1. Eliminating Early Elective Deliveries Data Collection FHA Hospital Engagement Network Florida Perinatal Quality Collaborative University of South Florida Florida Kickoff Meeting September 24, 2012

2. MAP-IT—Rapid Cycle Learning MAP-IT Mobilize Assess Plan Implement Track Source: Guidry, M., et. al. Healthy people in healthy comamunities: A community planning guide using healthy people 2010. Washington, D.C. U.S. Dept. of Health and Human Services. The Office of Disease Prevention and Health Promotion.

3. MAP-IT—Rapid Cycle Learning MAP-IT Mobilize Assess Plan Implement Track

4. Percent of NMI Deliveries <39 Weeks Gestation by Delivery Type Provisional Data Source: MOD Big 5 Pilot Project—Florida

5. Induction / Cesarean Scheduling Process Physician Leadership A. Enforce policy B. Approve exceptions Physician Leadership A. Enforce policy B. Approve exceptions Clinician and/or Patient Desire to Schedule a Non-medically Indicated (Elective) Induction or Cesarean Section Case NOT Scheduled if Criteria Not Met Elective Delivery Hospital Policy Clinician, Staff & Patient Education Reduce Demand QI Data Collection & Trend Charts Public Awareness Campaign Overview: Critical Elements for Successful Implementation

6. Scheduling Form or Delivery Log DateGANameIndicationLaborDil.Description

7. Scheduling Form—Key Data Elements Key Data Elements Type of Planned Delivery Gestational Age Gestational Age Dating Delivery Indication Other Reason Labor on Admission Outcomes?

8. Data Collection Options HRET—Use of a hospital designed system MOD—Use of a common data portal

9. ELIMINATING EARLY ELECTIVE DELIVERIES 1 HRET-FHA HOSPITAL ENGAGEMENT NETWORK (HEN) DATA OVERVIEW September 24, 2012

10. HOSPITAL ENGAGEMENT NETWORK Data Requirements HRET’s Comprehensive Data System (CDS) Overall hospital data Enter numerator & denominator No patient level data Requirement- per focus area One process measure One outcome measure Minimize data entry time burden Entering only 4 numbers in CDS! 1

11. HOSPITAL ENGAGEMENT NETWORK Data Requirements HRET’s Comprehensive Data System (CDS) CDS Encyclopedia of Measures OB Measures: #40-55 May define your own measure & submit it Submit baseline data Preferably prior to 2012 Flexible- baseline can be 1, 3, 6 or 12 months Submit monitoring data monthly (CDS) Submit monthly Progress Report (FHA) 2

12. HOSPITAL ENGAGEMENT NETWORK OB Process Measures- Examples Elective deliveries at >=37 weeks and <39 weeks (EED) Antenatal Steroids DVT Prophylaxis- C-Section OB Outcome Measures- Examples C- Section delivery rate Elective Births <39 week births admitted to the NICU 5 Minute Apgar 39 weeks Neonatal Mortality rate 3

13. HOSPITAL ENGAGEMENT NETWORK CMS Required Reporting- EED All hospitals must report EED rates Final Rule posted August 1, 2012 Data collection begins January 1, 2013 Payment Determination FY 2015 Hospital must report zero if no OB Using the Joint Commission measure PC-01 (EED) Same measure the HEN is using in the CDS Measure #40 in the CDS Encyclopedia of Measures 3

14. Comprehensive Data System HRET’s project data collection system –Web-based –Secure –Flexible https://www.hretcds.org/ 4

15. CDS ENCYCLOPEDIA OF MEASURES 40OBElective Deliveries at >=37 Weeks and <=39 Weeks (JC PC 1) Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed 41OBAntenatal Steroids (JC PC 3)Patients at risk of preterm delivery at 24-32 weeks gestation receiving antenatal steroids prior to delivering preterm newborns 42OBDVT Prophylaxis - C-Section (OB)Measures adherence to current ACOG, SMFM recommendations for use of DVT prophylaxis in women undergoing cesarean delivery 43OBC-Section Delivery Rate (JC PC 2) Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section 44OBElective <39 Week Births Admitted to NICU (March of Dimes) Number of infants admitted to the NICU or transferred to another hospital for care after a scheduled elective induction/ cesarean section between 37 0/7 and 38 6/7 weeks. 5

16. Aim: (Including your How Good and By When statement) Why is this project important?: Aim Statement Changes being Tested, Implemented or Spread Recommendations and Next Steps Lessons Learned Run Charts For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S) (Enter summary here) Enter summary here (what do you need from Executive Project Champion, sponsor at this time to move project?) Recommendations Next Steps for testing Project Title _______________ ( Name of Project Champion and Senior Leader Sponsor) © 2012 Institute for Healthcare Improvement Team Members (Names & Roles) Make fonts large, title, labels, dates and notes very simple on graphs prior to shrinking graphs. Should be able to fit 6-8 readable graphs here. If no data are available for a particular measures either create “empty” run list the name of the measure(s) to be collected. Self Assessment Score (1-5) = _____ Date:________

17. 7

18. HOSPITAL ENGAGEMENT NETWORK Progress Report 8

19. SUMMARY Implement improvement teams –Rapid Cycle: Small test of change Submit data monthly to CDS –One process measure (EED) and one outcome measure Participate in webinars, calls, meetings, etc. Submit progress reports Collaborate with other facilities Celebrate success!! 9

20. HOSPITAL ENGAGEMENT NETWORK Contacts Sally Forsberg RN, Director of Quality & Patient Safety (407) 841-6230, sally@fha.orgsally@fha.org Kim Streit, VP/Healthcare Research & Information Services (407) 841-6230, kims@fha.orgkims@fha.org Martha DeCastro, VP/Nursing (850) 222-9800, martha@fha.orgmartha@fha.org 10

21. March of Dimes Data Portal

22. Data Challenges Accurate mechanism for collecting the data Capturing correctly women admitted early for labor or other medical indications Assuring completeness of data collected Verifying accuracy of the data collected Entering or counting the data accurately Verifying the data entry or counting Providing accurate/consistent denominators Doing these consistently

23. Questions?