Understanding OB Adverse Event Measures

Transcription

1 Understanding OB Adverse Event Measures Partnership for Patients Pacing Event Tuesday, May 13, :00 4:15 pm (ET)

2 Welcome Jackie Moreland Tennessee Hospital Association Co-Lead Maternal Affinity Group

3 Partnership for Patients Campaign 211 Days and Counting! Our Patients are Counting on You!

4 Agenda Call to action: selecting and tracking measures Understanding patient needs throughout obstetric care; engaging the PFE community Review of current HEN performance around OB adverse events Ask the Experts: challenges with OB adverse event measures Requests and Offers

5 Questions To Run On What measurement strategies can my HEN apply to OB adverse events that need increased attention? What are possible solutions to our challenges in measurement of obstetrical harm?

6 Who is on the call today? a) Hospital administrator b) Hospital staff c) HEN (Director or Staff) d) QIO e) Federal Agency Partner f) Patient / Patient Advocate g) Other

7 Call to Action Lt. Fred Butler Jr. CMS

8 Patient Voice Michelle Baker

9 Requests and Offers From The PFE Community Knitasha V. Washington, DHA, FACHE NCD

10 HEN Performance Sue Felt-Lisk Program Evaluation Contractor

11 OB Adverse Event Measures Beyond EED, HENs are primarily reporting on birth trauma and OB trauma through PSI measures (PSIs 17, 18, and 19): HENs C-Section rate (of some sort): 6 HENs OB Hemorrhage measures: 4HENs Only one HEN is reporting any measure for pre-eclampsia 11

12 OB Adverse Event Metrics on Pre- Eclampsia and OB Hemorrhage Pre-Eclampsia Percentage of women age >= 18 years in Pregnancy, Childbirth, and the Puerperium with Preeclampsia/Eclampsia: Premier baseline for 238 hospitals =3.92% OB Hemorrhage Peripartum hysterectomy/total # mothers: Carolinas baseline for 14 hospitals =.12% Hysterectomies/total deliveries: Dignity baseline for 29 hospitals =.17% OB Post-partum hemorrhage from billing data: LifePoint baseline for 40 hospitals= 1.4% Percentage of women age >= 18 years in Pregnancy, Childbirth, and the Puerperium with Maternal Hemorrhage: Premier baseline for 238 hospitals = 2.3% 12

13 Rate of Birth Trauma-Injury to Neonate (PSI-17) per 100 Births, Improvement from Baseline

14 Rate of Obstetric Trauma-Vaginal Delivery With (PSI-18) and Without Instrument (PSI-19) per 100 Deliveries

15 Leading HENs Ascension: Meeting benchmark on birth trauma (PSI- 17) and strong improvement on brachial plexus and neonatal mortality, with hospitals (pictures next) Carolinas: 27% improvement on PSIs 18 and 19 and sustaining benchmark on PSI 17 w/18 hospitals Ohio: 26 and 23% improvement on PSIs 18 and 19 w/53 hospitals Nevada: 0 injuries to neonate in 4 of past 6 months; 34% decrease on PSI 18 w/12 hospitals LifePoint: 22% decrease in overall OB harms 15

16 Nevada: Top HEN Improver and Lowest 3-month Rate for PSI-18 16

17 Ascension: Brachial Plexus 17

18 Ascension: Neonatal Mortality Decrease 18

19 LifePoint: Overall OB Harms (billing data) 19

20 Copyright, The Joint Commission The Perinatal Care Project Erin Dupree, MD Chief Medical Officer, Vice President The Joint Commission Center for Transforming Healthcare Celeste Milton, MPH, RN Associate Project Director Center for Performance Measurement, The Joint Commission

21 Copyright, The Joint Commission Understanding OB Adverse Events Measures Partnership for Patients, Maternal Affinity Group May 13, 2014 The Joint Commission Celeste G. Milton, MPH, BSN, RN Associate Project Director, Certified Yellow Belt Center for Performance Measurement The Joint Commission Erin DuPree, MD, FACOG CMO and Vice President Joint Commission Center for Transforming Healthcare

22 Perinatal Care (PC) Core Measures Copyright, The Joint Commission

23 Copyright, The Joint Commission Perinatal Care Core Measure The Joint Commission Specification and Development 2008 National Quality Forum project Endorsed 17 measures 2009 Joint Commission Technical Advisory Panel formed 5 of 17 measures selected for core measures Accountability framework 1 for process measures 1. Research 3. Proximity 2. Accuracy 4. Adverse consequences 1. Chassin, M.R., Loeb, J.M., Schmaltz, S.P. & Wachter, R.M. (2010) Accountability measures using measurement to promote quality improvement. N Engl J Med. 363:

24 Copyright, The Joint Commission Under Consideration: PROPOSED Sentinel Event Definition A patient safety event (not primarily related to the natural course of the patient s illness or underlying condition), that reaches a patient and results in any of the following: Death Permanent harm Severe temporary harm * Intervention is required to sustain life * As defined by AHRQ: bodily or psychological injury that is not permanent (including pain and disfigurement) that interferes significantly with functional ability and quality of life.

25 Copyright, The Joint Commission Under Consideration: PROPOSED Ob Reviewable Sentinel Events An event is also considered sentinel if it is one of the following (even if the outcome was not death, severe temporary or permanent harm, or intervention required to save life)---

26 Copyright, The Joint Commission Severe Maternal Morbidity Definition ACOG, CDC, and SMFM: A patient safety event that occurs in the perinatal period (prenatal, intrapartum, and up to 24 hours postpartum) that requires the transfusion of 4 or more units of blood products (fresh frozen plasma, packed red blood cells, whole blood, platelets) and/or admission to the intensive care unit (ICU). Note: Admission to the ICU is defined by the World Health Organization as admission to a unit that provides 24-hour medical supervision and is able to provide mechanical ventilation and continuous vasoactive drug support.

27 Copyright, The Joint Commission Revised Sentinel Event Policy and New Patient Safety Chapter: Timeline Jan-June 2014: Internal and External reviews July 2014: Standards database lock Jan 2015 Anticipate new Sentinel Event Policy will be in effect

28 Copyright, The Joint Commission In Development: Perinatal Care Certification Strong focus on improving quality of care for normal physiologic birth through use of standards, clinical practice guidelines, and performance measures When: anticipate 2015 Contact us at

29 Copyright, The Joint Commission Disclaimer These slides are current as of (5/13/2014). The Joint Commission reserves the right to change the content of the information, as appropriate.

30 OB Adverse Events Expert Panel Deb L. Kilday, MSN, RN Premier HEN Erin Dupree, MD Chief Medical Officer, Vice President The Joint Commission Center for Transforming Healthcare Celeste Milton, MPH, RN Associate Project Director Center for Performance Measurement, The Joint Commission

31 Closing Comments Dennis Wagner PfP Co-Director CMS

32 Thank you for joining us today! Upcoming Event: National Safety Across the Board: Eliminating Pressure Ulcers May 20, 2014 LEAPT HENs should remain connected. Please do not hang up. Click the hyperlink that will appear on your screen to be taken to the rehearsal for May 30 th. Thank you! 32