1. Partnership for Patients Safe Deliveries Roadmap On-Boarding Webcast July 8, 2013

2. Safe Deliveries Roadmap Project Coordinator Mara Zabari, Director of Integration Partnership for Patients 206-216-2529 maraz@wsha.org

3. Project Leaders Tom Benedetti, MDDale Reisner, MD University of WashingtonSwedish Hospital

4. Safe Deliveries Roadmap Consultants Eric Knox, MD Kathleen Simpson PhD, RNC, FAAN

5. The Vision

6. The BIG Picture

7. Todays Webcast Objectives Project updates Review induction management bundle clarification Laying the foundation Medicaid Quality Incentive – OB measures Sharing practices Discuss upcoming activities

8. Participating Hospitals Cascade Valley Central Hospital Coulee Medical Center EvergreenHealth Harrison Medical Center Highline Medical Center Island Hospital Jefferson Healthcare Kittitas Valley Healthcare Lake Chelan Community Hospital Mid Valley Hospital Multicare Auburn Multicare Good Samaritan Hospital Multicare Tacoma General Hospital Newport Hospital Northwest Hospital Othello Community Hospital Overlake Hospital PeaceHealth Southwest PeaceHealth St. Joseph Providence Mt. Carmel Hospital Providence Regional Medical Center Providence St. Mary Medical Center Providence St. Peter Hospital Pullman Regional Hospital Samaritan Skagit Valley Hospital St. Francis Hospital St. Joseph Medical Center Sunnyside Hospital Swedish Ballard Swedish First Hill Swedish Edmonds Swedish Issaquah Three Rivers Hospital University of Washington Medical Center Walla Walla General Hospital Whidbey General Hospital Whitman Hospital Valley General Hospital Valley Hospital UW/Valley Medical Center Yakima Valley Hospital

9. Project Time Line Update June – July Laying the foundation August – November Education Tools testing and revision December Baseline data collection January Implement bundle practices AND, THEYRE OFF!

10. Other Project Updates Hospital questionnaire Contact lists List-serves Meeting notifications Primary contact Provider session topics Readiness assessment

11. Induction Management Bundle Clarification Failed Induction Definition: Induced, but does not enter active labor (>6cms) Uterine contractions Failure to achieve contractions every 3 min with cervical change after 24 hrs of pitocin plus ruptured membranes (if no contraindications), or Contractions every 3 min x 24 hrs without entering active phase for those with initial Bishop score less than 8 or if cervical ripening used Inadequate response to a needed, clinically appropriate, second cervical ripening agent Membranes have been ruptured with inadequate progress (assuming feasible and no contraindications to AROM) Pitocin has been given per hospital protocol if inadequate frequency +/or intensity of contractions occur after cervical ripening alone If ROM, Pitocin given x 12 hrs without regular contractions resulting in cervical change Discuss options for further management: Consider RBA of all options (D/C home w/plan for f/u versus C-Section, depending on the clinical situation)

12. Laying the Foundation Early Establishment of EDD ACOG Criteria Estimated Date of Delivery - use EDD, not EDC and report as wks + days, not in decimals – eg 38 5/7 wks (ReVitalize, 12/2012) The best obstetrical Estimated Date of Delivery (EDD) is determined by: 1) Last menstrual period (LMP) if confirmed by early ultrasound or no ultrasound performed *, or 2) Early ultrasound if no known LMP or the ultrasound is not consistent with LMP, or 3) Known date of conception (eg. ART, IUI, IVF) dating * Ultrasound-established dates should take preference over menstrual dates when discrepancy is >7 days in 1 st tri and >10 days in the 2 nd tri. US considered to confirm menstrual dates if GA agreement within 1 week by 1 st trimester CRL or within 10 days by averaging multiple 2 nd trimester fetal biometric measurements (up to 20 wks gestation) ACOG Practice Bulletin 101

13. Laying the Foundation Early Establishment of EDD 8% Rule Comparison of Ultrasound with LMP clinical dating for best EDD Most accurate method at any gestational age Method (may be used by Radiology, MFM): Convert LMP & US EGAs from wks to days, multiply x.08 for # days diff & use US if greater, use LMP if less than calculated variance. Eg: LMP ga is 9wks (63days x.08 = +/-5 days) but US ga is 10wks (or 7days greater) – thus the US is most accurate EDD for this pg (by ACOG would stay with LMP dating since +/- 1 wk) Hadlock FP, Deter RL, Harrist RB, Park SK. Estimating fetal age: Computer-assisted analysis of multiple fetal growth parameters. Radiol. 1984;152:497-501. Savitz DA, Terry JW, Dole N, Thorp JM, Siega-Riz AM, Herring AH. Comparison of pregnancy dating by last menstrual period, ultrasound scanning and their combination. Am J Obstet Gynecol. 2002;187:1660

14. Laying the Foundation Induction Consent Combination Patient Education and Consent Form explains: Why induction is being done (Medical indication or Elective) Potential Risks & Benefits & Alternatives Possible options for cervical ripening, if needed Oxytocin use Providers appreciate the balance of informing women of the increased risk of C/section, longer labor, poor fetal transition, when induction is not medically necessary – but information is presented in a manner to not scare them if delivery is medically indicated. Discuss & Sign at time of Scheduling the Induction! Fax to L&D Some versions include Bishop Score, thus may aid schedulers Do not take the place of hospital consents for care

15. Questions

16. Medicaid Quality Incentive Safe Deliveries: Induction Appropriateness and Elective Deliveries Prior to 39 Weeks (Hospitals with obstetrical programs only) Improvement measure: percent of patients undergoing a medical or non medical labor induction with documentation of consent, Bishop Score, and indication Sustaining measure: percent of patients with Elective Deliveries 37 to less than 39 weeks gestational age

17. Induction Appropriateness Numerator: Number of patients undergoing a medical or non-medical induction with documentations of consent, Bishops score and indication Denominator: Number of patients undergoing a medical or non-medical induction Documentation sources for Bishop score and induction can be taken from the consent, medical record, or checklist available if audited by the Healthcare Authority. Hospitals are encouraged to make a part of the medical record if possible.

18. Induction Appropriateness (Cont:) For hospitals that use on each of their induction patients a standard hospital consent that includes all elements, no audit is needed. For written consent the following is required under RCW 7.70.060(1): Identification of patient Name of hospital in which treatment is to be performed Name of attending physician Nature, anticipated results, alternatives to and risk of proposed treatment, including nontreatment When the proposed treatment will be given Date and time of signing the consent Signature of patient or patients representative Witness If hospital does not use a standard consent for all induction patients, the hospital will conduct an audit of a minimum of thirty records randomly selected to review if all elements of consent are present. Audit must be available for the Health Care Authority to review. http://www.wsha.org/qualityincentive.cfm

19. Induction Appropriateness (Cont:) Fields to be reported: Number of patients undergoing a medical or non-medical induction with documentation of consent, Bishop score and induction indication. (numerator) Number of patients undergoing a medical or non-medical induction. (denominator) Data collection period: September 1, 2013 - December 31, 2013 Reporting deadline: 45 days following the end of the quarter Award table:

20. Consent and Scheduling Form

21. Community Sharing

22. Elective Deliveries Prior to 39 Weeks (Applies to hospitals with obstetrical programs only) Sustaining Measure: Percent of Patients with Elective Deliveries 37 to Less than 39 Weeks Gestational Age Review Process No Sampling Safe Deliveries http://www.wsha.org/0513.cfm%20

23. Elective Deliveries Prior to 39 Weeks (Cont:) Fields to be reported: Patients with elective deliveries >= 37 and < 39 weeks of gestation Patients delivering newborns with >= 37 and < 39 weeks of gestation after exclusions removed (see denominator definition above) Data collection period: July 1, 2013 – December 31, 2013 Reporting deadline: 90 days following the end of a quarter and final data in by March 30, 2014 Award table:

24. Community Sharing

25. Meeting Schedule On-boarding (webcast) Thursday, August 15 th 7:00 – 8:00 a.m. Monthly (webcast) Tuesday, September 3 rd 7:00 – 8:00 a.m. Tuesday, October 22 nd 7:00 – 8:00 a.m. Tuesday, November 5 th 7:00 – 8:00 a.m. Thursday, December 5 th 7:00 – 8:00 a.m. Safe Table (in-person) Tuesday, November 19 th 9:00 – 2:30 p.m. First Quarter 2014 meetings will be determined by October 2013

26. Questions? Mara Zabari, Director of Integration Partnership for Patients 206-216-2529 maraz@wsha.org