1. 2015 QUALITY & EQUITY ROADMAP
Taking It to the Next Level:
Early Elective Delivery (EED) Prevention in Kansas Hospitals
Organization and Team Project Goals
• Since June 2012, the Kansas Healthcare Collaborative (KHC) has worked with more
than 50 Kansas birthing hospitals to reduce non-medically indicated early elective
deliveries (EEDs).
• Kansas hospitals collaborated statewide and nationally to adopt evidence-based
practices for EED prevention and achieved a 70.5 percent reduction in EED, exceeding
KHC’s initial aim of a 40 percent reduction by the end of 2014.
• KHC obtained data estimates of non-medically indicated early term deliveries from
Kansas birth certificates to corroborate the hospital data and to assess health care
disparities in early elective delivery.
Problem Description
• For decades, organizations like the American College of Obstetricians and
Gynecologists (ACOG) and the March of Dimes have been promoting the importance
of full-term pregnancies, yet EEDs still accounted for 10-15 percent of all deliveries
nationally. As more Kansas hospitals began to track TJC’s PC-01 EED measure through
the Partnership for Patients’ Hospital Engagement Network, rates were found to be
much higher than the national average at some hospitals across the state of Kansas.
• To our knowledge, potential disparities in EED in Kansas have not been studied.
Improvement Strategies
Measures
The Kansas Hospital Engagement Network approach included establishing a standardized
set of measures:
• Adoption of The Joint Commission PC-01 measure: Elective deliveries at >= 37 weeks
and < 39 weeks
• Adoption of three process measures developed with Wesley Medical Center: 1) use of
standardized scheduling tool, 2) documentation of indication prior to induction, and 3)
medical review of all elective deliveries prior to 39 weeks gestation.
• Early-term non-medically indicated births are identified based on obstetrical
procedures, medical risk factors and characteristic of labor and delivery reported on
the birth certificate.
Results
Potential Health Care Disparities in EED
Lessons Learned
• Kansas birthing hospitals have made tremendous strides over the past three years in
reducing EED, however, it is too early to claim success.
• The Kansas EED collaborative, along with other key influencers, are needed to
continue to assist hospitals to “take it to the next level” ― to achieve and sustain a
benchmark-level performance rate less than 2 percent.
• Recent Kansas statewide survey results and EED process and outcome data indicate
the majority of Kansas hospitals have not yet achieved highly reliable, sustainable
processes and culture to eliminate EED.
• Hospitals should collect data on race, ethnicity and language as part of their EED
reduction efforts.
Our Partners Our Sponsor
Kendra Tinsley, MS, CPPS
Executive Director
Kansas Healthcare Collaborative
Topeka, KS
The Kansas Hospital Engagement Network approach included:
• Raising awareness of EED as a patient safety issue at the Kansas HEN kick-off meeting
held in Topeka, June 2012.
• Quarterly EED webinars led by Kansas hospital improvement advisor from Wesley
Medical Center, Wichita, KS. Statewide collaborative was supplemented with national
AHA/HRET HEN events. All sessions focused on evidence-based interventions, quality
measures, safety culture and hospital sharing.
• Individualized support to assist hospitals to adopt a “hard-stop” policy.
• Resource sharing, including hospital policies, AHA/HRET change package and
distribution of March of Dimes’ EED Resource Kit to each birthing hospital in the state.
• Partnerships with the American Hospital Association, Health Research Educational
Trust, March of Dimes and other organizations.
Implementation of a policy to decrease the
rate of non-medically indicated deliveries
before 39 weeks of gestation has been found
to both decrease the numbers of these
deliveries and improve neonatal outcomes.1
~75% of all Kansas birthing hospitals with
hard-stop policies report adoption occurred
between June 2012 and December 2013.
Strongest influencers cited:
1.Participation in EED Collaborative
2.Medical guidelines and evidence
3.Hospital medical, quality committee
*Cohort-based analysis of data from facilities submitting at least 8
monthly data points based on The Joint Commission’s PC-01 measure
1. ACOG Committee on Practice Bulletins—Obstetrics. ACOG
practice bulletin no. 561: nonmedically indicated early-term
deliveries. Obstet Gynecol. 2013; 121:911-5.
Kansas HEN birthing hospitals reduced Early
Elective Deliveries by 74% relative to
baseline*
Baseline rate
17.4%
Current rate
4.4%
Partnership for Patients
HEN benchmark rate <2.0%
“REAL” Category
Non-Medically Indicated Births
(95% confidence interval)
2012 2013
RaceandEthnicity
White, Non-
Hispanic
36.3%
(34.4% - 38.2%)
31.8%
(29.9% - 33.7%)
Black, Non-
Hispanic
27.7%
(22.8% - 32.6%)
22.8%
(18.3% - 27.4%)
Other Non-
Hispanic
24.4%
(19.4% - 29.4%)
27.1%
(21.5% - 32.7%)
Hispanic 27.6%
(24.3% - 31.0%)
27.2%
(23.9% - 30.6%)
Primary
Language
English 34.0%
(32.4% - 35.5%)
30.0%
(28.5% - 31.6%)
Other 27.5%
(22.2% - 32.7%)
29.8%
(24.0% - 35.6%)
• Early-Term (37-38 weeks) non-medically
indicated (ETNMI) births* decreased from 3,629
(40.8%) in 2009 to 1,987 (30.0%) in 2013 in
Kansas. The reduction was similar for hospitals
participating in the Kansas HEN and hospitals
participating in other networks or not
participating in a network.
• There were differences in the magnitude and
direction of the change in ETNMI births from
2012 to 2013 relative to race and ethnicity and
primary language.
• Due to data limitations, the present analysis was
unable to account for hospital-reported EED
rate, the hospital-specific proportion of births in
each race, ethnicity and language subgroup and
other factors that could influence disparities in
ETNMI births.
• The causes for differences in ETNMI births by
race ethnicity and language are unknown. These
observations suggest hospitals should consider
race, ethnicity and language in their quality
improvement efforts.
*Early-term non-medically indicated births are
identified based on obstetrical procedures, medical
risk factors and characteristic of labor and delivery
reported on the birth certificate. It is being used
here as a proxy measure for the PC-01 early
elective delivery measure reported by hospitals for
the HEN.
Data Source: Kansas Department of Health and
Environment, Bureau of Epidemiology and Public
Health Informatics.
40.8 38.2 36.0 33.5 30.0
0
20
40
60
2009 2010 2011 2012 2013
ETNMI(%)
Year
Non-Medically Indicated Births*, Gestational Ages
37-38 Weeks, Kansas Birth Certificates, 2009-2013
Non-medically indicated births*, gestational ages
37-38 weeks, by race, ethnicity and primary
language spoken at home, Kansas Birth Certificates
(all Kansas hospitals), 2012-2013
Evidence from Kansas Vital Statistics