Agenda 2/10/2012. Project AIM. Improving Perinatal Health Outcomes: New York State Obstetric and Neonatal Quality Collaborative

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1 Improving Perinatal Health Outcomes: New York State Obstetric and Neonatal Quality Collaborative Marilyn A. Kacica, MD, MPH Chair Medical Director Division of Family Health NYSDOH Pat Heinrich, RN, MSN Quality Improvement Consultant In partnership with NICHQ the National Initiative for Children s Healthhcare Quality Agenda Time Topic 5 min Overall Project AIM 5 min Project Goals 5 min Methodology 20 min Strategies and Lessons Learned 5 min Q & A Project AIM Improve practice implement evidence-based interventions for improving neonatal and maternal outcomes and Reduce racial and ethnic disparities in maternal, perinatal and infant health outcomes 1

2 NYSONQC Interventions for Regional Perinatal Center (RPC) Level Focus Obstetrical Outcomes Reduce the number of scheduled deliveries performed without appropriate indication in women of 36 0 ₇ to 38⁶ ₇ weeks gestation Neonatal Outcomes Optimize early enteral nutrition in newborns < 30 6/7 weeks gestational age in the NICU Perinatal Regionalization Perinatal regionalization is an organized system of care centered around a Regional Perinatal Center (RPC) affiliated with lower levels of hospitals in a network Hospitals designated as one of 4 ACOG/AAP-defined levels based upon ability to provide care Level 1 normal low risk mothers and newborns Levels 2 moderate risk mothers and newborns (must have specialty care/nicu) Level 3 - high risk mothers and newborns (subspecialty care/nicu) RPC highest risk mothers and newborns (subspecialty care/nicu), also provide consultation and support, maternal and newborn transport, education and quality of care in affiliated hospitals. System ensures that mothers and neonates have timely access to the appropriate level of care. Perinatal Regionalization Current status of NYS s 136 OB hospitals 16 Regional Perinatal Centers (RPCs) consisting of 18 hospitals 35 Level III hospitals 25 Level II hospitals 58 Level I hospitals 2

3 Alignment The Triple AIM Behaviors and Physical Environment Social & Economic Factors Physical Environment Health Care Alignment National Title V Measures Outcome Measure #01: The infant mortality rate per 1,000 live births Outcome Measure #02: The ratio of the black infant mortality rate to the white infant mortality rate Outcome Measure #03: The neonatal mortality rate per 1,000 live births Outcome Measure #04: The post neonatal mortality rate per 1,000 live births Outcome Measure #05: The perinatal mortality rate per 1,000 live births plus fetal deaths Performance Measure #11: The percent of mothers who breastfeed their infants at 6 months of age Quality Patient Care in Labor and Delivery: A Call to Action For the first time, major U.S. maternity care professional organizations have issued a joint statement on maternity care quality. Titled, Quality Patient Care in Labor and Delivery: A Call to Action, the white paper comes out strongly in favor of: woman and family centered care, including effective and culturally sensitive communication, shared decision making, effective teamwork, especially during obstetric emergencies, and performance measurement and leveraging of results to improve quality. 3

4 Quality Patient Care in Labor and Delivery: A Call to Action Performance and Outcome Measures for tracking care process and outcomes data benchmarking quality Improvement A culture of improvement requires a continuous process for measuring, improving, evaluating, and repeating the process until the desired outcomes are achieved. The foundation to these improvement processes Using evidence-based protocols, reminders, and checklists can facilitate standardized care processes that can improve outcomes. ement/~/media/f23bce9264bf4f1681c1eb553dca32f4.ashx Select Topic (develop mission) Expert Meeting Learning Model IHI Breakthrough Series Prework Develop P Framework A D & Changes S Planning LS 1 Group Participants ( teams) LS 2 P A D S Supports Congress, P Guides, A D Publications S etc.. LS 3 Visits Phone Assessments Monthly Team Reports The Model for Improvement 3 Fundamental Questions What are we trying to accomplish? How will we know that changes are an improvement? Aim Measures The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2 nd Ed. (Jossey-Bass Business & Management), Gerald J. Langley, Kevin M. Nolan, Clifford L. Norman, 2009 What changes can we make that will result in an improvement? Ideas PDSA cycles 4

5 The PDSA Cycle for Learning and Improvement 1. Small scale test 2. Series of tests 3. Wide-scale tests 4. Implementation 5. Spread Act What changes are to be made? Next cycle? Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data Repeated Use of the PDSA Cycle Changes that Result in Improvement A P S D Implementation of Change Hunches Theories Ideas A P S D Follow-up Tests - over a variety of conditions to identify weaknesses Very Small Scale Test simple and designed to succeed Wide-Scale Tests of Change - designed to predict and prevent failures Roles & Responsibilities Role of DOH project sponsor leadership regulatory agency vs public health work Challenges and opportunities of multiple roles Challenges and opportunities of multiple roles Participating Team roles/expectations 5

6 Approach Create organizational structure Expert Workgroup Quality improvement panel Ongoing literature review Review NICU enteral feeding guideline documents Adjudicate procedural/project design issues Data panel Review data quality Review analyses Adjudicate data quality and analytical issues Partnership with NICHQ Nationally recognized/experienced OB faculty (Dr. Pete Cherouney) Quality Improvement Expertise OB Project Focus & Goals Assure that all initiations of labor or cesarean sections on women who are not in labor occur in NYS hospitals only when obstetrically or medically indicated by reducing scheduled deliveries without medical indication in women of 36 0/7 to 38 6/7 weeks gestation NYSONQC Obstetric Intervention Key Drivers Awareness of risks and expected benefits of late preterm/early term delivery by patients and consumers Dating criteria: optimal estimation of GA Hospital and physician practice policies that facilitate ACOG criteria Awareness of risks & expectations benefit of late preterm/early term delivery by a clinician Communication across all systems of care and a culture of safety and improvement. 6

7 New York State Obstetric and Neonatology Quality Collaborative Obstetric Intervention Driver Diagram 19 New York State Obstetrical and Neonatal Quality Collaborative Scheduled Delivery Form Scheduled is defined as all inductions and cesarean sections prior to onset of labor between 36 0/7 and 38 6/7 weeks gestational age Patient Demographics (includes delivery type) Clinical Data Patient Counseling Reason for Scheduled Delivery Maternal Fetal Psychosocial Infant Outcome Data collection, entry and verification documented if no maternal reason listed 7

8 NYSONQC Neonatology Intervention Goal Optimize early enteral nutrition in newborns < 30 6/7 weeks gestational age Aim In one year, reduce statewide the percentage of newborns < 30 6/7 weeks gestational age that are discharged from the NICU below the tenth percentile NYSONQC Neonatology Intervention Key Drivers Develop a system for optimal use of human milk Establish hospital and physician enteral feeding policies Establish awareness of risks and expected benefits of early enteral feeds Establish communication across all systems of care and create a culture of safety and improvement 8

9 New York State Obstetric and Neonatology Quality Collaborative Neonatology Intervention Driver Diagram Goal: Optimize early enteral nutrition in newborns <31 weeks gestational age. Key Changes Project Aim In one year, reduce state wide the percentage of newborns <31 weeks gestational age that are discharged from the NICU below the tenth percentile. Key Drivers Optimal use of human milk Hospital and physician enteral feeding policies Awareness of risks & expected benefit of early enteral feeds Culture of safety and improvement Educate mother: nutritional benefits of breast milk Develop a system for early lactation support Promote use of neonatology nutritionist Provide optimal storage systems for breast milk. Educate NICU staff: nutritional benefits of breast milk Include the use of breast milk in enteral feeding policy Collect data on use and trends to inform policy Collect existing hospital policies to review and compare, identify common elements. QI Panel to complete a peer/literature review. Develop essential components as guidelines for RPC protocols. Collect data on time to first feed, time to accelerate. Consistently educate and promote use of policies amongst NICU staff especially new physicians. Engage all NICU staff to provide feedback on protocol Educate staff on the evidence base for early enteral feeds, including disseminating relevant data. Family awareness campaign: benefits of early enteral feeds and use of human milk. Staff education: proper implementation of feeding protocol. Provide periodic in services on relevant topics to keep awareness raised. Provide frequent reinforcement of family education/support. Continuous monitoring and dissemination of data with discussion at staff/administration meetings. Develop ways to include all NICU staff input about feeding policies and data results. Develop process for family feedback on NICU environment relative to feeding practices. Encourage NICU staff to propose new ideas for improvement based on experience with implementing protocols. Planning and Coaching Activities Neonatal - Biweekly small group data panel conference calls (July to present) Variables of interest Standardizing data definitions Dealing with variation in data currently collected Development of a survey instrument to capture data regarding current RPC NICU enteral feeding practices OB & Neonatal Learning Collaborative Learning Sessions LS 1 Action Period Calls P Monthly data reporting A D S Strategies RPC role - Leadership Local Champions Connection to State/Project and Organizational Strategic Objectives OB Chair as National Leader to promote Multidisciplinary team - involve all key roles (dietitian, LC, Managers, clinicians etc..) Implications for future work 9

10 Data Revision to data tool Obstetrics Scheduled Delivery Data System 3 faces of Measurement Neonatal Intensive Care Unit Module Database Timeliness 3 Faces of Measurement Aspect Improvement Accountability Clinical Research Aim: Improvement of care Comparison, choice, reassurance, spur for change Methods: Test observability Test observable No test, evaluate current performance Bias Accept consistent bias Measure and adjust to reduce bias New knowledge Test blinded Design to eliminate bias Sample size Just enough data, Obtain 100% of Just in case data small sequential samples available, relevant, data Flexibility of hypothesis Hypothesis flexible, No hypothesis Fixed hypothesis changes as learning takes place Testing strategy Sequential tests No tests One large test Confidentiality of data Data used only by those involved in the improvement Data available for public consumption Research subjects identities protected The Three Faces of Performance Measurement: Improvement, Accountability and Research. Solberg, Leif I., Mosser, Gordon and McDonald, Susan Journal on Quality Improvement. March 1997, Vol.23, No. 3 Scheduled Delivery Type Number of scheduled deliveries =3,447 Number of scheduled c-sections=2,095 (60.8%) Number of vaginal deliveries=1,316 i (38.2%) 30 10

11 % All scheduled deliveries without indication Desired Change: Reduction of scheduled deliveries performed without appropriate indication for pregnant women of 36 0/7 to 38 6/7 weeks gestation Measure 3. Percent of all scheduled deliveries at 36 0/7 to 38 6/7 weeks without medical or obstetrical indication documented of all scheduled deliveries 30% 25% 25.6% 20.3% Percent 20% 15% 10% 15.1% 17.9% 17.4% 13.8% 16.5% 10.7% 8.3% 11.6% 12.2% 8.5% 5% 0% September October November December January February March April May June July August 25.59% 15.09% 17.95% 20.28% 17.44% 13.83% 16.48% 10.70% 8.27% 11.61% 12.15% 8.47% Percent n Number of scheduled deliveries=3, New York State Obstetric and Neonatal Quality Collaborative First Year Results Scheduled delivery 3,447 Scheduled Deliveries o 60.8% C-sections o 38.2% Vaginal Scheduled deliveries without medical indication All scheduled deliveries decreased by 67% Induction decreased by 86.2% C-sections decreased by 62% Primary C-sections decreased by 66% NICU admission without indication decreased by 61% Maternal Education about preterm delivery increased by 56.1% 32 Fenton Growth Percentiles for NYS Regional Perinatal Centers Transfers Out Mix of Home and Transfer Mostly D/C To Home Long Hospitalization Difficult Course 11

12 Proportion of Infants with Discharge Weight <10 th Percentile Perce ent (%) NYS-wide 31.4% Stony Brook WMC Montefiore AMC WCHOB No Shore Winthrop UHB Columbia Mt. Sinai LIJ Jacobi A B C D E F G H I J K L M N O P Q Rochester Weill Cornell Maimonides Bellevue Crouse Neonatal Lessons Learned Simply having protocols to initiate, advance or evaluate feeding tolerance is not associated with growth Risk of D/C weight < 10 th percentile is lower with: Earlier trophic feeds More rapid advancement Earlier first enteral feeding Earlier full enteral feedings Earlier first and full enteral feeds may explain over 80% of center variation in growth outcomes Overall Lessons Learned (consider stealing shamelessly ) There is NO failure in Quality Improvement A SMART Aim is essential to keep the team on track Roles, responsibilities, and expectations should be clear from the start Remember the importance of meeting facilitation set an agenda and finish with to dos for time between meetings Some is not a number Soon is not a time Hope is not a plan The interventions should be standardized as the evidence supports, however each site will want/need to have autonomy over how they make the changes to the new system 12

13 Funding Local Regional State Federal Plan how to sustain the improvements after the funding ends Strategies for spread Use existing infrastructure Regional Perinatal Centers (RPCs) in first phase Pilot the interventions and the tools Train the trainer approach Reach consensus where no evidence exists Spread Plan/Next Steps - RPCs responsible for Affiliate Hospitals (adding this new project to other previous work) Maintain central data repository for core measures In Summary If you plan to start this type of project: Collaborate with others (states, organizations, others working on same/similar projects (we learned from OPQC and IHI Perinatal Projects) Assess current practice at start of project to identify opportunities for improvement Identify local Opinion Leaders for faculty 13