The Collaborative to Support Vaginal Birth and Reduce ...

The Collaborative to Support Vaginal Birth and Reduce Primary Cesareans:

Background

Funding for the development of this toolkit and collaboratives was

provided by the California Health Care Foundation

T r a n s f o r m i n g M a t e r n i t y C a r e

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans



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Large Variation of Total Cesarean Rate Among 251 California Hospitals: 2013

Range: 15.0—71.4%Median: 32.5%Mean: 32.8%

Hospitals2



Why should we care about CS rates?n Relentless Rise without Baby or Mother benefit

¨ 6% in early 70’s, 20% in mid 80’s, 33% in 2010¨ CP rates, neonatal seizures unchanged since 1980¨ Overall, no benefit for long-term urinary continence

n Increased maternal and neonatal morbidity¨ Impaired neonatal respiratory function, NICU admits¨ Affects maternal-infant interaction/Breast Feeding¨ Increased maternal PP infections, VTE, transfusions¨ Longer recovery, 2X PP re-admissions

n Prior CS can have major complications¨ Placenta previa and accreta (invasion deep into or thru the uterine wall)è hysterectomy or worse

¨ Uterine rupture;; abdominal adhesions 33



Which CS rate?n Total Cesarean Rate

n Includes repeats: very different issues and significant variation of hospital rates of women with prior CS

n Primary CS Rate and AHRQ TSV CS raten Better but major variation of hospital rates of nulliparity—the most important driver of different CS rates

n Term Singleton Vertex is bettter but still mixes nullips with multips

n NTSV Cesarean Raten Nulliparous, Term, Singleton, Vertexn Most commonly used

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A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans5

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Maldistribution of NulliparityAmong 251 California Hospitals: 2014

Range: 23.2—60.1%Median: 37.3%Mean: 39.4%

Hospital

Urban and teaching hospitals have significantly higher rates of nulliparity

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Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Section Rate:

Performance Measure

§Risk Stratified (“standard population”)o No further risk-adjustment needed (more discussion later)

§Widely adopted nationallyo ACOG: Task Force on Cesarean Section rates (2000)

o DHHS: Healthy Person 2010 and 2020

o NQF endorsed, Joint Commission Perinatal Core Measure (PC-02), LeapFrog, CMS e-measure

§ >15 years experience

§ National data and trends available

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NTSV Cesarean Section Rate

§ Simple concept§ Focuses on the main source of variation among

hospitals and the main driver for the rise in primary CS

§ Focuses on labor management—dystocia/FTP§ Focuses on the first birth, and therefore her entire

reproductive future (90/90 rule)§Accounts for the major portion of variation

among hospitals!

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A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans 8

NTSV CS Rate Among CA Hospitals: 2014(Nulliparous Term Singleton Vertex)

(Source: Linked OSHPD-‐Birth Certificate Data)

Range: 12%—70%Median: 25.3%Mean: 26.2%

40% of CA hospitals meet national target

Large Variation = Improvement Opportunity

National Target =23.9%

Hospitals





Collaborative Action : Collective Impact`

Multiple Leverage Points are much more effective than one or two alone

Reduction of Early

Elective Deliveries

Performance Measures/ Public

Reporting

Collected Evidence/ QI Tool Kit

Professional Leadership

Data-‐driven QI Initiative

Health Plans (multiple strategies)

Medicaid: Fee For Service and

Managed Care

Purchaser/ Employer

Engagement

Public Engagement

Direct Participation of Pregnant Women

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Collaborative Action : Collective Impact`


Reduction of Primary Cesareans


Reporting






Managed Care

Purchaser/ Employer

Engagement

Public Engagement






Active Collaborators for the Project-1

§ Professional Organizations:o ACOG, AWHONN, ACNM: state and national

§ Hospital Associationso Hospital Quality Institute and 3 regional associations

§ CA Dept. of Health (engagement at the Secretary level)o Dept. of Health Care Services (Medicaid)o Dept. of Public Health (MCAH, Vital Records)

§ Purchasers/Health Planso Pacific Business Group on Health, large employerso Cover California (ACA), Cal-PERS,o Blue Shield, Anthem Blue Cross

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§ Liability insurers / Risk Managemento Betao NorCalo Risk Management Assocation

§ Public groups:o CHARTo Dept. of Insuranceo Consumers Union

Active Collaborators for the Project-2

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Key National Foundation Materials

New National Guidelines for Defining Labor Abnormalities and

Management Options

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Public Released April 28, 2016

Download from:CMQCC.org

79 pages in 5 parts

Followed by:20 appendices(graphics, flow charts)338 references

Tr a n s f o r m i n g M a t e r n i t y C a r e

CMQCC QI Collaboratives

n Two rounds of participation¨First round kicks off May 20, Los Angeles¨Second round kicks off October

n Use the for collaborative work

n 65 hospitals, minimum ¨already at enrollment target¨Special targeting for higher rate/higher volume

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Collaborative Actions : Collective Impact

§ ACOG/AWHONN/ACNM Speaker’s Bureau o Support for grand rounds and “light” QI supporto All day training on 5/4/2016

§ Slide set for Speaker’s Bureau, Collaborative § Regional Labor Support Workshops for labor nurses

o Lead by CNMs, Doulas and Nurse educators

§ Special materials, actions and surveys oAttitude Toward Birth survey / discussion tool for

providers/nurses to address culture

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Collaborative Actions : Collective Impact

§ Public Reporting of NTSV CS ratesoCHARToDept of Insurance/UCSF/Consumers UnionoMedia coverage (LA, SD and Sacramento

§ Public EngagementoConsumers Uniono Social Media strategiesoPrenatal care handouts at Clinics/WIC

§ Purchasers/Health PlansoCover California contract that by 2019 hospitals need to

have an NTSV rate <24%

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We are “All In” for this Project


Reduction of Primary Cesareans


Reporting






Managed Care

Purchaser/ Employer

Engagement

Public Engagement


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Tr a n s f o r m i n g M a t e r n i t y C a r e

Key Project Staff

n Toolkit: ¨ Holly Smith, MPH, MSN, CNM¨ David Lagrew, MD¨ Nancy Peterson, MSN, PNNP¨ Elliott Main, MD

n Collaborative:¨ Julie Vasher, RN, DNP, CNS¨ Kim Werkmeister, RN, CPHQ¨ Elliott Main, MD¨ David Lagrew, MD

n Data Center Team: ¨ Anne Castles, MPH¨ Andrew Carpenter, BA¨ Amanda Woods, BS¨ Elliott Main, MD

n Analysis:¨ Jeff Gould, MD, MPH¨ Anisha Abreo, MPH¨ Elliott Main, MD¨ Julie Vasher, RN, DNP, CNS¨ Christine Morton, PhD

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Data-Dr iven Qual i tyImprovement:

Analysi s, Measures

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Measure Analysis: Identify “Drivers” of the CS Rate

What Drives Our Nulliparous Term Singleton Vertex (NTSV) CS Rate?

Screen Shot from the CMQCC Maternal Data Center





Hospital X

Comparison Rates for the 3 Major NTSV Drivers





Comparison Rates for the 3 Major NTSV Drivers

Hospital X





Measures for the CollaborativeCMQCC Maternal Data Center

§ Performance Measures (using admin data, and chart review to validate inductions)

o NTSV CS rateo CS for Labor Arrest/CPD among NTSV spont. laborso CS among induced NTSV births

§ Balancing Measures (using admin data)

o Unexpected Newborn Complications (UNC) among NTSV births

o 3rd & 4th Degree Lacerations among NTSV birthso 5min Apgar ≤5 among NTSV Births (test measure)

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Structure Measures§Checklist of recommended policies, protocols, processes and tools (close to the “Top Ten”)

§One time only measures, once implemented

§Check status of implementation quarterly until complete

Unknown Not done Complete





Structure Measures Checklist-1

q Has your hospital implemented updated labor protocols for a unit-standard approach for providing labor support, and freedom of movement?

q Has your hospital implemented standard criteria for diagnosis and treatment of labor dystocia, arrest disorders and failed induction?

q Has your hospital implemented protocols and support tools for women who present in latent (early) labor to safely encourage early labor at home?






q Has your hospital developed a policy to implement intermittent monitoring policies for low-risk women?

q Has your hospital developed OB specific resources and protocols to support patients, and family through an unexpected/ traumatic Cesarean?

q Have you shared provider level measures with department members (may start with blinded data but quickly move to open release)?






q Were some of the recommended tools for the Safe Reduction of Primary C/S bundle (i.e. order sets, tracking tools) integrated into your hospital’s Electronic Health Record system?

q Has your hospital implemented training/procedures for identification and appropriate interventions for malpositions (e.g. OP/OT)?

q Has your hospital developed a policy to integrate doulas into the birth care team?





Labor Guideline – Process Measure

§ Review of all NTSV CS women with spontaneous labor and a dystocia code who did not meet the ACOG/SMFM guideline:o If <6cm dilated,

o If 6-10cm dilated, was there at least 4h with adequate uterine activity or at least 6h with inadequate uterine activity and with oxytocin?

o If completely dilated, was there 3h or more in Second Stage?

§Denominator: all NTSV CS women without a fetal distress code and with a dystocia code,

§Numerator: those who were consistent with bundle

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NTSV Labor Arrest/CPD: Consistency with Guidelines

(high number is good)





§ Review of all NTSV CS women with induced labor and a dystocia code who did not meet the ACOG/SMFM guideline):o If <6cm dilated at time of CS, were there at least 12 hours of oxytocin

after rupture of membranes?

o If 6-10cm dilated, was there at least 4h with adequate uterine activity or at least 6h with inadequate uterine activity and with oxytocin?

o If completely dilated, was there 3h or more in Second Stage?

§Denominator: Induced NTSV women without a fetal distress diagnosis

§Numerator: those who were consistent with bundle

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Labor Guideline – Process Measure

NTSV Induced Labor Management: Consistency with Guidelines

(high number is good)





Process Measures - Education

§At the end of this quarter, what cumulative proportion of OB physicians and midwives has completed an education program on the ACOG/SMFM Consensus Statement for labor management guidelines reflected in the unit-standard protocol? (Estimated in 10% steps by nurse manager or designee)

§At the end of this quarter, what cumulative proportion of labor nurses has completed an education program on the ACOG/SMFM Consensus Statement for labor management guidelines and labor support techniques reflected in the unit-standard protocol? (Estimated in 10% steps by nurse manager or designee)

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Data Quality Measures (monthly case reviews of Data Center pre-screened cases)

§ Birth Certificate Induction Coding Errors among NTSV women oDenominator: all NTSV CS women with codes for induction on the BC

oNumerator those with documented induction on chart review

§ ICD-10 Induction Coding Errors among NTSV womenoDenominator: all NTSV CS women with ICD-10 codes for oxytocin,

misoprostol or failed induction

oNumerator those with documented induction on chart review

§ These are “by-products” of the induction confirmation efforts

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