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PC-06: Unexpected Complications in Term Newborns

PC-06: Unexpected Complications in Term Newborns. WHA CheckPoint New Measure Orientation Beth Dibbert, Chief Quality Officer Alistair Carr, Senior Data Analyst. CheckPoint : Background and Guiding Principles. www.wicheckpoint.org

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PC-06: Unexpected Complications in Term Newborns

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  1. PC-06: Unexpected Complications in Term Newborns WHA CheckPoint New Measure Orientation Beth Dibbert, Chief Quality Officer Alistair Carr, Senior Data Analyst

  2. CheckPoint: Background and Guiding Principles • www.wicheckpoint.org • Pioneer in publicly reported, transparent hospital quality and patient safety data. • Since 2004, over 100 measures have come and gone, currently 51 measures. • Aligned to national and local priorities. • 100% of hospitals voluntarily participate in CheckPoint. • Commitment to transparency, minimal burden and duplication. • Early reporting on CheckPoint leads to faster improvement in Wisconsin. • Keeping the measures current and robust drives other stakeholders to CheckPoint rather than developing their own measures or reports. • Managed by the WHA Measures Team – 17 member representatives.

  3. How CheckPoint Works • Data Sources: CMS, NSHN, State Lab of Hygiene, PeriData.Net, Manual Data Entry. • Measures grouped: Birth, Infections, Mortality, Patient Experience, Readmissions, etc. • Star Ratings are used to compare hospital quality using a 3-star system, but we also display rates. • Hospitals can see their entire list of measure results. • Measure data display keys to remember: • “+” = too few data to calculate and display. • “-” = no cases met the measure inclusion criteria for that time period. • “NA” = the hospital does not provide that service or perform that procedure. • “DNR” = the hospital did not report data for that measure. • “IP” = the hospital is in process for reporting that data. • “NDA” = no data was available for that reporting period.

  4. How CheckPoint Works • Measure Authorization Process: • Hospitals control whether many measures are reported. • Services performed vs. public reporting authorized. • DNR either data missing or reporting not authorized. • User Accounts: • New account requests verified by WHA. • Permission to add/edit data, modify authorizations, and access preview reports. • CheckPoint mailing list. • One account per user-hospital combination. • Demographic (hospital info) edit: • HOSPITAL LOGIN > Add/Edit Data > Edit Demographic Data • Bug fixed – please review/update as needed.

  5. How CheckPoint Works • Data Update Schedule: • HOSPITAL LOGIN > CheckPoint Update Schedule link. • Deadlines, previews and public release dates. • Measure Specifications: • LEARN MORE > Details on Current Measures…hyperlinks embedded, but drilling-down is required. • LEARN MORE > Star Rating Method • Compares a hospital’s 95% confidence interval with the state average, not the hospital’s rate for a single measure. • Protects from random, acute cases, but shows consistent performance. • Insulates small hospitals form large mathematical swings due to small numbers. • Two stars is very respectable!

  6. Current CheckPoint Birth Measures and Data Sources • Most frequently viewed measures • PC-01: Early Elective Delivery • Vendor calculated data, user-entered manually into website. PeriData.Net has a file upload process. • PC-02: C-sections • Vendor calculated data, user-entered manually into website. PeriData.Net has file upload process. • PC-05: Exclusive Breastfeeding • Vendor calculated data, user-entered manually into website. PeriData.Net has a file upload process. • Newborn Screening Turnaround Time • Results calculated by Wisconsin State Lab of Hygiene and send to CheckPoint. • Infant Complications • PeriData.Net measure ONLY. Hospitals that do not participate in PeriData.Net registry do not have data in CheckPoint for this measure. • Configuration required to make this happen – contact AC.

  7. Infant Complications Measure Replacement • Infant Complications measure is proprietary to PeriData.Net. • In September 2018, the WHA Measures Team recommended replacing the Infant Complications measure with Joint Commission’s PC-06 measure. • PC-06 met the team’s criteria of applicability to birth hospitals, standardized definitions, NQF endorsement, and availability of comparison and benchmarking data. • PeriData.Net is developing a “mimic” measure, but CheckPoint will only be displaying PC-06. • The final CY 2018 of Infant complications data will remain frozen on CheckPoint until the first 2 quarters of 2019 are available to post.

  8. PC-06: Unexpected Complications in Term Newborns • Required by Joint Commission for its accredited hospitals having more than 300 births annually • Measure: % of newborns with unexpected complications among full term newborns with no preexisting conditions • Chart-abstracted • Outcome measure • Numerator: Newborns with severe or moderate complications • (Severe: neonatal death, intracranial hemorrhage, neurological damage, severe infections, etc.) • (Moderate: LOS greater than 5 days, transient tachypnea, CPAP, bone fracture, etc.) • Denominator: Liveborn single term newborns over 2500 gm in birth weight • Not risk-adjusted • CheckPoint will report the “Overall” rate only

  9. PC-06 FAQs • You can report PC-06 to CheckPoint even if your hospital has fewer than 300 births annually • Data calculated by an “approved” vendor will be entered into the CheckPoint website • PeriData.Net will not be an approved vendor for this measure. • If your data vendor does not support PC-06, and you have previously entered Infant Complications data via PeriData.Net, your PC-06 results will be displayed as “NDA”. • Contact AC to have this configured. • If your hospital is not Joint Commission accredited, your core measure vendor may support PC-06. • If your vendor is not listed on our “approved vendor” (dropdown on data entry form) list, please contact us.

  10. Data entry timeline • See CheckPoint Update Schedule – • All birth hospitals will need to enter PC-06 manually: • 2019Q1 due 7/2/19 • 2019Q2 due 10/1/19 • AC will follow-up if missing 2019 quarter(s). • CheckPoint Alert email will prompt you to look at the preview report • Two quarter Preview report (behind login) – Fall 2019 • Four Quarter Public report – Q1 2020

  11. How Painful is Data Entry? • Painless, 5-min OP procedure, no anesthesia, complications rare. • HOSPITAL LOGIN > Add/Edit Data > Add/Edit Perinatal Data > • Select Year-Quarter • Scroll Down to PC-06

  12. PC-06 Data Entry • Complete the fields • Click Review • Check your values • Click Submit…Done.

  13. Questions? • Please contact us: • Beth Dibbert, WHA Chief Quality Officer • bdibbert@wha.org • Alistair Carr, WHA Senior Data Analyst • acarr@wha.org

  14. THANK YOU

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