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 1-3 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. PDSA Plan 1. Objective 2. Questions and predictions (why) 3. Plan to carry out the cycle (who, what, where, when)

8. Plan 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? Data: what and how are you going to measure?

9. Two hospitals (data from RPC member institutions) University Affiliated Medical Center (UAMC) 4800 births annually 38% Primary Cesarean Community Hospital (CH) 1250 births annually 31% Primary Cesarean

10. 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.

11. Planning process 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. PDSA Plan 1. Objective 2. Questions and predictions (why) 3. Plan to carry out the cycle (who, what, where, when) Do (small scale) 1. Begin to implement the plan 2. Document problems and unexpected observations 3. Begin analysis of the data

13. Do Bundle selection Implementation – Interdisciplinary

14. Rapid cycle (“easy win”) UAMC Bundle interest Promoting spontaneous progress in labor UAMC Barrier Lack of consensus among care providers that C/S rate needs to be decreased CH Bundle interest Promoting comfort in labor Promoting spontaneous progress in labor CH Barrier RN staffing models that make bundle implementation difficult

15. 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

16. PDSA Plan 1. Objective 2. Questions and predictions (why) 3. Plan to carry out the cycle (who, what, where, when) Do (small scale) 1. Begin to implement the plan 2. Document problems and unexpected observations 3. Begin analysis of the data Study 1. Compare data to predictions 2. Summarize what was learned

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

18. PDSA Plan 1. Objective 2. Questions and predictions (why) 3. Plan to carry out the cycle (who, what, where, when) Do (small scale) 1. Begin to implement the plan 2. Document problems and unexpected observations 3. Begin analysis of the data Study 1. Compare data to predictions 2. Summarize what was learned Act 1. Next cycle of action. 2. What changes need to be made?

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

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

21. METRICS Cathy Emeis

22. 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

23. ACNM Data Center

24. REFLECTIONS Ana Delgado