Culture Shift and Improving Patient Care: Keys to Meaningful Reform

Is there anything more joyful to a mother than delivering a healthy baby? And helping that magical moment occur just a bit sooner is a good thing, right? Not according to the research.

Robert WiebeStudies indicate that choosing to deliver earlier than 39 weeks could pose a threat to the health of both baby and mother. In one study, late pre-term vs. term morbidity rates doubled for each gestational week earlier than 38 weeks.1

Many doctors, expectant mothers, and hospitals continue to schedule what are known as "early elective deliveries," or EEDs, even though clinical research has shown that reducing them leads to healthier babies, healthier mothers and lower overall healthcare costs.

This was important to us at Dignity Health, one of the five largest health systems in the nation. We tackled EEDs in all 31 of our hospitals with labor and delivery programs and have successfully reduced their use by more than 85 percent in less than a year, saving an estimated $1 million in neonatal intensive care unit costs. While implementing the change had its challenges, engaging our physicians and putting strong rules in place for when a delivery could be scheduled allowed Dignity Health to succeed.

EEDs have been on the rise

Some mothers like the convenience of planned deliveries. They like knowing that their physician will be the one to deliver their baby. They sometimes grow weary of being pregnant and assume there's little risk in moving up the delivery. Historically, some physicians have accommodated these mothers and have rarely noted a problem with the practice. But there is a problem. And in 2011, there was a need for consciousness-raising at Dignity Health.

To clarify, we're talking only about early elective deliveries. You can't prevent all early deliveries, of course; nor would you want to. There are good reasons for early delivery including various fetal issues, hypertension, preeclampsia, maternal diabetes and placenta problems.

But EEDs are choices made by physicians and mothers to deliver early when there is no medical need to do so. They come with unnecessary risks, including newborn feeding problems, respiratory distress syndrome, NICU admissions and a higher mortality rate. Since 1979, the American Congress of Obstetricians and Gynecologists has warned against delivering babies before 39 weeks in the absence of a medical indication.

Nonetheless, for the past two decades, the national rate of EEDs has been on the rise. Deliveries between 37 and 38 weeks gestation increased dramatically, from 19.7 percent of all live births in 1990 to 28.9 percent in 2006.2 More than 9 out of 10 women surveyed recently believed giving birth before 39 weeks is safe.3 The issue is important enough that the March of Dimes has given the nation's delivery wards a collective "C+" grade largely because of the prevalence of EEDs.

How Dignity Health tackled the EED problem

Beginning in 2011, Dignity Health examined two years of birth records in its hospitals, identified how many inductions or cesarean sections were performed in weeks 35 through 39, determined how many were elective and then gauged how the infants fared. In line with scientific studies, EEDs at Dignity Health had more frequent problems than births at 39 weeks or later.

Dignity Health took decisive action and got quick results. We were able to reduce the rate of EEDs from 7 percent to 1 percent in less than one year. The statistic reflects all 31 hospitals in the Dignity Health system with labor and delivery units. Most Dignity Health hospitals are now at zero. Notably, Woodland Healthcare in Woodland, Calif., reduced its EEDs from 12 percent to zero.

The challenge of change

Change was not easy. Early elective deliveries had become part of the medical culture. Fundamental to driving lasting change was understanding why these procedures were continuing to be performed long after warnings had been issued. One key reason was in the patient handoff among physicians. Many physicians were unaware that babies they delivered early ended up in the NICU. So if it isn't broken, they thought, why fix it?

Dignity Health's change initiative started with nursing leadership who dug into two years of data on EEDs and determined which cases ended up with babies in the NICU. They also looked at all early deliveries and their associated ICD-9 codes. When the nurse practitioners analyzed the codes against the detailed records, they "unmasked" early deliveries that turned out to be elective. "Mother in distress," for example, can mean the mother is truly at risk, or it can mean the mother is tired of being pregnant.

Change involved substantial physician involvement and education. The first step was bringing the data on EED morbidity — published research and Dignity Health's own data — to the physicians. That alone prompted most physicians to follow the guidelines, but a few holdouts thought the babies with problems were ones that other doctors delivered. That wasn't the case. More than once, the most stubborn holdouts turned out to be ones whose deliveries had some of the higher NICU admission rates.

However, the most effective measure in solving the problem was the work of our patient safety experts. They issued policies declaring that any physician scheduling a delivery before 39 weeks needed to demonstrate and document a valid medical necessity. Without medical necessity, staff would not allow the delivery to be scheduled and moms-to-be were sent home until the baby was full term. These directors became the gatekeepers; EEDs and associated NICU stays drastically declined.

Big change, big savings

As mentioned, the program saved Dignity Health an estimated $1 million in reduced NICU stays in the first year. Here's the breakdown:

The baseline period, April through August 2011, saw 355 EEDs, which we can extrapolate to 852 EEDs per year. Going forward, Dignity Health reduced that number to 9 EEDs per month, or 108 EEDs per year.

That's a reduction of 744 EEDs per year. If experience held true, and 9.4 percent of those babies would have gone to the NICU, that's 70 babies avoiding the NICU. At an average cost of $15,172 per stay, that amounts to $1,062,000 savings per year.  

Extrapolated outwards, if all California hospitals applied the same approach as Dignity Health, savings would jump to more than $104 million and almost 7,000 babies avoiding the NICU.4 Nationally, the numbers rise to $700 million in savings and more than 45,000 babies avoiding the NICU.

Changing methodologies

Dignity Health's successful change management strategy followed an implementation plan based on recommendations by the March of Dimes.5 The framework looks like this:

  • Aggressively educate clinical staff, patients and the public.
  • Implement policies for approving appropriate exceptions to the no-EED policy.
  • Reform elective delivery scheduling protocols to provide clear direction to nursing staff and scheduling clerks.
  • Designate a physician or physicians who "own" the EED reduction initiative and can approve exceptions to the policy.
  • Collect data on reductions in EEDs and the outcomes. Create charts to display those findings, widely disseminate the results and further enhance clinician education.

Many systems are now making similar changes, but what made Dignity Health's success so great was a combination of careful planning and diligent record keeping and auditing. The list of acceptable early delivery medical indicators offered by the March of Dimes was lengthened and strengthened to better fit our goals and hospitals. We also placed perinatal safety specialists at the facilities who audited 100 percent of medical charts for early deliveries. By combining these strategies, we began to see significant progress.

Easier said than done, but worth the effort

It worked, thanks in large part to culture change and the hospital champions who understood the problem and who were motivated to solve it methodically. Our Senior Vice President for Patient Safety, Barbara Pelletreau; perinatal Clinical Safety Specialists, Janet Fulton and Brenda Chagolla; and Laurence Shields, MD, and John Keats, MD, led the team at Dignity Health, ensuring that the culture changed enough to ensure that a great idea was quickly and systematically put into practice. Mothers, babies, doctors, families and the health system are all benefitting.

"The most important thing," Dr. Shields says, "is that by putting this plan in place, we are enabling families to take their newborns home healthier and sooner following delivery."

Robert L. Wiebe, MD, MPH, MBA, is EVP/Chief Medical Officer for Dignity Health. Dr. Wiebe leads Dignity Health’s organization-wide clinical and patient care efforts, including quality, patient safety, patient satisfaction, risk services and physician leadership development. Additionally, he oversees Dignity Health’s home health services and is instrumental in the full implementation of Dignity Health’s clinical information systems.

Footnotes:

1 Shapiro-Mendoza CK et al. Effect of late-preterm birth and maternal medical conditions on newborn morbidity risk. Pediatrics. 2008;121:e223–e232. Included in Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, and Kowalewski L. Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #08-85012 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; First edition published by March of Dimes, July 2010.
2 Martin J, Hamilton B, Sutton P, et al. Births: Final data for 2006, National Vital  Statistics Reports, Division of Vital Statistics (Percentages were prepared by the March of Dimes). Atlanta, GA: National Center for Health Statistics; 2009. (via CMQCC/CDPH/March of Dimes toolkit, p. 5)
3 Goldenberg RL, McClure EM, Bhattacharya A, Groat TD, Stahl PJ. Women’s perceptions regarding the safety of births at various gestational ages. Obstet Gynecol 2009 Dec;114(6):1254-8. Survey cited in CMQCC/CDPH/March of Dimes toolkit, p. vi.
4 Assumptions: ~600,000 babies born in California every year, 12.2% are EEDs and 9.4% of those babies end up in the NICU at a rate of $15,172 per stay [(600,000 x 12.2% = 73,200 EEDs), (73,200 EEDS x 9.4% = 6,880 NICU admissions), (6,800 x $15,172 = $104,383,360 savings)].
5 Main E, Oshiro B, Chagolla B, Bingham D, Dang-Kilduff L, and Kowalewski L. Elimination of Non-medically Indicated (Elective) Deliveries Before 39 Weeks Gestational Age. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #08-85012 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; First edition published by March of Dimes, July

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