Www.childbirthconnection.org Transforming Maternity Care 2020 Vision for a High Quality, High Value Maternity Care System and Blueprint for Action Intermountain.

www.childbirthconnection.org

Transforming Maternity Care

2020 Vision for a High Quality, High Value Maternity Care System

and Blueprint for Action

Intermountain Healthcare Women and Newborns Conference,

September 27-28, 2010

R. Rima Jolivet, CNM, MSN, MPHTransforming Maternity Care Project Director

Associate Director of ProgramsChildbirth Connection


Childbirth Connection

MissionTo improve the quality

of maternity care through research, education, advocacy, and policy.


Maternity care is a major segment of health care

• 85% of women give birth• Childbirth is the number one reason for being hospitalized• 25% of those discharged from the hospital are childbearing women

or newborns• Maternal and newborn charges are the runaway leader in hospital

charges: $86 billion in 2006• Childbirth accounts for 6 of the 10 most common hospital

procedures• Cesarean section is the most common operating room procedure• Employers and private insurers pay for half of all births, and

taxpayers and Medicaid programs pay for 42% of births

References at http://www.childbirthconnection.org/article.asp?ck=10621


Much of the care women receive is not consistent with the best evidence

The Milbank report reveals:• A pattern of wide practice variation,

unwarranted by health status or women’s preferences

• Overuse of many practices that entail harm and waste for mothers, babies, and the system at large

• Other effective, high-value practices that are systematically underused

www.childbirthconnection.org/ebmc/


Evidence-Based Maternity Care: Core Aim

• Provide effective care with least harm to childbearing women and newborns

• Possible care paths often have very different benefit/harm profiles

• Give priority to effective paths that are least invasive, ideally with limited or no known harms

Consistent with: First, Do No Harm


Examples of Overuse in Maternity Care

• Labor induction

• Epidural analgesia

• Cesarean section

• Continuous electronic fetal monitoring

• Rupturing membranes

• Episiotomy


Examples of Underuse in Maternity Care

• Smoking cessation interventions• External version• Continuous labor support• Measures to bring comfort and promote labor progress• Delayed and spontaneous pushing• Non-supine positions for giving birth• Delayed cord clamping• Early skin-to-skin contact• Interventions for breastfeeding initiation, duration• Interventions for postpartum depression


Unwarranted Practice Variation

• Manifold variation is common

• Across regions, hospitals, caregivers

• Across very narrow classes of women (Robson mode of birth categories)

• 124 Hospital Corporation of America facilities: almost “random” pattern of operative delivery

• Baicker and colleagues: higher rates of cesarean involve use in healthier women, with greater expense, inevitable excess morbidity, and no mortality gains


How Do We Reliably Deliver the Right Maternity Care at the Right Time?

• “Every system is perfectly designed to get the results it gets.” --Paul Batalden

• “The definition of insanity is continuing to do the same thing over and over again and expecting a different result.” --Albert Einstein

The solution is to change the system in which maternity care is delivered


Transforming Maternity Care: Looking Forward with Shared Perspective

The TMC Project:

• Multi-year collaboration with more than 100 maternity care leaders

• Broad participation

• Open, transparent group process to reach consensus through discourse

• Two direction-setting papers:

“2020 Vision” and “Blueprint for Action”

• Dissemination and implementation through Partnership and Community Action



Transforming Maternity Care Steps

• Vision: figure out where we want to go

• Blueprint: figure out how to get there

• Implementation: head off in that direction





What Is a Vision?



• A Vision Is:

• A framework for possibility

• A long clear sightline radiating forward

• A statement of fundamental human desires

• An open invitation and an inspiration for people to create ideas and events that correlate with its definitional framework

(Zander & Zander, 2000)



• A Vision Provides:

• A focal point for change

• A clear, shared definition of the goals

• Motivation to change, even when it is hard

• A rallying point that brings stakeholders together in service of a perceived greater good

(Kotter, 1996)




• Fundamental values and principles that apply across the whole continuum of maternity care

• Goals for each phase and for providers and settings for maternity care

• Attributes of the larger system that can reliably provide high quality, high value care to all childbearing women, their newborns and families



Fundamental Values and Principles

• 6 Aims, adapted from the seminal Institute of Medicine definitions of quality

• Further values and principles that are foundational to the Vision



6 Aims Applied to Maternity Care

• Woman-Centered• Safe• Effective• Timely• Efficient• Equitable

A new take on familiar definitions



Further Foundational Values & Principles for Maternity Care

• Life-changing experience• Care processes protect, promote, and support

physiologic birth• Care is evidence-based• Quality is measured, performance is disclosed



Further Foundational Values & Principles for Maternity Care

• Care includes support for decision making and choice

• Care is coordinated• Caregiver satisfaction and fulfillment is a core

value





Levels A & B: Women and their Support Networks, and

Microsystems that Provide Direct Care

• Care During Pregnancy• Care Around the Time of Pregnancy• Care After Giving Birth• Key Participants• Care Settings



Level C: Health Care Organizations

Envisioning system attributes that:

• Strengthen the structure of the care delivery system• Strengthen the maternity care workforce• Foster high-quality maternity care• Provide woman- and family-centered care



Level D: The Macro Environment of Care

Envisioning system attributes that:

• Strengthen performance measurement• Improve the functionality of payment systems• Strengthen professional education and guidance• Close priority gaps in research• Improve the functioning of the liability system• Enable reliable delivery of high quality maternity care


The Challenge of Change:

• “Facts do not change feelings, and feelings are what influence behavior. The accuracy and clarity with which we absorb information has little impact on us: it is how we feel about information that determines whether we will use it.” –Vera Keane, CNM, 1967

• “Fables can be powerful because they take serious, confusing, and threatening subjects and make them clear and approachable…In our modern, high-tech world, we can easily forget this simple yet profound truth.” –John Kotter, 2005


A Tale of Two BirthsA Fable to Illustrate the Vision


Fable to Illustrate the Vision

• Common response: “But we are already providing maternity care that is [fill in the blank: woman-centered, high-quality, evidence-based] now.”

• The fable was developed to compare a woman experiencing common elements of care within the present system and her friend who experiences care within the envisioned system

• Brings to life implications of the proposed vision for women, newborns and families

Available at www.childbirthconnection.org/vision/



Blueprint for Action:Steps Toward a High Quality, High Value Maternity

Care System

‘‘‘‘Who needs to do what, to, for, and with whom to Who needs to do what, to, for, and with whom to improve the quality of maternity care overimprove the quality of maternity care over

the next five years?’’the next five years?’’


Blueprint for Action:Steps Toward a High Quality, High Value

Maternity Care System

• Five stakeholder workgroups developed detailed sector-specific reports

• Actionable strategies in 11 critical focus areas

• Synthesized into a comprehensive Blueprint for Action by the Symposium Steering Committee

• Full stakeholder reports are published online at:

www.childbirthconnection.org/workgroups



Maternity Care System11 Critical Focus Areas:• Performance measurement and leveraging of

results

• Payment reform to align incentives with quality

• Disparities in access and outcomes of maternity care

• Improved functioning of the liability system



Maternity Care System11 Critical Focus Areas:• Scope of covered services for maternity care

• Coordination of maternity care across time, settings, and disciplines

• Clinical controversies (home birth, VBAC, vaginal breech and twin birth, elective induction, and maternal demand cesarean section)

• Decision making and consumer choice

• Scope, content, and availability of health professions education

• Workforce composition and distribution

• Development and use of health information technology (IT)


Blueprint for Action: Recommendations and strategies aimed at

every level of the maternity care system


Selected Blueprint Recommendations of Special Relevance to Maternity Care

Clinicians and Delivery Systems


Examples: Action Steps at the Delivery System Level

Performance Measurement and Leveraging of Results

• Develop, test, and submit needed measures to NQF

• Address critical gaps across the full episode of maternity care

•Develop state or regional quality collaboratives that bring hospitals, clinicians, consumers, and payors together to test the impact of performance measures on P4P, audit and feedback, QI indicators.



Payment Reform to Align Incentives with Quality

• Pilot maternity care payment reform models that restructure health system relationships and financing to align quality and value, and foster improved care coordination, including From Volume to Value model (Miller, 2008)

• Conduct regional demonstration projects involving all payors and providers

• Share results for learning and replication



Disparities in Access and Outcomes of Maternity Care

• Form quality collaboratives and community-based partnerships to evaluate and implement programs to close disparities in maternity care outcomes.

• Carry out comparative effectiveness research and apply disparities-sensitive criteria

• Test effect on outcomes and cost of preventive programs that have demonstrated an impact in populations experiencing disparities



Improved Functioning of the Liability System

•Widely adopt system-oriented patient safety and quality improvement programs, and measure and report experiences with malpractice claims and payments (see Simpson et al. 2006, 2009, 2010)

•Evaluate the impact on reduction of adverse events and liability experiences, and satisfaction of women and providers of promising maternity care interventions.

•Pilot, evaluate, and share results of ‘‘enterprise liability’’ programs that relocate responsibility from individuals to systems.


Examples: Action Steps at the Microsystem level

Clinical Controversies• Implement a multi-disciplinary team training program• Practice drills, simulation, interdisciplinary problem-

solving, communication training• Include midwives, physicians, nurses, anesthesia,

pediatrics, and risk management• Use this training to safely offer controversial practices

that are supported by high-quality evidence• VBAC, vaginal breech and twin birth, effective

coordination of care for out of hospital birth


Examples: Action Steps at the Delivery System level

Clinical Controversies/Performance Measurement• Institute benchmarking programs at the system level• Identify and move toward achievable target rates of VBAC,

vaginal breech and twin deliveries, induction of labor, and cesarean in low-risk first-time mothers

• Identify best practices, report innovation and successes• Learn from successful programs such as NNEPQIN


Examples: Action Steps at the Delivery System level

Coordination of Care Across Time, Settings, and Disciplines

• Convene an interdisciplinary team of family practice, midwifery, obstetric, and maternal-fetal medicine providers

• Look at actual community patient-safety data on near misses and reportable adverse events

• Develop community-specific consensus standards for risk criteria and system linkages appropriate to each level of care in the community

• Replicate the model and process used by Intermountain Healthcare (Hey, that’s YOU!!)


Examples: Action steps at the Macro level

Woman- and Family-Centered Maternity Care Home• Endorse legislation to support Medicaid demonstration

projects of the concept• Ensure that family physicians and obstetricians, all midwives

with nationally recognized credentials and nurse-practitioners are eligible to participate in demonstrations as all have the potential to provide exemplary care coordination

• Ensure that the Woman- and Family-Centered Maternity Care Home meets NCQA standards for the medical home



Health Professions Education• Ensure that students in each discipline learn from an

interdisciplinary teaching team • Create multi-disciplinary learning and teaching

opportunities• Create opportunities for education in settings outside

acute facilities, e.g., in community health centers, public health clinics, and freestanding birth centers

• Develop model evidence-based practicum experiences


Examples: Action Steps at the Macro level

Health Professions Education• Convene an education summit

• Plan a shared core maternity care curriculum and ways to integrate education across disciplines

• Ensure a foundation in health promotion, cultural sensitivity, woman- and family-centered care, skills and knowledge to support physiologic childbearing, evidence appraisal and a public health focus

• Learn from Duke University’s process of building a model universal women’s health curriculum across 6 disciplines (Taleff et al. 2009)


The potentialto improvematernity careis within ourreach, but none of us cando it alone.



TMC Project Goals:

•To garner and communicate political will to propel maternity care quality improvement efforts forward

– By providing a pivotal organizing focus: the 2020 Vision

– By fostering a coherent plan for action: the Blueprint

– By globalizing policy objectives and localizing their implementation

•To foster national, regional, and local efforts to improve maternity care quality and value

What Now?



The TMC Partnership: • Outreach and dissemination to decision makers

• A public-private multi-stakeholder partnership for joint Blueprint implementation projects of a significant scope

• The TMC Action Community: A forum for community-level partners to show support for the Vision and Blueprint, and get ideas and resources for ways to independently engage in this work within their own communities and practice settings…including the nw monthly “TMC Topics” webinar series

www.childbirthconnection.org/partnership


Where Does This Lead Us?

The Ultimate Vision

• Safe, timely, effective, efficient, equitable, woman/family-centered care

• Best in the world in maternal and child health outcomes

• Global recognition for our transformation


Childbirth Connection believes that deliberative, collaborative,

multi-stakeholder efforts are the best way to

improve thequality, value, and experience of care

for women,babies, families,

and all stakeholders. We know that maternity

quality matters.


Thank You!

R. Rima Jolivet, CNM, MSN, MPHTransforming Maternity Care Project Director

Associate Director of ProgramsChildbirth Connection

[email protected]

Www.childbirthconnection.org Transforming Maternity Care 2020 Vision for a High Quality, High Value Maternity Care System and Blueprint for Action Intermountain.

Documents

quality of maternity

effective care

right maternity care

harm slide

newborns possible care

childbearing women

major segment of health

healthier women