1. Improving The Grade Promoting Healthy Birth Outcomes in Ohio The Ohio Perinatal Quality Collaborative Dave McKenna Roni Christopher Barbara Rose We have no relevant conflicts of interest to disclose. …..a statewide improvement collaborative……

2. Through collaborative use of improvement science methods, reduce preterm births and improve outcomes of preterm newborns in Ohio as quickly as possible. (March 2007) Key features:  Focus on population perinatal health = all pregnancies  Collaboration between obstetrics and pediatrics  Evidence based decision making  Collaboration with state policy makers www.OPQC.net

3. Our Impact on Ohio 47% of all births occurred in OPQC hospitals 64% of preterm births (<37 weeks) occurred in OPQC hospitals 82% of births <34 weeks (preterm excluding late preterm) occurred in OPQC hospitals 80% of births 30-33 weeks occurred in OPQC hospitals and were likely influenced by our OPQC NICU infection interventions 87% of births 22-29 weeks occurred in OPQC hospitals (target of NICU infection project)

4. What have we accomplished? Focus on population health 50% of births; 80% of infants 22-29 weeks All Level 3 Target improved care and improved access to care Focus on continuum of care Prenatal (obstetrics) and neonatal care and decisions Collaborations between health care and public health Vital Statistics and Medicaid HB 197 National attention MOD, VON State Leaders Group, AAP neonatal quality measures group, CMS HAI research agenda Improved care ~1000 women per year move from 36-37 weeks to term better care of infants with catheters …..a statewide improvement collaborative……

5. OPQC NICU Participants …..a statewide improvement collaborative…… Akron Children's Hospital Akron Children's Hospital at St. Elizabeth Health Center Aultman Hospital - Canton Cincinnati Children's Hospital Medical Center Cleveland Clinic Dayton Children's Medical Center Doctor's Hospital – Columbus Fairview Hospital - Cleveland Good Samaritan Hospital - Cincinnati Grant Hospital - Columbus Hillcrest Hospital - Cleveland MetroHealth Medical Center - Cleveland Miami Valley Hospital - Dayton Mount Carmel East Hospital - Columbus Mount Carmel St. Ann's Hospital - Columbus Mount Carmel West Hospital - Columbus Nationwide Children's Hospital (Riverside, Grant, Doctor’s Campuses) - Columbus Riverside Hospital - Columbus St. Vincent Mercy Children's Hospital - Toledo Summa Health System - Akron The Ohio State University Medical Center – Columbus Toledo Children's Hospital University Hospital - Cincinnati University Hospital - Cleveland - Rainbow Babies

6. OPQC Obstetric Participants …..a statewide improvement collaborative…… Akron Children's Hospital - Maternal Fetal Medicine Akron General Aultman Hospital - Canton Fairview Hospital - Cleveland Good Samaritan Hospital - Cincinnati Grant Medical Center Hillcrest Hospital - Cleveland Mercy Anderson Hospital - Cincinnati MetroHealth Medical Center - Cleveland Miami Valley Hospital - Dayton Mount Carmel East Hospital - Columbus Mount Carmel St. Ann's Hospital - Columbus Mount Carmel West Hospital - Columbus Riverside Methodist Hospital - Columbus - St. Elizabeth Health Center - Youngstown - St. Vincent Mercy Medical Center - Toledo Summa Health System - Akron The Ohio State University Medical Center - Columbus The Toledo Hospital University Hospital Case Medical Center - MacDonald Women's Hospital - Cleveland

7. Project Aim: In one year, reduce by 60%, the number of women in Ohio of 36.1 to 38.6 weeks gestation for whom initiation of labor or caesarean section is done in absence of appropriate medical or obstetric indication (Scheduled delivery) Dating criteria: optimal estimation of gestational age Inform consumers of risk/benefits of deliveries < 39 weeks Communicate to patient/clinic/hospital ultrasound results Promote need for early dating to practitioners and consumers Public awareness campaign Promote need for early dating to practitioners and consumers Promote sonography < 20 weeks to establish dates Document criteria used to establish EDC Appropriate use of fetal maturity testing Empower nurses /schedulers to require dating criteria Identify a specific contact for authorization dispute re: dating Provide patient with hard copy results of ultrasound Empower nurses /schedulers to require dating criteria Document rationale and risk/benefit for scheduled deliveries at 36.1 to 38.6 weeks gestation Document discussion with patient about the above Both patient and MD sign consent statement for scheduled delivery between 36.1 and 38.6 weeks Physician awareness campaign: what are the reason(s) for scheduled delivery? Maximize access to Delivery and OR for optimal scheduling Facilitate scheduling policies that respect ACOG criteria Prenatal caregivers receive feedback from postnatal caregivers about neonatal outcomes of scheduled deliveries Ensure complete and accurate handoffs Ob/OB and Ob/Peds Document discussion with patient about risk/benefits of near-term delivery Promote need for early dating to practitioners and consumers Awareness of risks & expected benefit of near- term delivery by clinician Key Drivers Goal: Assure that all initiation of labor or caesarean sections on women who are not in labor occur only when obstetrically or medically indicated Hospital and physician practice policies that facilitate ACOG criteria Interventions Culture of safety and improvement Continuous monitoring of data & discussion of this effort in staff/division meetings. Project outcomes posted on units and websites. Develop ways to include staff and physician input about communications and handoffs Connect with organizational initiatives on safety and use existing approaches as possible Empower nurses /schedulers to require dating criteria Awareness of risks & expected benefit of near-term delivery by patients and consumers

8. OPQC OB Initiative: Our hand collected data…OPQC hospitals

10. OPQC OB Initiative: Are we making a difference? Birth Certificate Data for OPQC Hospitals

12. How we collaborate… Monthly review of the data Monthly action period calls Site visits 1:1 coaching as needed Use of the listserv and other communication methods

13. Key Changes=Improvement 16 teams have a written scheduled delivery policy that outlines acceptable reasons to delivery before 39 weeks We created a consumer flyer to educate on our AIM and it was translated into 6 languages 19 teams have a formal peer review process requiring a physician to adequately explain why he/she delivered before 39 weeks 3 hospitals have actively reached out to the private practice physicians groups to improve communication processes for scheduling 7 teams changed their scheduling workflow, i.e. dedicated fax machines, mitigation processes for questionable appointments, etc… All of the teams have, at minimum, adopted a procedural standard for scheduling inductions

14. Our Collaborative Makes an Impact OPQC wins the SMFM “Award of Research Excellence” in 2010 and the March 2010 issue of JCOG detailed this work 2009, we were recognized as a best practice for “Improving the Grade” by the National Office of the March of Dimes We have received a March of Dimes grant to disseminate this work to non-OPQC hospitals in 2010 We are presenting our NICU project at PAS next week

15. Future Projects Antenatal Steroids Care of P-PROM Progesterone Late Preterm 34-36 Regionalization Breast Feeding MgSO4 prophylaxis Smoking Substance Abuse Prematurity related Variation in current practice Existing practice guideline Measurable outcome Enthusiasm by participants …..a statewide improvement collaborative……

16. What we are thinking about: How does OPQC include more Ohio perinatal providers? How do we capture lessons learned? Scheduled deliveries at the other 101 Ohio maternity hospitals? NICU-associated infections in other Ohio NICUs or other NICU populations? …..a statewide improvement collaborative……

17. We continue to align our work with regulations: Ohio House Bill 197 Scheduled Births Before 39 Weeks Antenatal Steroids Appropriate Birth Site for VLBW Infants Cesarean Birth Rate in 1 st – Time Mothers Others

18. Questions? …..a statewide improvement collaborative……