vaginal Delivery National Average: 3.0%
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7% 15% 6% 9% 14% 30% 27% 24% 16% 8% 50% 14% 27% 7% 17% 25% 17% 8% 15% 16% 13% 17% 13% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Cesarean Sections From Inductions
National Average: 53% 12
11% 13% 21% 13% 17% 17% 14% 16% 17% 29% 29% 34% 30% 32% 36% 23% 28% 29%
0% 5% 10% 15% 20% 25% 30% 35% 40% 4th Qtr 2010 1st Qtr 2011 2nd Qtr 2011 3rd Qtr 2011 4th Qtr 2011 1st Qtr 2012 2nd Qtr 2012 3rd Qtr 2012 4th Qtr 2012
C-SECTION QUARTERLY TOTALS GHS
Primary Rate C-Section Rate
C-Section Rate National Average: 34% Primary Rate National Average: 21% 13
620 396 420 405 100 200 300 400 500 600 700 Sep-09 Sep-10 Sep-11 Sep-12
Number of Level II Nursery Days
GHS Level II Nursery Days
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0.04 0.01 0.04 0.05 0.05 0.01 0.02 0.02 0.02 0.02 0.02 0.01 0.37 0.25 0.09 0.33 0.38 0.08 0.14 0.22 0.06 0.14 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 Jan- 11 Feb- 11 Mar- 11 Apr- 11 May- 11 Jun- 11 Jul- 11 Aug- 11 Sep- 11 Oct- 11 Nov- 11 Dec- 11 Jan- 12 Feb- 12 Mar- 12 Apr- 12 May- 12 Jun- 12 Jul- 12 Aug- 12 Sep- 12 Oct- 12 Nov- 12 Dec- 12
2011 - 2012 39 Week Initiative
% of Total Non-Comp. Deliveries % Non-Compliant C/S % Non-Compliant Vag. Ind.
2011 GOAL: 5% 2012 GOAL: 0%
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2% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 4% 0% 14% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 5% 0% 0% 0% 0% 0% 0% 0% 4% 0% 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50%
Jan- 12 Feb- 12 Mar- 12 Apr- 12 May- 12 Jun- 12 Jul- 12 Aug- 12 Sep- 12 Oct- 12 Nov- 12 Dec- 12 Jan- 13 Feb- 13 Mar- 13 Apr- 13 May- 13 Jun- 13 Jul- 13 Aug- 13 Sep- 13 Oct- 13 Nov- 13 Dec- 13
2012 - 2013 39 Week Initiative
% of Total N/C Dev %N/C C/S % N/C Vag. Ind
2012 / 2013 WCH GOAL: 0% NATIONAL GOAL 5%
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Elective Induction Bundle- 71% in 2011 to 97% in 2012; Augmentation Bundle - 59% in 2011 to 85% in 2012
4-5% in 2011 to less than 1% in 2012
18%
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Lewis W. Blackman Patient Safety Champions Award
“Professionals whose passion has resulted in successful implementation of unit, practice and system-wide changes that promote patient safety and quality improvement”.
South Carolina Hospital Association 19
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Induction to C/Section rate
OB/GYN . Received March of Dimes grant for program.
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Evidence Based Resources:
American College of Obstetricians and Gynecologists: Practice Bulletins #9, 20, 17, 70, 76, 97, 106, 107, 433; Washington, DC: ACOG American Academy of Pediatrics & American College of Obstetricians and Gynecologist (2007). Guidelines for Perintal Care (6th ed). Elkgrove, IL. Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) Position Statements; Washington, DC Gabbe, S.G., Niebyl, J.R. & Simpson, J. L. (Eds) (2007). Obstetrics: Normal and Problem Pregnancies (5th ed). New York: Churchill Livingston Murray, M. (2007) Antepartal and Intrapartal Fetal Monitoring (3rd ed): New York: Springer Simpson, E.R. & Creehan, P.A. (2009) Perinatal Nursing (3rd ed), New York: Lippincott 22
Total number of deliveries= 3657 Overall Cesarean Section rate= 28.7% Primary C/S rate= 15.4% Repeat C/S rate= 13.3%
room, 8 bed high risk/ante partum, 39 bed postpartum/GYN
clientele
Top 3 Learning's
1. We are not always documenting the interventions with FHR decelerations 2. Oxytocin is not being decreased in 2nd stage of labor 3. SVE is not always being documented within 2 hours
4. We need to add FHR Categories to our computer documentation
Top 3 Surprises
1. We are not consistent as a unit in diagnosing when labor starts /refer to ACOG’s definition of labor
Elective deliveries less than 39 weeks gestation 37 to 38.6 weeks gestation
0% 2% 4% 6% 8% 10% 12% 14% May‐09 May‐10 Sep‐10 Oct‐10 Nov‐10 Dec‐10 Jan‐11 Feb‐11 Mar‐11 April‐11 May‐11 Jun‐11 Jul‐11 Aug‐11 Sep‐11 Oct‐11 Nov‐11 Dec‐11 Jan‐12 Feb‐12 Mar‐12 Apr‐12 May‐12 Jun‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13
% Elective Deliveries Numerator = Singleton Patients with elective deliveries completed Denominator= Patients delivering newborns with ≥ 37 and < 39 weeks of gestation
C/S Scheduling Process in OP OR Elective Delivery Scheduling Process *May 2007 Patient & Staff Education started
*Dec 2009 Policy *Jan 2010 AHRQ Patient Education brochure
Hard Stop 6/25/2013 Emory University Hospital Midtown Labor & Delivery GHA HEN EED participation 2012‐2013 Quality Enhancement Committee support
0% 5% 10% 15% 20% 25% 30% 35% 40% Jan‐12 Feb‐12 Mar‐12 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13
% Nulliparous Cesarean Sections Numerator= All nulliparous patients with Cesarean Sections Denominator= Nulliparous patients delivered
singleton newborn in vertex presentation ≥ 37 weeks gestation.
6/25/2013 Second Stage labor down bundle implemented Laboring down used by some providers since 2009
deliveries less than 39 weeks gestation
clinical trial completed. Practice changes being implemented
Baby Friendly Scorecard
EUHM Women's Health
Target
FY13 FY13 FY13 FY13
YTD Jan Feb March April
Establish Breastfeeding Policy (Step 1)
80% 90% 90% 100% 100% 100%
Staff Education on Policy (Step 2)
80% 24% 27% 36% 38% 38%
Prenatal Instructions Completed (Step 3)
80% 64% 66% 50% 44% 56%
Skin to Skin Contact after Birth (Step 4)
80% 17% 7% 27% 18% 18%
Breastfeeding Assistance Offered for Mothers (Step 5)
80% 48% 68% 49% 73% 59%
Breastfeeding Exclusivity (Step 6 / TJC Core Measure)
Monitor 27% 23% 31% 40% 30%
Rooming In for 23 of 24 Hours (Step 7)
80% 31% 35% 40% 40% 36%
Feeding on Demand Education Given to Mothers (Step 8)
80% 48% 49% 38% 49% 46%
No Pacifiers or Artificial Nipples (Step 9)
80%
Breastfeeding Support Group Recommended (Step 10)
80% 50% 80% 80% 82% 73%
By July 1, 2013, The Emory University Hospital Midtown Women’s Health Services will:
39 weeks
procedure, documentation checklist, and audit tool.
ready, room ready, information communicated etc)
documentation for EBL and Lacerations