1. Improving Birth Outcomes

2. DISCLOSURE
I have no financial interests or other relationship with manufacturers of commercial products, suppliers of commercial services, or commercial supporters. My presentation will not include any discussion of the unlabeled use of a product or a product under investigational use.

3. “Shapers of what might be.”
The Role of the Leader
“Servants of what is.”
And,
“Shapers of what might be.”

4. Leading is not Tidy Decisions are made and then reversed
Misunderstandings are frequent
Inconsistency is inevitable
Inside every solution are the needs of new problems
Most of the time most things are out of hand
Nonaka and Takeuchi, The Wise Leader

5. Health and Mortality

6. Will Changes in Models Force Changes in Structure and Systems?
Policy
(Payment Reform)
Organizational Structures
(ACOs)
Relationships/ Patterns of Interaction
Individual Behaviors
Organizational Performance
Structure
Process
Outcomes
Improvement Science
Hoffer-Gittlell, Heller School
Brandeis University

7. Where are you in the Model Life Cycle?
Viability
Adaptive Leadership
Technical
Leadership
Patient
Inflection Point
Clinical Model
Episodic Care 
Coordinated Care 
Patient Directed Care
Business Model
Fee for Service 
Bundled Payment/Capitation 
Disruptive Innovation?
Infrastructure
Segmented 
Integrated 
Cloud
Adapted from The Second Curve, Ian Morrison 1996
Models

8. The Patient’s Health Record Cloud Infrastructure
Fitness Center
Financial Services
Home Telemetry
Grocery Store
Pharmacy
Primary Care
Home Health Care
Long Term Care
Specialist
Hospitals

9. What is:

10. And what can be:

13. Opportunities Each week 174 babies premature
VLBW babies in South Carolina= $107 million per year.
Over a thousand VLBW births per year
235 VLBW cases are multiple birth deliveries
Small number but over 50% of hospital charges

14. Louisiana Birth Outcomes Initiative

15. Louisiana Philosophy We strive to improve health and health care by:
Using the “Lifecourse” theory
Motivating and building will for change with hope and optimism
Consensus, consensus, consensus

16. Louisiana Rankings Indicator US Louisiana Rank
Preterm birth (< 37 weeks gestation, %)
12.3
15.4
48th
Low Birth Weight (< 2,500 grams, %)
8.2
10.8
49th
Very Low Birth Weight (< 1,500 grams, %)
1.5
2.1
C-section rate (%)
32.3
38.0
Infant Mortality
(<1 year old, per 1000 live births)
6.75
9.17
46th
Source: Martin JA, Hamilton BE, Sutton PD, et al. Births: Final data for National vital statistics reports; vol 59 no 1. Hyattsville, MD: National Center for Health Statistics

17. Interventions to Improve Birth Outcomes
Infant
FIMR
Prenatal
Birth
Postpartum & Interconception
Increase use of smoking cessation treatment
Increase use of 17P
Reduce preterm & repeat C-section
New indicators for hospital quality monitoring
Risk assessment and care plan for women with adverse outcome
Family planning
Intensive care coordination/case management
Chronic disease management
Screening and treatment for behavioral health
Home Visitation (Healthy Start, NFP)
Early and Adequate Prenatal Care

18. Top Down Tony Keck Louisiana Department of Health and Hospitals
Louisiana Perinatal Commission
Authorized in 2006, 16 member commission appointed by Governor Jindal
Blue Ribbon Panel

19. Bottom Up Birth Outcomes State Wide Action Teams Care Coordination
Five action teams which represent community partners, consumers, advocates, public health professionals, clinicians, hospital administrators, and insurers
Care Coordination
Health Disparities
Patient Safety and Quality
Behavioral Health
Data and Measurement

20. Ideas
"Ideas are like rabbits. You get a couple and learn how to handle them, and pretty soon you have a dozen."
-- John Steinbeck
This state is at the forefront of increasing national attention on birth outcomes. You are the first rabbit, and soon, there will be dozens who follow in your footsteps because you had the courage to lead this movement now.

21. Birth Outcomes Priorities
Increase Data Capacity and Performance Measurement
Institute statewide comprehensive Behavioral Health screening and brief intervention for pregnant women in Medicaid
Pilot and expand access to Interconception Care Coordination
Increase Patient Safety and Quality of Care

23. Patient Safety and Quality of Care
To create a culture of continuous quality improvement and safety in Louisiana’s birthing hospitals.
Current status should be progress against the goal. Be explicit. What percentage of your overall goal have you attained?

24. Gestational Age That Women Consider it Safe to Deliver

25. Rise in Induction of Labor in US 1990-2006

26. Complication Rates, Scheduled Repeat Cesareans by Weeks of Gestation

28. 115 in a 55 95 in a 55 75 in a 55 55 in a 55 Individual Autonomy
Forbidden
behavior except
under extreme
circumstances
95 in a 55
Safety regs
& good practices
Certification/
accreditation
standards
Individual Autonomy
75 in a 55
Collective
memory of
experiences
55 in a 55
Individual
Pressures
the ‘illegal-illegal’ space (for almost all of us!)
Perceived
Vulnerability
Usual space
of action
Illegal-normal
space
VERY UNSAFE SPACE
Guidelines as defined by professional standards Legal space
Forbidden
by all
Belief in
Systems-
guidelines
<1% % % 80% % percent of staff
PERFORMANCE

29. Progress!
39 week initiative begins

30. Data and Measurement
Create transparency, accountability and quality improvement infrastructure for perinatal quality improvement measurement and reporting.
Current status should be progress against the goal. Be explicit. What percentage of your overall goal have you attained?

31. Perinatal Quality Scores
Pre-term births
VLBW by level NICU
Nulliparous term singleton vertex C-sections (NTSV)
Elective deliveries < 39 weeks gestation

32. Behavioral Health
Ensure that all women in Medicaid receive a behavioral health screen, brief intervention referral and treatment for substance use, depression and violence
Current status should be progress against the goal. Be explicit. What percentage of your overall goal have you attained?

35. Care Coordination
To provide care coordination for every woman in Louisiana Medicaid who has had an adverse pregnancy outcome
Current status should be progress against the goal. Be explicit. What percentage of your overall goal have you attained?

38. Best Babies Zone Community Development Economic Development
Educational
Development
Health
Development

39. Where are you in the Model Life Cycle?
Viability
Adaptive Leadership
Technical
Leadership
Patient
Inflection Point
Clinical Model
Episodic Care 
Coordinated Care 
Patient Directed Care
Business Model
Fee for Service 
Bundled Payment/Capitation 
Disruptive Innovation?
Infrastructure
Segmented 
Integrated 
Cloud
Adapted from The Second Curve, Ian Morrison 1996
Models

40. Perinatal Improvement Community
SC Vision Team
Tony, BZ
Perinatal Improvement Community
SC Hospital Partners
Champions

41. Department of Health and Hospitals Louisiana Birth Outcomes Initiative
DHH Bienville Building
628 N. 4th Street
Baton Rouge, Louisiana
(225)
Website:
The Birth Outcomes Initiative
Rebekah Gee, MD, MPH, MS, FACOG
Director of Birth Outcomes
Michelle M Alletto, MPA
Deputy Director
Bruce Greenstein, Secretary
Kathy Kliebert, Deputy Secretary
Jerry Phillips, Undersecretary
This document was published in-house by the DHH Office of Birth Outcomes