Perinatal Quality Collaboratives 101

Perinatal Quality Collaboratives 101


[Coordinator:] Good afternoon
and thank you for standing by. All lines will be in listen only until the question-and-answer
portion of the call. At that time to ask a
question, depress star then 1 and please be sure to record
your first and last name. Today’s call is being recorded. If you have any objections you
may disconnect at this time. Dr. Henderson you may now begin. [Zsakeba Henderson:]
Good afternoon everyone. My name is Zsakeba Henderson and
I’m an obstetrician/gynecologist and medical epidemiologist
in the Division of Reproductive Health
at the Centers for Disease Control
and Prevention. I lead the state-based perinatal
quality collaborative program here at CDC and I would
like to welcome you to the first presentation
in a series of webinars we are sponsoring on perinatal quality
collaboratives. This webcast will present an
overview of quality improvement in perinatal and maternal
care including information about the purpose,
basic structure and past successes
of collaboratives. Our presenters today are Dr.
Marilyn Kacica and Barbara Rose. Dr. Kacica is the Medical
Director of the Division of Family Health within the New
York State Department of Health. She provides leadership
for New York State maternal and child health epidemiology
programs, health informatics and quality improvement. She is a board-certified
pediatrician with sub specialties
in infectious diseases and preventive medicine. Dr. Kacica is a fellow of the
American Academy of Pediatrics and a Clinical Associate
Professor of Epidemiology at the State University
of New York, University of Albany
School of Public Health. Dr. Kacica has served
in leadership roles in quality improvement
initiatives dealing with asthma, school-based health centers and the current New York State
Perinatal Quality Collaborative. Barbara Rose is Program Director for the Ohio Perinatal
Quality Collaborative. She has a Master’s
Degree in Public Health from Saint Louis University
plus 30 years of experience in the fields of nursing, public
health, physician practice, program management and community-based
health improvement. Her primary responsibilities
include providing administrative oversight and leadership to a successful state-wide
perinatal collaborative to improve birth
outcomes in Ohio. And more recently, she
is a senior-level manager and contributor to local
community health improvement efforts using data
to make decisions around child well being and
measuring program outcomes. At the end of this presentation
you will have the opportunity to ask questions and
participate in the discussion. The slides and audio from this
presentation will be archived on our Web page at
www.cdc.gov/reproductivehealth/ maternalinfanthealth/pqc. I will now turn the presentation over to Dr. Marilyn
Kacica and Barbara Rose. [Marilyn Kacica:] Thank you
Zsakeba and welcome everybody. Thanks for taking the time to
listen to this presentation. At the end of this webinar
participants will be able to explain the need and purpose of perinatal quality
collaboratives, understand how some
collaboratives function and the basic structure
of a collaborative — I think no two collaboratives
are the same — and then discuss the successes
that at least we have achieved and I think if you use this
method others have achieved success also. So I think that everybody knows in a collaborative structure
you have a lot of partners and within the perinatal quality
collaborative you have perinatal care providers, you have
public health professionals and the goal is to
improve pregnancy outcomes for women and newborns. And you do this through
advancing evidence-based clinical practices
and processes. I think everyone’s aware of
the need for collaboratives to improve what we’re doing. Preterm birth affects more
than 500,000 babies or one of every eight infants
born in the United States. It’s the most frequent
cause of infant death and it’s the leading cause of long-term neurological
disabilities in children and it is really costly to
the U.S. healthcare system, costing more than $26
billion each year. Within our collaborative
we very early on organized around a mission. And our mission is to provide
the best and safest care for women and infants in
New York by preventing and minimizing harm
through the translation of evidence-based practice
guidelines to clinical practice. [Barbara Rose:] Good afternoon
everyone, this is Barbara Rose. I’m the Director of the Ohio
Perinatal Quality Collaborative, also known as OPQC. On the screen you see
the mission of OPQC. We started convening in 2007 and
started our first collaborative in the middle of 2008. In Ohio we have about
144,000 births a year and our public partners,
clinical providers and data and quality improvement
folks came together and with the understanding
of wanting to use improvement methods
to improve birth outcomes to all 144,000 births that we
have each year in the state. So there’s a lot of similarities
among many state collaboratives. I just was in Chicago
over the weekend at the Vermont Oxford
Network Congress. Many of you on the phone might
be neonatal care providers and many of the state
collaboratives across the county
have been started by either an interested
passionate neonatologist and/or a maternal fetal
medicine physician. At the moment across the country
there are at least 17 states that have some form of
organized state level perinatal improvement. Ohio, New York and California
all currently have some funding from the CDC. And if I might just
mention the other states that have a semblance of
perinatal collaborative: Colorado, Florida, Illinois,
Indiana, Kentucky, Louisiana, Massachusetts, Michigan,
Minnesota, Mississippi, New Jersey, North
Carolina, Tennessee, Virginia and Wisconsin so
pretty impressive. In Ohio and New York the
OB projects that we started with we’re reducing
— at least in Ohio — we were reducing scheduled
deliveries, less than 39 weeks, without a medical
indication and we’re currently in a project looking
at appropriate use of antenatal steroids
for women who are at risk of delivering preterm between 24
weeks’ and 34 weeks’ gestation. Both the New York
and Ohio also have – actually the New York neonatal
project is reducing central line associated blood stream
infection otherwise know as CLABSI and in Ohio we’re
reducing late onset infection in 22 to 29 week
gestation infants. And then the second
neonatal outcome in the New York project
is reducing the percentage of newborns less than 31 weeks’
gestation that are discharged with below the tenth
percentile of growth. Just to talk a little
bit about the structure of the Ohio Perinatal
Quality Collaborative. We have a blended funded
model and we have faculty from across the state. Our Quality Improvement Lead is
Carol Lannon at the University of Cincinnati, Cincinnati’s
Children’s Hospital. Our OB is Jay Iams at the
Ohio State University. And our Neo Lead is Michele
Walsh at Rainbow Babies at Case Western in Cleveland. We also have regional clinical
leads for both the OB project and the neonatal project
and we’ve worked really hard to make it a true
representation of faculty and hospital practices
across the state. The Ohio Department of
Health has allocated a couple of different funding streams
from state funds that then go through Ohio Medicaid to draw
down from federal match dollars. We have a third-party
administrator that manages those contracts
and deliverables to us. We’re delighted to be
one of the three states that have a multiyear
funding stream from the CDC. We have had several years of
support from Ohio March of Dimes and National March of Dimes to continue our quality
improvement education work across the state. And then we have a
tremendous amount — it’s actually difficult
to calculate it — in kind contributions
from clinical staff across the state doing the
work on the front lines as well as many of our regional
leaders who work either for very little compensation or actually devote their
time to the project. [Marilyn Kacica:] So as far as in New York we are a very
different model of funding and I think we began
very much on a shoestring in that we had basically
initially no state dollars so it was mostly
in kind staff work and we were working our
experts across the state who are very generous in
contributing their time. And then we were able to identify some limited state
dollars so that we could work on getting more of the quality
improvement consultant work with us as we are not
experts or were not experts when we began this
project in 2010. We initially partnered with
the National Initiative for Children’s Healthcare
Quality who during the first year
really helped us with the model and then we were very
fortunate as Barbara mentioned to also receive the
Centers for Disease Control and Prevention grant which
has helped immensely here in our organization and
our ability to do our work. So I would say that initially
most of what we did was in kind. We were very supported by
our partners across the state and I think that was how
we began our project. [Barbara Rose:] So this
slide I’m not going to — this is Barb — this slide
sort of speaks for itself, but Ed Donovan was the founder of the Ohio Perinatal
Quality Collaborative. Ed is a longstanding faculty
member of the University of Cincinnati and
a neonatologist, one of the early
physicians in the field. And he really brought
together our public partners, the Medicaid and the Department
of Health offices as well as faculty and providers
across the state and really asked the question
to find out how much interest and will there was in Ohio to develop a state level
perinatal collaborative really population based and doing
improvement focused towards all the birth in the state. And lucky for us many
people in the room at the – at our room meetings
stood up and said that they were indeed interested
in being part of this and that if we were going to improve
perinatal outcomes in Ohio that neonatology and obstetrics
would need to work together on the mom and the baby dyad and that was really
a pretty big factor in how we first got
organized in 2007 and 2008. We used the quality
improvement methods. In Ohio we used the IHI’s
model for improvement and I have a couple of slides
coming up just to document that. Many of you may use
that or a variation of the model for improvement. Another key to helping
practitioners improve care on their front line is
regular measurement — data collection and
measurement and feedback of individual site-specific
data — and then also looking at the collaboratives
aggregate data over time. We have had a number of
publications over the years from our faculty leads which we
think just adds another measure of credibility in getting the
word out in peer review journals and we’ve also had some
coverage in the popular press around the work and the results that we’ve collectively
achieved. And then lastly for
those of you who work in quality improvement you know
that sharing of the results, what did you do, what did
you test, what worked, what didn’t work, what are
your results, is a key part to the learning and
pushing towards improvement. It’s a bit of a challenge
when you’re in the same geographic region
and you might have hospitals who are in the same community
working down the street from each other and
there’s that sort of inborn competition
giving folks a little bit of hesitation sometimes
to do transparent sharing. And I think in Ohio we’ve made
some real progress in getting, one, not only our data sharing and multisite confidentiality
agreements but just really folks working
toward improving the population health outcome of
births in the state. So both Ohio and New York have
these multi-stakeholder networks that both Marilyn and I have
outlined just a little bit. Many, many, many of the
other states that I mentioned who have structured perinatal
collaboratives have used a similar stakeholder-network
model. We use the Institute for Healthcare Improvement
Breakthrough Series Model: what do we want to
accomplish, how will we know that a change is an improvement
and what changes can we make that will result
in an improvement. And like I said we track
process and outcome measures and both Marilyn and
I have a few examples to show the viewers how we
track those results over time. I think in addition to having
the models for improvement, using the quality improvement
science and feeding back data to the sites, we have
monthly action period calls that have a fairly specific
rigor to the structure and we always start those
calls with the aggregate, the collaborative’s
aggregate data. We never share site-specific
data unless the site has asked us to do so. And then periodically,
usually once or twice a year, we have a face-to-face learning
session, usually a day or day and a half session where the
OB teams and the neo teams, that team being a physician and
nurse leader, an administrative or data person, come together
and spend the day with us. We have group exercises,
team time, usually some very focused
(unintelligible) leaders participating and that balance
of monthly check-in calls and periodic face to face
really keeps people engaged, get them talking interpersonally
about sharing their ideas and sharing the changes and we’ve had some really
good success with that. [Marilyn Kacica:] So I am going
to just walk you through some of the things that we’ve done and using much the same
methodology as Ohio and I’m sure the
other collaboratives across the country. But New York ranks eighth
nationally in infant mortality and 22nd in premature births. And we have approximately
250,000 births a year which is about the third largest
in the nation. We have multiple focuses within
our quality collaborative. We are focusing on the
preterm deliveries. In the neonatal outcomes we’re
focusing on enteral feeding and improving birth weight — discharge weight in infants
born less than 31 weeks — and we’re also working on
reducing CLABSI infections. So I think, you know,
Barbara alluded to this with how the Ohio
collaborative was established and I think it’s very important
and one of the hardest things to do is to make sure you have
the right leadership on board to facilitate your work. We within the Health Department
were very lucky to have buy in with our executive
leadership. But then we had to reach
out to our partners across the state both in
obstetrics and neonatology. And with neonatology
they were already engaged in a very active
collaborative with the CLABSI; however this was new
to the obstetricians. So we wanted to make sure as
we built the collaborative that we were addressing
all their concerns and that we were
addressing the right issues when we went forward so we established multiple
expert work groups to advise us. So in focusing on the obstetrical project these
are the types of activities that we did with our experts. We had to formally define
what a scheduled delivery was and believe it or not
that took some time. And we had to also decide what
was an appropriate indication which took a lot of research
and a lot of discussion as to what we would consider
appropriate for this project. We had to specify the sample
size and we are focusing on deliveries between 36
and less than 39 weeks’. We decided it would be a
monthly data submission. And we followed the improvement
measures and we do this through run charts which
you’ll see an example of. So this is one of about
ten measures that we follow with our obstetrical initiatives
and it’s sort of a composite when we look at all scheduled
deliveries without indication. And we began this project
in 2010 like in the fall so around September and we
began with a rate of about 25% of deliveries without
indication. And throughout time you can see
that now we’re down to about 7% or 8% and of course it
fluctuates as all things do within a facility
and human nature. So I think that we’ve made some
great progress in this measure. So just to summarize the
collaborative that began in 2010, we followed about
6000 deliveries and about 60% of those were c-sections. And of scheduled deliveries
without medical indication, we decreased scheduled
deliveries by about 65%. We decreases inductions by about
70%, c-sections decreased by 64% and we also looked at
primary c-sections. And we’ve been able to
decrease those by about 78%. We’re also focusing on maternal
education and we’ve increased that by about 53%, 54% although
I think we still have a lot of work to do in that measure. For our next steps
we’ve been lucky that within New York State
there’s a joint initiative with the Healthcare
Association of New York and Greater New York
Hospital Association who received a CMS grant and formed the New York State
Partnership for Patients. And one of their focuses
is reducing preterm birth so we’ve been lucky enough to
sort of merge with the project to become one as we roll out to all birthing
hospitals in the state. So up to this date we’ve
recruited about 100 facilities and that represents about 80%
of the hospitals in the state who are now working
on this project. To briefly talk about our
Enteral Feeding project, the aim of this project was to
reduce statewide the percentage of newborns less than 31
weeks’ gestational age that are discharged from a NICU
below the tenth percentile. This is a little bit
different in that is something that takes longer to achieve. So in looking at the measures
and following what we can with the discharge weight,
we’re collecting data quarterly. So I think with any
collaborative you have to decide based on what you’re
measuring how you’re going to approach the data
collection and the reporting. And I think if you look at
this, if you look at the top, that’s data from 2009 and then
the bottom is data from 2010, and this is (unintelligible)
growth chart to follow preterm
weight and we’re focusing on the mostly discharged
to home. So in 2009 you can see that we
have about 30% what we found of the infants were leaving
less the tenth percentile. And between 2009
and 2010 you can see that line shifting upward and
that was just I think a lot of it was follow up, looking
at the data and people because you’re paying attention to the issue things
just seemed to improve. So now we’re in 2011, we’re
going to be looking to see if that line has
improved even further. We began this project with
our regional perinatal centers who have the biggest percentage
of these preterm infants and if you look at on the left
are the regional perinatal centers indicated by
the letters and then on the x axis are the
percent of the newborns that are discharged less
than the 10th percentile. And it’s easy to see that there’s a very wide
among these hospitals. The mean percent was
about 32% and you can see that some were doing very
well with only about 12% and then we have one outlier
hospital that has about 60% of their infants going home
less than the tenth percentile. Another way to look at this is
what is the risk of your infant if they’re admitted to one of
these facilities going home less than the tenth percentile? And there’s about a 4.5
to 5-point difference between the best and the
hospital with the highest rate, ranging from about a risk of
0.4 to a risk of almost 2. So I think there was a
lot of work done to figure out what is the difference
among these different hospitals, what can we work on to
improve this and we did a lot of very specific work but
what we found overall was that feeding practices
and protocols varies within an RPC and
among the RPCs. And I demonstrated,
I showed you the risk of discharge below the tenth
percentile varied widely. We also saw that simply having
a protocol to initiate, advance or evaluate feeding tolerance
was not associated with growth and that the risk of
discharge weight less than the tenth percentile was
lower with earlier first enteral and earlier full
enteral feedings. And I know everyone
is – whenever you talk about feedings these preterm
infants you know there’s a worry about necrotizing enterocolitis
and we found the risk that NEC was higher with
later and longer trophic feed and earlier introduction
of fortifier. So we’re still working on this
and I’m sure there will be more to come as far as this. What we’re planning to do, you
know, of course is to now look at the 2011 data
to compare to 2010. We’re also looking
at head circumference which we didn’t initially
have collected but we thought was
important to also look at. We’re comparing practice and
protocol usage between high and low performing RPCs
to see if we can sort of identify some best practice
and as we mentioned we want to share that so we
can improve the outcome for all the infants
in the state. With our CLABSI Reduction
project it began in 2007 and this was an effort of our regional perinatal
centers initially to reduce CLABSI
rates in their NICUs. And what they actually
found was that the use of a checklist was
very important to performance and outcome. And also on the left if
you would look at this, it was really important to
have empowerment of the staff as a team so that no
matter what role you played on the team it was equal and
if you saw something happening that should not be, you
had every right to correct that no matter who
was the offender. So I think having that
empowerment really is important for a team to be successful. So to look at have we reduced
CLABSI rates from the beginning in 2007 to 2010 the
rate has gone from 4 central line associated
bloodstream infections per 1000 patient days to 1.6 in 2010
and we’ll soon have 2011 data. So there was a 60%
decline in this rate. So I think from this as Barbara
said there are many publications and Dr. (Shulman) was the lead
in our publication on this which identified and
talked about the method and the use of a checklist. And what we’re planning to
do is now roll this project out to our level three
nurseries in the state. These nurseries are
already of course reporting to our Healthcare
Acquired Infection program and their rates are higher than what our regional
perinatal centers are. So I think we have
an opportunity here to improve that also. [Barbara Rose:] Thanks Marilyn. So unfortunately Ohio’s
numbers are not looking too good in terms of infant mortality
and premature births so a lot of motivation to continue
this improvement work at the population level. I talked a little bit before
about the three main buckets of work, if you will, are the
leadership and administration, the quality improvement,
coaching and training and the regular data
reporting on a monthly basis at the site level as
well as the aggregate. And then I wanted to mention
when we first started in 2008, our neonatal project was
reducing late onset infection in 22 to 29 weekers. So in Ohio we have
24 level three, which is the highest level
of NICUs in our state, that participated in the
inaugural OPQC project and that representing
almost 100% of all the 22 to 29 weekers across the state. In the OB project
in deliveries less than 39 weeks we had 20
large maternity centers from across the state that
signed up to participate. That represented
about 47% of the birth so we had a pretty
good representation. And between the two
projects, the neo project and the OB project that
signed up to be part of the inaugural group. We’ve been wonderfully
successful in the first phase of the project and we currently
in 2011, 2012 ramped up to start up a second phase of projects. For those 24 NICUs and the
22 to 29 weekers we did when we first started about 18% of those infants had
a late onset infection and we do use the VON — V, O,
N — definition for infection. We saw a 20% decrease to
about 14% of those babies, still way more babies with
infections than we wanted to see so we’ve maintained that
project and added a human milk as medicine component which I’ll
talk about in just a minute. And we also have insertion
bundle and a maintenance bundle for this project and we see as the maintenance bundle
reliability goes higher, the infection rate
with this group starts to decrease noticeably. Related to the scheduled
delivery project, we’ve again because
we look at this in a statewide basis
we have tracked a total of 6000 fewer births a year
happening at 36 to 38 weeks without medical indication
and I’ll show you that birth certificate
graph in a just a moment. So for the three years that this
initiative has been in place that means that 24,000 births
have been shifted resulting in almost 200 fewer near-term
infants being admitted to the NICU and a cost savings
of about $11 million each year. These are the run charts. I’m not going to
into them at length. But the run chart on
the right which has lots of zigzag lines is actually
the VON measure of infection for our 24 participating
sites, showing where we started at baseline was about 18%. We’ve gotten down to 14% and with increased
maintenance bundle reliability and these infants
getting earlier initiation of human milk, we’re starting to see the infection rate
continue on a downward trend. The smaller graph to the left
is the maintenance bundle. We do track an all or none
maintenance bundle measure every month from our sites and we’re
shooting for 100% reliability. And over the last couple
of months we’ve been up in the 95% range which
is really encouraging. It means that folks are asking
does this line need to be in and then doing all components
of the maintenance bundle. And then the graph on the
bottom with the red line and the small blue squares
shows the percent of infants that have had any human milk
in the first 72 hours of life and that’s right
in the 80% range. That collaborative has
just been going since March and we are looking to
get that up to 100%, 100% of 22 to 29 weekers in our level three nurses have
some human milk preferably mother’s milk by
72 hours of age. And our balancing
measures for the human milk and infection project
are looking at growth rates and
then also NEC. I don’t have any graphs
of those yet but both of those balancing measures are
showing some promising results. It looks like the NEC rate
for this group of patients is on its way down and
the low level of growth is actually
lower than we expected. So stay tuned in
another few months and we should have some results
that are ready for primetime on those two balancing measures. So our neonatology
leader Michele Walsh from Rainbow Babies in
Cleveland, these are a couple of quotes that she reminds
the teams that line care by itself was not effective in
reducing bloodstream infections, that both the safety
techniques and the introduction of human milk early is what our
key driver is leading us to do. And we also have a very
strong underpinning principle that to continue to improve
the birth outcomes that OBs and the neos must work together. So Jay Iams is our OB leader. As I mentioned before he’s
a maternal fetal medicine specialist from the
Ohio State University. He led the 39 week scheduled
delivery project and now that same group of
20 OB providers across the state started this
spring a quality improvement initiative to make sure
that women who are eligible for anti-natal steroids
between 24 and 33 and 6/7ths weeks’ gestation
receive anti-natal steroids before they deliver. And the bar graph on the right
with the green and the red when we started in October
2011 was just about 50/50, about half the women who were
eligible got anti-natal steroids again in this 20-hospital
group and about 50% didn’t. And you can see since
October 2011 to August 2012 which is the top bar on
that, we’re up to almost 80% of women getting a
full course of ANCS. The blue bar is a partial
course and the red is no ANCS. So this particular group of practices is making
progress on that. The next step for this will
be to determine what elements of this bundle have been
successful and take that out to the other maternity
providers across the state. This is one of the graphs
that OPQC is known for. In addition to site-specific
data and both the neonatology project and the OB project we use
the Vermont Oxford Network Inspection as our population
measure of improvement in the neo project and we
use birth certificate data as our population measure
in the 39 weeks project. This graph shows this is
birth certificate data on a monthly basis. We’ve worked out an
ongoing relationship with Ohio Department
of Vital Statistics and now we get monthly downloads of our electronic
birth certificate data. The vertical line is where
OPQC started in September 2008. The lower line of the
blue squares is the 36 to 38 weeks’ scheduled
deliveries and to the left of the vertical line
you’ll see a baseline. That’s pretty constant,
not much change in the previous 24 months. OPQC as well as a
(unintelligible) coming out with their 39 week statement
again and a fair amount of popular press picking
up on the whole issue of scheduled deliveries but
OPQC also got its start then. Since OPQC started the blue
squares have consistently gone down so 36 to 38 weeks
scheduled deliveries without indication
are on a decline, and the pink squares
represent a shift in the 39 to 41 week deliveries. And there’s a statistical
difference in the change there. So the pink going up
and the blue going down is statistically
significant. And this is where that
actually 26,000 births where we say were shifted
from near term to full term with the savings of about
$24 million to $26 million to the healthcare system
over the last three, three and a half years. So last December when
Ohio and New York and California had the
opportunity to travel to Atlanta and meet with each other face
to face with Zsakeba Henderson and her team and Dr. Bill
Callaghan as we were getting into the funded work around
state perinatal collaboratives, we had some great
dialog and exchange and we’re just really struck
by how supportive the CDC is of this state perinatal
collaborative work. And this quote from Dr.
Callaghan really caught our attention because
one of the things that we are actively
working on in Ohio is to improve the accuracy
of birth certificate data. When we started using
birth certificate data in 2008 people thought
we were crazy. They said how can you possibly
use birth certificate data, everybody knows that
that is really inferior. And we believed the
more people used it that understood what
it was being used for that the quality would go up and as we tracked birth
certificate data we also had site-specific data that
we were comparing it to. And one of the very
exciting deliverables that Ohio is working on for
the CDC work is we did a number of site visits earlier
this year when we went out to the smaller hospitals
or what we call our level two, so a little bit smaller volume,
delivery hospitals and met with not only clinical leaders,
nurse managers and the OB lead but also with the birth
certificate clerks, a tremendous amount of
variation as you can imagine in who actually filled
out the birth certificate at the hospital. The electronic version is due
to the state within ten days of the delivery and there’s
also a lot of variation about where people look for the
particular clinical information that fits that variable. So under development, hopefully
in draft form by early 2013. Our five online modules each
which will take about 20 minutes to complete and those
modules will be for any and all hospital
staff across the state who enter birth certificate
data into the IPHIS system. Those modules will be Why is
the Birth Certificate Important to the Healthcare of Women and
Newborns, What are the Variables in the Ohio Birth Certificate
and What do They Mean, Where are Select Birth
Certificate Variables Found in the Medical Record,
How Can I know if I have Accurately
Entered Data Into IPHIS which is the electronic system, and then How Can I Improve
the Data Entry Processes at My Hospital. So we believe that these online
modules are one of the first of their kind in the country
and we will be testing them with some of our pilot sites
in Ohio and are really excited to take the next step. Another project that has
been underway this year in 2012 is taking
the lessons learned from the 39 weeks’
scheduled delivery project in the first 20 hospitals and
taking it out to a new round of 15 maternity hospitals
who were not at the table for
the first phase. And that learning
session was in March. Those 15 hospitals who had the
site visits were learning how to improve birth certificate
data as well as working with their clinical
team about making sure that the birth certificate data that gets entered accurately
reflects the clinical practice at that institution. We’re seeing some improvement
in scheduled deliveries without medical indication. On the way down the goal
line there is less than 5% by birth certificate and
as an aggregate this group of 15 hospitals is
doing pretty well. I have to say of that of
that 15 there’s about two that remain pretty
significant outliers and our clinical
administrative team are working on some strategies
to help the outliers. But again this 15 has helped us
learn how to spread what works on the clinical side as well
as help understand the accuracy of the birth certificate data. This is just a published piece
that we allocated a little bit of our CDC funding to go
to Burness Communications to get the word out across
the state about the value of the 39 weeks’
scheduled delivery project and to show some
of those results. For those of you who
may or may not be aware of Burness Communications,
they’re a large firm outside of Washington, D.C. and
they do quite a bit of work with public health
and non profits. They’ve been just
terrific to work with and this piece has gotten
a fair amount of traction. This is our newest piece that
we’re really, really pleased with and are in the
process of fine tuning it. This is our second Burness piece and this actually geared
toward parents and the public at about an eight
grade reading level. This is human milk is medicine so this is a patient education
piece that talks about the value of human milk and
how important it is. And when you unexpectedly
deliver preterm the best thing you can do for your
baby is to express or pump breast milk
for him or her. It talks about the three
myths around pumping and then we did feature
an Ohio mom and preemie who had a really good experience
pumping for her little guy. So this is the piece
as is from Burness. One of our sites is rewriting it
at a fifth grade reading level for some of our moms who
have a lower literacy level and then we’ve just gotten the
Spanish version from Burness and I don’t have a
copy of that yet. So again I think
this is something that the content is evidence
based, it’s got some color, it’s got a family story and
really finding a lot of utility with this, just now getting
it out to – our sites are able to use the PDF and print
it off as many as they want and then we’ll be probably
posting some kind of version that doesn’t have the OPQC
logo on it but I’m happy to talk a little
bit more about this. We’re pretty proud
of this piece. And so for next year because
we’ve got 144,000 births and 110 maternity
hospitals, we still need to spread the 39 week project out to the remaining 80
hospitals as well as package up the anti-natal steroid
best practice bundle. The neo group, probably starting
in the spring or summer of 2013, is going to be looking at
neonatal abstinence syndrome. Michele Walsh our neo lead has
different funding from the state and is doing a pilot project on
addicted infants who get care at the six children’s
hospitals across the state and they’re collecting a lot
of clinical data on the infants and also testing some best
practices on how to care for the infants as
well as the moms. So once her pilot project wraps up then we will probably be
using the OPQC infrastructure to get those best
practices in a QI format out to hospitals
across the state. And the OB project, Dr. Iams and his clinical advisory group
are working on a key driver and some preliminary metrics
for their progesterone for women who are at risk for
preterm birth. That’s either 17P or other forms
of progesterone administrations. And once the key
driver and measures and our anti-natal steroid
project all get wrapped up by the end of 2012, we’ll probably kick this off
again in early to mid 2013. So we always have our
eye on the prize of how to improve birth
outcomes across the state and have a couple new
projects that are percolating that we’re really
exciting about. So I think hopefully
between our two examples, both the Ohio Perinatal
Quality Collaborative and the New York State
Perinatal Quality Collaborative that you’ve gotten an
understanding of some of the methods and some of the
partners and some of our results and that there is really is
sort of a national movement of looking at how to continue
to improve perinatal outcomes in terms of clinical
outcomes that are experienced for families and infants and certainly reducing
the cost of prematurity. So we talked about our projects. There’s always continued
room for improvement. I don’t think we’re
ever quite finished. There’s always sustainability
and spread to other hospitals, developing other projects,
making sure that what we’ve done over the last two or three years
continues to stay in place. And I think that’s the end
of the formal presentation from Marilyn and I and I
think the intention is to open up for any questions
or discussion points. [Zsakeba Henderson:]
At this point I’d like to ask the operator to
open the lines for questions. [Coordinator:] Once again to ask
a question depress star then 1 and please be sure to record
your first and last name. Again to ask a question, depress
star 1 and record your name. One moment. [Kristen:] Hi Zsakeba this
is Kristen from New York. We have one question
in the chat. It says, “You mentioned
that maternal education re: preterm birth was improved by
about 53%, please elaborate on how this outcome
was measured.” [Marilyn Kacica:] This
is Marilyn in New York. The way that we look at
this with our facilities is that we look at the percent
of women that are informed about the maternal and fetal
risks — risks and benefits — of scheduled delivery so
that there has to be a system in place when the mom comes in
to deliver or for scheduling that they ask the mom if
she has either been educated or they design some
process to figure out if the mother
has been educated. I think the difficulty with
this one is that documentation in the chart isn’t
always there because a lot of this education
will happen prior to the mom coming
to the hospital. So I think that’s
one of the issues with improving this measure. It’s a lift and I
think that, you know, facilities are concentrating
on this and we will be concentrating
on this more in the future. And I have to say that I think that everyone thinks
it’s important but I think everyone
is struggling with how to do it the best way. [Coordinator:] There
are no questions on the phones at this time. [Zsakeba Henderson:] Are there
any other further questions? Okay if there are no
further questions… [Coordinator:] We do
have another one here. It’s from Jeff Gould
and he says, “How is data collected
in New York?” [Marilyn Kacica:] And it
depends on the project. So with our obstetrical
project we initially began with a data collection tool
that was installed in each of the RPCs because
when we looked at our birth certificate
data we did not have enough of the fields in there in
order to really say one way or another whether something
was truly medically indicated or not. So we developed a new tool and
now that is a web-based tool as we are rolling out to all
the hospitals in the state. As far as our neonatal project
we have a neonatal intensive care unit module within our
statewide perinatal data system that has been in place for
years, since 2003 or ’04, and neonatal intensive
care units are mandated to enter data into that. So that’s where we follow
our neonatal measures. As well as now with
the CLABSI part of that information
is also coming through the NHSN
here at the state. [Zsakeba Henderson:] Are
there no further questions? [Coordinator:] There are
no questions on the phones. [Zsakeba Henderson:]
Okay thank you. We would like to thank
Marilyn Kacica and Barbara Rose for giving us an excellent
introduction to the work of perinatal quality
collaboratives. We would also like to thank
you all for participating in our webinar Perinatal
Collaboratives 101 and invite you to join us for
our next webinar in December on Quality Improvement
Principles and Getting Started. We hope that the Web page and this webinar series
will facilitate exchange of information and
promote visibility of perinatal quality improvement
activities throughout the country. To help accomplish
these goals we plan to list active collaboratives
and provide contact information and links to their Web
sites on our Web page. We encourage you to visit the
Web page and submit information for your collaborative
if you would like to be included
in this effort. You can contact us
at the DRH Info link at the bottom of the Web page. Thank you again and
have a nice afternoon.

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