Reducing Early Elective Deliveries: Perinatal Quality Improvement Collaboratives

1. Reducing Early Elective Deliveries: Perinatal Quality Improvement Collaboratives Zsakeba Henderson, MD Maternal and Infant Health Branch Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion Centers for Disease Control and Prevention National Center for Chronic Disease Prevention and Health Promotion Division of Reproductive Health

2. Networks of perinatal care providers and public health professionals working to improve pregnancy outcomes for women and newborns. • CDC Division of Reproductive Health currently supports • California Perinatal and Maternal Quality Care Collaboratives (CPQCC, CMQCC) • New York State Perinatal Quality Collaborative (NYSPQC) • Ohio Perinatal Quality Collaborative (OPQC)

3. Perinatal Quality Collaboratives • Members of the Collaborative identify processes of care that require improvement and use the best available methods to effect change and improve outcomes as quickly as possible • Quality improvement methods are based on principles developed and used in other areas of quality improvement • Baseline and ongoing collection of data is imperative • Involves rapid collection and return of data to member facilities to meet objectives to improve care

4. Perinatal Quality Collaboratives • Goals of collaboratives include • Achieving a new level of safer, more effective care • Minimizing risks to patients • Successful efforts include • Reduction of late preterm and early term deliveries • Improvements in use of antenatal steroids for premature infants • Reduction in neonatal central line – associated bloodstream infections

5. States with PQCs and CDC/DRH funding States with PQCs States with PQCs in development Multi-state PQC

6. Reduction of Early Elective Deliveries <39 Weeks • The goal is to reduce scheduled births <39 weeks gestation that lack a medical indication • Approaches include • “Champion” leaders at member institutions • Educational efforts (webinars, conference calls, learning sessions) • Improving documentation of gestational age dating criteria • Improving documentation of indications for delivery • Feedback through review of site-specific and aggregate data • Troubleshooting of systemic and local issues • Data sources include medical records, patient discharge data, vital records

7. Reduction of Early Elective Deliveries <39 Weeks • Improvement efforts have been successful: • A rapid-cycle process improvement program substantially decreased elective scheduled early-term deliveries to less than 5% in a group of diverse hospitals across multiple states.* • In New York State, PQC efforts resulted in a 68% decrease in scheduled deliveries without medical indication between 36 -38 weeks gestation and 20% decrease in admissions to neonatal intensive care units (NICUs) (September 2010 and January 2013, NYSPQC) • In Ohio, nearly 23,000 babies that would have been delivered at 36-38 weeks were delayed to 39 weeks, representing an increase of 8 percent in full-term deliveries (2008-2012, OPQC). *Oshiro B, et al. Obstet Gynecol. 2013 May;121(5):1025-1031.

8. Data for Quality Improvement • Improving quality requires • Accurate information • Complete information • Timely feedback • Data is also used for performance measurement • Joint Commission • Centers for Medicare and Medicaid Services • Physician Consortium for Performance Improvement • Hospital Compare websites

11. Strategies to improve birth certificate data quality • Provider education (medical record documentation) • Birth clerk training • Standardization of obstetric definitions • Identification of key data items (frequently missing or inconsistent, e.g. Ohio’s Baker’s dozen) • Validation of birth certificate data • Providing feedback on data quality to all staff involved in data documentation and collection

12. Improving birth certificate data quality:Ohio Perinatal Quality Collaborative • Recruitment by ODH and OPQC Ob • Call with each site to describe project • Site visit by ODH and OPQC QC with site’s clinical and birth data staff • Learning Session with all teams, clinical and data staff • Monthly group webinars • Review of data and sharing of successful strategies • Individual coaching calls as needed

13. Improving birth certificate data quality:Ohio Perinatal Quality Collaborative Birth Certificate Exercise • What are the barriers of accurate birth certificate data collection? • What do you see as opportunities for improvement?

14. Improving birth certificate data quality:Ohio Perinatal Quality Collaborative

15. Ohio Perinatal Quality Collaborative -Opportunities for Accurate Birth Certificate Completion • Ability to go back and correct data in IPHIS • Improve training of birth certificate clerks • Find ways to extract IPHIS data from EMR • One dedicated person to collect data

16. Improving birth certificate data quality:Ohio Perinatal Quality Collaborative • Monthly review of medical records to check birth certificate data accuracy • Analysis of hospitals’ birth data variable processes • Development of training module for staff entering data into IPHIS • Use of participant feedback to refine training modules and begin to disseminate modules throughout Ohio.

17. Improving birth certificate data quality:California Maternal Quality Care Collaborative • Survey of birth clerks to identify priority areas for quality improvement • Multi-stakeholder taskforce for data quality improvement • Framework of strategies for improving perinatal data quality developed

18. Improving birth certificate data quality:California Maternal Quality Care Collaborative • Standardize obstetric data definitions • Educate clinical and coding personnel • Promote redesign and system changes • Apply principles of Clinical Quality Improvement to Data Quality Improvement (DQI) • Create value for Perinatal DQI for hospitals

19. California Maternal Quality Care Collaborative • Birth clerk training pilot in Santa Clara County hospitals • Expansion of intensive birth clerk data trainings and analytic support • Addition of data quality improvement metrics to the California Maternal Data Center (CMDC). https://demo.datacenter.cmqcc.org/hospitals/1 • Match data quality to perinatal metrics calculations

20. Improving birth certificate data quality:CMQCC/California Maternal Data Center • CMDC is the source of rapid-cycle data for maternal quality improvement projects • Validation and use of perinatal quality and data quality measures • Interacitve web-based tool for rapid collection and feedback • Data quality metrics added to the CMDC include: • Missing/Inconsistent Birthweight (Among <2500 gram newborns) • Missing/Inconsistent Gestational Age (Among < 37 week newborns) • Percent Unknown in Birth Certificate Data • Missing/Inconsistent Diabetes Diagnosis • Missing/Inconsistent HTN Diagnosis • Missing/Inconsistent PROM • Missing/Inconsistent Induction

21. Perinatal Quality Care Collaboratives:Improving perinatal care and data quality • Use of QI science to reduce early elective deliveries has been shown to work • Statewide efforts to collect and report outcomes in a timely fashion is possible • Efforts will require continued attention to improving data quality

22. zhenderson@cdc.gov Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion