Culture Change Implementation Guide

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Culture Change Implementation Guide

CMQCC developed the Labor Culture and Attitudes Survey to explore the very large variation in hospital and physician cesarean section rates that are not explained by patient characteristics or practice. To make the results actionable, we have identified and linked culture themes with interventions. Culture concerns the ‘big’ picture on an L&D unit. There are several primary interventions that have been useful for ALL L&D units: collaborate, communicate and celebrate.

• Collaborate: create a philosophy of staff actively helping each other out

• Communicate as a care team: establish open and transparent discussions about patient care issues

• Communicate as a unit: disseminate quality improvement (QI) team progress regularly

• Celebrate and acknowledge: share individual and team successes publicly and often

• Consider opportunities for alternative communication methodologies: keep team members engaged

Culture change can be addressed through small actionable steps involving communication, shared decision making, action, reflection, and celebration.

So where to start? The survey responses have been organized into seven (7) overarching themes:

1. Estimation of birth risks 5. Cesarean Case Reviews

2. Personal Concerns 6. Assessment of Unit Practices

3. Maternal Empowerment 7. Support for Best Practices

4. Maternal Preparation

The report format allows you to identify the themes with low scores as compared to Top Quartile hospitals. Response rates above 30% provide the most representative views of your unit’s culture; conversely, low response rates to the survey should be interpreted cautiously. The best use of the survey results for facilities with only a handful of responses is to study how top quartile hospitals answered and then use as a discussion guide with your staff. The Guide connects each theme to Actions Steps and then for each Action Step, it links onwards to specific resources to accomplish the step.

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Theme 1: Estimation of Birth Risks

Theme 1: Estimation of Birth Risks Question: Action Resources How strong is your agreement with approaches for reducing cesarean birth rate around the following:

• Cesarean birth is safer for the baby than vaginal birth

• Provide inter-professional and inter-disciplinary education

• CMQCC Resource: Risk Considerations

for Primary Cesarean

• CMQCC Toolkit Background. Pg. 19-24

• YouTube: Patient Story: Kristen Terlizzi, (4:20)

• Review your hospital’s NTSV Primary Cesarean rate and Unexpected Newborn Complications (UNC) rates in the Maternal Data Center

• CMQCC Maternal Data Center (your individual hospital log in page)

• Cesarean birth is as safe as vaginal birth for women

• Provide inter-professional and inter-disciplinary education

• CMQCC Toolkit Background, pg. 19-24

• YouTube: Patient Story: Kristen Terlizzi

https://www.cmqcc.org/resource/guidelines-risk-considerations-primary-cesarean-delivery


https://www.cmqcc.org/VBirthToolkitResource

https://www.youtube.com/watch?v=RMnQZUqQhjU

https://datacenter.cmqcc.org/sign_in



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Theme 2: Personal Concerns

Theme 2: Personal Concerns Question: Action Resources These questions explore how you feel about this issue:

• If my partner or I were pregnant with an apparently normal pregnancy, I would prefer an elective cesarean birth instead of a vaginal birth

• Develop and conduct inter-professional and inter-disciplinary education around the short- and long-term risks of cesareans


• YouTube: Patient Story: Kristen Terlizzi • CMQCC Resource: Risk Considerations

for Primary Cesarean

• I fear vaginal birth for myself or my partner as it may compromise sexual functioning



• CMQCC Resource: Risk Considerations for Primary Cesarean

• I fear vaginal birth for myself or my partner as it may lead to urinary or fecal incontinence or pelvic floor injury




• Because of the unpredictability of vaginal birth, I would prefer a scheduled cesarean section birth for myself or my partner


• Patient/Family Support Bundle, Council on Patient Safety in Women’s Health Care


• YouTube: Patient Story: Kristen Terlizzi











http://safehealthcareforeverywoman.org/wp-content/uploads/2017/11/Support-after-Severe-Maternal-Event-Bundle.pdf




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Theme 3: Maternal Empowerment Theme 3: Maternal Empowerment Question: Action Resources How strong is your agreement with approaches for reducing cesarean birth rate around the following:

• Having a vaginal birth is more empowering experience than delivery by cesarean birth

• Encourage patients to participate in childbirth preparation that matches the learning style of the learner (e.g. online courses, printed information, or traditional classroom style) and align your practice and unit culture with evidence-based childbirth practices

• ACOG Committee Opinion 687, Approaches to Limit Intervention During Labor and Birth

• CMQCC Toolkit Appendix D, Tools by Topic: Childbirth Education - For Patients, Part 1, Strategy 1, pg 1. (pg 88 of Toolkit)

• Lamaze.com online courses

• Direct all patients to www.mybirthmatters.org., a consumer education tool to help women ask the right questions about cesarean and to find tools and information to support informed decision making (available mid-June 2018)

• Develop basic childbirth education printed materials for patients


• CMQCC Toolkit Appendix D, Tools by Topic: Childbirth Education - For Patients, Part 1, Strategy 1, pg 1. (pg. 88 of Toolkit)

• Research online courses for applicable content


• CMQCC Toolkit Appendix D, Tools by Topic: Childbirth Education - For Patients, Part 1, Strategy 1, pg 1. (pg. 88 of Toolkit)

(Theme 3 continued on next page)

https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth




https://www.cmqcc.org/resource/appendix-d-tools-arranged-topic



https://www.lamaze.org/ParentOnlineEducation

http://www.mybirthmatters.org/









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• An important determinant of a successful vaginal birth is the woman’s own confidence in her ability to give birth

• Integrate shared decision making on your unit between patients, providers and nurse through all staff training to empower more informed choices that incorporate patients’ values and desires

• CMQCC Toolkit Table 3: Key Strategies for Improving the Culture of Care, Strategy #2, Improve Communication through Shared Decision Making at Critical Points in Care (pg. 28 of Toolkit)

• CMQCC Toolkit Table 4: Patient Decision Points that Impact Risk of Cesarean (pg. 31 of Toolkit)

• CMQCC Toolkit Appendix D, Tools by Topic: Shared Decision Making - For Providers and Hospitals, Part 1, Strategy

2, pg. 7. (pg. 94 of Toolkit)

• AHRQ Toolkit for Education on Shared Decision Making

• CMQCC Toolkit Appendix E: Birth Preferences Guide (pg. 95 of Toolkit)


• Encourage women, at the point of entry into care and especially at time of entry into labor care, to tell staff and nurses of their desires and plans for labor and birth


• Lamaze.com online courses • BirthTools.org • CMQCC Toolkit Appendix E: Birth

Preferences Guide (pg. 95 of Toolkit)

• Implement consistent use of the Birth Preferences Guide during prenatal care as a model for Shared Decision Making


• Consider CenteringPregnancy model of prenatal care, a group prenatal care model that incorporates comprehensive childbirth education into every visit and has excellent perinatal outcomes

• CMQCC Toolkit, top paragraph: CenteringPregnancy information, pg. 30

• UCSF’s approach to incorporating CenteringPregnancy into practice model

• Centeringhealthcare.org (Theme 3 continued on next page)












https://www.ahrq.gov/professionals/education/curriculum-tools/shareddecisionmaking/index.html


https://www.cmqcc.org/resource/appendix-e-cmqcc-birth-preferences-guide





http://birthtools.org/







http://whrc.ucsf.edu/whrc/gex/cp.html

http://whrc.ucsf.edu/whrc/gex/cp.html

https://www.centeringhealthcare.org/

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• Women who deliver their baby by cesarean section miss an important life experience

• Nursing empowerment of patient through labor support, improved coping strategies, and shared decision making

• CMQCC Toolkit Appendix D, Tools by Topic: Labor Support and Support Infastructure - For Providers and Hospitals, Part 2, Strategy 3, pg. 4. (pg. 91 of Toolkit)

• CMQCC Toolkit Appendix D, Tools by Topic: Pain Assessment and Management - For Providers and Hospitals, Part 2, Strategy 3, pg. 6. (pg. 93 of Toolkit)

• CMQCC Toolkit Appendix D, Tools by Topic: Shared Decision Making - For Providers and Hospitals,Part 1, Strategy 2, pg. 7. (pg. 94 of Toolkit)


• BirthTools.org

• CMQCC Toolkit Appendix F: Coping with Labor Algorithm (pg. 98 of Toolkit)














http://www.birthtools.org/

https://www.cmqcc.org/resource/appendix-f-coping-labor-algorithm


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Theme 4: Maternal Preparation

Shared decision making is a collaborative process that begins in the prenatal period between the obstetric provider and the patient. The concepts of shared decision making involve the patient becoming an active participant in the planning for the impending birth based on available best practice evidence presented by the provider and the preferences and beliefs of the patient. “The ACOG committee Opinion 492 Effective Patient Physician Communication states that shared decision making promotes patient engagement, treatment adherence and improved outcomes while reducing risk” (CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans). The SHARE model utilized to define the shared decision making concepts can be found on pg 30 in the above toolkit. Nursing has an integral responsibility to foster this shared decision making process by encouraging the obstetric patient to share her birth preferences as agreed upon with her provider during the prenatal period. Documentation of these preferences in the medical record allows all members of the health care team to understand and support the plan of care as designed by the patient and her provider.

Nursing responsibilities include developing a nursing care plan and labor support that embraces the patient’s preferences. Labor support includes providing education and information to make informed decisions, emotional support that encourages self-confidence during labor, ensuring all comfort measures are providedaccording to each woman’s preference. Successful labor support also involves the agreement of the health care team to allow for the presence of external support systems, including family members or doulas, who can provide continuous bedside assistance that nursing responsibilities sometimes prohibit. Ongoing and systematic education for the patient and family regarding changes in maternal or fetal condition, allows the patient to be informed and make changes to the birth plan as appropriate

Theme 4: Maternal Preparation Question: Action Resources How strongly do you agree with the following statement:

• Most of my patients have sufficient knowledge about vaginal and cesarean birth to make informed choices

• Reinvest in childbirth preparation/patient education

• Consumer Reports Videos (available soon!)


• CMQCC Toolkit, Key Strategies for Supporting Intended Vaginal Birth, pg. 14



(Theme 4 continued next page)










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• Encourage patients to participate in childbirth education



• Lamaze.com online courses • BirthTools.org

• Evaluate and revise as needed, available education resources for patients


• CMQCC Toolkit Appendix D, Tools by Topic: Childbirth Education – For Patients Part 1, Strategy 1, pg 1. (pg. 88 of Toolkit)

• Train staff in shared decision-making


• CMQCC Toolkit Table 4: Improve Communication through Shared Decision Making at Critical Points in Care (pg. 30 of Toolkit)


• CMQCC Toolkit Appendix D, Tools by Topic: Shared Decision Making - For Providers and Hospitals – Part 1, Strategy 2, pg. 7. (pg. 94 of Toolkit)

• Increase communication between physicians and nurses


• Increase patient engagement with direct feedback to staff







http://www.birthtools.org/





















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• Prenatal involvement of provider and patient to develop a birth plan and modeling of shared decision making



• CMQCC Toolkit Appendix D, Tools by Topic: Labor Support and Support Infastructure - For Providers and Hospitals – Part 2, Strategy 3, pg. 4. (pg. 91 of Toolkit)

• CMQCC Toolkit: Improve the Support Infrastructure and Supportive Care During Labor, pg. 44-45


• CMQCC Toolkit Appendix D, Tools by Topic: Labor Support and Support Infastructure - For Patients, Part 2, Strategy 3, pg. 4. (pg. 91 of Toolkit)

• CMQCC Toolkit Appendix D, Tools by Topic: Shared Decision Making – For Patients, Part 1, Strategy 2, pg. 7. (pg. 94 of Toolkit)

• CMQCC Toolkit Appendix T, pg. 15: Model Policies: Freedom of Movement in Labor (pg. 135 of Toolkit)

• CMQCC Toolkit Appendix T, pg. 23-26: Pain Management Policy (pg. 143-146 of Toolkit)

• Nursing empowerment of patient through labor support and coping strategies, shared mental modeling and shared decision-making

• CMQCC Toolkit Appendix D, Tools by Topic: Shared Decision Making - For Providers and Hospitals, Part 1, Strategy 2, pg. 7. (pg. 94 of Toolkit)


• CMQCC Toolkit Appendix D, Tools by Topic: Labor Support and Support Infastructure - For Patients, Part 2, Strategy 3, pg. 5. (pg. 92 of Toolkit)

• CMQCC Toolkit: Improve the Support Infrastructure and Supportive Care During Labor, pg. 44-45


























https://www.cmqcc.org/resource/appendix-t-model-policies-fetal-surveillance-freedom-movement-induction-labor-pain



















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• Nursing empowerment of patient through labor support and coping strategies, shared mental modeling and shared decision-making


• CMQCC Toolkit Appendix T, pg. 15: Model Policies Freedom of Movement in Labor (pg. 135 of Toolkit)

• CMQCC Toolkit Appendix T, pg. 23-26: Pain Management Policy (pg. 143-146 of Toolkit)








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Theme 5: Cesarean Case Reviews Theme 5: Cesarean Case Reviews Question:

Action

Resources How strong is your agreement with the following approaches for reducing cesarean birth rate:

• Provide education and reinforcement of ACOG/SMFM guidelines

• Presentation of guidelines at department meetings, e-mail, bulletin boards, etc.


• ACOG/SMFM Safe Prevention of Primary Cesarean Delivery

• CMQCC Toolkit Appendix A: Summary of Recommendations for the Safe Prevention of Primary Cesarean Delivery (pg. 80 of Toolkit)

• Printed guidelines readily accessible – laminated cards, badge tags, etc.

• Badge Card Example




• CMQCC Toolkit Appendix K: Labor Dystocia Checklist (pg. 111 of Toolkit)

• Pre-cesarean birth peer review of all elective cesareans

• Institute a cesarean section scheduling form/process

• CMQCC Toolkit Appendix T Model Policies, pg. 16-19: Elective Cesarean

Policy Example, (pg. 136-139 of Toolkit)

• CMQCC Toolkit Appendix T Model Policies, pg. 20: Scheduling Form Example, (pg. 140 of Toolkit)

• CMQCC Toolkit Appendix I: Elective Cesarean (Non-Medically Indicated) Consent Example (pg. 109 of Toolkit)

• The Cesarean Option Slides/Brochure

• Create a policy including criteria for elective cesareans

• CMQCC Toolkit, Appendix I: Elective Cesarean (Non-Medically Indicated) Consent Example (pg. 109 of Toolkit)

• CMQCC Toolkit Appendix T Model Policies, pg. 16-19: Elective Cesarean Policy Example (pg. 136-139 of Toolkit)





https://www.acog.org/Clinical-Guidance-and-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery


https://www.cmqcc.org/resource/appendix-summary-obstetric-care-consensus-safe-prevention-primary-cesarean-delivery



https://share.cmqcc.org/t/labor-progress-badge-cards/421






https://www.cmqcc.org/resource/appendix-k-labor-dystocia-checklist











https://share.cmqcc.org/t/the-cesarean-option-cedars-sinai-course/298

https://www.cmqcc.org/resource/appendix-i-informed-consent-elective-non-medically-indicated-cesarean-birth






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• Require an elective cesarean consent form signed prior to admission

• CMQCC Toolkit, Appendix I: Elective Cesarean (Non-Medically Indicated) Consent Example (pg. 109 of Toolkit)

• Provide formalized education content to patients

• The Cesarean Option Slides/Brochure

• Internal sharing of provider cesarean rates

• Institute internal sharing of provider cesarean rates

• CMQCC Implementation Guide: Guidelines for understanding and un-blinding provider-level NTSV cesarean rates, pg. 29

• CMQCC Toolkit Table 32: Key Strategies for using Data to Drive Reductions in Cesareans, pg. 70

• See “Provider-Level Reports” in Maternal Data Center under “Support” tab

• Engage hospital administration by routinely sharing rates



• Review Provider-Level Reports in MDC to help leadership, physicians and staff be aware of individual and hospital-wide NTSV rates and trends


• Share PDF reports generated in MDC

• Departmental peer review of all cesarean births not meeting ACOG/SMFM guidelines

• Pre-cesarean Time Out before patient is taken to the OR – review of labor dystocia checklist

• CMQCC Toolkit Appendix J: Pre-cesarean Checklist for Labor Dystocia or Failed Induction (pg. 110 of Toolkit)

• CMQCC Toolkit Appendix K: Dystocia Checklist Example (pg. 111 of Toolkit)

• Institute departmental peer review of all cesarean births not meeting ACOG/SMSM Guidelines









https://share.cmqcc.org/t/the-cesarean-option-cedars-sinai-course/298

https://www.cmqcc.org/resource/implementation-guide-toolkit-support-vaginal-birth-and-reduce-primary-cesareans

















https://www.cmqcc.org/resource/appendix-j-pre-cesarean-checklist-labor-dystocia-or-failed-induction















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Theme 6: Assessment of Unit Practices

The concept, theory, and attributes of high-reliability organizations (those that operate in highly complex and hazardous technological systems essentially without mistakes over long periods of time) has been applied to clinical perinatal practice (Knox, Simpson, & Garite, 1999). The description of high reliability perinatal units was based on observation differentiating units that produced more or less harm to patients using professional liability claims as a proxy for perinatal injury. The following attributes of low-risk, harm-free, highly reliable obstetric (OB) units were identified:” (Simpson & Creehan, AWOHNN’s Perinatal Nursing).

• Safety is the core concept of the organizational culture. Safety is seen as everyone’s responsibility

• Safety is the number one priority and takes precedence over issues of convenience or financial considerations

• Potential risks and benefits to patients are considered prior to any decision-making process

• Every team member has the obligation to speak up when there are concerns for patient safety

• Every team members input is of equal value and respectful communication is an expectation

• Transparency is routine and formulates the assessment, planning and implementation of process improvement

• Case debriefing are a routine practice to identify process improvement opportunities and to prepare for unexpected outcomes

• Situational awareness is rehearsed utilizing simulation training to foster optimal team communication and refine practice skills

• Professional behavior is practiced from the top on down

• Practice is based on relevant evidence-based policies and procedures

When health team members collaborate together, patient outcomes and satisfaction can be improved. “Disseminate and use the best available evidence, including individual and hospital-level data, to guide practice patterns.” (Lawrence et al., 2012).

• Successful implementation strategies for evidence-based guidelines include:

• Grand rounds

• Education classes/conferences

• Simulation training

• Competency fairs, skills training

• Development of a data and communication strategy. (Bingham & Main, Common Barrier to Implementation of Evidence-based Clinical Guidelines and Participation in Quality Improvement Projects)


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Theme 6: Assessment of Unit Practices Question: Action Resources Specific to your own hospital’s environment and practices, how strong is your agreement with the following statements:

• The culture of my L&D unit supports vaginal birth and discourages overuse of cesareans

• Be deliberate about inclusion of physicians and nurses in COMBINED education and quality improvement activities


• CMQCC Resource: Recognition of Successful Practices on Labor and Delivery

• Unblinded NTSV rates at staff meetings

• CMQCC Implementation Guide: Guidelines for understanding and un-blinding provider-level NTSV cesarean rates, pg.29

• Utilize an NTSV Bulletin Board on the units recognizing rates and ‘saves’


• Recognize providers (MD, CNM, RN) with low NTSV rates and highlight their practices


• There are too many cesarean births performed in my L&D unit

• Joint sharing of cesarean section rates




• Share outcomes on unit • CMQCC Implementation Guide: Guidelines for understanding and un-blinding provider-level NTSV cesarean rates, pg. 29








https://www.cmqcc.org/resource/guidelines-recognition-successful-practices
































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• Staff on my L&D unit support the laboring woman’s informed choices, values and preferences

• Regular meeting time to reflect on current practices and practice changes (RN and MD)



• Educate all staff and nurses on shared decision making



• Develop mechanism to obtain feedback from patient about the care they received during labor

• In my L&D unit, provider work flow considerations (i.e., need to be back at the office or at home affect medical interventions in labor

• Consider Hospitalists or other cross-coverage programs

• In my hospital, doulas who accompany women in labor are welcomed into the labor support team

• Consider hospital-based doula programs and/or encourage patients to utilize personal doulas in labor

• CMQCC Webinar: UCSD Volunteer Doula Program: A Model for Integrating Childbirth Assistants…

• CMQCC Webinar: Doulas: Including Practice into Hospital Care

• CMQCC Toolkit, Supportive Care from Doulas, pg. 40

• CMQCC Toolkit, Strategies to Encourage the Collaborative Use of Doulas, pg. 46

• Doulas, Utilization as Labor Support Policy Sample (courtesy Memorial Care)

• CMQCC Toolkit Appendix D, Tools by Topic: Shared Decision Making - For Providers and Hospitals, Part 2, Strategy 4, pg 7. (pg. 94 of Toolkit)














https://www.youtube.com/watch?v=3jUY99l4IC8&feature=youtu.be



https://www.youtube.com/watch?v=swPNiyv1JEM&feature=youtu.be






https://share.cmqcc.org/t/doula-and-labor-support-policy-sample/395






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• Improve education for staff and nurses about the benefits of doulas to improve the working relationships during labor


• CMQCC Webinar: Doulas: Including Practice into Hospital Care


• CMQCC Toolkit, Strategies to Encourage the Collaborative Use of Doulas, pg. 46



• Integrate doulas into the birth care team

• CMQCC Toolkit, Strategies to Encourage the Collaborative use of Doulas, pg. 46



• Improve teamwork, communication, and collegial rapport between nurses and doulas in order to promote safe, patient-centered care and continuous labor support


• Develop unit guidelines to foster the delineation of roles and expectations


• Our L&D staff are skilled at providing effective labor coping strategies

• Training in labor support and coping strategies


• CMQCC Toolkit, Improve the Support Infrastructure and Supportive Care During Labor, pg. 44-45

• CMCC Toolkit Appendix F: Coping with Labor Algorithm (pg. 98 of Toolkit)


• CMQCC Toolkit Appendix T, Model Policies pg. 15: Freedom of Movement in Labor, (pg. 135 of Toolkit)













































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• CMQCC Toolkit Appendix T pg. 16-19: Pain Management Policy (pg. 136-139 of Toolkit)

• Improve nursing knowledge and skill in supportive care techniques that promote comfort and coping


• Improve unit infrastructure and availability of support tools




• Improve assessment of pain and coping


• On my L&D unit, labor nurses are encouraged and supported to spend the majority of their time in the room with the patient throughout her labor

• Remove staffing and documentation barriers to supportive bedside care

• CMQCC Toolkit, Remove Staffing and Documentation Barriers to Supportive Bedside Care, pg. 45

• AWHONN 2010 Nurse Staffing Guidelines




















http://www.awhonn.org/?PerinatalStaffing

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Theme 7: Support for Best Practices “One of the Healthy People 2020 goals is to increase the proportion of women who attend prenatal childbirth classes. Women who are well prepared for labor and birth are better situated to engage with providers in conversations about care, create realistic and informed plans, and to share in decision making at points in time when the greatest impact on maternal and infant outcomes is most likely” (CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans). It is incumbent on hospital leadership to review availability and accessibility to childbirth preparation classes and develop a plan to address any identified barriers. The barriers are generally multifactorial and can be categorized by financial obligation, time commitment or transportation issues. It is crucial to coordinate the existing childbirth preparation curriculum with the current clinical practice philosophies on the labor and delivery unit. Attendees should understand what to expect when they arrive on the unit for the actual delivery after attending a childbirth education event. Harnessing the expertise of the labor and delivery nurses to present these educational offerings can often be a method that results in informed patients and begins the process of building trusting relationships between the patient and the hospital.

Consideration should be given to providing these educational offerings using a variety of methodologies to meet the complex needs of the population served. The development or utilization of online education programs, phone apps of hard copy handouts are all options that can be made available in addition to general classroom sessions. Patient learning preferences should be taken into account when designing a childbirth education program including the cultural needs of the clientele from each facility. Options for assisting with the development or redesign of a childbirth education program can be found on pg, 29 of the toolkit.

Theme 7: Support for Best Practices Action Resources Agreement with approaches for reducing cesarean birth rate around the following:

• Changing medical and nursing education to encourage more positive attitudes towards vaginal birth?

• Institute inter-professional and inter-disciplinary education

• CMQCC Toolkit Improvement Strategies, Implement Institutional Policies that Uphold Best Practices…, pg. 41

• CMQCC Webinar: Intermittent Fetal Monitoring: A Strategy for Reducing Primary Cesareans

• CMQCC Webinar: Induction of Labor, Risks, Benefits and Techniques for Increasing Success

• CMQCC Slides: Induction of Labor, Risks, Benefits and Techniques for Increasing Success






https://www.youtube.com/watch?v=t_L3NdYz05I&feature=youtu.be




https://www.youtube.com/watch?v=Ju21nQoV7zE&feature=youtu.be




https://www.cmqcc.org/resource/induction-labor-risk-benefits-and-techniques-increasing-success








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• Changing medical and nursing education to encourage more positive attitudes towards vaginal birth?

• CMQCC Resource: Examine the Outcomes of Labor Induction in your Facility


• Evaluate and update childbirth education


• CMQCC Toolkit Appendix D - Tools by Topic: Childbirth Education – For Patients Part 1, Strategy 1, pg. 1. (pg. 88 of Toolkit)


• Direct all patients to www.mybirthmatters.org., a consumer education tool to help women ask the right questions about cesarean and to find tools and information to support informed decision making

• Eliminate routine continuous electronic fetal monitoring (EFM) for low risk patients

• CMQCC Webinar: Intermittent Fetal Monitoring: A Strategy for Reducing Primary Cesareans

• Provide more doula services


• CMQCC Webinar: Doulas: Including practice into hospital care


• CMQCC Toolkit, Strategies to Encourage the Collaborative Use of Doulas,” pg. 46


• CMQCC Toolkit Appendix D, Tools by Topic: Shared Decision Making - For Providers and Hospital, Part 2, Strategy 4, pg. 7. (pg. 94 of Toolkit)


https://www.cmqcc.org/resource/guidelines-examine-outcomes-labor-induction-your-facility


































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• Examine the outcomes of elective inductions at your facility

• CMQCC Webinar: Induction of Labor, Risks, Benefits and Techniques for Increasing Success

• CMQCC Slides: Induction of Labor, Risks, Benefits and Techniques for Increasing Success

• CMQCC Toolkit Appendix D, Tools by Topic: Induction of Labor – For Providers and Hospitals, Part 3, Strategy 2, pg. 3. (pg. 90 of Toolkit)

• CMQCC Toolkit Appendix D, Tools by Topic: Oxytocin -For Providers and Hospitals – Part 3, Strategy 2, pg. 5. (pg. 92 of Toolkit)

• CMQCC Resource: Examine the Outcomes of Labor Induction in your Facility

Providing more midwifery services?

• Education for physicians, staff, and leadership on the outcomes data and value of midwifery care

• See Midwife.org Resource: Midwifery: Evidence-Based Practice

• See ProPublica Resource: A Larger Role for Midwifery Could Improve Deficient U.S. Care

• Pacific Business Group on Health Resource: How to Successfully Integrate Midwives into Your Practice

• Pacific Business Group on Health Resource: Integrating CNMs: Financial Considerations for Developing a Business Plan

• Integrate midwifery services into current practice model

• See Miwife.org Resource: Midwifery: Evidence-Based Practice

• See Propublica Resource: A Larger Role for Midwifery Could Improve Deficient U.S. Care

• Implementing a program that supports early labor at home?

• Improving patient preparation for labor and birth

• CMQCC Toolkit, Appendix D: Delay of Latent (Early) Labor Admission – For Patients, Part 2, Strategy 2, pg. 1. (pg. 88 of Toolkit)

• CMQCC Webinar: Latent Labor Management by Beth Stephens-Hennessy

• CMQCC Toolkit Key Strategy #2, for Early Labor Supportive Care Policies and Active Labor Admissions, pg. 42





















http://www.midwife.org/acnm/files/cclibraryfiles/filename/000000004184/midwifery-evidence-based-practice-march-2013.pdf


https://www.propublica.org/article/midwives-study-maternal-neonatal-care



http://www.pbgh.org/midwifery#Making%20a%20business%20case%20for%20midwifery

http://www.pbgh.org/midwifery#Making%20a%20business%20case%20for%20midwifery

http://www.pbgh.org/storage/documents/Maternity/Financial_Considerations_for_Midwifery_Business_Plan.pdf











https://www.youtube.com/watch?v=kZfVHBIIkoM&feature=youtu.be












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• Implementing a program that supports early labor at home?

• Provide alternatives to admission for women in early labor

• CMQCC Toolkit, Appendix D: Delay of Latent (Early) Labor Admission – For Providers and Hospitals, Part 2, Strategy 2, pg. 1 (pg. 88 of Toolkit)


• Implement a program that supports early labor at home


• Reinforce education around defining active phase labor as ‘6 is the new 4’ for physicians, nurses, and patients



• Providing more direct (in-room) nursing time with laboring women?

• Remove staffing and documentation barriers to supportive bedside care

• CMQCC Toolkit Remove Staffing and Documentation Barriers to Supportive Bedside Care, pg. 45

• AWHONN 2010 Nurse Staffing Guidelines

References:

1. ACOG Committee Opinion Number 492, May 2011, effective Patient-Physician Communicaiton. ACOG Number 492

2. Knox GE, Simpson KR, Garite, TJ et al. High reliability perinatal units: an approach to the prevention of patient injury and medical malpractice claims. https://www.ncbi.nlm.nih.gov/pubmed/10538014

3. Simpson & Creehan, AWOHNN’s Perinatal Nursing 4. Lawrence HC, Copel JA, O’Keeffe DF, Bradford WC, et al. (2012). Quality patient care in labor and delivery: A call

to action. American Journal of Obstetrics and Gynecology, 207(3), 147–148. doi:10.1016/j.ajog.2012.07.018

5. Bingham D, & Main EK. 2010. Effective implementation strategies and tactics for leading change on perinatal units. Journal of Perinatal and Neonatal Nursing, 24( 1), 32–42. B

5/2018





















/Users/vcape/Desktop/1.%09https:/www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Effective-Patient-Physician-Communication

/Users/vcape/Desktop/1.%09https:/www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Health-Care-for-Underserved-Women/Effective-Patient-Physician-Communication

https://www.ncbi.nlm.nih.gov/pubmed/10538014

Culture Change Implementation Guide

Documents

Transcript of Culture Change Implementation Guide