OPQC Progesterone Project Action Period Call

May 22, 2014

12:15-1:15 PM ET

Welcome

Please do not put the call on hold, but please do mute your line!

• Use the MUTE button on your phone or

• *6 to place the call on MUTE and *6 to come off of MUTE

Progesterone Teams • AGMC's Women's Health Clinic

• Aultman Physician Center-OB/GYN Clinic

• Brown County Women's Health

• Center for Health Services - Women's Services

• Center for Women's Health, University of Cincinnati Medical Center

• Doctors Hospital Women's Health Center

• Faculty Medical Center—OB Resident Clinic GSH

• Fairview Perinatal Department

• Five Rivers Health Centers, Center for Women's Health

• Generalist Faculty Practice at MacDonald Women's Hospital (MAC 1200)

• Maternal Fetal Medicine at Hillcrest Hospital Atrium

• Mercy OB/GYN Associates Family Care Center/ MFM Clinic

• MetroHealth Women's Clinic

• Mount Carmel West Outpatient Clinic

• OSU Martha Morehouse MFM Clinic (Kenny Road Clinic)

• OSU McCampbell Hall, OB Resident Teaching Clinic

• OSU Prematurity Clinic

• Outpatient Care Center at Grant Medical Center

• Riverside OB Community Care Clinic/ MFM Consultative Practice

• St. Ann's OB/GYN Clinic

• St. Elizabeth's Health Center Maternal Fetal Medicine

• Tri-State Maternal Fetal Medicine Associates, Inc.

• Wellness on Wheels, OhioHealth

• Women's Health Center at Summa Akron City

• Women's Health Clinic, UH Cleveland

Register for the June Learning

Session! • Where:

The Ohio Union at the Ohio State University

1739 High St.

Columbus, OH 43210

• When:

Thursday, June 26, 2014

Registration opens at 8:30

Sessions start at 9:00

Who Should Attend?

• The Team:

– Lead OB

– Lead RN

– Administrative Manager

– Progesterone Navigator (at your site)

– Hospital Liaison

• Improvement is a team effort!

• Registration link – http://events.constantcontact.com/register/event?llr=r

ozgyolab&oeidk=a07e98t5o1lcbce7224

12:15 PM Welcome and objectives Martha Rome

12:20 PM Cervical Length Measurement

Dr. Jay Iams

12:45 PM Team presentation

12:50 PM Introduction to the Progesterone Navigators

Robin Beringer Jill Morley

12:55 PM Storyboards for June Learning Session

Beth White

1:10 PM

Wrap Up and Next Steps

Martha Rome

Agenda

Objectives for Today’s Call

• Identify protocols to ensure cervical length measurement

• Characterize tests of change ready for implementation

• Identify and solve barriers to administration of progesterone

• Prepare to share work at the June Learning Session

WHERE ARE WE?

1°DRIVERS 2°DRIVERS

Initiate progesterone within 7

days of identification of Short

Cervix ≤ 20 mm

Revision Date: 12-11-13

A STATEWIDE QUALITY IMPROVEMENT PROJECT TO REDUCE OHIO PREMATURE BIRTHS BEFORE 37 WEEKS BY IDENTIFYING AND TREATING PREGNANT WOMEN ELIGIBLE FOR PROGESTERONE SUPPLEMENTATION

SMART AIM

BY July 1, 2015,

DECREASE THE

RATE OF

PREMATURE

BIRTHS in Ohio

Less than 37

weeks by 10%,

and Less than 32

weeks by 10%

GLOBAL AIM

REDUCE INFANT

MORTALITY IN OHIO

BY REDUCING

PREMATURE BIRTHS

Identification of

Women with Hx SPTB

Identification of

Women with Cervical

Length ≤ 20 mm

Prescription of

Progesterone to

Eligible Women at

Risk for Preterm Birth

Removal of Administrative Barriers to Administration of Progesterone

Initiate progesterone

supplementation before 17

weeks in women with a prior

SPTB between 16 and 36 weeks

Adopt a cervical ultrasound

screening algorithm (selective

or universal)

Sonographers credentialed to

perform TVU for cervical

length measurement

Prompt initiation and completion of all administrative steps in provision of progesterone Rx

Reduction of Fertility Practices that are Known to Increase Higher Order Multiple Gestations

Earlier and More Consistent

Recognition of Risk

Potential INTERVENTIONS

• Adopt presumptive eligibility for 1st prenatal

visit

• Identify and develop a “Progesterone

Navigator” to reduce administrative barriers to

progesterone therapy

• Connect women to insurance and other

resources needed to administer progesterone

• When and where appropriate, refer women to

high-risk OB practice/MFM for follow up

prenatal care and progesterone therapy

• Adopt and use ACOG 2012 PTB Guidelines

• Use a log, flag or tracking system to help

ensure that women receive progesterone

therapy when and as needed

• Credential sonographers in CLEaR &

FMF Cervical Length screening

• Use systems that facilitate screening at

the appropriate gestational age

• Use a prompting system (such as a checklist) at

the first OB visit to screen women for history of

preterm birth (PTB)

• Use systems that allow for fast-track of the the

1st prenatal visit for women with a history of

PTB

• Provide early dating ultrasounds routinely to

pregnant women

The starting rates used in the Smart Aim are based on Ohio birth certificate data for the entire state for 2012, using OB estimate of gestational age. Documents from other sources may show a higher rate and are likely

different because they use a either calculated or combined estimate of gestational age. Specific details for measures, including data sources and calculations will be documented and available to all OPQC participants.

Create and implement policies that support the use of progesterone in women at risk for PTB

• Work with key stakeholders including Ohio

Medicaid, Managed Care & FFS, and Private

Insurance companies, pharmacies, ACOG,

March of Dimes etc.

• Use Beacon Coordinators to to support

regional efforts in state metropolitan areas

that increase use of progesterone in women at

risk for PTB

CERVICAL LENGTH

MEASUREMENT

WHY, WHO, HOW AND WHEN?

Dr. Jay Iams

Identification of Candidates for Progesterone Why, Who, How, and When? Iams, Obstet Gynecol June 2014

Find &

Rx

Women

with a

Prior

PTB

Find &

Rx

Women

with a

Short

Cervix

What About Women with No Hx of Preterm Birth?

• Options for Cervical Length Screening

Select IN - Women with Risk Factors

G-U Infections, Cx Dysplasia, Fertility Rx, Hx ≥ 2 EAbs, Family Hx PTB, African Americans, Depression, extremes of BMI, …

Select OUT - Low Risk Women

All but Multiparas w/ > 1 Term Birth or Cx > 35 on TA Scan

Universal – Screen all between 18 - 24 weeks

• None have been tested in real world

Credentialed Sonographers to Measure Cervix

CLEAR (ACOG+SMFM+AIUM+ACR+ACOOG) & Fetal Medicine Foundation

Offer Credentialing Help from OPQC + ODH + OHA

Rx ASAP with Vaginal Progesterone IF Cervical Length ≤ 20 mm Before ____ Weeks of Gestation

Adopt an Algorithm for the Near Short Cervix

Remind Me Again. Why Are We Doing This?

PTB = The Number 1 Cause of Infant Death. Ohio is 47th in Infant

Mortality

Stuart Campbell: “Doing nothing is no longer an option.”

Remind Me Again. What Are the Downsides?

Indication Creep.

Doing this poorly costs same as doing it well and saves fewer babies.

There will always be lawyers.

So What Does OPQC Want Us To Do?

Do Than Waiting for a Woman with a Short Cervix to Appear

Make a

That is Appropriate for Your Patients

That Assures Cervical Scans are Done Correctly

That You Are Ready to Talk to Women With Unexpected Risk of Preterm Birth

the Women You Find Each Month

You Create The Best Care Algorithm For Your Patients

Tell OPQC How Many Women Are Found and Treated

TEAM PRESENTATION

AIM: Establish CL Screening for women without a history

of SPTB. Initially this will be via trans-abdominal scans,

but we will be transitioning to universal trans-vaginal

scans as our sonographers become certified.

We expect this transition to occur by June 1, 2014

So What Does OPQC Want Us To Do?

Do Than Waiting for a Woman with a Short Cervix to Appear

Make a

That is Appropriate for Your Patients

That Assures Cervical Scans are Done Correctly

That You Are Ready to Talk to Women With Unexpected Risk of Preterm Birth

the Women You Find Each Month

You Create The Best Care Algorithm For Your Patients

Tell OPQC How Many Women Are Found and Treated

Questions?

The Progesterone Project Learning Session Storyboard

June 26, 2014

Share Your Progress

• Use this outline as a guide to tell other teams at the Learning Session about your ongoing work in the Progesterone project.

• Customize these slides to reflect your team’s efforts. Feel free to insert pictures, graphs and narratives to create a storyboard that you think best describes your team. Choose your own slide design in Powerpoint: one that suits your style or maybe use your health system’s template.

• When you are finished adapting these slides, print them and bring them with you to the 6/26/14 Learning Session.

• You will be given a 40”x40” space on a standing display and push pins to mount your storyboard.

• Questions? Contact Beth White at bethewhite@aol.com or 419.343.2166 or Mary Ann Swank at swankm@childrensdayton.org or 937.641.3463.

• Save your storyboard slides as a Powerpoint document with your hospital name, such as “BestHosp.Storyboard.ppt”.

• Send your storyboard to OPQC at opqc@cchmc.org by Wednesday, 6/25/14. After the Learning Session, they will be posted on Progesterone website.

The Progesterone Project Learning Session Storyboard

June 26, 2014

[Insert Your Team’s Name] Storyboard

List your team members names and their role on the team

Show us your PDSA cycles

• Display 1 or 2 of your completed (or actively in progress) PDSA cycles

• Tell: – Why did you choose this test?

– How did it go?

– Did your results match your predictions?

– What would you do differently next time?

• If you have any “ramps” of PDSAs show how you went from one to the next

“Progesterone Investigation”

• Digging deeper into our Progesterone processes

– Looking for processes that work well

– Looking for processes that “failed” to broaden

capability in your organization and community

to decrease pre-term birth

“Progesterone Investigation”

• 1-2 women who had spontaneous preterm birth or PROM who did not get progesterone

• 1-2 women who had spontaneous preterm birth or PROM who did get progesterone

• 1-2 women who did not have a spontaneous preterm birth and did get progesterone

“Progesterone Investigation”

– Try to identify 1 or 2 patients in each category

• Ask residents or nursing staff to help you look

• Patients do not have to be your clinic patients

– Complete one “Investigation Form” per patient

– On the storyboard, summarize what you

found:

• Were risk factors noted?

• If the woman didn’t receive progesterone, can you track the reasons?

• Tell the “story” of how things went smoothly or hit a glitche

Barriers

• Describe a barrier to progesterone administration that your team has encountered and resolved!

• If you completed a Barrier Form*, you may consider including that.

*Barriers To Efficient Administration of

Progesterone to Prevent Preterm Birth

(Injectable 17-OHPC and Vaginal Products)

Your Unique Plan

•Every clinic and every team is unique. Briefly describe here your team’s plan for the next 3 months of the project.

– What do you hope to test?

– How will you know that your planned small tests of change will result in improvement?

– How will your plan help you reach the aim?

– How will your plan strengthen your system?

Share Seamlessly

• What especially helpful lesson have you learned so far that you can tell other teams?

Steal Shamelessly

• If you could ask any Progesterone team a question and get an answer that will help your patients, what would you ask?

Final Word

• You have the final word.

• What would your team like to express?

• PI Form and storyboard template can be found on SharePoint:

– opqc.net/Member log in/Progesterone/Resources

– https://portal.opqc.net/Progesterone/_layouts/WordViewer.aspx?id=/Progesterone/Resources/Progesterone%20Investigation%20form.docx&Source=https%3A%2F%2Fportal%2Eopqc%2Enet%2FProgesterone%2FResources%2FForms%2FAllItems%2Easpx%3FInitialTabId%3DRibbon%252EDocument%26VisibilityContext%3DWSSTabPersistence&DefaultItemOpen=1

– https://portal.opqc.net/Progesterone/_layouts/PowerPoint.aspx?PowerPointView=ReadingView&PresentationId=/Progesterone/Resources/Progesterone%20Storyboard%20Template.ppt&Source=https%3A%2F%2Fportal%2Eopqc%2Enet%2FProgesterone%2FResources%2FForms%2FAllItems%2Easpx&DefaultItemOpen=1

THE PROGESTERONE

NAVIGATORS

Robin Beringer, MSN, CNM •Toledo, OH

Current Roles:

•Nurse Educator

•Nurse Midwife

•Progesterone Navigator!

Will Cover:

•Paramount

•Buckeye Community Health Plan

•Medicaid & Medicare

Fun Facts:

•I love to travel…so little time, so much to see!

•That’s me with my son—he graduates with his

B.S. from the U.S. Coast Guard Academy May

23, 2014

•Lower picture: Me looking for my golf ball, I

REALLY need lessons.

Jill Morley and Izzy

Jill Morley -- Background • Registered Nurse for past 30 years all in

Obstetrics

– Marion General Hospital, Marion, Oh -- 1984-1995

– Kaiser Permanente, Cleveland, Oh -- 1995-2000

– University Home Care, Columbus, Oh -- 2000-2005

– Nationwide Children's Homecare, Columbus,

Oh 2005-Present

• Covering Insurance Plans:

– Molina

– CareSource

– United

– Healthcare Community Plan

NEXT STEPS

The Systems Inventory

• Purpose: understand the systems in place at

your clinic that allow you to systematically

screen women for risk, connect them to

treatment and follow their outcomes through

birth.

• Please complete the survey at the

following link: Clinic Systems Inventory

Tool by June 9th.

Wrap up and next steps • Complete the Systems Inventory by June 9th.

• Find patients for the Progesterone Investigation

• Create a Storyboard for the June Learning Session

• Collect data and report online: – Monthly Site Profile by June 6th

– Candidate Forms at 24-28 weeks (ongoing)

– Complete Candidate Forms when women deliver (ongoing)

Thank you for joining the call and sharing your great work!