A Note to the Speaker DELETE THIS SLIDE BEFORE PRESENTATION The following slides have been developed to support presentations on the elimination of non-medically indicated deliveries <39 weeks gestational age and should be tailored to meet the needs of the audience. When adapting the slide deck, the following guidelines must be considered: The slide deck is copyrighted by the State of California. Slides contained in this deck should not be changed or amended. Additional slides can be added, but new slides must not contain the CMQCC logo, March of Dimes logo or the State of California copyright.

An Implementation Strategy Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age An Implementation Strategy Slide Set #2 The following is an implementation overview slide set designed for the program implementation (QI) team. It can be adapted to help support and outline the key change strategies within an institution that need to be addressed to eliminate elective deliveries <39 weeks. Funding for the development of this toolkit was provided by: Federal Title V block grant funding from the California Department of Public Health; Maternal, Child and Adolescent Health Division was used by the California Maternal Quality Care Collaborative to develop the toolkit; and March of Dimes.

A Daunting Task Implementation can be a daunting task. The goal of this deck is to break down implementation into manageable step-by-step action items that will drive change.

Objectives Learn the step-by-step process necessary for successful implementation of the elimination of elective deliveries before 39 weeks project Gain a deeper understanding of the importance of the following implementation components: Who to involve Tools needed (i.e. policy, scheduling guidelines) Engaging people to drive and sustain change How to overcome barriers Tracking outcomes Describe the common barriers to full implementation Read slide.

Key Points Education provided to obstetricians and patients regarding ACOG guidelines and best practices is important Nursing support and medical leadership are crucial Modest change at most, until physicians were held accountable, nurses were empowered, and guidelines were enforced (“Hard Stop”) One Grand Round does not drive change Data reporting helps facilitate change Patient education can also drive change Key points to successful implementation

Overview: Critical Elements for Successful Implementation This schematic gives an overview of the process for implementing a successful program to reduce or eliminate elective deliveries taking place before 39 weeks gestation. Both the patient and clinician are critical in reducing elective deliveries. This process must begin with educating not only the clinician, but also the patient as to why it is unsafe to deliver pregnant women before 39 weeks unless there is a medical or obstetrical reason to do so. The hospital staff are also a key player in this process. In addition, a policy must be created and the medical leadership must be on board. The process will be a lot smoother and cause less angst amongst the hospital staff if they are not placed in a position of having to tell the physician they cannot schedule a delivery. In the event that there is a dispute, the staff must be empowered to refer the scheduling physician to medical leadership for resolution. Finally, data must be collected and charts reviewed periodically to track progress.

What Do We Need to Get Started? MAP-IT Mobilize Assess Plan Implement Track This MAP-IT chart is a rapid cycle method for implementing change. The first step is to organize a QI team to outline the process and to oversee the project. The second step involves this group assessing the scope of the problems and the barriers to change. The third step involves strategizing on how to overcome barriers to change and to plan an implementation process. The fourth step is to implement the plan of action. The fifth step is to track progress and then to make adjustments in the plan as necessary. Source: Guidry, M., et. al. Healthy people in healthy comamunities: A community planning guide using healthy people 2010. Washington, D.C. U.S. Dept. of Health and Human Services. The Office of Disease Prevention and Health Promotion.

Mobilize the Team Identify physician champion Involve all stakeholders needed to change culture: Obstetricians, Midwives, Family Practice Physicians, Nurses, Schedulers, Quality Improvement Team, Analysts, Hospital Administration, Service Line Directors, Public Relations, Public Health, Payers, Business, Others Involve people early Identification of a physician champion and nurse leader who will champion the initiative and lead the team of stakeholders is essential. Soliciting Hospital CEO/Hospital Administration leadership early in the process is key. Team should establish common vision for culture change, goals and implementation start date. Image: renjith krishnan / FreeDigitalPhotos.net

Mobilize the Team Getting Stakeholders to be Stakeholders Effective communication strategy Stakeholders must be able to express their concerns Motivation We’re part of a team Win-Win Data presentation (local) In order for real change to occur, the team should establish a method to openly and honestly communicate barriers, brutal facts, progress and success. Ways to motivate and build the team: Reminding them that it will take a team to drive change and that their contributions matter, however, great or small Project is a “Win-Win” for hospital and moms and babies. Local presentation of hospital data will reveal changes in non-medically indicated deliveries before 39 weeks and can keep the team motivated. Image: renjith krishnan / FreeDigitalPhotos.net

Assess the Situation Determine Your Starting Point What is your induction and cesarean section rate? (Baseline assessment) Elective vs. indicated Before 39 weeks and between 370/7 and 386/7 weeks What are your NICU admission rates and trends? Assess your scheduling process Who schedules inductions and cesarean sections? Do you know the Estimated Gestational Age and indication at the time of scheduling? Who are the champions, adopters and resisters? What is the process for referring a case? What are the barriers to change? Outlined on the slide are hospital investigation questions to help inform the team on the changes needed to establish a sustainable program to eliminate elective deliveries <39 weeks.

Distribution of births by gestational age United States, 1990 and 2009 Assess the Situation Communication: Data are Local! Distribution of births by gestational age United States, 1990 and 2009 What is your local hospital data? This slide shows United States Natality Data, which illustrates the change in birth by gestational age from 1990 to 2009. In 2009, fewer babies were born at 40 to 41 weeks and more babies were born at 37 to 39 weeks compared to 1990. Using your own data to illustrate your hospital’s deliveries by gestational age is a powerful tool. What are the numbers in your hospital? Up to 40% induction rates in the U.S. What are your hospital’s induction and cesarean section rates? 37-38 weeks Gestational age is calculated in completed weeks. Source: National Center for Health Statistics, 1990 and 2009 final natality data. Prepared by March of Dimes Perinatal Data Center, August 2012

Plan Change Tactics Overview Develop revised scheduling process and guidelines Establish an appeal process for deliveries that don’t meet scheduling guidelines (“Hard Stop”) Appoint physician leader(s) to enforce scheduling process and approve exceptions Revise scheduling forms, policy and procedure Develop data collection plans and forms Formalize change in hospital policy Determine which clinician and patient education materials are needed This is an overview of the key change components needed to drive change. Read slide.

Plan Change Tactics A Tool to Educate Patients Educating patients is a key change component. As patients comprise perhaps half of the decision-making process, it is important to educate the patient. Patient education should ideally take place during prenatal care, before the discomfort of the last weeks of pregnancy and far enough ahead to influence her expectations. Here is an example of a patient education tool (provided courtesy of the March of Dimes) that can be used to educate patients in the office or at prenatal classes. Featured on the slide is a copy of the brain card that providers can use to assist them in educating their patients about why the last weeks of pregnancy count. © 2007 Bonnie Hofkin Illustration marchofdimes.com

Develop a Scheduling Process Available in the Toolkit Plan Change Tactics Develop a Scheduling Process Standardizing the scheduling process is another key change component. A sample scheduling algorithm is shown here and the next few slides will walk us through this process.

Plan Change Tactics Establish professional consensus on indications for early delivery These are not exhaustive lists! But close… (e.g. prior classical CS) ACOG and The Joint Commission (TJC) have each published a list of indications that may justify the need for an early term delivery. These lists are not exhaustive. For example, prior classical cesarean section is not on the list. These lists can help inform and build consensus among hospital clinical staff about what conditions are considered medically vs. non-medically indicated Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age Spong et al. Obstet Gynecol. 2011 Aug;118(2 Pt 1):323-33.

Plan Change Tactics Caveats About the Indication Lists The Joint Commission list was developed for ease of data collection utilizing ICD-9 codes. Two additional indications that do not have ICD-9 codes are now accepted by The Joint Commission - prior classical CS and prior myomectomy. Everyone understands that there are cases in which earlier delivery is indicated and but the indication is NOT on the list - but these should be uncommon. No one is expecting a ZERO rate. Off-list indications should be prospectively scrutinized. The published ACOG and TJC indication lists are not absolute or all-inclusive. Read slide.

Sample Scheduling Form Available in the Toolkit Plan Change Tactics Develop and adopt a scheduling form and process Sample Scheduling Form Developing a scheduling form outlining medical and non-medical indications for delivery <39 weeks and a formal procedure for scheduling deliveries <39 weeks will help to standardize the scheduling process. Standardizing the scheduling process for C-sections and inductions is a key change component because the scheduling process can be utilized to review and challenge all scheduled deliveries <39 weeks before they are performed. Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age

Plan Change Tactics Overview of Changes to the Scheduling Process Patient is NOT scheduled and is allowed to go into labor spontaneously. Accurate gestational dating. Appropriate indication for induction or cesarean section for gestational age. Patients scheduled either by calling the scheduler, electronic submission or faxing in the request. Elective deliveries - including repeat scheduled cesarean sections - must be at least 39 weeks gestation based upon ACOG criteria. Changes to the scheduling process are outlined on this slide. Read slide.

Plan Change Tactics Scheduling Process (continued) Any scheduling conflicts will be directed to the OB Chair or Director of L&D for resolution. Ongoing problems that are identified will either be resolved as soon as possible or discussed at future department meetings. Data will be reported on a regular basis to inform everyone about how the project is going. Additional changes to the scheduling process are outlined on this slide. Read slide.

Plan Change Tactics Confirmation of Term Gestation Early ultrasound, < 20 weeks gestation, is more accurate than an ultrasound after 20 weeks gestation at determining gestational age and benchmarking < 39 weeks gestation. Ultrasound-established dates should only take precedence over LMP-established dates when the discrepancy is greater than 7 days in the first trimester and 10 days in the second trimester Confirmation of gestational age is an important part of this initiative. Outlined on this slide are ACOG criteria for establishing confirmation of term gestation. Uniform procedures among hospital clinicians in establishing gestational age should be discussed to ensure consistency. Adjusting gestational dates is one way that some doctors try to work around the scheduling policy. ACOG Practice Bulletin: Ultrasonography in Pregnancy Number 101, February 2008

Plan Change Tactics Create or rewrite hospital policy To ensure that the elimination of elective deliveries <39 weeks is sustainable, process changes should be formalized in hospital policy. Creating or rewriting hospital policy should be a formal process. Knowing how your hospital creates or rewrites policy before beginning the change process may be helpful. Establishing formal hospital policy that outlines the elimination of elective deliveries <39 weeks is a key change component. A sample hospital policy is contained in the Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age toolkit. Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age

Plan Change Tactics Identify strong physician and nursing leadership Empower nurses to handle “appeals” for exceptions Establish “Hard Stop” process Success will be realized through the identification and leadership of strong physician and nurse leaders who have the respect of their colleagues and enough clout to drive change. Nurses should be empowered to question the deliveries < 39 weeks that don’t meet scheduling guidelines and should be able to call a “hard stop”. Nurses should be empowered to ask the requesting physicians if they would like to speak to the appointed medical leader about “appealing” the delivery because it does not meet scheduling guidelines. Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age

Sample Data Collection Form Plan Change Tactics Available in the Toolkit Develop data collection plans and forms Tracking data on non-medically indicated deliveries <39 weeks will validate progress in eliminating elective deliveries <39 weeks. A sample data collection form and QI measurement are outlined in the Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age toolkit. Data collected at the time of scheduling can be collated to track progress over time. Sample Data Collection Form Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age

Implement Convene department and staff meetings to educate physicians and staff Baseline assessment Ongoing data collection plan Policy and procedure with Approved Indications New scheduling process and forms Provide educational materials for physicians, staff, and patients Choose start date and begin data collection and reporting on a regular basis It is important to inform everyone about the project. Key information should include baseline data before the project starts. Also, physicians must be included early in the process and should be able to provide input and have their questions answered and concerns addressed.

Track Progress Use data and audit tools to track the number of non-medically indicated deliveries <39 weeks Develop trend charts and report back to staff and providers on a regular basis Address issues and concerns as soon as possible Tracking data secures buy-in and sustains results Of course, it is essential to track progress and give feedback to the staff and physicians on an ongoing basis and to address issues and concerns sooner rather than later.

Track Progress Data Collection Resources Elimination of Non-medically Indicated Deliveries Before 39 Weeks Toolkit March of Dimes Perinatal Quality Improvement portal (PQIp) California Maternal Quality Care Collaborative (CMQCC) Website The Joint Commission Resources available to support hospitals with data collection.

Understanding Barriers to Change: It’s All About People It is important to consider how people will personally be affected by the change process. Uncertainty can evoke a wide range of emotions: frustration, anger, despair, acceptance, enthusiasm and elation. Which emotion is encountered will depend on whether people make the change willingly or unwillingly. People are the key ingredient and can be a significant barrier in the change process. Read Slide Source: NHS Modernisation Agency 2005. ‘Improvement Leaders Guide, Managing the human dimensions of change’. Department of Health Publications, London www.modern.nhs.uk

“People” Barriers Not aware why change is necessary Feel that there are other more important issues. Don’t agree with the proposed change, or feel that change is harmful. Disagree about how the change should be implemented. Feel criticized by the change process. Feel that they have done this before and nothing changed. Feel that there will be extra work. Read slide. Source: NHS Modernisation Agency 2005. ‘Improvement Leaders Guide, Managing the human dimensions of change’. Department of Health Publications, London www.modern.nhs.uk

Readdress Concerns The “UNKNOWN” is scary. Educate as much as possible to decrease uncertainty before implementation. Continue to communicate throughout the implementation process and listen to people’s concerns. Addressing concerns engages people and makes them part of the team and part of the solution. Read slide

Review progress serially and provide feedback Success Breeds Success Less than 39 weeks (%) Review progress serially and provide feedback Progress will be a key motivator to drive and sustain change. It is important to regularly share data with all stakeholders. Pictured: Intermountain Healthcare data which illustrates their sharp decline in elective deliveries < 39 weeks over time. Source: A Quality Improvement Toolkit: Elimination of Non-Medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age

Implementation Summary Need a motivated QI Team Leadership is critical RNs need to be empowered Develop the necessary tools (hospital policy, scheduling guidelines, process and form) People need to be engaged Data collection and tracking are essential for success Sustained improvements will be realized through culture change Outlined is a summary of the key implementation change components. Read slide.

Questions?

For More Information, Contact: Barbara Murphy barbar@stanford.edu Leslie Kowalewski LKowalewski@marchofdimes.com The March of Dimes and California Maternal Quality Care Collaborative Toolkit is a great place to start for further information