NNEPQIN: Northern New England Qualtiy Improvement Network
In 2009, the last year for which there is national data, the United States Cesarean Section rate was 1 in 3. Sadly, for most women, the old adage of once a cesarean always a cesarean, is becoming a reality. Prior to 2002, all 33 hospitals in NH and VT offered trial lf labor after cesarean delivery (TOLAC). But by the end of 2002, 14 of the 33 had closed their services, leaving some locations with no TOLAC service within a 50 mile radius. In response to the declining availability of TOLAC in our region, the Maternal Fetal Medicine (MFM) Specialists at Dartmouth Hitchcock and the University of Vermont (the two tertiary care centers serving all of NH and VT) held a series of six meetings with a goal of improving the safety and availability of TOLAC in Northern New England. While the initial meeting was by invitation only to department chairs, risk managers and perinatal nurse managers, subsequent meetings were open to the array of person participating in perinatal services. Under the leadership of the MFM specialists, three work products were created: 1) A TOLAC guideline that matches resource to risk; 2) A patient education handout; and, 3) A patient Consent Form. The products, now in their third version, are posted in MS Word format and available for public download from the NNEPQIN website.
In 2004, at the conclusion of the VT/NH VBAC project meetings, the group again led by the MFM Specialists from the two referral centers, decided to form the Northern New England Quality Improvement Network (NNEPQIN). Our mission is to improve perinatal throughout the region by continuing the collaborative work begun in the VBAC project. To help ensure safety of TOLAC, NNEPQINs next project was emergency cesarean section drills, for which we won the 2005 ACOG Wyeth Ayerst award. This project entailed creating a tool kit for performing drills, including scenarios, lists of equipment, and an evaluation tool. In addition, we collaboratively created a guideline for performing an emergency cesarean section, including potential resources for a variety of steps and a model STAT cesarean section tray that could be used by nurses with minimal operative experience.
NNEPQIN has used the same methodology to develop new guidelines, all in MS Word format, to promote local customization and implementation. Topics for guideline development are determine based on data from a regional delivery registry, OBNET, case reviews of unanticipated outcomes and member feedback. We identify a clear leader for each guideline. At least five institutions participate in the development of an initial draft of the guideline, which is then brought to the entire NNEPQIN membership for further evaluation and review. The final form is again reviewed at a NNEPQIN general meeting, prior to the guideline being posted on our internet. Guidelines have been developed for elective induction of labor, medically indicated induction of labor, pitocin use, obesity and cervical ripening. NNEPQIN encourages global sharing of these guidelines and appreciates feedback from individuals who are not part of NNEPQIN.
STRUCTURE and FUNCTION
NNEPIQN is a voluntary consortium of hospitals that includes almost every obstetrical service in NH and VT, along with services from ME, NY and MA. The NH and VT Association of Home Birth Providers, Departments of Health and March of Dimes Chapters are members of NNEPQIN. Annual membership fees are $400/year. Members originally signed a Memorandum of Understanding, which was replaced three years ago with a more formal agreement. We revise our agreement every few years, and do not make specific modifications based on individual institution’s requests. Contracting coordination is provided by the Hitchcock Foundation as part of their charitable mission.
NNEPQIN holds approximately three education meetings each year. The content of the meetings is driven by direct feedback of the participants and by data from a regional web based delivery registry called OBNET. Part of each meeting includes guideline development. Two meetings are free of charge, provide 6-7 hours of education credits, and have potluck for food to encourage “community spirit” and keep expenses down. They are held at Dartmouth Hitchcock, and have minimal expenses aside from honoraria and travel for outside speakers. Administrative duties for the meetings are shared between Dartmouth Hitchcock and the University of Vermont. Initially, speakers were drawn from the two perinatal centers but quickly expanded to regional invited guests and presenters from the member community hospitals s. We have successfully provided potluck breakfast, lunch and snacks for audiences of over 200 individuals and have truly honed the division of the alphabet based on last name and food item. Our annual meeting is a two day event held at a hotel and NNEPQIN members are given reduced registration rates. Since fall 2006, NNEPQIN has held 16 conferences and awarded 9,443 hours of continuing nursing education and 2,607 hours of continuing medical education credits, with an average of 130 nurses, physicians and home birth providers attending each conference.
Since the release of the VT/NH VBAC guidelines, the number of hospitals offering TOLAC in the region has risen from a low of 57.5% in 2002 to 82% in 2011. The resumption of VBAC services in the Seacoast Region of NH and the northern region of VT/NH has played a crucial role in this trend. In 2009, NNEPQIN held a two day TeamSTEPPS training program and created 101 Master Trainers in 27 institutions for $75.00/person (typical course registration fees range from $500-2000.00). Prior to the regional efforts of NNEPQIN, few institutions had obstetrical drill programs, and now almost all members perform drills on a regular basis. As a result of targeted education programs, along with guideline development and sharing of success stories at meetings, NNEPQIN members have significantly improved rates of HIV screening, and reduced rates of elective labor induction and routine episiotomy.
In 2010, NNEPQIN established a Confidential Review and Improvement Board (CRIB). The purpose of the CRIB is to provide multi-institutional case review of unanticipated obstetric outcomes, with a focus on care processes and institution guidelines. NNEPQIN has specifically asked the hospitals in the region to submit cases of uterine rupture during TOLAC, but many types of cases are submitted. Thus far, the CRIB has reviewed 14 cases from 10 institutions, with a total of 12 institutions participating in the review. These reviews have led to new education initiatives and have confirmed the risk stratification and resource matching used in our VBAC guidelines.
KEYS to NNEPQIN Success:
• Consensus and Equality: While the major structural support and CME lectures come from the tertiary medical centers in the region, all NNEPQIN members pay the same institutional fee and have equal input at meetings and guidelines, regardless of degree, type of hospital or type of practice. We have found tremendous resources in our obstetrical community, which would have been ignored had a hierarchical approach been used. Physicians, midwives, administrators, and nurses collaborate as equals.
• Maternal Fetal Medicine Leadership: MFM leadership and involvement in guideline development has facilitated the implementation of these guidelines in the region’s hospitals, as they are assured of tertiary level support for their practices.
• Nursing leadership: NNEPQIN has strong support from the NH and VT perinatal nurse manager groups.
• Low Cost: Membership fees are $400/institution. Case review fees are $75.00/case. Membership allows unlimited registration for the free CME events, which typically provide 6-7 hours of credit per day. It also provides access to the private side of our website, where lecture are posted. Recently, we established a chat room, in the private side of the website. Both Dartmouth Hitchcock and University of Vermont provide personnel, space and services to support the network free of charge.
• Volunteer: Most of our local speakers waive speaker honoraria. All committee leaders and members volunteer their time to develop guidelines, attend CRIB meetings, etc., which is a significant time commitment for the individuals and their institutions.
• Potluck: Humans are social beings. “Catering” by potluck sets the stage for the collaboration and coordination that are required for guideline development and regional perinatal care. A potluck produces fantastic food and acts as an ice-breaker. Some of our most difficult conference participants were the best cooks and we watched their attitudes and interactions change over time. Recipe exchange became a means of forming bridges. In addition, providing food via potluck greatly reduces meeting expenses. Our typical meeting costs are $150.00 for 150 individuals. Catered food of similar quality would cost between $30.00/participant.
• Broad Based Development: NNEPQIN has an exceptionally wide variety of participants. All guidelines start with members’ education, ensuring a shared understanding of the available literature. All institutions are invited to participate in the development process and to submit their local guidelines to aid in development of the regional guideline. The broad based participation results in work products that are stronger, richer and more universally applicable than anything that could be created by a single institution or small group of institutions. We are continually amazed by the skills brought to the table. For example, a number of our members have been editors, creative directors and authors prior to embarking on a career in medicine. Despite not specifically including a patient advocate, the wide range of prenatal care providers (from MFM specialist to home birth) addresses the range of hopes and concerns that women bring to birth. The grass roots nature of NNEPQIN promotes a feeling of ownership and inclusion among the participants for the guidelines that are developed.