Innovation Profile: A collaborative effort to reduce early inductions.

Transcription

1 Innovation Profile: A collaborative effort to reduce early inductions. Snapshot Summary The Sutter Medical Center Sacramento implemented a data driven and collaborative intervention to addressed elective inductions <39 weeks. Elective deliveries <39 weeks were contributing to transitional and feeding issues for newborns in addition to increasing cesarean section rates among new mothers. The main aspects of the intervention involved establishing a task force group, collecting baseline data and setting targeted goals, creating a scheduling policy, and setting up a system for physician case reviews. The Sutter Medical Center Sacramento decreased the number of elective deliveries from a fourth quarter 2010 baseline rate of 15.1% to 5.5% in 2011 using the Joint Commission measure of elective inductions as a percentage of all deliveries <39 weeks. Hospital Background Mixed Payer Non Profit Hospital Date First Implemented First Quarter 2011 What They Did Description of the Intervention The Sutter Medical Center Sacramento initiated a yearlong intervention addressing elective inductions and cesarean sections <39 weeks. The multi faceted intervention brought nursing, physician, medical records, data specialists and CNS representatives to work collaboratively in a task force and data subcommittee to decrease elective deliveries less than 39 weeks. Main components of the intervention were hospital specific goals, scheduling procedure and process development and implementation, data collection and analysis, and a system for physician case reviews. Developed Goals and Strategies: The intervention was initially hospital specific, and then implemented system wide as a monthly measure reviewed by Sutter leadership. A collaborative task force group was created which addressed the issues related to the consequences of early deliveries as well as understanding of the reasons early elective deliveries were occurring. This group then developed an improvement plan. o Task Force Group: A group of MDs, the L&D Assistant Nurse Manager, a clinical nurse specialist and the perinatal clinical data coordinator worked together in the planning, implementing, and monitoring aspects of the intervention.

2 Common Strategies: o Securing Leadership Support: A crucial component of the intervention was achieving buy in from hospital leadership members such as physician champions, administrators, nurse leaders, and the clinical system documentation and data coordinators. o Scheduling Improvements: A new scheduling policy and form were created to formalize the scheduling process. Nurses and unit secretaries were trained about scheduling criteria and processes. Scheduling requests outside of criteria were reviewed by designated physicians. Training and Education: Implementing various types of education enabled greater change, as the following components were crucial to reducing rates and meeting goals: o Identifying Opportunities for Improvement: Early elective inductions and C Sections were tracked and monitored every day, and any early elective delivery was considered an opportunity for improvement (OFI). The OFI review system was crucial to success it enabled a dialogue among care providers to address issues and decrease early delivery rates. Meetings of task force members to review the cases were held regularly. o A System of Physician Case Reviews: Striving to garner communication among physicians, the review system addressed any <39 weeks elective schedule requests that failed to meet The Joint Commission (TJC) criteria for medically indicated delivery < 39 weeks. Those cases were identified, analyzed, and discussed. Another aspect of the review system was gaining approval by the OB/GYN department to post avoidable cases with blinded physician identification along with the reason the case fell into the avoidable category. This information has been posted in the physician lounge for the first and second quarter of Un blinded cases will begin to be posted in the third quarter of o Staff Trainings: Numerous educational venues were utilized to transform knowledge and norms. Physicians and nursing leaders were trained about the < 39 Week Elective Delivery Initiative via the OB Admin and OB QI medical staff committee meetings as well as the OB Department, OB M&M and OB Quality of Care committee meetings. Coding and documentation information was also presented and the new scheduling policy was approved by the department. o Patient/Family Education: Information brochures from the March of Dimes were provided to the physicians for use with their patients. These materials helped educate and set realistic expectations for their patients. Data Analysis: Baseline data from the 2010 fourth quarter were collected and goals were set accordingly. o Management: The data management software MIDAS was instrumental in indentifying and sorting particular cases for review. This streamlined data collection process increased the analysis speed, thus furthering the reviewing process. In order to deal with complex scheduling issues, new scheduling algorithms related to late pregnancy dating were developed. o Analysis: Determining and presenting reliable data and case information was essential in proper reporting to administration and physicians. A process was set up to allow timely correction of OFI cases according to TJC criteria allowing for accurate identification of elective deliveries < 39 weeks gestation.

3 External Support Groups: Sources such as the March of Dimes and CMQCC assisted with practice changes and enabled care providers and schedulers to make decisions. o March of Dimes/CMQCC/CDPH: A March of Dimes/California Maternal Quality Care Collaborative/CA Dept. of Public Health Elimination of Non medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age Tool Kit was utilized, which assisted in addressing and improving scheduling criteria, providing healthcare provider education and developing a scheduling policy and process. Factors Important to Success Key elements of the planning and development process including the following: Goals: The fourth quarter 2010 baseline data of 15.1% was used to develop department goals. The 2011 target was to decrease the number of elective deliveries < 39 weeks to 10% with a stretch goal of 7%. The elective delivery rate for the 2011 calendar year was 5.5%. The 2012 goals are 5.0% with a stretch goal of 4.5%. Reporting Data: Progress was enabled by routinely reporting accurate data to the team of physicians and nurses. This dialogue was fostered in biweekly reviews of the OFI cases looking for coding issues and practice trends. Creating an efficient system of identifying and correcting OFI cases contributed to improvements. Monthly progress charts displaying the rate of avoidable/unavoidable cases, monthly case lists of avoidable elective deliveries presented for peer review, and a quarterly elective delivery trend chart are produced. These charts were presented at OB Administrative Committee, the OB QI Committee and at the Hospital Council meetings. Communication: Regular dialogue between the Task Force Group and the OB/GYN department committees fostered a culture of change. Interdisciplinary collaboration among staff was a focal point of success. Challenges Scheduling: Developing a consistent streamlined scheduling process became one of the main challenges and it was described as a moving target at times. Managing changing schedules on a very busy L&D unit in an efficient manner became an art form in many respects. Challenges were overcome by hiring and training a dedicated scheduler with tools to navigate scheduling issues. A well trained scheduler needs sufficient knowledge to answer a OB related scheduling questions in addition to coordinating with physicians for those cases needing review. Resources Used and Skills Needed Staffing: Recently, a scheduling position was created to manage all scheduled procedures in the L&D unit. Prior to that, no new staff were hired. Tools and Other Resources March of Dimes educational materials. March of Dimes, CMQCC, CA Dept. of Public Health. Elimination of Non Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age Toolkit.

4 Did it Work? Results Quarterly Report The elective delivery rate has consistently trended downward since initiation of the intervention.

5 Elective Delivery by Type There was a significant decline in avoidable elective deliveries as defined by the TJC definitions.

6 Adopting Considerations Getting Started with This Innovation Coordinate QI champions and other hospital leaders Develop a efficient data analysis system Set well defined and obtainable goals Sustaining This Innovation Report and share data amongst care providers Continually engage numerous leaders from the physician, nursing, and data departments If you would like additional information about this success story please contact: admin@henlearner.org