1. Habersham Medical Center Kelly J. Allen, RN, BSN, RNC

3.   Acute Care Hospital Licensed for 53 Bed  Average Daily Census 24  Family Birthing Center  Annual Census 450/yr.  Level II Nursery  Community Wellness Program  Long Term Care for 84 Residents  HCMC Home Health Agency  Six Physician Practice Offices Habersham Medical Center

4.   Habersham Medical Center’s mission is to provide high quality, caring in a compassionate, professional and economical manner to all persons in Habersham County and adjacent areas. Mission Statement

5.   How to determine “due date”  Brain development between 36-40 weeks.  Why it is important to wait 39 weeks to deliver  Organ growth  Vision and hearing impairment  Weight/warmth  Suck and swallow Established

6.   2006 HMC Blue Cross Blue Shield Quality Initiative for Perinatal Care (Joined 6 months into the active year) In the beginning…

7.   - Does your hospital have a policy in place prohibiting elective deliveries prior to 39 weeks gestation?  (including elective C-Sections) Perinatal Care 1

8.   - Does your hospital have a policy in place requiring the use of ACOG recommended DVT/VTE prophylaxis for patients undergoing cesarean section delivery? Perinatal Care 2

9.   Does your hospital have a policy in place adopting ACOG recommendations for the appropriate use of corticosteroids for patients experiencing labor/birth prior to 34 weeks gestation? Perinatal Care 3

10.   - Does your hospital have a policy in place that requires bilirubin level screening of all infants prior to post-delivery discharge? Perinatal Care 4

11.   2006-2012  HMC identified our policy stated we did not perform elective deliveries <39 weeks but did not allow for the outliers related to best practice/ ACOG standards. POLICY

12.  Describe your first (or next) test of change Person Responsible When to be done Where to be done 1. Expand the current policy to include Medical Indications for Induction of Labor by ACOG & IHC standards. Kelly AllenMarch 2012 Patient Care Safety Council, Patient Care Treatment Services, & MEC. GOAL- Revise Process- Step One

13.  List the tasks needed to set up this test of change Person Responsible When to be doneWhere to be done 1. Schedule time to review guidelinesKelly AllenMar-12Pre-Meetings 2. Review with OB/GYN PhysiciansKelly AllenMar-12FBC 3. Review with staffKelly AllenMar-12Staff Meeting 4. Take through committeeKelly AllenApr-12PCSC 5. Take through committeeKelly AllenMay-12PCTS 6. Take through committeeTeri NewsomeJun-12MEC 7. Roll out to all staffKelly AllenJun-12Staff Meeting Step Two

14.  Predict what will happen when the test is carried out Measures to determine if prediction succeeds 1. Screening of elective deliveries will take place at the time of scheduling. 1. Monitoring of all deliveries <39 week deliveries. 2.Monitor all “scheduled” <39 week deliveries have appropriate documentation to support delivery. Step Three

15.   DO:  Describe what actually happened when you ran the test of change.  Found our documentation did not meet the expectation of our policy.  Found no screening tool available at the time the elective delivery was being scheduled. Step Four

16.   STUDY:  Describe the measured results and how they compare to the predicted results.  After the implementation of the scheduling procedure, it brought a more focus on the policy.  Documentation improvement noted after revision of the policy and scheduling procedure. Step Five

17.   ACT-  Describe what changes to the plan will be made for the next cycle from what you learned  All inductions are required to sign an Induction Instructions Form explaining the potential risks and benefits of Labor Induction.  Hardwiring the process into our education program would sustain the progress.  Including the monitoring of deliveries to the Credentialing and Privileging process.  100% <39 week deliveries are reviewed. Step Six

18.   Commercial  Supporting March of Dimes (making a change in national perception)  March of Dimes commercial educates the public the need to let the baby fully grow up to 39 weeks.  HMC Instruction Sheet supports the March of Dimes public commercial. Community Education

19.   Incorporate standards into Family Birthing Center’s initial orientation and annual orientation.  Review 100% <39 week delivery for appropriateness of care and medical indications for delivery.  Provide staff feedback. Education

20.   Send CEO, CFO, and Sr. VP Patient Care Treatment Services OB Adverse Event Data via email.  Place on Administration’s Communication Board.  Place on Family Birthing Center’s Communication Board.  Manage up the Family Birthing Center’s good work in meetings with leadership. Administrative Involvement

21.  “Objective”  Eliminate all non-medically indicated deliveries less than 39 weeks by January 1 st, 2013.

23.   Zero elective deliveries < 39 weeks gestation x 6 months.  Average APGAR at the 5 minute post birth check = 9  2012 HMC has had 7 transports to higher level of care:  29 week with No Prenatal Care  35.4 LUGR  37.3 Labor-gastroschisis  28.6 NRFHT’s  36 & 38 week PIH  38.2 Active Labor  HMC continues to improved outcomes save lives! In conclusion…

24.  New Beginnings…