Creating effective teams and valuing patient-centered care to change culture and improve equity on labor and delivery: a qualitative study.

Publisher: BioMed Central Country of Publication: England NLM ID: 101088677 Publication Model: Electronic Cited Medium: Internet ISSN: 1472-6963 (Electronic) Linking ISSN: 14726963 NLM ISO Abbreviation: BMC Health Serv Res Subsets: MEDLINE

Original Publication: London : BioMed Central, [2001-

Qualitative Research* ; Patient-Centered Care* ; Cesarean Section*; Humans ; Female ; Pregnancy ; California ; Florida ; Interviews as Topic ; Organizational Culture ; Focus Groups ; Patient Care Team/organization & administration ; Delivery, Obstetric ; Quality Improvement ; Organizational Innovation

Background: Efforts to reduce cesarean birth overuse have had varied success. De-implementation strategies that incorporate change to organizational characteristics (i.e. culture) can improve adoption and sustainability. This study aimed to identify culture change strategies used by hospitals that achieved significant and sustained cesarean reduction and eliminated racial disparities in cesarean birth.
Methods: Hospitals in California and Florida that (1) engaged in quality initiatives to reduce cesarean births; (2) demonstrated at least a 5% cesarean birth reduction; and (3) sustained the reduction for 18 months after participation were invited to participate. Hospitals that reduced also cesarean racial disparity were prioritized for recruitment. Qualitative, semi-structured interviews were performed with leaders, obstetricians, family physicians, midwives, and nurses providing intrapartum care. Reflexive thematic analysis and values coding were used.
Results: 35 participants from 6 hospitals (3 in California, 3 in Florida) participated in interviews or focus groups. Nurse-focused strategies included: leadership demonstrating support for proactive labor support (e.g., Spinning Babies, comfort measures, nursing time at bedside); enhanced communication through inter-disciplinary team huddles; clear delineation of roles; and a chain of command that assured nurses could advocate for their patients freely and without retribution. Physician-focused strategies included regular and publicly visible feedback delivered by trusted messengers, drawing attention to successful vaginal births, and highlighting the contributions of labor support. A theme of hiring/retaining for "fit" was articulated at all hospitals, most notably, the hospital that eliminated their cesarean birth racial disparity, where "fit" was conceptualized as empathy, humanism, and a desire to meet community needs.
Conclusions: This study identified specific de-implementation strategies for hospitals to change implementation context, namely culture, to achieve and sustain reduction of cesarean birth. Hospitals looking to sustain culture change should adapt strategies to align with existing clinician values, change attitudes through sharing successful vaginal births, and modify beliefs through education from trusted messengers. Strategies to reduce racial disparities should emphasize designing teams that are aware of and prioritize community needs, including hiring staff from the local community, and partnering with community-based organizations.
Competing Interests: Declarations. Ethics approval and consent to participate: This study adhered to the Declaration of Helsinki as approved by the NorthShore University HealthSystem (now Endeavor Health) Institutional Review Board. This study was approved under expedited review with a waiver of signed consent. Participants gave informed consent verbally prior to their interviews, which was documented by the study team using a coded identifier. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests.
(© 2024. The Author(s).)

Callaghan WM, Creanga AA, Kuklina EV. Severe Maternal Morbidity Among Delivery and Postpartum Hospitalizations in the United States. Obstet Gynecol. 2012;120(5):1029–36. https://doi.org/10.1097/aog.0b013e31826d60c5 . (PMID: 10.1097/aog.0b013e31826d60c523090519)
Centers for Disease Control and Prevention. Severe Maternal Morbidity. Atlanta (GA): CDC. Available from: https://www.cdc.gov/maternal-infant-health/php/severe-maternal-morbidity/index.html .
MacDorman MF, Thoma M, Declcerq E, Howell EA. Racial and ethnic disparities in maternal mortality in the United States using enhanced vital records, 2016–2017. Am J Public Health. 2021;111(9):1673–81. https://doi.org/10.2105/AJPH.2021.306375 . (PMID: 10.2105/AJPH.2021.306375343835578563010)
Osterman MJK, Hamilton BE, Martin JA, Driscoll AK, Valenzuela CP. Births: Final data for 2021 . Hyattsville (MD): National Center for Health Statistics; 2023. Available from: https://pubmed.ncbi.nlm.nih.gov/36723449 .
Betrán AP, Torloni MR, Zhang JJ, Gülmezoglu A, Aleem H, Althabe F, et al. WHO statement on caesarean section rates. BJOG. 2016;123(5):667. https://doi.org/10.1111/1471-0528.13526 . (PMID: 10.1111/1471-0528.1352626681211)
Ye J, Betrán AP, Guerrero Vela M, Souza JP, Zhang J. Searching for the optimal rate of medically necessary cesarean delivery. Birth. 2014;41(3):237–44. https://doi.org/10.1111/birt.12104 . (PMID: 10.1111/birt.1210424720614)
Molina G, Weiser TG, Lipsitz SR, Esquivel MM, Uribe-Leitz T, Azad T, et al. Relationship between cesarean delivery rate and maternal and neonatal mortality. JAMA. 2015;314(21):2263–70. https://doi.org/10.1001/jama.2015.15553 . (PMID: 10.1001/jama.2015.1555326624825)
Kern-Goldberger AR, Booker W, Friedman A, Gyamfi-Bannerman C. Racial and ethnic disparities in cesarean morbidity. Am J Perinatol. 2021;40(14):1567–72. https://doi.org/10.1055/s-0041-1739305 . (PMID: 10.1055/s-0041-173930534891196)
Reduce cesarean births among low-risk women with no prior births - MICH 06. Available from: https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth/reduce-cesarean-births-among-low-risk-women-no-prior-births-mich-06 .
King PL, Keenan-Devlin L, Gordon C, Goel S, Borders A. 4: Reducing time to treatment for severe maternal hypertension through statewide quality improvement. Am J Obstet Gynecol. 2018;218(1):S4. (PMID: 10.1016/j.ajog.2017.10.415)
Einerson BD, Miller ES, Grobman WA. Does a postpartum hemorrhage patient safety program result in sustained changes in management and outcomes? Am J Obstet Gynecol. 2015;212(2):140-4.e1. https://doi.org/10.1016/j.ajog.2014.07.004 . (PMID: 10.1016/j.ajog.2014.07.00425019484)
Parchman ML, Palazzo L, Austin BT, Blasi P, Henrikson NB, Gundersen G, Ganos E. Taking action to address medical overuse: common challenges and facilitators. Am J Med. 2020;133(5):567–72. https://doi.org/10.1016/j.amjmed.2020.01.001 . (PMID: 10.1016/j.amjmed.2020.01.00132032544)
Main EK, Moore D, Farrell B, Schimmel LD, Altman RJ, Abrahams C, et al. Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. Am J Obstet Gynecol. 2006;194(6):1644–51 discussion 51–2. (PMID: 10.1016/j.ajog.2006.03.01316643812)
Main EK, Morton CH, Melsop K, Hopkins D, Giuliani G, Gould JB. Creating a public agenda for maternity safety and quality in cesarean delivery. Obstet Gynecol. 2012;120(5):1194–8. https://doi.org/10.1097/aog.0b013e31826fc13d . (PMID: 10.1097/aog.0b013e31826fc13d23090538)
White VanGompel E, Perez S, Datta A, Wang C, Cape V, Main E. Cesarean overuse and the culture of care. Health Serv Res. 2019;54(2):417–24. https://doi.org/10.1111/1475-6773.13123 . (PMID: 10.1111/1475-6773.13123307902736407356)
Clinkscales A, Barrett CA, Endres B. How does culture fit into de-implementation? A scoping review of empirical research. 2023. https://doi.org/10.31219/osf.io/wb7vr . (PMID: 10.31219/osf.io/wb7vr)
Caughey AB, Cahill AG, Guise J-M. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014;210(3):179–93. https://doi.org/10.1016/j.ajog.2014.01.026 . (PMID: 10.1016/j.ajog.2014.01.02624565430)
Main EK, Moore D, Farrell B, et al. Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. Am J Obstet Gynecol. 2006;194(6):1644–52. https://doi.org/10.1016/j.ajog.2006.03.013 . (PMID: 10.1016/j.ajog.2006.03.01316643812)
Kozhimannil KB, Law MR, Virnig BA. Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Aff (Millwood). 2013;32(3):527–35. https://doi.org/10.1377/hlthaff.2012.1030 . (PMID: 10.1377/hlthaff.2012.103023459732)
Institute for Healthcare Improvement. Quality Improvement Essentials Toolkit. Cambridge (MA): IHI. Available from: https://www.ihi.org/resources/tools/quality-improvement-essentials-toolkit .
No OCC. 1: safe prevention of the primary cesarean delivery. Obstet Gynecol. 2014;123(3):693–711. https://doi.org/10.1097/01.aog.0000444441.04111.1d . (PMID: 10.1097/01.aog.0000444441.04111.1d)
Main EK, Chang SC, Cape V, Sakowski C, Smith H, Vasher J. Safety Assessment of a Large-Scale Improvement Collaborative to Reduce Nulliparous Cesarean Delivery Rates. Obstet Gynecol. 2019;133(4):613–23. https://doi.org/10.1097/AOG.0000000000003109 . (PMID: 10.1097/AOG.000000000000310930870288)
Glisson C, Schoenwald SK, Hemmelgarn A, Green P, Dukes D, Armstrong KS, Chapman JE. Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy. J Consult Clin Psychol. 2010;78(4):537–50. https://doi.org/10.1037/a0019160 . (PMID: 10.1037/a0019160206588103951378)
Chambers DA, Glasgow RE, Stange KC. The dynamic sustainability framework: addressing the paradox of sustainment amid ongoing change. Implement Sci. 2013;8(1):117. https://doi.org/10.1186/1748-5908-8-117 . Published 2013 Oct 2. (PMID: 10.1186/1748-5908-8-117240882283852739)
White VanGompel EC, Perez SL, Datta A, Carlock FR, Cape V, Main EK. Culture That Facilitates Change: A Mixed Methods Study of Hospitals Engaged in Reducing Cesarean Deliveries. Ann Fam Med. 2021;19(3):249–57. https://doi.org/10.1370/afm.2675 . (PMID: 10.1370/afm.2675341808458118480)
Brownson RC, Colditz GA, Proctor EK. Dissemination and implementation research in Health: Translating Science to practice. New York, NY: Oxford University Press; 2023. (PMID: 10.1093/oso/9780197660690.001.0001)
Breimaier HE, Heckemann B, Halfens RJ, Lohrmann C. The Consolidated Framework for Implementation Research (CFIR): a useful theoretical framework for guiding and evaluating a guideline implementation process in a hospital-based nursing practice. BMC Nurs. 2015;14:1–9. https://doi.org/10.1186/s12912-015-0088-4 . Published 2015 Aug 12. (PMID: 10.1186/s12912-015-0088-4)
Glisson C, Hemmelgarn A, Green P, Dukes D, Atkinson S, Williams NJ. Randomized Trial of the Availability, Responsiveness, and Continuity (ARC) Organizational Intervention With Community-Based Mental Health Programs and Clinicians Serving Youth. J Am Acad Child Adolesc Psychiatry. 2012;51(8):780–7. https://doi.org/10.1016/j.jaac.2012.05.010 . (PMID: 10.1016/j.jaac.2012.05.01022840549)
Glisson C, Schoenwald SK, Hemmelgarn A, et al. Randomized trial of MST and ARC in a two-level evidence-based treatment implementation strategy. J Consult Clin Psychol. 2010;78(4):537–50. https://doi.org/10.1037/a0019160 . (PMID: 10.1037/a0019160206588103951378)
Williams NJ, Glisson C. Testing a theory of organizational culture, climate and youth outcomes in child welfare systems: A United States national study. Child Abuse Negl. 2014;38(4):757–67. https://doi.org/10.1016/j.chiabu.2013.09.003 . (PMID: 10.1016/j.chiabu.2013.09.00324094999)
Improving health care delivery: The “Learning Collaborative” approach. 2005. Available from: https://www.commonwealthfund.org/publications/other-publication/2005/jun/improving-health-care-delivery-learning-collaborative#:~:text=The%20%22learning%20collaborative%22%20approach,%20in%20which%20clinical%20staff .
Caughey AB, Cahill AG, Guise JM, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014;210(3):179–93. https://doi.org/10.1016/j.ajog.2014.01.026 . (PMID: 10.1016/j.ajog.2014.01.02624565430)
Lagrew DC, Kane Low L, Brennan R, Corry MP, Edmonds JK, Gilpin BG, et al. National Partnership for Maternal Safety: Consensus Bundle on Safe Reduction of Primary Cesarean Births—Supporting Intended Vaginal Births. J Obstet Gynecol. 2018;47(2):214–26.
Main EK, Chang SC, Cape V, Sakowski C, Smith H, Vasher J. Safety Assessment of a Large-Scale Improvement Collaborative to Reduce Nulliparous Cesarean Delivery Rates. Obstet Gynecol. 2019;133(4):613–23. (PMID: 10.1097/AOG.000000000000310930870288)
White VanGompel E, Perez S, Wang C, Datta A, Cape V, Main E. Measuring labor and delivery unit culture and clinicians’ attitudes toward birth: Revision and validation of the Labor Culture Survey. Birth. 2019;46(2):300–10. (PMID: 10.1111/birt.1240630407646)
Alvesson M. Understanding organizational culture. Los Angeles: SAGE; 2013.
Schein EH. Kurt Lewin’s change theory in the field and in the classroom: Notes toward a model of managed learning. Reflections SoL J. 1999;1(1):59–74. (PMID: 10.1162/152417399570287)
Schein EH. Organizational culture: A dynamic model. Cambridge, Mass: Alfred P. Sloan School of Management, Massachusetts Institute of Technology; 1983.
Byrne D. A worked example of Braun and Clarke’s approach to reflexive thematic analysis. Qual Quant. 2022;56(3):1391–412. (PMID: 10.1007/s11135-021-01182-y)
O’Donovan R, McAuliffe E. Exploring psychological safety in healthcare teams to inform the development of interventions: combining observational, survey and interview data. BMC Health Serv Res. 2020;20(1):810. (PMID: 10.1186/s12913-020-05646-z328677627456753)
Schein EH. Kurt Lewin’s change theory in the field and in the classroom: Notes toward a model of managed learning. Syst Pract. 1996;9:27–47. (PMID: 10.1007/BF02173417)
Canales MK. Othering: Toward an Understanding of Difference. Adv Nurs Sci. 2000;22(4):16–31. (PMID: 10.1097/00012272-200006000-00003)
Rooks JP. The midwifery model of care. J Nurse Midwifery. 1999;44(4):370–4. (PMID: 10.1016/S0091-2182(99)00060-910466283)
American College of Obstetricians and Gynecologists. Committee opinion no 687: Approaches to limit intervention during labor and birth. Obstet Gynecol. 2017;129(2):e20–7. https://doi.org/10.1097/aog.0000000000001905 . (PMID: 10.1097/aog.0000000000001905)
Healthy People 2030. Reduce cesarean births among low-risk women with no prior births - MICH 06. Washington (DC): U.S. Department of Health and Human Services. Available from: https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth/reduce-cesarean-births-among-low-risk-women-no-prior-births-mich-06#:~:text=Various%20evidence-based%20strategies%20aimed%20at%20hospitals%20and%20health%20care%20providers .
LeTourneau B. Managing Physician Resistance to Change. J Healthc Manag. 2004;49(5):286–8. (PMID: 15499802)
Dan O, Hochner-Celnikier D, Solnica A, Loewenstein Y. Association of catastrophic neonatal outcomes with increased rate of subsequent cesarean deliveries. Obstet Gynecol. 2017;129(4):671–5. (PMID: 10.1097/AOG.000000000000192528277351)
White VanGompel E, Main EK, Tancredi D, Melnikow J. Do provider birth attitudes influence cesarean delivery rate: a cross-sectional study. BMC Pregnancy Childbirth. 2018;18(1):184. (PMID: 10.1186/s12884-018-1756-7298436225975533)
Hirschinger L, Scott S, Hahn-Cover K. Clinician support: five years of lessons learned. Patient Saf Qual Health Care. 2015;12(2):26–31.
Quillivan RR, Burlison JD, Browne EK, Scott SD, Hoffman JM. Patient safety culture and the second victim phenomenon: connecting culture to staff distress in nurses. Jt Comm J Qual Patient Saf. 2016;42(8):377-AP2. (PMID: 274564205333492)
Substance Abuse and Mental Health Services Administration. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. Rockville (MD): SAMHSA. Available from: https://www.samhsa.gov/resource/dbhis/samhsas-concept-trauma-guidance-trauma-informed-approach .
Lyndon A, Malana J, Hedli LC, Sherman J, Lee HC. Thematic analysis of women’s perspectives on the meaning of safety during hospital-based birth. J Obstet Gynecol Neonatal Nurs. 2018;47(3):324–32. (PMID: 10.1016/j.jogn.2018.02.008295513975938121)
King PL, Lee S, Johnson I, Weiss D, Borders A. Early improvement in implementing key birth equity strategies in a statewide quality improvement effort. Am J Obstet Gynecol. 2023;228(1):S606. (PMID: 10.1016/j.ajog.2022.11.1028)
Shakibazadeh E, Namadian M, Bohren MA, Vogel JP, Rashidian A, Nogueira Pileggi V, et al. Respectful care during childbirth in health facilities globally: a qualitative evidence synthesis. BJOG. 2018;125(8):932–42. (PMID: 10.1111/1471-0528.1501529117644)

K08HS028028 Agency for Healthcare Research and Quality

Keywords: Cesarean birth reduction; Culture change strategies

Date Created: 20241224 Date Completed: 20241224 Latest Revision: 20241224

20241224

10.1186/s12913-024-12108-3

39716247