NNEPQIN CPRB Confidential Peer Review Board A proposal for regional institutional review of care. NNEPQIN Fall Meeting November 14, 2009 Jerome Schlachter, MD

“Peer review is alive only in rare pockets in this country.” - Richard Boothman, JD, ACOG Today 2008

AJOG, August 2008 Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety Steven L. Clark, MD; Michael A. Belfort, MD, PhD; Spencer L. Byrum, LCDR (ret.) USCG; Janet A. Meyers, RN; Jonathan B. Perlin, MD, PhD

Clark S, AJOG, Aug “Although some superb, effective local peer review committees exist, those seeking to establish such processes face significant challenges, given current medical staff and hospital board structures.”

Clark S, AJOG, Aug “Effective peer review is essential to quality medical practice yet may be impossible to achieve at a local level in some departments.”

HCA Process National committee supplements the local committee. National committee supplements the local committee. Review committee composition: 14 OB, 3 Neo, 3 RN, including outside experts. Review committee composition: 14 OB, 3 Neo, 3 RN, including outside experts. Cases of severe outcome: deaths, seizures, brachial plexus injury, uterine rupture, ICH. Cases of severe outcome: deaths, seizures, brachial plexus injury, uterine rupture, ICH. Over 400 cases/yr., 97% consensus reached. Over 400 cases/yr., 97% consensus reached.

NNEPQIN CPRB ConfidentialPeerReviewBoard

Part of a comprehensive, region-wide, patient safety agenda. Part of a comprehensive, region-wide, patient safety agenda. Available for institutions that want to supplement their internal perinatal quality assurance program with a regional case review process. Available for institutions that want to supplement their internal perinatal quality assurance program with a regional case review process. A single case or a series of cases may be appropriate. A single case or a series of cases may be appropriate.

NNEPQIN CPRB Mission: To provide an in-depth, multidisciplinary analysis of unanticipated perinatal outcomes in the region. To support learning from systems failures. To improve assessment for, anticipation of and prevention of adverse perinatal events.

NNEPQIN CPRB Structure Personnel Personnel Physician chair rotates Physician chair rotates Nurse review coordinator (DHMC) Nurse review coordinator (DHMC) 1 MD, 1 RN from each institution 1 MD, 1 RN from each institution Additional specialty representation Additional specialty representation Members must attend at least one meeting/yr. Members must attend at least one meeting/yr. No attendance = no case review. No attendance = no case review.

NNEPQIN CPRB Structure Two meetings held per year. Two meetings held per year. Hospitals, patients or providers initiate review. Hospitals, patients or providers initiate review. Hospitals collect and submit information. Hospitals collect and submit information. Chair assigns cases for presentation. Chair assigns cases for presentation. Cost: $50 per case. Cost: $50 per case.

NNEPQIN CPRB Process Hospitals may submit all or selected cases. Hospitals may submit all or selected cases. Examples: Examples: 5’ Apgar <= 3 or intrapartum IUFD 5’ Apgar <= 3 or intrapartum IUFD Maternal death or unanticipated ICU admission Maternal death or unanticipated ICU admission Term non-anomalous NICU admission/transfer Term non-anomalous NICU admission/transfer Umbilical blood gas 12 Umbilical blood gas 12 Return to OR after prior operative procedure in OR Return to OR after prior operative procedure in OR Requirement for Massive Transfusion: 6 more units of blood product Requirement for Massive Transfusion: 6 more units of blood product

NNEPQIN CPRB Process Requested records are blinded by the Hospital Requested records are blinded by the Hospital Last 2 hours of the fetal heart rate tracing Last 2 hours of the fetal heart rate tracing Admitting H&P and all provider progress notes Admitting H&P and all provider progress notes Labor flow sheets and other flow sheets as appropriate Labor flow sheets and other flow sheets as appropriate Laboratory data Laboratory data Nursing progress notes Nursing progress notes Delivery note and discharge summary Delivery note and discharge summary Newborn birth summary, discharge summary and progress notes as appropriate Newborn birth summary, discharge summary and progress notes as appropriate Relevant care guidelines and policies Relevant care guidelines and policies

NNEPQIN CPRB Process Blinded confidential case presentation and review. Blinded confidential case presentation and review. Consensus decision of board. Consensus decision of board. Report forwarded to hospital Q/A committee and the NNEPQIN PSO. Report forwarded to hospital Q/A committee and the NNEPQIN PSO. Hospital records destroyed. Hospital records destroyed.