Transcript Document

Instructions to cook up the
Baker’s Dozen
Made Fresh Daily
Kelly Friar, Chief, Office of Health and Vital
Statistics and Accreditation Coordinator
Ohio Department of Health
Significance for Public Health
Public Health Accreditation Board
PHAB
• Community Health Assessment
• Community Health Improvement Plan
• Dept. Strategic Plan
• Quality Improvement Plan
• Workforce Development Plan
• Performance Management System
2012 Vision Awards
Achieving Excellence in Public Health
Through Innovation
Category A –
Programs with a budget of greater than $250,000
First Place
Ohio Department of Health
Ohio Perinatal Quality Collaborative (OPQC)
The Ohio Perinatal Collaboration to Improve Birth Data and Prematurity Outcomes is a creative approach to using
public health surveillance data (birth certificates) as a supplement to data collected from medical records to
serve as the metrics that can inform and accelerate perinatal quality improvement initiatives. The Ohio Perinatal
Quality Collaborative (OPQC), Ohio’s public/private partnership focused on improving health outcomes using
quality improvement science, has documented early successes in reducing late preterm scheduled deliveries
without medical indication in 20 delivery hospitals in Ohio. Spreading what works will be essential in reducing
prematurity and having a measurable impact on population health. This effort is state administered by investing
and partnering in OPQC where the improvement happens. Over many decades Ohio has relied heavily on birth
certificates as source of data to measure population-level changes over time, but only recently has turned to
them to measure improvements in health care and outcomes.
The Baker’s Dozen
Top Key Variables in IPHIS
Variable
1. Total number of Prenatal visits
IPHIS Tab
Prenatal
2. Pregnancy Risk Factors: pre-pregnancy and gestational diabetes
Pregnancy
3. Pregnancy Risk Factors: pre-pregnancy and gestational hypertension
Pregnancy
4. History of prior preterm birth
Pregnancy
5. Induction of Labor
Labor & Delivery
6. Augmentation of Labor
Labor & Delivery
7. Antenatal corticosteroids (ANCS)
Labor & Delivery
8. Antibiotics received by the mother during delivery
Labor & Delivery
9. Birth weight
Newborn
10. Obstetrical estimate of gestational age
Newborn
11. Abnormal conditions of the newborn:
Assisted ventilation after delivery and NICU admission
Newborn
12. Congenital abnormalities of the Newborn
Newborn
13. Breast feeding at discharge
Newborn
Why Are We Doing This?
• OPQC’s Mission: Improve Infant Health
• Through collaborative use of improvement
science methods, reduce preterm births
and improve outcomes of preterm
newborns in Ohio as soon as possible
• What Causes Perinatal & Infant Mortality?
• Preterm Birth
• Birth Defects
• SUID et al
Our Shared Vision
• Decrease prematurity and infant
•
mortality in Ohio
OPQC, ODH-Vital Statistics and OHA
• Using the PLAN-DO-STUDY-ACT cycle of
continuous quality improvement to facilitate
improved data collection to accurately
measure progress toward goal of reducing
non-medically indicated deliveries prior to 39
weeks gestation
Bill Callaghan, MD MPH
Centers for Disease Control and Prevention
December 1, 2011
“The focus of
healthcare for women
and infants over the
next century depends
on the quality of the
data collected by
those who fill out the
birth certificates.”
Obstetric Quality 2007
“ There are currently no uniformly
accepted measures of obstetrical quality.
Many traditional measures of obstetrical
quality are flawed and newer measures
are still undergoing necessary
validation.”
- Jennifer L. Bailit, MD, MPH
OBG Survey 2007
OB Quality Monitoring
• National Quality Foundation
• Joint Commission
• Ohio Hospital Compare
• Leap Frog
• CMS
• Ohio Perinatal Quality Collaborative
• PCPI
• PQRS
JOINT COMMISION:
Perinatal Care Measures
• PC-01 Elective Delivery
• PC-02 Cesarean Section (NTSV)
• PC-03 Antenatal Steroids
• PC-04 Health Care-Associated
•
Bloodstream Infections in Newborns
PC-05 Exclusive Breast Milk Feeding
https://manual.jointcommission.org/releases/TJC2013A/PerinatalCare.html
PC -01
• Numerator: Patients with elective
•
•
deliveries
Denominator: Patients delivering
newborns with >= 37 and < 39 weeks of
gestation completed
Inductions and cesarean delivery
included
JOINT COMMISION:
New for July 1, 2013
“It is acceptable to use data derived from vital
records reports received from state or local
departments of public health if they are
available and are directly derived from the
medical record with a process in place to
confirm their accuracy. If this is the case,
these may be used in lieu of the acceptable
data sources listed below.”
https://manual.jointcommission.org/releases/TJC2013B/DataElem0265.html
<39 Week Scheduled Delivery – 20 Charter Hospitals
Promedica
Toledo Hospital
UH Case
MacDonald Women’s
Mercy St. Vincent
Medical Center
Fairview
Hospital
Metro Health
Akron Children’s MFM
Akron General
Aultman Hospital
Mt. Carmel
St. Ann’s
Mt. Carmel East
Mt. Carmel West
Miami Valley
OSU
Riverside
Hospital
Wexner
Methodist
Mercy Anderson
UH Cincinnati
Good Samaritan
Hillcrest
St. Elizabeth
Health Center
Summa Health
System
BC Data Varies By:
• Hospital
• Maternal Dis
• Credentials
• State
Effects of the Initial OPQC
39 Week Scheduled Birth Project
September 2008  March 2013
• 30,000 births shifted to 39-41 weeks
• Conservative estimate = 3% fewer
“near term” NICU admissions: N = 950
• 950 x $20,000 per NICU Admission =
• $19,000,000 savings in 4 ½ years
Lessons From the Initial 39 Week Project
• Create A Culture of Change
• Learn From All Participants
• Improve Communication
• Data Collectors, Data Users, Data Analysts
• OPQC = Data for You to Use, Not the Police
• Birth Certificate = A Q.I. Instrument
• More Training and More Cross Talk
• Use  Greater Accuracy  Promotes Use
• Rapid Turnaround Essential
<39 Week Scheduled Delivery and Birth Certificate Accuracy
15 Pilot Hospitals
Ashtabula County
Bay Park
Promedica
Mercy Regional
Lorain
Blanchard
Valley
Mercy Canton
St. Rita’s Lima
Southview
Good Samaritan
Dayton
Kettering
Genesis
Bethesda
Fairfield
Lancaster
The Christ Hospital
Bethesda
North
Southern
Ohio Medical
Center
Team Sharing and Learning
Harvard School of Education http://socrativegarden.wordpress.com/2011/08/04/1-2-3-word-cloud/
Two reasons for inaccurate gestational age entry
1. Sometimes the gestational age is “rounded up” in IPHIS.
• Gestational age is NEVER TO BE ROUNDED UP; it is
recorded in completed weeks.
• For example, 38 weeks, and 5 days is properly termed 38
weeks.
2. Often there is no agreement re: where in the medical
record gestational age should be recorded; in addition,
varying gestational ages are found in the medical record.
• Consistent agreement regarding where in the medical
record the IPHIS variable for gestational age is found will
greatly increase your accuracy.
Remaining 73 Ohio Maternity Hospitals
•
•
January 2013
thru April 2014
Divided into
three separate
“Waves” with
staggered start
dates
Differences from Charter and
Pilot Sites
• Updated the report of allowed
medical indications from
Birth Registry/IPHIS data
•
*Change in measure from
36.0 - 38.6 weeks to 37.0-38.6
weeks gestation; more in
harmony with Joint
Commission, Leap Frog and
Ohio Hospital Care
Can You Do This In Your Hospital ?
What Are The Keys to Success?
• Adopt ACOG Guidelines
• Use a Scheduled Birth Form (ACOG or Site Specific)
• Document the Pregnancy Dating Method
• Document the Reasons for Scheduled Birth
• OPQC Is Not The Police = Start with Soft Stop
• Rapid Data Turnaround
• Frequent Group & Site PDSA’s
• Enthusiasm from Local Leaders
PDSA
• Plan
• Look at a particular aspect of project
• Review intervention options
• Plan implementation of intervention
• What do you predict will happen?
• Do
• Execute the intervention
• Study
PDSA
• How did the intervention go?
• Did it go the way you expected?
• What was the outcome?
• Was the a measure?
• Act
• Accept
• Adopt
• Abandon
13 Key IPHIS Variables
Handout
Is there any way to get
gestational age correctly
recorded in IPHIS all the time?
Essential Data Elements to Accurately
Document Gestational Age
• Earliest Ultrasound that documented GA
• Ideal CRL
• Best < 20 weeks gestation
• documentation by provider
• estimate of GA
• what it is based on
Second Step-entering Data into
IPHIS
Make sure everyone agrees where to find
best OB estimate of GA and EDD
 acquisition of data
Recording of data
Transfer of data
Monitoring of process
IPHIS to Patient Medical Record Checklist
Directions, Data Dictionary, and Examples
Photo courtesy of fotolia.com
IPHIS to Patient Medical Record Checklist
Hospital: ____________________ Month: ____________
IPHIS
Pregnancy tab:
Risk Factors
IPHIS
Pregnancy tab:
Risk Factors
IPHIS
Labor & Delivery
tab: Characteristics
of Labor & Delivery
IPHIS
Labor & Delivery
tab: Characteristics
of Labor & Delivery
IPHIS
Newborn tab:
Other
Variable
Pre-pregnancy and
Gestational diabetes
Chart 5
Y N
Total
Y
Total
N
Total
Y+N
Chart 1
Y N
Chart 2
Y N
Chart 3
Y N
Chart 4
Y N
Chart 5
Y N
Total
Y
Total
N
Total
Y+N
Chart 1
Y N
Chart 2
Y N
Chart 3
Y N
Chart 4
Y N
Chart 5
Y N
Total
Y
Total
N
Total
Y+N
Chart 1
Y N
Chart 2
Y N
Chart 3
Y N
Chart 4
Y N
Chart 5
Y N
Total
Y
Total
N
Total
Y+N
Chart 1
Y N
Chart 2
Y N
Chart 3
Y N
Chart 4
Y N
Chart 5
Y N
Total
Y
Total
N
Total
Y+N
Total
Y
Total
N
Total
Y+N
Does the data documented in
IPHIS match the data found in
the patient records?
Variable
Obstetrical estimate of
gestation at delivery
Chart 4
Y N
Does the data documented in
IPHIS match the data found in
the patient records?
Variable
Antenatal corticalsteroids (ANCS)
Chart 3
Y N
Does the data documented in
IPHIS match the data found in
the patient records?
Variable
Induction of Labor
Chart 2
Y N
Does the data documented in
IPHIS match the data found in
the patient records?
Variable
Pre-pregnancy and
Gestational
hypertension
Chart 1
Y N
Does the data documented in
IPHIS match the data found in
the patient records?
Total “yes” responses divided by total
“yes” + “no” responses=
%
Step 1
Analyze results and dig deeper
•
•
Is there any difference among
data suppliers, documentation,
data collectors?
What data do you want to work
on ?
Fishbone Diagram: Design
Policies
People
Primary Cause
Problem
Statement
Procedures
Place
36
Fishbone Diagrams: Tips
• Use Fishbone Diagram on an on-going basis
• Identify contributing factors to each cause
• Dig deeply into the causes of the causes
• May do multiple diagrams to get at the root
•
•
cause
Use data to verify – what is causing the most
or worst error of error?
Don’t jump to solutions!
What We Are Doing
• Reviewed 10 charts: information in chart,
•
•
on the ODH facility worksheet and in
IPHIS.
Discovered: Missing/incorrect data in
numerous IPHIS fields.
Plan: Change the way data is collected and
review data prior to entering in to IPHIS.
Scheduled Delivery Form
• One Page Inclusive: Facilitates
•
•
•
information from admitting physician.
Variables from IPHIS that are medical
indications for elective delivery <39
weeks.
Faxed to Maternity Dept.
Reviewed by RN prior to scheduling
mother for elective delivery.
Step 2. Experiment with a
solution: improve a specific
problem with a specific solution
• Pilot
• Run
• Audit
40
Step 3: Display Results Data
Checksheets
A
A1
A1
A1
D1
D1
D1
D2
D2
D2
A2
A2
A2
A
A
B
B
B
UCL
Sigma=
Sigma=
CCR
X
X
LCL
Gap
41
Hover Function
Modules
1.
Why is the birth certificate important to the healthcare of women and newborn
infants?
Use of the birth certificate as a QI tool is discussed in detail in this Module.
2.
What are the variables in the Ohio birth certificate and what do they mean?
3.
Where are select birth certificate variables found in the medical record?
4.
How can I know if I have accurately entered data into IPHIS?
5.
How can I Improve the data entry processes at my hospital?
The importance of obtaining the correct gestational age is highlighted as well as
the “Bakers Dozen of the Most Important Variables,” with appropriate definitions
for each.
Select variables are highlighted as well as the need for collaboration between the
clinical and data abstraction teams.
This is the most technical of all the Modules, providing an overview of the IPHIS
software and the data checks within it. A suggested quality review of hospital’s
submissions is also covered.
This Module reviews the Model for Improvement, AIM statements, & PDSA’s.
Keys to Success
• Communication
• Don’t assume
• Consensus and key personnel buy-in
• Grit and determination
• Monitoring of efforts (DATA)