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Copyright ©American College of Nurse-Midwives Inc. All Rights Reserved
HealthyBirthInitiativeâ
Reducing Primary Cesareans Collaborative
December 8, 2017 Webinar
Copyright ©American College of Nurse-Midwives Inc. All Rights Reserved
Goalsfortoday’swebinar
• Review how to hold gains and sustain change
• Get an overview of simplifications and changes to the data center for 2018
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Sustaining Change
Diana R. Jolles PhD, CNMFaculty Frontier Nursing University
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ObjectivesSustainability, Standardization, Spread and Scale
• Distinguish clearly how testing, implementing, and spreading a change are all different steps in the sequence of improvement
• Build communication strategies that foster and support spread
• How do you hardwire the new processes, methods, systems to create the "new norm"?
• Explore next steps in sustainability, standardization, and spread.
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• Expect huge improvements and spread right away
• Don’t bother testing- do a large pilot
• Check huge mountains of data just once every quarter
SEVENSPREADLYSINS
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• Give one person the responsibility to do it all
• Rely solely on vigilance and hard work
• Spread success unchanged• Require the person and team
who drove initial improvements to be responsible for spread
SEVENSPREADLYSINS
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CaseStudies
• 5 million lives• Denver Health • Kolter• IHI Sustaining
Improvement
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CaseStudy:5MillionLives§ Sustainability: Locking in the progress that hospitals have made already and continually building upon it; and § Spread: Actively disseminating best practice and knowledge about every intervention and implementing each intervention in every available care setting.
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Sustainability:HoldingtheGains
1. Supportive Management Structure2. Structures to “Foolproof” Change 3. Robust, Transparent Feedback Systems 4. Shared Sense of the Systems to Be
Improved 5. Culture of Improvement and a Deeply
Engaged Staff6. Formal Capacity-Building Programs
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DHMCHoldingtheGainsNationalRates
N=1,573
DenverHealth2005N=269
DenverHealth2010
N=1,064
DenverHealth2015
N=1253
Continuouslaborsupport ------- 2% 67% 55%
Ambulation 24% 12% 75% 64%
Hydrotherapy 6% 3% 61% 38%
Intermittentauscultation 15% 2% 67% 58%
Intermittentauscultationonly
3% 0% 29% 21%
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DHMCHoldingtheGainsNationalRates
N=1,573
DenverHealth2005N=269
DenverHealth2010
N=1,064
DenverHealth2015
N=1253
Successwithpainreliefintention
------- 50% 76% 75%
Physiologicpushing 21% ….. 59% 79%
Non-lithotomybirthposition
43% 1% 98% 98%
Delayedcordclamping ------ ……. 58% 67%
Breastfeedinginitiationinthebirthroom
------ 45% 75% 74%
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MaintainingTransformation• HARDWIRE TEAM • Extremely important looking to the future - strong physician
support moving forward. Strong support throughout hospital administration and with other departments.
• Participation in executive committees - i.e. medical staff.• What happens when there is new physician leadership?
• Ensure strength of the service - (many things involved in this - trust, integrity, credibility, stable staff, excellent outcomes)
• Be very active when interviewing/selecting new physician leadership
• Develop reliable, trusting relationships beyond the OB service - director of ambulatory care, etc.
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MaintainingTransformation• HARDWIRE TEAM• How to maintain a happy team that is adhering to the
mission and providing quality care.• work/life balance• Fostering strenths• Building trust, credibility
• Developing leaders• Formal• Informal
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MaintainingTransformation• HARDWIRETEAM:• Constantvigilancetomaintainhighly-functioningcollaborativeteam.
• BuildingandmaintainingTrust,credibility,integrityvital• Continuingtolearnfromeachother- MDs,RNs,etc.Supportingourdifferencesandsimilarities.
• Participatingincollaborativegroups- QI,P&P• Beingavoiceinbroaderhospitalgroupsandinitiatives- Priv/cred,MSEC,communityhealth
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MaintainingTransformation
• HARDWIRE ACCOUNTABILITY AND DATA DRIVEN DECISIONS • Ongoing self-assessment, data collection and analysis
• Data collection over 10 years.• Peer review - chart audits, formal CNM review of cases,
QI • IPE - informal to formal - constant education despite
formality.• OBs, FPs, med students, RNs
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DISCUSSIONChange: It is the Only Constant
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HealthyBirthInitiativeâ2018 Revision of the ACNM DATA CENTER
FiscalSponsor:TheA.C.N.M.Foundation,Inc.
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GoalsforThisPresentation
• Learn about the new, streamlined
ACNM DATA CENTER
• Be familiar with the revised measures
23
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Process• Steering Committee reviewed use of data
center by participants, including comments from coaching sessions (3/17)
• Sub committee and staff held 3 meetings to analyze patterns and make decisions (4/17-7/17)
• Meetings with vendor to confirm principles of revision and decisions (8/17)
• Revision completed and tested early 10/17
24
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Principles• Reduce data collection burden• Keep most relevant and useful
measures• Make “deep-dives” and analysis easier• Allow large institutions to use sampling
methodology• Keep a few “optional” variables to allow
a more robust analysis of bundle implementation for those who want it.– Can be used for audits
25
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GeneralMeasuresDeleted
• Cesarean Rate Among Epidurals < 5cm• Cesarean Rate Among Epidurals at 5cm
or Greater• C Section Among Independent
Midwifery Management• Physiologic Birth
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https://www.dropbox.com/s/jr4erkbiae0dtwo/9_29_17%20master_patient_worksheet_1.4%20tracking%20changes%20.xlsx?dl=0
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GeneralVariablesDeleted• Any Pitocin before 3rd stage of labor• Did the woman have nitrous oxide in the
first or second stage of labor?• Did the woman have opiates in the first
or second stage of labor? • At what dilation did the woman receive
her epidural?• Did the woman have an episiotomy?• Independent Midwifery Management in
labor and birth
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IAMeasuresDeleted• 5-minute Apgar Below 7 Among Women
Eligible for IA• Rate of First Stage IA Among Women
Eligible for IA• Rate of IA Throughout Labor Among
Women Ordered to Receive IA• 5-minute Apgar Below 7 Among Women
Eligible for IA• Change from IA to EFM due to staffing
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IAVariablesDeleted
• Eligible for I/A• Mode of fetal monitoring ordered• Was the requirement for 1:1 staffing in
order to perform intermittent auscultation THE reason for changing from IA to EFM?
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ComfortMeasureDeleted
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• Hydrotherapy• Percentage of NTSV women using
water immersion (tub) or shower during labor. Nitrous Oxide
• Opioid• Coping Scale• Cesarean Rate Among Epidurals <
5cm• Cesarean Rate Among Epidurals at
5cm or Greater
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ComfortVariablesDeleted• Was 1:1 continuous labor support
provided:§ by a physician or midwife?§ by a registered nurse?§ by doula?
Replaced by: • Was 1: 1 continuous labor support
provided?• Did the woman use a tub or shower
for comfort during labor31
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ProgressMeasureDeleted
NoneHowever:• Spontaneous labor and birth will be
displayed as a general measure
32
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ProgressVariablesDeleted• Was 1:1 continuous labor support
provided:§ by a physician or midwife?§ by a registered nurse?§ by doula?
Replaced by: • Was 1: 1 continuous labor support
provided?
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OptionalMeasures
General Measures:Rate of First Stage IA Among NTSV
Comfort:Continuous Labor Support
Labor ProgressRate of using graphing tool for labor progress.
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OptionalMeasures
For IA: • Rate of First Stage IA Among NTSV• Rate of Second Stage IA Among NTSV• Rate of IA Throughout Labor Among
NTSV• IA Throughout Labor and Apgar Below
Seven Among NTSV
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ThesechangeswillstartwiththeJan,2018datacollection
• This means that you begin using the new data collection forms Jan 1, 2018
• You will download them from the website from this page:
https://datacenter.acnm.org/response_set_worksheets
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Newinstructionshere
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Clickherefromanyscreen
Clickheretodownloaduserguide
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Thenewportalgoes“live”onFeb15th,2018
• You must have completed all data uploads for 2017 by then. If there is any chance you cannot do that, please let us know ASAP.
• If you want to have access to all of the historical variables, you must download all charts and spreadsheets for 2017 by mid Feb. They will not be available to you after that.
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Actionsyoumusttake
• Schedule a team meeting to discuss this change with all members, especially those who are involved in collection activities.
• COMPLETE (i.e. completely finish all months data collection and uploading) for 2017 by Feb. 15th 2018.
• Download a full set of your 2017 datafor futher analysis by Feb. 15th 2018– This will be your last opportunity for you
to access the older data set.41
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