The CMQCC Collaborative to Support Vaginal Birth and Reduce Primary Cesareans Hospital Application and Perinatal Quality Improvement Team Commitment Hospital Application and Perinatal Quality Improvement Team Commitment Form Instructions Active participation in the Supporting Vaginal Birth and Reducing Primary Cesareans Collaborative requires the dedication of a multi-­‐disciplinary team at each hospital that is committed to improving outcomes. Collaborative participants are expected to have a minimum of three key participants and three supporting participants from each hospital. Once the participation requirements are reviewed, completed and signed, please scan this form and e-­‐mail to Valerie Cape at [email protected]. This will be the first step in applying for the Collaborative. Information about the Collaborative The Collaborative to Support Vaginal Birth and Reduce Primary Cesareans is a multi-­‐stakeholder, multi-­‐
hospital effort to promote vaginal birth and reduce unnecessary cesarean deliveries in California. It is a one-­‐year commitment led by the California Maternal Quality Care Collaborative (CMQCC), an organization with proven success and experience driving improvement in hospitals through statewide collaboratives and rapid-­‐cycle data analytics. The Collaborative activities will assist hospitals across the state of California to reduce nulliparous term singleton vertex (NTSV) cesareans through the implementation of the patient safety bundle developed by the Council on Patient Safety for Women’s Health, as well as through the use of the Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, developed by CMQCC and a taskforce of experts from across California. The Collaborative is structured to include in-­‐person and virtual learning sessions, as well as small group sharing and mentoring with local experts who provide accessible clinical and implementation expertise to their assigned teams. Other experts in patient safety, implementation, quality improvement, and data analytics will provide assistance to hospital teams during the Collaborative. This will be accomplished through monthly web based calls, as well as other educational opportunities both virtual and on site to work with hospitals to decrease NTSV cesarean rates. Round 1 of the Collaborative began May 2016. Round 2 will begin January 2017 and run through December 2017. Round Two Hospital Application V11.22.16 Benefits of Hospital Participation The Collaborative is funded by a grant from the California Health Care Foundation, so there is no charge to participating hospitals. Participating hospital teams will receive training materials, educational webinars, detailed data reports in real-­‐time, on-­‐site assistance from experts and will be able to network with hospital teams across the state that are also participating in this project. Participants will be able to identify themselves as CMQCC Partner Organizations in electronic communication signature lines as well as through posters distributed for display in the organization. SHORT-­‐TERM BENEFITS LONG-­‐TERM BENEFITS A framework of support to implement the Reduce NTSV cesarean delivery rates Supporting Vaginal Birth by Reducing Primary Cesareans Toolkit bundle elements Identification of clinical and culture gaps for Increase vertical collaboration throughout prioritized focus organizational hierarchy Mentor support for implementation of Deliver consistent care bundle elements Identify trends sooner based on real-­‐time Provide safe environment necessary for data reports maternal safety improvement work to flourish Use of the CMQCC Maternal Data Center to Reduce the risk of complications for mothers track and benchmark your institutions’ data such as: hemorrhage, uterine rupture, for NTSV cesareans in real time, as well as placenta abnormalities, cardiac events, over 30 other hospital clinical performance infection, venous thromboembolism (VTE) measures with the ability to utilize statewide and blood transfusions. comparative data and drill down data analysis to the provider and provider group levels Data Collection Requirements Your hospital will be responsible for timely and accurate data collection and submission, although much of the data is collected automatically through the Maternal Data Center. Your hospital will have access to reports in real time. Examples of available reports include improvement in overall NTSV cesarean delivery rates, detailed analytics for provider level data, provider group level data and process measures that identify progress towards implementation of the recommendations in the toolkit. Your team will be responsible for collecting, submitting and/or reviewing automatic data submissions including the following measures: Round Two Hospital Application V11.22.16 Survey Assessments Frequency Quality Improvement Readiness Assessment Once Clinical Assessment of Recommended Bundle Elements Quarterly Birth Attitudes Survey Twice Data Measures Frequency NTSV Cesarean Rates (Joint Commission PC-­‐02 measure / Automated data Quarterly collection in MDC) Process Measures related to bundle element implementation Quarterly Perinatal Quality Improvement Team Requirements Your hospital’s success in the Collaborative will be dependent on your QI team’s participation in educational opportunities. The Perinatal Quality Improvement team should plan to participate together in as many of the sessions as possible. Virtual and In-­‐Person Meetings Frequency Full Day Regional In-­‐Person Learning Session Twice One Hour Mentor Small Group Calls Monthly One Hour All-­‐Collaborative Webinar Learning Sessions Quarterly On-­‐Site Mentor Visit Once during Collaborative Hospital Participation Requirements Action Due Dates Action Items Due Dates Complete the Hospital Application and Perinatal Quality Improvement December 20, Team Letter of Commitment 2016 Identify and Assemble Perinatal Quality Improvement Team December 31, 2016 Work with CMQCC to complete the Data Use Agreement with the December 31, Maternal Data Center 2016 Participate in educational programs including the onboarding/ orientation January 2017– webinar series, content and CE-­‐specific webinars December 2017 Regularly meet as a team to implement interventions and monitor January 2017 – performance December 2017 Complete survey assessments and upload data according to the data January 2017 – collection schedule December 2017 Round Two Hospital Application V11.22.16 Promoting Vaginal Birth and Reducing Primary Cesareans Collaborative Hospital Perinatal Quality Improvement Team Commitment Form Signatures below represent our hospital’s application and commitment to participation in the Supporting Vaginal Birth and Reducing Primary Cesareans Quality Improvement Collaborative. Hospital Name: Address of Hospital: Current NTSV Cesarean Rate: Required Name E-­‐mail Signature Will Attend Team Round 2 Kickoff Members Meeting Y/N Physician Champion Nursing Champion Quality Improvement Staff Champion Administrative Leader Champion Other Key Team Members Please scan and e-­‐mail this page of the completed and signed form to: Valerie Cape at [email protected]. Round Two Hospital Application V11.22.16