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Optimizing Pre-39-Week Labor Induction at North Memorial

February 13, 2014
by Mark Hagland
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Jon Nielsen, M.D. shares his insights on the gains made in optimizing pre-term labor induction at North Memorial

Hospitals and health systems nationwide are struggling these days to create a healthcare system of improved care quality and patient safety, efficiency, cost-effectiveness, accountability, and transparency. Yet a small number of pioneering organizations are already charting a bold, clear course—among them, North Memorial HealthCare, a two-community-hospital health system based in Robbinsdale, a suburb of Minneapolis-St. Paul, which encompasses the 300-bed North Memorial Medical center in Robbinsdale and the 100-bed Maple Grove Hospital.

Leaders there have launched themselves on a path that will position their organization beautifully to adopt the principles of the new healthcare, and it is one that is already reaping rewards. The core of what the leaders at North Memorial are doing is to leverage healthcare IT to facilitate enterprise-wide continuous quality improvement, not only for its own sake, but to achieve clinical transformation across diverse patient care service lines in the organization.

As a result, the leaders at North Memorial HealthCare were named the co-second-place winning team in the Healthcare Informatics Innovator Awards program. They will be honored at the Healthcare Informatics Innovator Awards reception in Orlando in February, during the annual HIMSS Conference.

All the members of the leadership team provided HCI with extensive interviews. Below are excerpts from HCI Editor-in-Chief Mark Hagland’s interview with Jon Nielsen, M.D., a practicing gynecologist, and medical director of the Women’s and Children’s Service at North Memorial Healthcare. Previously, interviews with J. Kevin Croston, M.D., the organization’s chief medical officer, and Jeffrey Vespa, M.D., medical director for clinical quality for the health system, have already been published. In this interview, Dr. Nielsen delves into the details of the initiative to reduce pre-39-week elective labor inductions, the first project taken on by the North Memorial leadership in the context of the organization’s overall quality effort. The core achievement of that project: reducing elective pre-39-week labor induction from 1.2 percent to 0.3 percent of deliveries, over the period of about one year. Below are excerpts from the interview with Dr. Nielsen.

How did the North Memorial project around pre-elective induction reduction come about?

About three or four years ago, we had engaged a consulting firm that was then called Health Care Quality Catalysts, and is now known as Health Catalysts. They came in with a certain way of analyzing data, and set up a data warehouse for our system, to help us work with data, and give us guidelines as to how each service line might want to approach quality. So with Women’s and Children’s, they looked at a lot of different quality issues, and at variation. And Kevin Croston, M.D., the chief medical officer, and I worked together. And the first thing we looked at was the pre-39-week elective induction issue, and we set up a multidisciplinary quality team, between two-and-a-half and three years ago.


Jon Nielsen, M.D.

And so we put a team together, and formed a clinical review team of doctors and nurses—nine doctors and six nurses, as well as some senior administration oversight people, though they didn’t get much involved—so the core team would make a plan and present it to the review team. It became a pretty interesting group, and we set some high goals, and met them earlier than expected.

What was your team’s core goal with this effort?

To increase the appropriate induction rate and decrease the inappropriate inducton rate, around infant labor and delivery. We actually started at 4 percent of pre-39-week babies fetuses being electively induced, and were already ahead nationally at the start. But we used Epic, and optimized it, to help us fill in the blanks. And we disseminated in the information to the six groups working in the hospital system, and pushed out the information to the group level (doctors who were non-compliant with the program did get individual data).

You were able to bring the elective pre-39-week induction rate down from 1.2 percent of deliveries to 0.3 percent. What key elements helped bring the rate down?

The first thing was the awareness—when people saw the data that said that it would probably have real impact to deliver at 38 weeks instead of 39 weeks—that awareness was the beginning. And then we got the key stakeholders involved from the beginning, and that made a difference; and then the peer pressure [to improve compliance with best practices] kicked into place.

And that meant that physicians not adhering to the 39-week standard now needed to get your approval, as medical director, correct?

Yes, we set the criteria, and if they didn’t meet the criteria, they had to speak to the medical director. And we found that people really didn’t like to make that call very often. So once we had the data set that qualified them, and we kept the nurse from having to be the enforcer, that the nurse didn’t have to enforce anything, things moved forward pretty quickly.

To be honest, historically, a couple of the major factors involved in elective pre-39-week induction of labor have been the convenience of the mother and the convenience of the physician, correct?

Absolutely. And we put out an educational piece for patients, because the patients didn’t realize that there was a risk. “It’s only three or four days, and my doctor’s going out of town, and I really want that doctor”—that kind of thing. But we created just a page-and-a-half paper handout for the moms, and that really helped, as did many one-on-one conversations. There are still a few gray areas in terms of diagnoses and criteria; and if doctors end up making decisions that fall into the gray, we engage conversations with them saying, let’s be a little bit more careful. An example is hypertension in pregnancy: when the patient gets pre-eclamptic—how serious does it have to be? But then when you really break it down and define it, was it really pre-eclampsia or just slightly elevated hypertension? We deal with a lot of situations like that.

Do you see the landscape around elective induction as having changed broadly over time in the physician culture, in terms of decision-making becoming more evidence-based and data-driven over time?

Yes, I’ve been around a long time watching that transition. And I kind of bristle a bit about the evidence-based thing, because we probably only have about 20 percent of things in medical practice that are actually solidly evidence-based, but on the other hand, it’s very satisfying to sit at the service-line level and look at the initiatives we want to push forward on in the near future, and to define our outcomes objectives around those initiatives.

Ultimately, the broader context of this is that the entire healthcare system is moving away from volume and towards value, right?

Yes, absolutely. And as flawed as certain elements in the ACA [Affordable Care Act] are, boy, the fundamentals are good.

What would your core core advice be to CIOs and CMIOs around all of this?

The role of the data analyst is so important in all this work. And it’s so important having someone who can move that data. We had a designated analyst with our initiative, one of the people whom Greg [Kern, manager, measurement and reporting] has on his team; and she was fabulous. And she taught us how to think about our data and use it. You really need someone from the IT side to get everything into place. And within our service line, as we try to expand to seven or eight guidance teams, we don’t have that data analyst as readily available as before, and that absence has slowed us down a bit. So it’s been interesting from a clinician viewpoint, to spend as much time as I have, with the quality people. We’re moving forward on this journey, and we’re doing it now almost without the “training wheels.”

 


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