Assuring Safety and High- Quality, Patient Centered Services Along the Continuum of Perinatal Care Secretary’s Advisory Committee on Infant Mortality November 14, 2012
Dec 17, 2015
Assuring Safety and High-Quality, Patient Centered Services Along the Continuum of Perinatal Care
Secretary’s Advisory Committee on Infant Mortality
November 14, 2012
Data-Driven Perinatal Quality Improvement
Through Public-Private Partnering
Elliott K. Main, MDDirector, CMQCC
Chair, Dept. OB/GYN, California Pacific Medical Center Clinical Professor, Dept. OB/GYN, Univ. Calif. San Francisco
Visiting Professor, Dept OB/GYN, Stanford University
: Transforming Maternity Care
California…. 2011 Population: 37,691,912 1
3 large metropolitan areas, but extensive remote rural areas 2011 Births: 502,118 2
1 of 8 US births, Texas next with 377k Equal to a large European country
2010 Infant Mortality: 4.7 / 1,000 3 ~4th lowest state in US, but still ~27th in the world
2011 Preterm Birth Rate: 9.8% 4 (March of Dimes: “B”) Currently ~280 birthing facilities with >50 annual births
1 US Census Bureau (est.), June 20112 NCHS: NVSR 61:05, Oct 20123 CDPH: MCAH, May 20124 NCHS: 2011 Preliminary Natality data
: Transforming Maternity Care
Improving Maternity Outcomes
Social Determinates
Medical Determinates
4
Faster change?Easier to test?
Cheaper?
: Transforming Maternity Care
How does Data-Driven QI improve maternal and neonatal outcomes?
Multi-Stakeholder Quality Collaboratives State-wide perinatal outcomes database Significant effort for Data Quality Using transparent data to drive and
incent care
Pos: 50 states testing new ideas Neg: 50 states all “doing their own thing”
: Transforming Maternity Care
CMQCC and CPQCC
Mission: Data-driven QI for mothers and newborns
California Perinatal Quality Care Collaborative (CPQCC) Established 1996 >95% of all Neonatal Intensive Care Units in California Secure data center—pioneer for data driven QI Model of working with state agencies to provide data of value
California Maternal Quality Care Collaborative (CMQCC) Established 2006 California Maternal Mortality Review Committee (Title V, MCAH) QI toolkits: Elective Delivery <39wks, Hemorrhage, Preeclampsia, Large-scale QI Collaboratives: Hemorrhage, Preeclampsia Statewide Maternal Data Center (CDC and CHCF supported)
: Transforming Maternity Care
CMQCC Key Partner/StakeholdersState Agencies: MCAH, Dept Public Health OSHPD Healthcare Information Division Office of Vital Records (OVR) Regional Perinatal Programs of California (RPPC) DHCS, Medi-CalPublic Groups California Hospital Accountability and Reporting Taskforce (CHART) Kaiser Family Foundation March of Dimes (MOD) Pacific Business Group on HealthProfessional groups American College of Obstetrics and Gynecology (ACOG) Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) American College of Nurse Midwives (ACNM), American Academy of Family Physicians (AAFP)Key Medical and Nursing Leaders University and Hospital Systems Kaisers, Sutter, Sharp, CHW, Scripps, Public hospitals,
: Transforming Maternity Care
Examples of Current Maternal QI Projects
VLBW (<1500g) infants to deliver at appropriate level of care (Level III NICU)
Early (<39 weeks) Elective Delivery Reducing Low-risk First-birth Cesareans Increasing Exclusive Breast Milk Feeding Reduction of complications in pregnant
women with hypertension
: Transforming Maternity Care
Regionalization of care for VLBW has diminished in the last decade despite strong evidence of benefit
California has large variation with major quality opportunities in urban areas
: Transforming Maternity Care
VLBW infants (<1500g) Admitted Directly to NICU
MMWRNov 12, 201059:144-7
: Transforming Maternity Care
Delivery of <1500gm Infant NOT at a Level III Center
HP 2010, HP 2020,
Turn the national goal into a hospital-level quality measure CMQCC Sponsored NQF Endorsed
<1500g infant not delivered at an appropriate level of care Denominator: Livebirths >24 weeks gestation at a NON-Level III
hospital Numerator: Births <1500gm and >500gms Exclusions: none Risk Adjustment: none
Large Regional and Hospital Variation for the Delivery of VLBW not in an Appropriate Level of Care
: Transforming Maternity Care
The California Maternal Data Center(CMDC) Project Vision
Build a statewide data center to collect and report timely maternity metrics—in way that is low cost, low burden and high value for hospitals
Produce metrics that will support QI and L&D service line management
Improve quality of administrative data
Facilitate reporting to national performance organizations
Over time, publicly report select set of robust measures to inform decisions of childbearing women
: Transforming Maternity Care
PDD--Discharge Diagnosis File(ICD9 codes)
Birth Certificate File(Clinical Data)
1. Links Birth Data to OSHPD file2. Runs exclusions3. Identifies CS and Inductions 4. Prints list of charts for review
CMQCC Maternal Data Center: Data Flow
CMQCC Data Center
REPORTSBenchmarks against other hospitals
Sub-measure reports
Calculates all the Measures<39wk Elective Delivery
CHART REVIEWLabor?/SROM?
(~6% of cases for brief review)
Limited manual data entry for this measure
Uploads electronic files
Mantra: “If you use it, they will improve it”
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Built-in Quality Analysis: where do we go next?
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Comprehensive Vision for Maternal Data QI in California
1) Standardize Definitions
2) Education (MD’s, BC staff, Coders)
3) Redesign / System Changes
4) Improving Data as QI Project
5) Create Value for Maternal Data QI for hospitals
Obstetric Data Definitions Project
National MeetingAugust 2-3, 2012Arlington, Virginia
Project Objectives
To nationally standardize obstetric clinical data definitions.
To educate and advocate for national implementation of the standardized obstetric data elements and definitions in electronic medical records, birth certificates, and data registries
To increase and improve performance measurement and implementation of the national obstetric data standards and encourage data aggregation.
Many Stakeholders… National vital records (NCHS, NAPHSIS) State vital records State departments of health (MCH) Federal agencies (CMS, CDC, NLM, AHRQ, NICHD) Quality organizations (TJC, Leapfrog, NQF) Health IT / Coding organizations EMR vendors Payers (Medicaid and commercial) Providers (obstetrics, family medicine, nursing, midwifery) Large scale QI collaboratives Advocacy groups (March of Dimes)
Data Quality Reports• Identify discrepancies or missing data in Birth Certificate
and Discharge data files• Use to target data performance/quality improvement
23Screen shot from the California Maternal Data Center
Data Quality Reports
• Identify discrepancies or missing data in Birth Certificate and Discharge data files
• Use to target data quality improvement
25
A hospital with a system for transferring clinical data to the BC
: Transforming Maternity Care
Late Preterm Birth (34+0 to 36+6 wks)
Late Preterm Birth makes up >70% of all PTB
Late Preterm Birth accounted for ~80% of the rise in PTB in the prior 10 years
Late Preterm Birth accounts for 75% of the decline in PTB in the last 3 years
Late Preterm Birth accounts for much of the variation in PTB rates among states and among hospitals
Is there a QI opportunity here?
What components make up the
Preterm Birth Rate?
: Transforming Maternity Care
Health Equity
<1500g Birth Not at Appropriate Location
Late Preterm Birth
Exclusive Breast Milk during Birth Hospitalization
Low-risk First Birth Cesarean Delivery
All have significant racial/ethnic disparitiesAll could be helped by focused QI projects
: Transforming Maternity Care
Recipe for Improving Care
Quality Measures
Hospital LevelProvider Level
Define the Issues Locally
Transparency
Financial
Incent Systems Change
Public ReleaseBenchmarking
Pos/Neg IncentivesValue-Based Purchasing
Unintended Consequences? Balancing Measures!
Data quality?If you use it, they will improve it!
: Transforming Maternity Care
Role(s) for HHS
Quality Measures
Support measure developmentSupport wide-spread useSupport data collaboratives
Transparency
Financial
Support public releaseRaise awareness
Reduce perverse incentivesExplore positive incentivesValue-Based Purchasing
Support development of Balancing Measures
Support Data QI projectsUse admin data and they will improve it!
: Transforming Maternity Care
Reporting Mandates Coming
ED<39 weeks measure included in Hospital IQR Program for FY 2015 payment determination: data collection beginning with January 2013 discharges
The Joint Commission will require reporting of perinatal set for hospitals that perform deliveries
Medicaid Adult Measure Set published; Medi-Cal Quality Dashboard under development
Medi-Cal has received a federal grant to test collection and reporting of perinatal metrics. CMDC is an active participant.
: Transforming Maternity Care
CMDC’s Clinical Quality Measures
NQF Joint Commission Leapfrog CMS Medi-
CalCHA HEN
Elective Deliveries 37 - 39 week rate (PC-01) C-Section rateTerm 1st Birth (NTSV) (PC-02) Infants < 1500 grams at appropriate level
Episiotomy rate Healthy Term Newborn rate Antenatal Steroids (PC-03) Neonatal Blood Stream Infections (PC-04)
Exclusive Breast Milk (PC-05)
Cu
rre
ntS
oon
Requires some additional chart review (minimized by using the CMDC)
: Transforming Maternity Care
CMDC’s Clinical Quality MeasuresJoint
Commission Chart Review Needed with CMDC
Elective Deliveries 37 - 39 week rate (PC-01)
# of charts reduced to <6% of OB cases and then a very brief review
C-Section rateTerm 1st Birth (NTSV) (PC-02) --none--
Infants < 1500 grams at appropriate level --none--
Episiotomy rate --none--
Healthy Term Newborn rate --none--
Antenatal Steroids (PC-03) With CPQCC, >95% of cases are transferred, identifies missing cases
Neonatal Blood Stream Infections (PC-04) --none--
Exclusive Breast Milk Feeding (PC-05) Generates a “smart” randomized sample
for chart review
Cu
rre
ntS
oon
Requires some additional chart review (minimized by using the CMDC)
1 (San Francisco & North
)
2 (Sacramento & NE)
3 (East S
F Bay)
4 (South SF Bay )
5 (Centra
l Valley)
6 (Los Angeles)
7 (Inland Empire
)
8 (Orange County)
9 (San Diego & East)
10 (Kaise
r North
)
11 (Kaise
r South)
15
20
25
30
35
40
NTSV CS (State mean = 28.1%)Total CS (State mean = 31.3%)
HP 2020 NTSV CS Target = 23.9%
California Perinatal Region (2007 data)
Med
ian
Ces
area
n R
ate
(%)
: Transforming Maternity Care
Improving Maternity Outcomes: CMQCC Interactions with National Projects
Quality Measures
Maternal Mortality/Morbidity
Data Quality
37
JC, NQF, NPP
AMA PCPI
CDC/AMCHPACOG/CDC
MCHB
Medi-Cal AdvisCMS Expert Panel
ACOG reVITALizeNAPHSISNCHS