Statewide quality improvement initiative to implement immediate postpartum long-acting reversible contraception.

BACKGROUND: Women face barriers to obtaining contraception and postpartum care. In a review of Tennessee birth data from 2014, 56% of pregnancies were unintended, 22.7% were short-interval pregnancies, and 57.9% of women who were not intending to get pregnant were not using contraception. Offering long-acting reversible contraceptive methods in the immediate postpartum period allows women who desire these effective methods of contraception to obtain unobstructed access and lower unintended and short-interval pregnancy rates. OBJECTIVE: We report the experience of Tennessee's perinatal quality collaborative that aimed to address unintended and short-interval pregnancy by increasing access to immediate postpartum long-acting reversible contraception through woman-centered counseling and ensuring reimbursement for devices. This followed a policy change in November 2017 that allowed women who were insured under Tennessee Medicaid programs (TennCare) to achieve access to immediate postpartum long-acting reversible contraception. STUDY DESIGN: From March 2018 to March 2019, 6 hospital sites participated in this statewide quality improvement project that was based on the Institute of Health Improvement Breakout Collaborative model. An evidence-based toolkit was created to provide guidance to the sites. During the year of implementation, monthly huddles occurred, and each facility took a differing amount of time to implement immediate postpartum long-acting reversible contraception. Various statewide and hospital-specific barriers occurred and were overcome throughout the year. RESULTS: In total, 2012 long-acting reversible contraception devices were provided to eligible and desiring women. All but 1 institution was able to offer immediate postpartum long-acting reversible contraception by March 2019. Reimbursement was the biggest statewide barrier because rates were low initially but improved through intensive intervention by dedicated team members at each site and the state level. Even with dedicated team members, false assurances were given repeatedly by billing and claims staff. CONCLUSION: A statewide quality improvement project can increase access to immediate postpartum long-acting reversible contraception. Implementation and reimbursement require a dedicated team and coordination with all stakeholders. Verification of reimbursement with leaders at TennCare was essential for project sustainment and facilitated improved reimbursement rates. The impact on unintended and short-interval pregnancies requires long-term future investigation.

A Statewide Quality Improvement Collaborative to Increase Breastfeeding Rates in Tennessee.

BACKGROUND AND OBJECTIVES: Tennessee has low breastfeeding rates and has identified opportunities for improvement to enhance maternity practices to support breastfeeding mothers. We sought a 10% relative increase in the aggregate Joint Commission measure of breastfeeding exclusivity at discharge (TJC PC-05) by focusing on high-reliability (≥90%) implementation of processes that promote breastfeeding in the delivery setting. METHODS: A statewide, multidisciplinary development team reviewed evidence from the WHO-UNICEF "Ten Steps to Successful Breastfeeding" to create a consensus toolkit of process indicators aligned with the Ten Steps. Hospitals submitted monthly TJC PC-05 data for 6 months while studying local implementation of the Ten Steps to identify improvement opportunities, and for an additional 11 months while conducting tests of change to improve Ten Steps implementation using Plan-Do-Study-Act cycles, local process audits, and control charts. Data were aggregated at the state level and presented at 12 monthly webinars, 3 regional learning sessions, and 1 statewide meeting where teams shared their local data and implementation experiences. RESULTS: Thirteen hospitals accounting for 47% of live births in Tennessee submitted data on 31,183 mother-infant dyads from August 1, 2012, to December 31, 2013. Aggregate monthly mean PC-05 demonstrated "special cause" improvement increasing from 37.1% to 41.2%, an 11.1% relative increase. Five hospitals reported implementation of ≥5 of the Ten Steps and two hospitals reported ≥90% reliability on ≥5 of the Ten Steps using locally designed process audits. CONCLUSION: Using large-scale improvement methodology, a successful statewide collaborative led to >10% relative increase in breastfeeding exclusivity at discharge in participating Tennessee hospitals. Further opportunities for improvement in implementing breastfeeding supportive practices were identified.