1. Healthy Birth Initiative
Reducing Primary Cesareans Collaborative
February 2, 2018 Webinar
Welcome to the first webinar
Changed format, will go over detail in a few minutes

2. You will be hearing these voices this month!
Ana Delgado Holly Smith
Lisa Kane Low Leslie Cragin
This is the group of coaches and volunteers that you’ll be hearing each month:
Cathy and Ann are leading the work with me to plan the curriculum for the year
Ana and Holly will be our facilitators and coaches each month
Rachel will work to triage specific follow up coaching requests
Katie will work to troubleshoot data issues with you
Leslie and Lisa are our overall directors
Rachel Breman Kate Chenok

3. Reminders about webinar etiquette
Please keep your phones on mute during the presentation
However, please participate during the discussion section of the webinar!
Slides will be posted to the RPC website and Basecamp after the webinar
This is your time – please be present!

4. Overview of the RPC Curriculum
Team formation
Understanding the "readiness part" of your bundle.
How to review and change your policies to support your bundle
PDSA and small tests of change
Calculating the financial returns from bundle implementation
Bringing information about change to the whole enterprise
Communicating about change and engaging resistant people
Shared Decision Making - case studies
Sustaining Change
Topics we will cover over the course of the year in monthly webinars

5. Overview of the RPC Curriculum
Team formation
Understanding the "readiness part" of your bundle.
How to review and change your policies to support your bundle
PDSA and small tests of change
Calculating the financial returns from bundle implementation
Bringing information about change to the whole enterprise
Communicating about change and engaging resistant people
Shared Decision Making - case studies
Sustaining Change
Topics we will cover over the course of the year in monthly webinars

6. Format of webinar Presentation and information sharing
Active collaborative discussion and coaching

7. Introduction Lisa Kane Low, CNM, PhD
President, American College of Nurse-Midwives

8. Today’s presentation: Understanding the links between the Bundles, Bundle Checklists and Data
Leslie Cragin, CNM, PhD has worked in academic and birth center collaborative practice settings and is retired from her work as Clinical Professor at UCSF Department of Obstetrics, Gynecology and Reproductive Sciences. Her program of research examined the outcomes of care by midwives in the USA and Mexico with a focus on underserved populations. She served on the inter-association Midwifery Data Collaborative and was chair of the Division of Research’s Data Section. She represents ACNM the Executive Committee of the California Maternal Quality Care Collaborative. She was the chair of American College of Nurse-Midwives’ (ACNM) Designing Data Task Force and is the ACNM representative to the ACOG convened Women’s Health Registry Alliance. She is currently the Director of ACNM's first multi-hospital QI Collaborative: The Healthy Birth Initiative: Reducing Primary Cesareans.

9. Goals for today Review Team Checklist for first Quarter
Understand the relationships of the Data, the Bundle Checklists (formerly “Deliverables”) and the Bundles
Understand how these can assist you in working on the Readiness section of your bundle
Be prepared to articulate next steps for YOUR project

10. First Quarter 2018 checklist
Did you attend the 1/5 webinar OR Did you review the presentation materials and recording on Basecamp or the RPC member website?
Are you having regular team meetings?
Has your team developed a charter? OR Have you refreshed/reviewed your team charter?
Did you join Basecamp? AND Do you use Basecamp to locate resources?
Have you logged onto the RPC Member Website?

11. data, the Bundles and the Bundle Checklists (formerly “Deliverables”)
Understand the Links Between
data, the Bundles and the Bundle Checklists (formerly “Deliverables”)

12. Informs the problem, drives the selection of a bundle and provides evidence that change is occurring.
Data

13. What does the data in your setting tell you?
Is your NTSV rate driven by labor dystocia or
Is your NTSV rate driven by fetal intolerance of labor
(that is, management of Cat. 2 tracings)

14. Which is the driver in my hospital?? -Data can provide the answer
Latent phase admission
Nullip. (first birth) labor induction
Esp. with unfavorable cervix
Dystocia/Failure to progress
Arrest or protraction disorder
2nd Stage (failure of descent)
Predicted macrosomia
Patient choice
Non-reassuring Fetal Status
Oxytocin/misoprostol associated tachysytole

15. Evidence and Culture Change
What “Drives” the Actions within the Bundles?
Evidence and Culture Change

16. Evidence Based Care
Consistently endorsed as the goal for all providers of care
Clinical guidelines, bulletins and practice recommendations all employ evidence measures
YET
Having the evidence does not mean practice changes

17. Culture Supporting Vaginal Delivery/Physiologic Birth
Success means that clinical providers, administrative support and the public:
appreciate the true value of achieving a vaginal delivery
respectfully acknowledges the desires of the patient
maintains educational processes, facilities, equipment and staff expertise which can maximize the chance of successfully obtaining vaginal delivery which is safe for mother and infant(s).

18. Implementation of Quality Improvement Bundles
Readiness!
Implementation of Quality Improvement Bundles

19. The bundles Check List Assists in assessment
Assist in setting goals and processes to be used
Measures progress
The bundles Check List

21. Assessments to be completed at intervals during the year
These assessments are meant to both measure progress and guide you to the next steps.

22. Example: Promoting Spontaneous Progress in Labor
Bundle
Readiness
Every unit
Has a unit policy that provides a plan of care, including allocation of space, to enable women in early labor to receive comfort measures and support and to return home prior to active labor admission when safety criteria are met and shared decision making is used to determine acceptability of plan.
Check list
Readiness
1a) Is there a unit policy for early/latent labor?
1b) Is there space to enable women in latent labor to receive comfort measures and support?
1c) Are there safety criteria [in the policy] for return home prior to active labor admission?

23. Example: Promoting Spontaneous Progress in Labor
Bundle
Readiness
Every unit
Provides initial and ongoing training and skill development for all maternity care professionals about evidence-based care practices that support maternal choice and promote spontaneous labor progress with no known risk, eg, mobility, upright positioning, continuous labor support, passive second stage descent, and physiologic pushing.
Checklist
Readiness
2) Is there initial training and skill development for all maternity care professionals (MD, CNM, RN) about evidence based care practices that support maternal choice and promote spontaneous labor?
e.g., mobility,
upright positioning,
continuous labor support,
passive second stage descent,
and physiologic pushing
3) Is there ongoing training for all maternity care professionals (MD, CNM, RN) about evidence based care practices that support maternal choice and promote spontaneous labor?

24. Example: Promoting Spontaneous Progress in Labor
Bundle
Readiness
Every unit
Establishes a common, interprofessional policy for labor care that specifies objective and evidence-based criteria for diagnosing active labor, describes the system of communication to signal that physiologic parameters of labor duration have been exceeded, and indicates triggers for considering interventions to accelerate labor, e.g., oxytocin augmentation or artificial rupture of membranes.
Checklist
Readiness
5. Is there an established interprofessional policy for labor care that:
a) specifies evidence based criteria for diagnosing active labor?
b) describes the system of communication to signal physiologic parameters of labor duration have been exceeded?
c) triggers a protocol for intervention consideration?

25. Readiness has 5 main components
Training/education of all staff in the basic bundle topic
-Initial and ongoing
Guidelines, and/or policies needed for the topic to be implemented
Resources- staffing levels, equipment
Patient education/Shared decision making
Supportive Culture

26. Review the checklist for your Bundle
Review the bundle and the checklist.
Start with Readiness Section
Use it to guide your Smart Goals
Complete checklist before you start
If you have already started, complete the first applicable time (e.g. if started QI activities for the bundle in Dec, fill out the 3 mo. column in late Feb.

27. Remember
All practices are “necessary” and, taken together, “sufficient” to expect improvement in patient outcomes
The checklist helps you to see if you are moving to the point where you should see some improvement

28. Back to Data Assists in assessment of progress
Assist in evaluating goals and processes
Measures progress toward % of reduction
Can assist in “deeper dive” to uncover areas for further improvement
Back to Data

29. Process measures relate to the bundles
Bundles were designed to address the top two actionable factors contributing to primary C/S amenable to physiologic approach
Fetal intolerance  decrease use of EFM*
Arrest of labor  support normal progress
 increase care and coping
*in low risk women following the evidence

30. Required Process measures assess support of physiologic birth
Comfort and Coping Bundle: Percent women assessed for coping in labor. Progress of Labor Bundle: Percent women with 1:1 continuous labor support. Fetal monitoring (“IA”) Bundle: Percent of women assessed for (eligibility for) IA
So in addition to the checklist, the data center also helps you to track progress.

31. Other variables address bundle elements
Bundle Element: Establishes a common, interprofessional policy for labor care that specifies objective and evidence-based criteria for diagnosing active labor, describes the system of communication to signal that physiologic parameters of labor duration have been exceeded, and indicates triggers for considering interventions to accelerate labor, e.g., oxytocin augmentation or artificial rupture of membranes. Deliverable: Are there objective criteria to assess a woman's stage of labor?
Labor Progress Bundle
Was 1:1 continuous labor support provided?
Did the provider or team use a graphing tool to assess labor progress (optional question)
Use

32. Once your bundle is chosen go to the RPC member page and download the “Evidence for Bundles.ppt” and review.
Next Steps 1. Download your Bundle data Collection sheet from the ACNM Data Center 2. by Feb 21, 2018 Design and Implement your Data Collection Process 3. Become familiar with the actions in your Bundle 4. by March 15th- Submit your pre-Implementation deliverable sheet to

33. Your coaches Ana Delgado, MSN, CNM Holly Smith, MPH, MSN, CNM
Ana is Associate Clinical Professor at UCSF, and Assistant Director of Inpatient Obstetrics at ZSFG.
In addition to teaching and providing clinical care, she has been leading obstetric quality improvement efforts at her hospital since Ana was integral to the design and founding of ACNM’s Reducing Primary Cesareans Collaborative, and has served as faculty, coach, and member of the Steering Committee since its inception.
She holds a BA from Claremont McKenna College, and an MS from University of California, San Francisco
Holly Smith, MPH, MSN, CNM
Holly is the Clinical Lead for the Southern California cohort of the CMQCC Collaborative to Support Vaginal Birth and Reduce Primary Cesareans, a comprehensive statewide effort to reduce unnecessary cesareans in California. She was the Task Force Co-Chair and Lead Editor of the CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, released in April Holly served as faculty and coach for ACNM’s Reducing Primary Cesareans Collaborative during 2017.
Holly’s clinical experience includes a variety of domestic and international locations including California, the east coast, Guatemala, and Germany. Most recently, she practiced at Kaiser Permanente Roseville Medical Center in Roseville, CA. She holds a BSN from the University of San Francisco, an MSN from Georgetown, and an MPH from the University of Illinois at Chicago.

34. Pointers for encouraging a rich discussion
No question is too basic -- don’t be afraid to ask questions of us and your peer hospitals – if you have a question, it’s likely someone else does, too
At the same time, if the question is really specific, we may suggest that we follow up individually with you to manage our time
Step up, step back

35. Reminder for 2016/17 Cohorts
Have you downloaded any historical data you want to keep before the upcoming deadline of February 15, when the data center will be transitioning to the new, simplified model?

36. Starter questions
How is your data collection going? We have noticed that some of you have not submitted either baseline or new data.
Are you making progress on setting SMART goals and developing your charters?
Have you completed the bundle checklist for this or last year’s bundle?
When you completed your bundle checklists:
What surprised you?
What do they think the biggest challenges are?
What resources do you feel you need in order to get started?