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Birth & Death Certificate Indiana Perinatal Quality Improvement Collaborative – Quality Improvement Committee 11/13/2014 Erica Park Nancy Swigonski, MD,

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Presentation on theme: "Birth & Death Certificate Indiana Perinatal Quality Improvement Collaborative – Quality Improvement Committee 11/13/2014 Erica Park Nancy Swigonski, MD,"— Presentation transcript:

1 Birth & Death Certificate Indiana Perinatal Quality Improvement Collaborative – Quality Improvement Committee 11/13/2014 Erica Park Nancy Swigonski, MD, MPH, FAAP Kathleen Frogge, Program Director 2

2 “YOU CAN DESIGN AND CREATE, AND BUILD THE MOST WONDERFUL PLACE [SYSTEM] IN THE WORLD. BUT IT TAKES PEOPLE TO MAKE THE DREAM A REALITY.” WALT DISNEY

3  Overall goal: Reduce Indiana’s infant mortality rate  In order to reach overall goal, Indiana needs good data  2 areas of data:  Birth certificate  Death certificate OVERALL GOAL

4 Death Certificate Indiana Perinatal Quality Improvement Collaborative – Quality Improvement Committee 11/13/2014

5 DEATH CERTIFICATE PROCESS

6 1. Funeral home receives a call from the hospital or the parents

7 DEATH CERTIFICATE PROCESS 1. Funeral home receives a call from the hospital or the parents 2. If parents decide to use their funeral services, infant will be transferred to the funeral home

8 DEATH CERTIFICATE PROCESS 3. Hospital initiates a burial transit permit Fills out Sections A & B

9 DEATH CERTIFICATE PROCESS 4. Person who picks up the body fills out more of the permit Fills out Sections C

10 DEATH CERTIFICATE PROCESS 5. Funeral home completes the permit - fills out Sections D & E  3 copies of this permit  1. Health department by the hospital  2. Crematory or cemetery  3. Health department

11 DEATH CERTIFICATE PROCESS 6. Funeral director logs onto IDRS to initiate the death certificate – generally within 24-48 hours but may be longer if waiting for the mother’s release from hospital

12 DEATH CERTIFICATE PROCESS 6. Funeral director logs onto IDRS to initiate the death certificate – generally within 24-48 hours but may be longer if waiting for the mother’s release from hospital 7. IDRS opens with an initial search  If name is already in the system, it will match the name to the search  If name is not in the system, it will initiate a new death certificate form

13 DEATH CERTIFICATE PROCESS 8. Funeral director fills out demographic information

14 DEATH CERTIFICATE PROCESS 8. Funeral director fills out demographic information 9. Funeral director sends death record to the physician  Physician must be registered in the system  Physician will receive an email notifying him/her that a death certification is in queue  Email includes decedent’s name, date and time of death, place of death, etc.

15 DEATH CERTIFICATE PROCESS 10. Physician logs onto IDRS and fills out medical information and certifies the death

16 DEATH CERTIFICATE PROCESS 10. Physician logs onto IDRS and fills out medical information and certifies the death 11. Physician sends the death record back to the funeral director  Funeral director receives a similar email notification

17 DEATH CERTIFICATE PROCESS 10. Physician logs onto IDRS and fills out medical information and certifies the death 11. Physician sends the death record back to the funeral director  Funeral director receives a similar email notification 12. Funeral director finishes certificate

18 DEATH CERTIFICATE PROCESS  Fetal deaths are registered in a separate system  Key differences:  Fetal death report requires more parent demographic information  If the fetus is <20 weeks gestation, the funeral home does not have to report and the hospital can dispose the body

19  Met with funeral director  Discussed the death certificate process and issues with timeliness  Physicians not registered into the system causes delays  Time it takes to fill out the death certificate data into IDRS  Live birth: ~10 minutes  Fetal death: ~15-20 minutes DEATH CERTIFICATE INFORMATION GATHERING

20  Neonatologist  Physicians must be registered into the IDRS – if the attending physician is not registered this could cause delays  Recent switch to electronic birth records and lack of training may be causes of delay  Physicians do not know they are able to initiate the death certificate  Ultimately these delays cause delays in burial of the baby DEATH CERTIFICATE INFORMATION GATHERING

21  https://vrqa.isdh.in.gov/inthin/indextest.html https://vrqa.isdh.in.gov/inthin/indextest.html DEATH CERTIFICATE INFORMATION GATHERING

22  Key issue is getting physicians registered into IDRS  Physicians can start the death record, but this was unknown  Others can start the death record with the physician later signing with their personal identification number (PIN), but this was unknown DEATH CERTIFICATE DATA - FINDINGS

23  Online Training  Training manuals  Indiana = 78 pages  CDC = 65 pages  IDRS system not self-explanatory  Webinar link does not work DEATH CERTIFICATE DATA - FINDINGS

24  Where in your hospital/system are there problems with the death certificate process?  What ideas do you have to make the system better?  What methods at your hospital work well? DEATH CERTIFICATE PROCESS – BRAINSTORMING

25  Identify the hospitals with highest number of infant deaths and focus efforts on those first  Register and demonstrate IDRS to physicians during hospital orientations  Preload physicians into the system  Pilot a program using staff to initiate the certificate DEATH CERTIFICATE DATA - RECOMMENDATIONS

26 Birth Certificate Indiana Perinatal Quality Improvement Collaborative – Quality Improvement Committee 11/13/2014

27 BIRTH CERTIFICATE PROCESS – THEORETICAL

28 1a. Mother fills out the Mother’s Worksheet section of the CDC- issued 12 page birth certificate form BIRTH CERTIFICATE PROCESS THEORETICAL

29 1a. Mother fills out the Mother’s Worksheet section (MWS) of the CDC-issued 12 page birth certificate form 1b. Hospital staff fills out the Facility Worksheet section (FWS) of the CDC-issued 12 page birth certificate form BIRTH CERTIFICATE PROCESS THEORETICAL

30 1a. Mother fills out the Mother’s Worksheet section (MWS) of the CDC-issued 12 page birth certificate form 1b. Hospital staff fills out the Facility Worksheet section (FWS) of the CDC-issued 12 page birth certificate form 2. Hospital staff logs onto BDRS BIRTH CERTIFICATE PROCESS THEORETICAL

31 1a. Mother fills out the Mother’s Worksheet section (MWS) of the CDC-issued 12 page birth certificate form 1b. Hospital staff fills out the Facility Worksheet section (FWS) of the CDC-issued 12 page birth certificate form 2. Hospital staff logs onto BDRS 3. Hospital staff uses the CDC-issued 12 page birth certificate form to fill out the electronic birth registration form BIRTH CERTIFICATE PROCESS THEORETICAL

32 4. County health department receives birth registration data BIRTH CERTIFICATE PROCESS THEORETICAL

33 4. County health department receives birth registration data 5. State Department of Health receives birth registration data BIRTH CERTIFICATE PROCESS THEORETICAL

34 4. County health department receives birth registration data 5. State Department of Health receives birth registration data 6. CDC receives birth registration data BIRTH CERTIFICATE PROCESS THEORETICAL

35 BIRTH CERTIFICATE INFORMATION GATHERING  Vital Records Training Modules http://in.gov/isdh/25584.htm http://in.gov/isdh/25584.htm  For birth clerks, hospital staff that works with IBRS  3 modules on the ISDH website  Each take ~30 minutes to complete  Module 1: Improving the Quality of Birth Certificate Data  Module 2A: All Birth Worksheet Data Matters Part A  Module 2B: All Birth Worksheet Data Matters Part B  Visited hospitals to outline the birth certificate process

36 BIRTH CERTIFICATE FINDINGS

37 Findings from the hospital visits  CDC-issued 12 page worksheet was “split” into 5 separate worksheets  Hospital has 300 births/day  If no interruptions can get through 20-25 births into the BDRS/day  Time it takes to fill out (ideal)  Ranges from 15 min–1.5 hours BIRTH CERTIFICATE DATA - FINDINGS

38 The actual process is much more complex than the theoretical process Obstacles faced by the hospital staff  Missing data  Takes time to find sources of missing data and contact the mother for information BIRTH CERTIFICATE DATA - FINDINGS

39 The actual process is much more complex than the theoretical process Obstacles faced by the hospital staff  Missing data  Takes time to find sources for missing data and contact the mother for information  Variation in data sources (online, paper)  Which source has the correct information? BIRTH CERTIFICATE DATA - FINDINGS

40 The actual process is much more complex than the theoretical process Obstacles faced by the hospital staff  Missing data  Takes time to find sources of missing data and contact the mother for information  Variation in data sources (online, paper)  Which source has the correct information?  Availability of external data  Example: prenatal care if begun in a different hospital BIRTH CERTIFICATE DATA - FINDINGS

41 The actual process is much more complex than the theoretical process Obstacles faced by the hospital staff  Missing data  Takes time to find sources of missing data and contact the mother for information  Variation in data sources (online, paper)  Which source has the correct information?  Availability of external data  Example: prenatal care if begun in a different hospital  Changes to the questions and answer choices on the CDC- issued 12 page worksheet  Example: choices for “Mother’s Race” BIRTH CERTIFICATE DATA - FINDINGS

42  Variations of the birth certificate registration process in hospitals  Accuracy of the data must be addressed  Timeliness of the data must be addressed BIRTH CERTIFICATE PROCESS FINDINGS

43 WHAT HAVE OTHER STATES DONE? WHAT ARE BEST PRACTICES?

44 BIRTH QUALITY WORKGROUP  Recently, the CDC formed a Birth Data Quality Workgroup to survey data quality practices among the State Departments of Health  Online survey  Focused on activities that evaluate and ensure data quality  Asked about actions in response to data quality findings  46/52 completed the survey (88.4% participation)  Results of the study led to 2 specific recommendations

45 BIRTH QUALITY WORKGROUP RECOMMENDATIONS  1. Data must be evaluated on an ongoing basis  Importance of rapid cycling  Recommend quick response to poor data quality from birth facilities – weekly or monthly vs. quarterly or yearly

46 BIRTH QUALITY WORKGROUP RECOMMENDATIONS  2. Effective communication of data quality is necessary  1. Concrete feedback  2. Increase awareness about the merit of data quality  3. Provide regular trainings and newsletters  4. Publish reports about performance to increase transparency  5. Connect with upper-level clinicians and hospital administrations

47 BIRTH CERTIFICATE FINDINGS FROM OTHER STATES StateRecommendations/Actions Washington“Why Quality Data is Important and Help to Improve Your Data” guide; website comparing data quality of facilities OhioReal time auditing; development of a new standardized H&P to contain all necessary points CaliforniaIncreased regional trainings; development of a CMQCC Maternal Data Center

48 STATE OF WASHINGTON  The State of Washington has developed a Birth Data Quality Query System (BDQQ) webpage on their State Department of Health website  “The BDQQ is a tool to help you improve your birth data quality”  The BDQQ system provides hospital profiles of “percent unknown” for selected items on the birth certificate

49 STATE OF WASHINGTON  There are 4 possible ways to look at the data for each birth facility using the BDQQ system:  1. “Average % Unknown” compared to facilities of similar birth volume  There are 4 possible ways to look at the data for each birth facility using the BDQQ system:  1. “Average % Unknown” compared to facilities of similar birth volume

50 STATE OF WASHINGTON  2. “% Unknown” of certain birth data items compared to state

51 STATE OF WASHINGTON  3. “% Unknown” of certain birth data items over time

52 STATE OF WASHINGTON  4. “Average % Unknown” compared to WA state over time  State also has a PDF link on this site to their guide  Guide explains the reports and the birth certificate in layman’s terms

53 STATE OF OHIO  Ohio Perinatal Quality Collaborative (OPQC) and the Ohio Department of Health Vital Statistics performed a study focusing on 4 phases of birth data registration  Phase I: Completing the electronic health record  Algorithms to flag incomplete charts  Empowering nursing staff  Increased teaching of hospital staff

54 STATE OF OHIO  Phase II: Empowering staff  Nurses encouraged to contact OB providers if data was missing  Emphasized safety benefits to hospital staff peer-to- peer

55 STATE OF OHIO  Phase III: Real Time Auditing  Nursing supervisors began real time auditing for incomplete medical record  Pregnancy card created for each pregnant women  Phase IV: Real Time Auditing Continued and Expanded to High Risk Groups

56 STATE OF CALIFORNIA  California Maternal Quality Care Collaborative (CMQCC) development of a California Maternal Data Center (CMDC)  CMDC is a statewide data center that collects and reports timely maternity metrics (including data quality) in a way that is “low cost, low burden, and high value for hospitals”  Similar to Washington, but with more detail  CMDC is overseen by a multi-stakeholder Steering Committee composed of clinicians, hospitals, payers, purchasers, consumer organizations, and relevant state agencies

57 STATE OF CALIFORNIA  Demonstration site link: https://demo.datacenter.cmqcc.org/hospitals/1 https://demo.datacenter.cmqcc.org/hospitals/1  Demonstration site link: https://demo.datacenter.cmqcc.org/hospitals/1 https://demo.datacenter.cmqcc.org/hospitals/1

58  What are the steps that are taken to fill out the birth certificate?  Who provides information? What sources are used to fill out the birth certificate (paper, electronic)?  What if you are unable to find information? What steps do you then take?  Are there any specific areas on the birth data registration form that are particularly difficult, unclear or usually not able to be filled out? Why is it difficult?  How long does it take to complete a birth certificate registration form?  How long does a fairly “straightforward” birth take versus a more complicated one?  How many births are entered in 1 day?  How many births per week are entered?  How long from the time of birth to entry into the system (average and range)?  How long have you or the person who usually fills out birth certificate information been doing this job?  Are you/they hired specifically as a birth clerk or do you/they have other duties also?  What other duties?  How many hours per day are dedicated specifically birth data entry?  What training did you/they receive regarding birth certificate?  Have you/they used the birth certificate data training modules on the Indiana State Department of Health website?  If so, did you/they find it helpful? BIRTH CERTIFICATE PROCESS – WHAT IS THE PROCESS IN YOUR HOSPITAL?

59  Where in your hospital/system are there problems with the birth certificate process?  What works well in your hospital?  What ideas do you have to make the system better? BIRTH CERTIFICATE PROCESS – BRAINSTORMING

60  1. Provide feedback  Distribute a list of variables that commonly have errors to hospital administration BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

61  1. Provide feedback  Distribute a list of variables that commonly have errors to hospital administration  Notify hospital administrative and clinical leadership about the deficiencies in vital records process BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

62  1. Provide feedback  Distribute a list of variables that commonly have errors to hospital administration  Notify hospital administrative and clinical leadership about the deficiencies in vital records process  Use a website to publish performance reports to increase transparency BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

63  1. Provide feedback  Distribute a list of variables that commonly have errors to hospital administration  Notify hospital administrative and clinical leadership about the deficiencies in vital records process  Use a website to publish performance reports to increase transparency  Increase vital records staff to be able to give more immediate feedback BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

64  2. Provide training incentives  Recommend hospitals to include completion of training modules in performance review BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

65  2. Provide training incentives  Recommend hospitals to include completion of training modules in performance review  Provide regular trainings and newsletters for birth registration staff BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

66  2. Provide training incentives  Recommend hospitals to include completion of training modules in performance review  Provide regular trainings and newsletters for birth registration staff  Develop a post test and/or a Certificate of Completion for staff completing modules BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

67  2. Provide training incentives  Recommend hospitals to include completion of training modules in performance review  Provide regular trainings and newsletters for birth registration staff  Develop a post test and/or a Certificate of Completion for staff completing modules  Pursue CEUs for nurses and CMEs for physicians for completing birth certificate training modules BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

68  3. New systems improvements  Add definitions of fetal death and live birth on the electronic birth and death registration systems BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

69  3. New systems improvements  Add definitions of fetal death and live birth on the electronic birth and death registration systems  Add a drop down box with causes of death on the screen that match the CDC codes BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

70  3. New systems improvements  Add definitions of fetal death and live birth on the electronic birth and death registration systems  Add a drop down box with causes of death on the screen that match the CDC codes  Allow staff to receive email re: death certificate at the same time as the physician BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

71  4. Extend roles and approaches  Communicate to physicians that they should register in IDRS and that they can initiate the death record BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

72  4. Demonstrate and implement  Communicate to physicians that they should register in IDRS and that they can initiate the death record  Encourage hospitals to have physicians register in the IDRS during hospital orientation BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

73  4. Demonstrate and implement  Communicate to physicians that they should register in IDRS and that they can initiate the death record  Encourage hospitals to have physicians register in the IDRS during hospital orientation  Communicate that staff (nurses, clerical staff) can be authorized and trained to complete initial data that is then confirmed by the physician and submitted BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

74  4. Demonstrate and implement  Communicate to physicians that they should register in IDRS and that they can initiate the death record  Encourage hospitals to have physicians register in the IDRS during hospital orientation  Communicate that staff (nurses, clerical staff) can be authorized and trained to complete initial data that is then confirmed by the physician and submitted  Communicate that the hospital can initiate the prenatal birth record BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES

75 “Not every change is an improvement, but every improvement is a change; you can’t do anything better unless you can manage to do it differently. You’ve got to let yourself do better than other people.” Eliezer Yudkowsky STEPS TOWARDS EFFECTIVE CHANGE

76  Indiana does very well in the completion of birth and death certificate data  However, improvements can still be made to improve the quality of the data  In order for Indiana to successfully reduce the infant mortality rate, the state must have good quality birth and death certificate data SUMMARY

77 REFERENCES 1.Ahuja S, Bakus K, Crawford G, Fontana C, Gambatese M, Jessen A, Justice D, Madsen-Straight A, Martin J, Pagnano S, Reed P, Thoma M, Tretter E, Wishart L. Efforts to improve birth data quality: results from a survey of data quality practices among US vital records jurisdictions. Hyattsville, MD: National Center for Health Statistics. 2014. 2.Ford S, White B. Summary of birth certificate data collection challenges: lessons learned from Ohio and other states. Columbus, OH: BEACON Ohio Department of Health. 2012. 3.Birth data quality query system. 2014. Washington State Department of Health. Retrieved July 20, 2014 from https://fortress.wa.gov/doh/bdqq/bdqq.aspx. 4.Main E, Castles A, Murphy B. Partnering for maternal data quality improvement. California Maternal Quality Care Collaborative. 2013.


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