1. Healthy Birth Initiative  Reducing Primary Cesareans Collaborative

2. Our Team for Jan. 8 th Webinar Elliot Main Leslie Cragin Cathy Emeis Ana Delgado Kate Chenok

3. Agenda for Reducing Primary Cesareans Webinar Jan 8 th 2016 1-2:30 p.m. Eastern (12 Central, 11 Mountain, 10 Pacific) Intro2 Bundle Implementation Process10 Unwarranted variation/drivers20 Discussion10 Data collection process 20 Questions15 Reflections on barriers/facilitators5 Wrap up2

4. Objectives for Call Understand the overall process of implementing a bundle Discuss unwarranted variation in the drivers of NTSV Cesarean Birth Review the variables and process for collecting QI data

5. BUNDLE IMPLEMENTATION PROCESS Leslie Cragin

7. Plan- Big Picture What are you trying to accomplish? Reduce NTSV cesarean section rate – What is your target amount and time frame (1 year?) Team: content experts, leaders Predictions: what drives your NTSV cesarean birth rate? What decrease do you want to see Data: what and how are you going to measure?

8. Initial Work Identify your patient/target population Analyze your drivers and contributing factors for the NTSV rate Choose your bundle Become familiar with what will be measured and how, including outcomes and processes Develop a preliminary picture about how all the elements work together to get the desired result, and note the most important elements (could be a driver diagram or other visual tool) Describe an ideal system: How will care be delivered? Identify major gaps between this and the current system. Tackle an “easy” part of the system first.

9. Structure and Process MAP-IT Mobilize people and resources Assess Implement Track

10. Two hospitals (data from RPC member institutions) University Affiliated Medical Center (UAMC) 4800 births annually 38% Primary Cesarean Barrier Lack of consensus among care providers that C/S rate needs to be decreased Community Hospital (CH) 1250 births annually 31% Primary Cesarean Barrier RN staffing models that make bundle implementation difficult

11. Planning- Assess UAMC Strengths Institutional commitment to lowering the C/S rate Commitment to evidence based practice UAMC Barrier Lack of consensus among care providers that C/S rate needs to be decreased CH Strengths Culture of change in our workplace Commitment to evidence- based practice CH Barrier RN staffing models that make bundle implementation difficult

12. Other Assessments Deliverables Drivers

13. Key bundle elements Develop guidelines and policies in support of change Training for everyone who is part of the care team All needed resources are reliably available Shared decision making is a part each conversation about an intervention or procedure Data is gathered to support the QI process

14. UAMC Bundle interest Promoting spontaneous progress in labor CH Bundle interest Promoting comfort in labor Promoting spontaneous progress in labor

15. Rapid cycle improvements UAMC Goal: All providers educated about importance of reducing NTSV – Champions for reduction of rate mobilized, – Grand Rounds “debate” held – Existing policies reviewed for consistency with the evidence CH Goal: All women who desire an unmedicated birth will have access to comfort measures – Inventory of current supplies – Lunch time trainings in care practices

16. Study Data analysis Compare results to predictions What was learned?

17. Act How can you get closer to your goal? What changes can you make to be more successful?

18. Jan – Logistics, Train in data collection, and Implement – Assess drivers and select bundle Feb – Begin first PDSA cycle March – First cycle completed?

19. NTSV: UNWARRANTED VARIATION AND DRIVERS Dr. Elliot Main

20. METRICS Cathy Emeis

21. Metrics Outcome Measure: NTSV cesarean rate Balancing Measure: Apgars less than 7 at 5 min. Variables for all NTSV patients: 13 Variables per bundle: 4-7

22. Before Data Collection Begins: Before data collection begins, have an Information Technology Specialist at your hospital ensure : 1.the monthly data collection spreadsheet is located in a secure location on your network, accessible to all the individuals who will be using it. 2.a current version of Microsoft Excel is installed at the workstations that will be used to input the data.

23. The RN and/or CNM/MD who attended the delivery should do the following: Step 1: Determine if the patient case was NTSV: 1.Nulliparous (no prior pregnancies beyond 20 weeks) 2.Term (37+0 weeks gestational age) 3.Singleton 4.Vertex presentation After Every Delivery:

24. Step 2 Open the spreadsheet

25. Step 3: Answer using drop down Answer all the questions from left to right using the available drop-down options. Please DO NOT populate any of the questions with manually typed responses.

26. PLANNING DATA Ana Delgado

27. Planning Survey: Top Ranked Assets Responses% Who Ranked in Top 3 Commitment to evidence-based practice95% Institutional commitment to lowering the C/S rate67% Front-line staff commitment to lowering the C/S rate 67% Significant in-house QI expertise42% Culture of change in our workplace35% Consumer interest in lowering the C/S rate29% Adequate funding to procure needed supplies and equipment 21%

28. Planning Survey: Top Ranked Barriers Responses% Who Ranked in Top 3 Lack of consensus among care providers that C/S rate needs to be decreased 62% Skepticism about specific bundle items54% RN staffing models that make bundle implementation difficult 43% Lack of funding for necessary staff time. supplies or equipment 32% Overly bureaucratic processes that make change very slow32% Workplace culture is not receptive to change30% Technical difficulties related to data collection25% Resistance to protocol or bundle-driven care24% Lack of staff champions20% Problems with collecting the raw data13% Lack of shared decision-making between providers and patients 4%

30. Planning Survey: Priorities for Jan. 28 Meeting Topics% who ranked as priority (top 5) Review of the evidence behind each bundle84% More information about the structure and timeline of the collaborative itself 60% Specific QI techniques (fishbone diagrams, rapid cycle PDSA, etc) 56% How to facilitate difficult conversations56% Tips for creating a culture of change48% Support for leadership development for my collaborative team 48% Hands-on data collection tech support44% How to identify and cultivate stakeholders36% Opportunity for making peer/regional connections20%