Transforming Maternity
Care
2020 Vision for a High Quality,
High Value Maternity Care System
and Blueprint for Action
Intermountain Healthcare
Women and Newborns Conference,
September 27-28, 2010
R. Rima Jolivet, CNM, MSN, MPH
Transforming Maternity Care Project Director
Associate Director of Programs
Childbirth Connection
www.childbirthconnection.org
Childbirth Connection
Mission
To improve the quality
of maternity care
through research,
education, advocacy,
and policy.
www.childbirthconnection.org
Maternity care is a major
segment of health care
• 85% of women give birth
• Childbirth is the number one reason for being hospitalized
• 25% of those discharged from the hospital are childbearing women
or newborns
• Maternal and newborn charges are the runaway leader in hospital
charges: $86 billion in 2006
• Childbirth accounts for 6 of the 10 most common hospital
procedures
• Cesarean section is the most common operating room procedure
• Employers and private insurers pay for half of all births, and
taxpayers and Medicaid programs pay for 42% of births
References at http://www.childbirthconnection.org/article.asp?ck=10621
www.childbirthconnection.org
Much of the care women receive is
not consistent with the best evidence
The Milbank report reveals:
• A pattern of wide practice variation,
unwarranted by health status or women’s
preferences
• Overuse of many practices that entail harm and
waste for mothers, babies, and the system at
large
• Other effective, high-value practices that are
systematically underused
www.childbirthconnection.org/ebmc/
www.childbirthconnection.org
Evidence-Based Maternity Care: Core Aim
• Provide effective care with least harm to childbearing
women and newborns
• Possible care paths often have very different
benefit/harm profiles
• Give priority to effective paths that are least invasive,
ideally with limited or no known harms
Consistent with: First, Do No Harm
www.childbirthconnection.org
Examples of Overuse in Maternity Care
• Labor induction
• Epidural analgesia
• Cesarean section
• Continuous electronic fetal monitoring
• Rupturing membranes
• Episiotomy
www.childbirthconnection.org
Examples of Underuse in Maternity Care
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Smoking cessation interventions
External version
Continuous labor support
Measures to bring comfort and promote labor progress
Delayed and spontaneous pushing
Non-supine positions for giving birth
Delayed cord clamping
Early skin-to-skin contact
Interventions for breastfeeding initiation, duration
Interventions for postpartum depression
www.childbirthconnection.org
Unwarranted Practice Variation
• Manifold variation is common
• Across regions, hospitals, caregivers
• Across very narrow classes of women (Robson mode
of birth categories)
• 124 Hospital Corporation of America facilities: almost
“random” pattern of operative delivery
• Baicker and colleagues: higher rates of cesarean
involve use in healthier women, with greater expense,
inevitable excess morbidity, and no mortality gains
www.childbirthconnection.org
How Do We Reliably Deliver
the Right Maternity Care at the Right Time?
• “Every system is perfectly designed to get the results
it gets.”
--Paul Batalden
• “The definition of insanity is continuing to do the
same thing over and over again and expecting a
different result.” --Albert Einstein
The solution is to change the system in which
maternity care is delivered
www.childbirthconnection.org
Transforming Maternity Care:
Looking Forward with Shared Perspective
The TMC Project:
• Multi-year collaboration with more than 100
maternity care leaders
• Broad participation
• Open, transparent group process to reach
consensus through discourse
• Two direction-setting papers:
“2020 Vision” and “Blueprint for Action”
• Dissemination and implementation through
Partnership and Community Action
www.childbirthconnection.org
www.childbirthconnection.org
Transforming Maternity Care Steps
• Vision: figure out where we want to go
• Blueprint: figure out how to get there
• Implementation: head off in that direction
www.childbirthconnection.org
2020 Vision for a High Quality, High Value
Maternity Care System
www.childbirthconnection.org
Transforming Maternity Care:
Looking Forward with Shared Perspective
What Is a Vision?
www.childbirthconnection.org
Transforming Maternity Care:
Looking Forward with Shared Perspective
• A Vision Is:
• A framework for possibility
• A long clear sightline radiating forward
• A statement of fundamental human desires
• An open invitation and an inspiration for people
to create ideas and events that correlate with its
definitional framework
(Zander & Zander, 2000)
www.childbirthconnection.org
Transforming Maternity Care:
Looking Forward with Shared Perspective
• A Vision Provides:
• A focal point for change
• A clear, shared definition of the goals
• Motivation to change, even when it is hard
• A rallying point that brings stakeholders
together in service of a perceived greater good
(Kotter, 1996)
www.childbirthconnection.org
Transforming Maternity Care:
Looking Forward with Shared Perspective
2020 Vision for a High Quality, High Value
Maternity Care System
• Fundamental values and principles that apply across the
whole continuum of maternity care
• Goals for each phase and for providers and settings for
maternity care
• Attributes of the larger system that can reliably provide
high quality, high value care to all childbearing women,
their newborns and families
www.childbirthconnection.org
2020 Vision for a High Quality, High
Value Maternity Care System
Fundamental Values and Principles
• 6 Aims, adapted from the seminal
Institute of Medicine definitions of quality
• Further values and principles that are
foundational to the Vision
www.childbirthconnection.org
2020 Vision for a High Quality, High
Value Maternity Care System
6 Aims Applied to Maternity Care
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Woman-Centered
Safe
Effective
Timely
Efficient
Equitable
A new take on familiar definitions
www.childbirthconnection.org
2020 Vision for a High Quality, High Value
Maternity Care System
Further Foundational Values & Principles
for Maternity Care
• Life-changing experience
• Care processes protect, promote, and support
physiologic birth
• Care is evidence-based
• Quality is measured, performance is disclosed
www.childbirthconnection.org
2020 Vision for a High Quality, High Value
Maternity Care System
Further Foundational Values & Principles
for Maternity Care
• Care includes support for decision making and
choice
• Care is coordinated
• Caregiver satisfaction and fulfillment is a core
value
www.childbirthconnection.org
2020 Vision for a High Quality, High Value
Maternity Care System
www.childbirthconnection.org
2020 Vision for a High Quality, High Value
Maternity Care System
Levels A & B:
Women and their Support Networks, and
Microsystems that Provide Direct Care
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Care During Pregnancy
Care Around the Time of Pregnancy
Care After Giving Birth
Key Participants
Care Settings
www.childbirthconnection.org
2020 Vision for a High Quality, High Value
Maternity Care System
Level C: Health Care Organizations
Envisioning system attributes that:
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Strengthen the structure of the care delivery system
Strengthen the maternity care workforce
Foster high-quality maternity care
Provide woman- and family-centered care
www.childbirthconnection.org
2020 Vision for a High Quality, High Value
Maternity Care System
Level D: The Macro Environment of Care
Envisioning system attributes that:
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Strengthen performance measurement
Improve the functionality of payment systems
Strengthen professional education and guidance
Close priority gaps in research
Improve the functioning of the liability system
Enable reliable delivery of high quality maternity care
www.childbirthconnection.org
The Challenge of Change:
• “Facts do not change feelings, and feelings are what
influence behavior. The accuracy and clarity with which
we absorb information has little impact on us: it is how
we feel about information that determines whether we
will use it.” –Vera Keane, CNM, 1967
• “Fables can be powerful because they take serious,
confusing, and threatening subjects and make them
clear and approachable…In our modern, high-tech
world, we can easily forget this simple yet profound
truth.” –John Kotter, 2005
www.childbirthconnection.org
A Tale of Two Births
A Fable to Illustrate the Vision
www.childbirthconnection.org
Fable to Illustrate the Vision
• Common response: “But we are already providing
maternity care that is [fill in the blank: woman-centered,
high-quality, evidence-based] now.”
• The fable was developed to compare a woman
experiencing common elements of care within the present
system and her friend who experiences care within the
envisioned system
• Brings to life implications of the proposed vision for
women, newborns and families
Available at www.childbirthconnection.org/vision/
www.childbirthconnection.org
Transforming Maternity Care:
Looking Forward with Shared Perspective
Blueprint for Action:
Steps Toward a High Quality, High Value Maternity
Care System
‘‘Who needs to do what, to, for, and with whom to
improve the quality of maternity care over
the next five years?’’
www.childbirthconnection.org
Blueprint for Action:
Steps Toward a High Quality, High Value
Maternity Care System
• Five stakeholder workgroups developed
detailed sector-specific reports
• Actionable strategies in 11 critical focus areas
• Synthesized into a comprehensive Blueprint for
Action by the Symposium Steering Committee
• Full stakeholder reports are published online at:
www.childbirthconnection.org/workgroups
www.childbirthconnection.org
Blueprint for Action:
Steps Toward a High Quality, High Value
Maternity Care System
11 Critical Focus Areas:
• Performance measurement and leveraging of
results
• Payment reform to align incentives with quality
• Disparities in access and outcomes of maternity
care
• Improved functioning of the liability system
www.childbirthconnection.org
Blueprint for Action:
Steps Toward a High Quality, High Value
Maternity Care System
11 Critical Focus Areas:
• Scope of covered services for maternity care
• Coordination of maternity care across time, settings, and
disciplines
• Clinical controversies (home birth, VBAC, vaginal breech and
twin birth, elective induction, and maternal demand cesarean
section)
• Decision making and consumer choice
• Scope, content, and availability of health professions education
• Workforce composition and distribution
• Development and use of health information technology (IT)
www.childbirthconnection.org
Blueprint for Action:
Recommendations and strategies aimed at
every level of the maternity care system
www.childbirthconnection.org
Selected Blueprint
Recommendations of Special
Relevance to Maternity Care
Clinicians and Delivery Systems
www.childbirthconnection.org
Examples: Action Steps at the Delivery
System Level
Performance Measurement and Leveraging of
Results
• Develop, test, and submit needed measures to NQF
• Address critical gaps across the full episode of maternity
care
• Develop state or regional quality collaboratives that bring
hospitals, clinicians, consumers, and payors together to
test the impact of performance measures on P4P, audit
and feedback, QI indicators.
www.childbirthconnection.org
Examples: Action Steps at the Delivery
System Level
Payment Reform to Align Incentives with Quality
• Pilot maternity care payment reform models that restructure
health system relationships and financing to align quality
and value, and foster improved care coordination, including
From Volume to Value model (Miller, 2008)
• Conduct regional demonstration projects involving all
payors and providers
• Share results for learning and replication
www.childbirthconnection.org
Examples: Action Steps at the Delivery
System Level
Disparities in Access and Outcomes of
Maternity Care
• Form quality collaboratives and community-based
partnerships to evaluate and implement programs to
close disparities in maternity care outcomes.
• Carry out comparative effectiveness research and apply
disparities-sensitive criteria
• Test effect on outcomes and cost of preventive programs
that have demonstrated an impact in populations
experiencing disparities
www.childbirthconnection.org
Examples: Action Steps at the Delivery
System Level
Improved Functioning of the Liability System
• Widely adopt system-oriented patient safety and quality
improvement programs, and measure and report
experiences with malpractice claims and payments (see
Simpson et al. 2006, 2009, 2010)
• Evaluate the impact on reduction of adverse events and
liability experiences, and satisfaction of women and
providers of promising maternity care interventions.
• Pilot, evaluate, and share results of ‘‘enterprise liability’’
programs that relocate responsibility from individuals to
systems.
www.childbirthconnection.org
Examples: Action Steps at the
Microsystem level
Clinical Controversies
• Implement a multi-disciplinary team training program
• Practice drills, simulation, interdisciplinary problemsolving, communication training
• Include midwives, physicians, nurses, anesthesia,
pediatrics, and risk management
• Use this training to safely offer controversial practices
that are supported by high-quality evidence
• VBAC, vaginal breech and twin birth, effective
coordination of care for out of hospital birth
www.childbirthconnection.org
Examples: Action Steps at the
Delivery System level
Clinical Controversies/Performance Measurement
• Institute benchmarking programs at the system level
• Identify and move toward achievable target rates of VBAC,
vaginal breech and twin deliveries, induction of labor, and
cesarean in low-risk first-time mothers
• Identify best practices, report innovation and successes
• Learn from successful programs such as NNEPQIN
www.childbirthconnection.org
Examples: Action Steps at the
Delivery System level
Coordination of Care Across Time, Settings, and
Disciplines
• Convene an interdisciplinary team of family practice,
midwifery, obstetric, and maternal-fetal medicine providers
• Look at actual community patient-safety data on near
misses and reportable adverse events
• Develop community-specific consensus standards for risk
criteria and system linkages appropriate to each level of
care in the community
• Replicate the model and process used by Intermountain
Healthcare (Hey, that’s YOU!!)
www.childbirthconnection.org
Examples: Action steps at the
Macro level
Woman- and Family-Centered Maternity Care Home
• Endorse legislation to support Medicaid demonstration
projects of the concept
• Ensure that family physicians and obstetricians, all midwives
with nationally recognized credentials and nurse-practitioners
are eligible to participate in demonstrations as all have the
potential to provide exemplary care coordination
• Ensure that the Woman- and Family-Centered Maternity Care
Home meets NCQA standards for the medical home
www.childbirthconnection.org
Examples: Action Steps at the Delivery
System Level
Health Professions Education
• Ensure that students in each discipline learn from an
interdisciplinary teaching team
• Create multi-disciplinary learning and teaching
opportunities
• Create opportunities for education in settings outside
acute facilities, e.g., in community health centers,
public health clinics, and freestanding birth centers
• Develop model evidence-based practicum
experiences
www.childbirthconnection.org
Examples: Action Steps at the
Macro level
Health Professions Education
• Convene an education summit
• Plan a shared core maternity care curriculum and ways
to integrate education across disciplines
• Ensure a foundation in health promotion, cultural
sensitivity, woman- and family-centered care, skills and
knowledge to support physiologic childbearing,
evidence appraisal and a public health focus
• Learn from Duke University’s process of building a
model universal women’s health curriculum across 6
disciplines (Taleff et al. 2009)
www.childbirthconnection.org
The potential
to improve
maternity care
is within our
reach, but
none of us can
do it alone.
www.childbirthconnection.org
Transforming Maternity Care:
Looking Forward with Shared Perspective
TMC Project Goals:
• To garner and communicate political will to propel
maternity care quality improvement efforts forward
– By providing a pivotal organizing focus: the 2020 Vision
– By fostering a coherent plan for action: the Blueprint
– By globalizing policy objectives and localizing their
implementation
• To foster national, regional, and local efforts to improve
maternity care quality and value
What Now?
www.childbirthconnection.org
Transforming Maternity Care:
Looking Forward with Shared Perspective
The TMC Partnership:
• Outreach and dissemination to decision makers
• A public-private multi-stakeholder partnership for joint
Blueprint implementation projects of a significant scope
• The TMC Action Community: A forum for communitylevel partners to show support for the Vision and
Blueprint, and get ideas and resources for ways to
independently engage in this work within their own
communities and practice settings…including the nw
monthly “TMC Topics” webinar series
www.childbirthconnection.org/partnership
www.childbirthconnection.org
Where Does This Lead Us?
The Ultimate Vision
• Safe, timely, effective, efficient, equitable,
woman/family-centered care
• Best in the world in maternal and child health
outcomes
• Global recognition for our transformation
www.childbirthconnection.org
Childbirth Connection
believes that
deliberative,
collaborative,
multi-stakeholder efforts
are the best way to
improve the
quality, value, and
experience of care
for women,
babies, families,
and all stakeholders.
We know that maternity
quality matters.
www.childbirthconnection.org
Thank You!
R. Rima Jolivet, CNM, MSN, MPH
Transforming Maternity Care Project Director
Associate Director of Programs
Childbirth Connection
jolivet@childbirthconnection.org
www.childbirthconnection.org