Welcome! Wave 2 - Group Webinar #3. Decreasing births < 39 weeks gestation without medical indication and improving birth registry accuracy project

Transcription

1 Welcome! Wave 2 - Group Webinar #3 Decreasing births < 39 weeks gestation without medical indication and improving birth registry accuracy project Ohio Perinatal Quality Collaborative Ohio Department of Health, Office of Vital Statistics Ohio Hospital Association July 22, 2013

2 Please don t put us on HOLD! If you need to step away: Use the MUTE button on your phone or You can use *6 to place the call on MUTE and *6 to come off of MUTE

3 Roll Call: Please sign in with your name and hospital affiliation

4 Agenda Time Topic Presenter Noon Welcome, roll call, and review of Agenda Susan Ford 12:10 pm Data Review Updated Quarter 2 Aggregate Chart Mike Marcotte, MD 12:15 pm Month 2 in review Lessons Learned from Process Flow Maps Lessons Learned from IPHIS-Patient Chart Reviews Sharon Bryson, Clinical Manager OB, ProMedica St. Luke s 12:20 pm Birth Registry Accuracy: IPHIS skills 12:30 pm Less than 39 week inductions: Hard stop vs. Soft Stop; Policies regarding elective inductions prior to 39 weeks w/o a medical indication Scheduling inductions and C/S at your site 12:45 pm Using quality improvement strategies to make changes: Model for Improvement: Question 3 Judy Nagy Mike Marcotte, MD Susan Ford 12:55 pm Next steps Susan Ford

5 <39 Week Scheduled Delivery and Birth Registry Accuracy Wave 2 Hospitals Community Hospital & Wellness Center Mercer County Van Wert County Hospital Highland District Hospital Mercy St Charles Promedica Flower Hospital Promedica St. Luke s Wilson Memorial Hospital Community Upper Valley Medical Madison County Hospital Memorial Health Care System Bellevue Hospital Marion General Hospital Southwest St. John General Medical Center MedCentral Health System - Mansfield Marietta Memorial Hospital Pomerene Hospital O Bleness Memorial Hospital East Ohio Regional Medical Center Trumbull Memorial Northside Medical

6 Wave 2 teams Bellevue Hospital Community Hospitals and Wellness Centers East Ohio Regional Medical Center Highland District Hospital Madison County Hospital Marietta Memorial Hospital Marion General Hospital MedCentral Health System Mansfield Memorial Health Care System Mercer County Joint Township Community Hospital Mercy St. Charles Hospital Northside Medical Center O Bleness Memorial Hospital ProMedica Flower Hospital ProMedica St. Luke's Hospital Pomerene Hospital Southwest General Medical Center St. John s Medical Center Trumbull Memorial Hospital Upper Valley Medical Center Van Wert County Hospital Wilson Memorial Hospital

7 2006-Q1 (n=1033) 2006-Q2 (n=1089) 2006-Q3 (n=1091) 2006-Q4 (n=0923) 2007-Q1 (n=1033) 2007-Q2 (n=1026) 2007-Q3 (n=1162) 2007-Q4 (n=1000) 2008-Q1 (n=1014) 2008-Q2 (n=1023) 2008-Q3 (n=1020) 2008-Q4 (n=0918) 2009-Q1 (n=0840) 2009-Q2 (n=0918) 2009-Q3 (n=0970) 2009-Q4 (n=0770) 2010-Q1 (n=0779) 2010-Q2 (n=0769) 2010-Q3 (n=0850) 2010-Q4 (n=0898) 2011-Q1 (n=0826) 2011-Q2 (n=0859) 2011-Q3 (n=0938) 2011-Q4 (n=0837) 2012-Q1 (n=0864) 2012-Q2 (n=0871) 2012-Q3 (n=0912) 2012-Q4 (n=0875) 2013-Q1 (n=0830) 2013-Q2 (n=0707) Percent with no medical indication Births induced at weeks with no apparent medical indication for early delivery, by quarter, Aggregate of Wave 2 sites Sep. 2008: 39-Week project begins Source: Ohio Department of Health, Vital Statistics Goal Quarterly Percent Baseline Average Percent Control Limits

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9 Month 2 in Review

10 ProMedica St. Luke s Hospital Process Flow Map Mom admitted to Labor & Delivery; given Maternal Worksheet. Admitting RN obtains Facility Worksheet. Begins to fill out first 12 questions from patient H&P, and prenatal information (which is either available on EMR or has been faxed to the unit, dependent on the practitioner.) Facility Worksheet is place on the front of the patient chart until mom delivers. RN taking care of mom at delivery fills out Facility Worksheet with the exception of the last 3questions (infant living transferred and breast feeding at discharge?) No Mom and baby discharged. Discharging RN completes last 3 questions on Facility Worksheet and checks that it is complete. Paternity affidavit competed and clerk notarizes. Yes Is mom unmarried? Mom has 24 hrs. after delivery to complete and turn in the Maternal Worksheet. Yes Both Worksheets submitted to the Nurse Manager of L&D. Nurse Manager Reviews for completeness. Complete? No Completes - missing info by looking up in patient chart. Both Facility and Maternal Worksheets are sent to Medical Records. County registrar picks up completed birth certificates once a week at the hospital. Physician signs document and returns via courier to SLH. MR prints the document and mails it to the physician via USPS mail for signature. MR enters data into IPHIS and submits as complete. MR looks thru Worksheets to be certain that all questions are answered. Follows up with mom if info is incomplete or illegible. r

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12 OPQC: Decreasing births < 39 weeks gestation without medical indication and improving birth registry accuracy project Aim In 9 months, improve birth registry accuracy so that focused variables** will be transmitted accurately in 95% of records (** Pre-pregnancy and Gestational Diabetes; Prepregnancy and Gestational hypertension; Induction of Labor; ANCS; OB estimate of GA) Revised: Key Drivers Strong communication between clinical team and birth data staff Trained clinical and birth data teams Audit Process for data verification Appreciation of the Importance of the Birth Registry information IPHIS (BR) fields include essential and specific information/definitions Identification and spread of best practices for data entry and verification Interventions Identify a key clinical contact for birth data team Identify all sources of birth data Identify process for flow of data into the birth registry (IPHIS) system Ensure birth data team has access to necessary clinical data Utilize ODH and OPQC online education modules for training of birth data and nursing staff Ensure clear understanding of birth registry variables Ensure clear understanding by birth data team of medical terminology related to birth registry variables Coaching/reinforcement by OPQC and state quality coordinators Use medical record to IPHIS quality review feedback to identify gaps Continuous monitoring of Birth Registry data reports Clarify IPHIS definitions and instructions Group and individual webinars and 1:1 support by state quality coordinators to identify key changes

13 IPHIS: Integrated Perinatal Health Information System Ohio s birth registry software IPHIS Overview Judy Nagy

14 The Support Site When in doubt, check it out

15 IPHIS Half the Fun is Knowing Where to Get an Answer Forms, Guides, Tip Sheets and Updates Getting Help From a Real Person! Correcting Information Edits

16 The Vital Support Site

17 Hover Function

18 The Unknown Variable STOP using Unknown in IPHIS UNKNOWN None is still a choice Verify: Does mom or baby have any of the listed conditions? If yes, check the correct ones If no, check None.

19 Unknown vs. None UNKNOWN is not an option that a hospital needs to correctly identify problems or conditions / anomalies at birth. Check boxes are available for items that are confirmed by the patient medical record. Anything that cannot be confirmed should be marked as NONE. For data items that ask for a date or number (i.e., number of prenatal visits, number of cigarettes smoked, date of last menstrual period, etc.), 99 is still a valid option.

20 Get Help BEFORE Completing a Record Call the Help Desk at , Option #3 Please do not call specific staff at Vital Statistics Representatives can answer questions regarding corrections, unlocks, and notes. Surrogacy, foundling, and paternity issues should be directed to Suzie Grayson in the Registration Unit, at

21 Understanding Edits IPHIS has built in edits that will display when an answer does not fall within a specific range. It s important to verify what the system is telling you. Make a note! Notes are important to explain yourself. Why the system thinks a response is incorrect when it isn t.

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23 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. Bill Callaghan, MD MPH Centers for Disease Control and Prevention December 1, 2011

24 OPQC: Decreasing births < 39 weeks gestation without medical indication and improving birth registry accuracy project Goal: Assure that all initiation of labor or caesarean sections on women who are not in labor occur only when obstetrically or medically indicated Interventions Inform consumers of risk/benefits of deliveries < 39 weeks Communicate to patient/clinic/hospital ultrasound results Promote need for early dating to practitioners and consumers Public awareness campaign Aim In 9 months, reduce to 5% or less, the number of women in Ohio of 37.0 to 38.6 weeks gestation for whom delivery is scheduled in the absence of appropriate medical indication Revised: Key Drivers Awareness of risks & expected benefit of scheduled delivery prior to 39.0 weeks by patients and other consumers Dating criteria: optimal estimation of gestational age Hospital and physician practice policies that facilitate ACOG criteria Awareness of risks & expected benefit of near-term delivery by clinician Culture of safety and improvement Promote need for early dating to practitioners and consumers Promote sonography < 20 weeks to establish dates Document criteria used to establish EDC Appropriate use of fetal maturity testing Empower nurses /schedulers to require dating criteria Identify a specific contact for authorization dispute re: dating Provide patient with hard copy results of ultrasound Empower nurses /schedulers to require dating criteria Document rationale and risk/benefit for scheduled deliveries at 37.0 to 38.6 weeks gestation Document discussion with patient about the above Both patient and MD sign consent statement for scheduled delivery between 37.0 and 38.6 weeks Physician awareness campaign: what are the reason(s) for scheduled delivery? Maximize access to Delivery and OR for optimal scheduling Facilitate scheduling policies that respect ACOG criteria Prenatal caregivers receive feedback from postnatal caregivers about neonatal outcomes of scheduled deliveries Ensure complete and accurate handoffs OB/OB and OB/Peds Document discussion with patient about risk/benefits of near-term delivery Promote need for early dating to practitioners and consumers Continuous monitoring of data & discussion of this effort in staff/division meetings. Project outcomes posted on units and websites. Develop ways to include staff and physician input about communications and handoffs Connect with organizational initiatives on safety and use existing approaches as possible Empower nurses/schedulers to require data criteria

25 ACOG Committee Opinion 561 April 2013 Implementation of a policy to decrease the rate of non-medically indicated deliveries before 39 weeks of gestation has been found to both decrease the number of these deliveries and improve neonatal outcomes; however, more research is necessary to further characterize pregnancies at risk for in utero morbidity and mortality

26 Poll With regards to scheduling a delivery prior to 39 weeks without a medical indication our hospital has a: Hard stop Soft stop No stop Uncertain

27 Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth Clark, et al. February 2010 AJOG HCA (27 hospitals) largest system in US 3 month period 2007 baseline 17,000+ Intervention Hard stop Soft stop Education only 3 month period 2009 measure 17,000+

28 Hard Stop Adopt policy that prohibited purely elective inductions and CS < 39 weeks Policy enforced by hospital personnel empowered to refuse to schedule any such deliveries Questionable indication handled in standard chain of command

29 Adopt similar policy Soft Stop Elective deliveries < 39 weeks allowed if ordered by attending physician All such cases referred to peer reviewed committee for evaluation and potential action

30 Education Only Provide education to attending physicians No formal policy developed

31 Reduction in elective birth <39 weeks: 3 approaches to change Clark SL, Frye DR, Meyers JA et al Am J Obstet Gynecol 2010 HARD STOP SOFT STOP EDUCATION ONLY

32 Other Outcomes NICU admission rate > 37 weeks Baseline % After intervention % (p = < 0.001) Stillbirth rate (balancing measure) Baseline 0.69% After intervention 0.71% (p = 0.38)

33 Percent NICU Admissions By Weeks Gestation Deliveries Without Complications, (n=84,538) 10% 8% 6% 4% 2% NICU Admissions Click 6.66% to edit Master title style 3.36% 3.44% 2.47% 2.65% Click to edit Master subtitle style 4.26% 0% 37th 38th 39th 40th 41st 42nd Oshiro et al. Obstet Gynecol 2009;113: Gestational Weeks 33

34 Respiratory Distress Syndrome (RDS) By Weeks Gestation Deliveries Without Complications, (n=84,538) Percent 2.5% 2.0% Click to 1.92% edit Master title style 1.5% 1.0% 0.68% 0.42% 0.41% 0.67% 0.78% Click to edit Master subtitle style 0.5% RDS 0.0% 37th 38th 39th 40th 41st 42nd Gestational Weeks Oshiro et al. Obstet Gynecol 2009;113:

35 Percent Ventilator Usage By Weeks Gestation Deliveries Without Complications, (n=84,538) 2.0% Click to edit Ventilator Master Use title style 1.8% 1.6% 1.4% 1.2% 1.0% 0.8% 0.6% 0.4% 0.2% 0.0% 1.19% 0.47% 0.47% Click to edit Master 0.25% subtitle 0.30% style 37th 38th 39th 40th 41st 42nd 0.39% Gestational Weeks Oshiro et al. Obstet Gynecol 2009;113:

36 What about 38 weeks + 4 to 6 days? Tita (NEJM 2009;360:111) (MFM Network) Examined 2,463 scheduled CS babies in this age range Respiratory outcomes worse than 39 weeks (RR= % CI , p=0.01), similar to 38 weeks as a whole Click to edit Master title style Wilminik (AJOG 2010;202:250.e1-8) (Netherlands) Examined 5,046 scheduled CS babies in this age range Respiratory outcomes worse than 39 weeks (RR=1.4 95% CI , p=0.01), Click similar to edit to 38 weeks Master a whole subtitle style 36

37 Scheduling Inductions at your Hospital

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39 NOTE: Important to note that a culture change has occurred at Bethesda North. Obstetricians are aware of the expectation and policy that inductions should be 39 weeks or greater if there is not a medical indication to induce.

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41 Poll Do you have a scheduling form for deliveries that needs to be completed by requesting OB/offices and sent to L&D? Yes No Uncertain

42 Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? Aim Measures Changes Act Study Plan Do P D S A Sequential small tests of change Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance

43 Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement? What is a PDSA or sequential small test of change? Putting a small change into effect on a temporary basis and learning about its impact.

44 What is Not a Test? Data collection Implementing a solution Rolling out an educational program Getting a form, policy, procedure approved by the official committees

45 The PDSA Cycle Act What changes are to be made? Next cycle? Adopt, Adapt, or Abandon Study Complete the analysis of the data Compare data to predictions Summarize what was learned Plan Hypothesis or Idea Questions and predictions Plan to carry out the cycle (who, what, where, when) Do Carry out the plan Document problems and unexpected observations

46 Identify Possible Changes Think Creatively Brainstorm with your QI team Collect ideas from staff who contribute to the birth registry Adapt known good ideas Read the professional literature Network with other hospitals and the ODH Vital Statistics Look at the Key Driver Diagram Look at your process flow map again Identify opportunities within the gaps Office of

47 Plan the test What is the objective of the test? population? What tasks are necessary in order to conduct the test? Develop the action plan of tasks who, when, what How will you measure the impact of the test? What do you predict will happen? Do--test the change Plan...Do...Study...Act Study the results of the test What were the results from the test? Were there any unexpected observations? Was your prediction correct? What do you need to do next? Act on your results Adapt do you need to make revisions & re-test? Adopt do you need to scale up a successful test? Abandon did your test fail but you were able to learn from it?

48 Key Points for PDSAs 1. Do initial PDSAs on smallest scale possible A cycle of one usually best: one patient, one doctor, one day Failed cycles are good learning opportunities, particularly when small 2. As move to implementation, test under as many conditions as possible Think about factors that could lead to breakdowns, supports needed, naysayers

49 Key Points for PDSAs (cont d) 3. Always identify the prediction or hypothesis before testing the change Allows improved learning from failures and refinement of your theory 4. Use a study measure specific to the PDSA Usually not one of the project measures Is a measure specific to the small test of change Qualitative results are very valuable in early PDSAs

50 Smaller Scale Tests: The Power of one Conduct the test with one clinic day one physician one patient

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53 Storyboard Information Creating Your Team Storyboard Instructions and Tips for Success Throughout this project, your assignments will build on one another to create a storyboard that you may use to track and present your progress as a team. A suggested PowerPoint template can be found on the OPQC website: These slides should be customized to reflect your team s efforts. Complete as much of the storyboard as possible, and continue to work on it with your team each month. You will have the opportunity to share your storyboard with other team hospitals at our August 26 th Learning Session.

54 Next Steps/Homework Meet as a team and choose a small test of change. Implement one PDSA Continue to add to/work on Storyboards Register for August s Learning Session Complete Monthly Progress Report (including 10 chart reviews) Link will be sent from Shirley Bogart at ODH-VS 7/24

55 Learning Session Monday, August 26 th Registration link to be sent from OPQC Crowne Plaza Columbus - Dublin Put faces with voices! Learn more great things about Quality Improvement! Get good ideas from other teams!

56 Resources OPQC web site: OPQC Susan Ford, RN BEACON Quality Improvement Coordinator Judy Nagy, State Registrar Stephanie Wilson, Project Specialist