WHA Collaborative Improvement on Third and Fourth Degree Tears

Dates of first Collaborative Learning Session announced!

WHA is pleased to announce that the first Learning Session will be held on Wednesday 15 and Thursday 16 November 2017 in Sydney.

Services who have enrolled are urged to hold discussions to identify their collaborative team.   We will soon be providing enrolled teams with a Pre-work Handbook to assist in preparing for the first Learning Session.

Dates for introductory webinars and face to face learning sessions will be advertised in coming weeks.

Launch of the third and fourth degree tears Breakthrough Collaborative is imminent!

WHA is delighted to confirm that it has established an improvement partnership with the NSW Clinical Excellence Commission to jointly host a Breakthrough Collaborative with the aim of reducing by 20% the number of women harmed by a third or fourth degree tear by the end of 2018. This unique partnership brings together experts in improvement science with maternity clinicians and leaders who are passionate about improving outcomes for women. Drawing on the proven improvement methodologies of the US based Institute for Healthcare Improvement, this Collaborative will provide participating teams with intensive support and coaching to reliably implement a bundle of evidence based practices aimed at reducing harm to women from third and fourth degree tears.

Over the past several months WHA & the CEC have convened an Expert Panel with medical, midwifery and consumer experts.  The Panel has reviewed the research evidence and identified the key evidence based strategies for reducing third and fourth degree tears.  Improving recognition & response for women who do experience a severe tear has also been a focus of the Panel’s work.

Invitations to enrol in this Collaborative have been distributed to hospitals across Australia. A good number of services have already enrolled, and further enrolments are being received each week. 

The collaborative will be launched in early August, with the finalisation of the learning resources, decisions on lead sites to pilot the agreed bundle of care, and finalisation of the Pre-Work Handbook for enrolling teams imminent. 

Collaboratives are conducted through a number of face to face learning sessions. Between these sessions, teams implement change strategies during applied action periods where they are supported to undertake small scale improvements with an aim of identifying successful strategies quickly.  Participating services will learn how to hold the gains and embed practices in a manner that will ensure lower rates of tears are achieved and maintained well beyond 2018.

For further information, contact the WHA Collaborative team on collaborative@wcha.asn.au or 02 6175 1900.

What is a Breakthrough Collaborative?

This project will draw upon the methodology for collaborative improvement developed over many years by the Institute for Healthcare Improvement (IHI) in the US, and successfully employed by hospitals in Scotland, the UK, the US and other places, to achieve sustained improvements in patient care. For some examples of the use of this methodology & its results overseas see: the Scottish Patient Safety Program.

The IHI describes a breakthrough collaborative as a process that typically involves multiple hospitals working together over a 12-18 month period to support the reliable application of existing knowledge about best practice to a problem of common interest to the group so as to improve patient care and outcomes.  Their methodology usually involves at least 3 face to face Learning Sessions spread over about a 12 month period, plus regular exchange of data and insights between these meetings as each hospital tests its own theories on how best to implement the changes needed to achieve and sustain improvement.

The key criteria to choose the topic for any collaborative are:

  • That the problem affects a significant number of patients or involves significant harm to patients
  • There is a gap between what we do and what the evidence tells us we should be doing
  • There are known, evidence based interventions or changes that, if consistently used, will improve outcomes for women
  • The processes and outcomes are able to be reliably measured
  • There is a business case to make investing in collaborative improvement worthwhile

The IHI is clear that a Breakthrough Collaborative is a resource intensive tool that is not well suited to all improvement problems.  Its strength as a methodology is that it focuses on spread and adaptation of existing knowledge about best practice care to multiple settings to accomplish a common aim – in our case reducing harm to women from 3rd or 4th degree tears.  It is designed to achieve sustained improvement embedded in organisational culture and systems. Teams that participate report feeling buoyed by the momentum of regular peer & expert support to strive for and achieve improved outcomes for patients over the short and longer term.

Why third and fourth degree tears?

WHA consulted with a range of member groups during October and November 2016, to seek their advice on what the highest priority problem might be on which it would be useful to focus a collaborative improvement project.  This work culminated with the decision was taken to start with a Collaborative focused on 3rd & 4th degree tears.

Third & fourth degree tears can have a lifelong impact on women's physical, psychological & social health and wellbeing. There is clear evidence that some WHA member hospitals are succeeding in minimising this harm to women, and that their success is not simply underreporting of harm.  WHA is keen to facilitate sharing of learning to assist all member hospitals to minimise this harm to women.  Furthermore, in 2016 the Australian Health Ministers Advisory Council (AHMAC) confirmed that it would implement a system to penalise services for a short-list of Hospital Acquired Complications (HACs). 3rd & 4th degree tears have been included on the shortlist. From 2018, in addition to the cost of care for women who sustain a perineal tear, services will also be penalised (to an amount as yet to be determined) for women who are identified as sustaining 3rd or 4th degree tears.  It is therefore timely to work together in an effort to minimise rates of 3rd and 4th degree tears.   

How many women are affected by 3rd or 4th degree tears?

Approximately 73% of women giving birth vaginally experience varying degrees of tear in Australia (AIHW, 2015a). While grazes, first and second degree tears of the anterior vaginal wall are usually associated with little to no morbidity for women, injury to the posterior vaginal wall, muscles or anal sphincter can present an array of physical and psychological morbidities for women many months or years after birth (Frohlich & Kettle, 2015).

During 2014, 3.1% (n=6,365) of women having a vaginal birth in Australia experienced a third or fourth degree tear (AIHW, 2016). Women’s Healthcare Australasia (WHA) data for 2015/16 reports that 3.65% (n=3,310) of women experienced a third or fourth degree tear (WHA, 2016). What is of interest is the variation in rates of 3rd and 4th degree tears across hospitals within Australia, and that research has indicated that the rate of severe tears is rising (Priddis, et al., 2013).

Hospitals supporting more than 500 births per annum participating in the WHA Benchmarking Maternity Care program for 2015/16 reported rates of 3rd and 4th degree tear ranging between 1.3% and 5.6%, with an average of 3.43% (WHA, 2016). For hospitals supporting less than 500 births per annum the rates varied from 0% to 10%, with an average of 2.46%. Rates of third and fourth degree tear also vary by level of maternity care. Level 1-5 hospitals report an average rate of 3.1%, and level 6 (tertiary)  hospitals report an average of 4% (WHA, 2016).

What happens next? 

We are interested to identify some women who may be interested in sharing patient stories with the collaborative participants. We would be grateful for any advice/leads you may be able to provide on individuals who may be interested to participate. 

We look forward to working with member hospitals to progress this important project throughout 2017 & 2018.

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