Reducing Elective Early-Term Deliveries: One Hospital’s Groundbreaking Optimization Work

Healy: Yes, and because of Pete and because of PeriGen, we were able to review the inductions and determine whether the elective inductions were called for or not.

Peter St. Marie: So the baseline induction rate—any patient receiving pitocin—was about 16 percent. That figure represented all patients who received pitocin or induction, including for medically indicated reasons. The lowest group, two of them, had 16 percent receiving pitocin, and the highest rate was 40 percent. This is all patients receiving pitocin, either for medically justified reasons or for other reasons. So clearly, the 40-percent practices were performing non-medically indicated inductions. So Dr. Healy got the doctors together and said, let’s get together and define what “medically indicated” means, and it was us and the four leaders of the groups, plus anyone who wanted to join us. And we went diagnosis by diagnosis; there was some disagreement on different diagnoses, but Dr. Healy, through literature and skillful presentation skills, gained some consensus, and we narrowed it down to a list of reasons for medical indications. So we created a clinical pathway.

So to book an induction, the offices had to call a central scheduling office. And if they gave an approved medical indication for induction, they would book it. If they didn’t, they would have to call Dr. Healy directly. He’s a very nice guy; but he does have a backbone. So this was the basic plan. We’ve taken this a step farther since then, and now any patient who we discover is being induced without an approved medical indication, those charts are audited monthly, and if there’s a violation, that chart is sent to our peer review committee, where those charts are reviewed monthly, because some doctors have found a backdoor way to do that.

Healy: We went live in September 2011; and initially, I received a lot of phone calls. But as time has progressed and we’ve tracked the induction rate monthly, those phone calls have certainly decreased, and people have accepted the new policy. It’s not perfect, but I can tell you that many doctors are actually relieved about this, because the doctors can cite me or the hospital.

And so sometimes the convenience push is coming from the moms, too, of course?

Healy: Yes, and I’ll say that many of the pregnant moms simply don’t want to wait.

What is the rate now of early-term inductions that are not medically indicated?

Healy: The pre-39-week elective induction rate is now zero. And 40 percent was for all inductions in that group.

What percentage of the 40 percent figure of early-term inductions was not medically indicated, do you think?

Healy: I don’t have that number off the top of my head, but I suspect that it could have been half of that percentage, because I would guess that 20 percent were medically indicated. And I can add that when we looked at the numbers for the number we presented at ACOG, our elective induction rate was 6 percent and fell to 2 percent after we instituted the policy.

How long did it take to fall from the 6 percent to the 2 percent?

Healy: From January 1, 2009 to August 1, 2011.

So over two-and-half years?

Well, the post-policy period was actually form September 2011 to June 2012.

So that rate fell relatively quickly, then?

Healy: Yes, because these hard stops were put in place; if they didn’t satisfy certain criteria, they weren’t allowed to book the induction.

What is the core of what PeriGen does?

Healy: What PeriBirth does is it’s the EHR, which and allows us to track each delivery and induction.

St. Marie: And attempting a study based on the old paper records is incredibly time-intensive. Here, we can stratify all patient types and situations.

Grow: We can query the record for anything we want. The big advantage of having PeriBirth and any EHR, is that you can pull all the records quickly and in a systematic way. I pulled all the delivery reports for all the deliveries for the whole time period, and was able to pull that into some software and then analyze the data any way we wanted, and for even making the case at the beginning to even make the case for doing this.

What would you say to CIOs and CMIOs about how to help facilitate this kind of initiative?

Grow: From the clinical side, there are cases where they’re forced to enter data.

Healy: They’re forced to enter data into certain fields.

St. Marie: That’s a big part of getting complete data into the medical record. And the other big part of PeriBirth is, I can do a query of the database to look at all deliveries between any two dates, and can get all the information, basically.

Healy: And the physicians love that we can track things: how often are docs doing an episiotomy, or how often is pitocin being given? So we can track all things that are important to us, and can educate the doctors on things.

St. Marie: And it’s relatively easy for me to give Dr. Healy a timeframe, and to pull any kind of indicator, and can merge everything together and do an analysis on it.

Grow: So from a CQO type of perspective, we can create quality dashboards that are very specific and that save money and improve care, so that’s very valuable. So from a departmental perspective, we can run report cards, if you will, to drill down from who’s delivering excellent quality and who isn’t.