Perinatal Patient Safety Briefing Deck Tool 3 Perinatal Patient Safety Briefing Deck Purpose Notes and Considerations To help perinatal patient safety leaders make the case to administrators and physicians for investing in improving perinatal patient safety Directions for customizing the slides with hospital-specific information are included on green boxes throughout the presentation. The green boxes should be deleted before presenting the slides to your target audience. Alternatively, this presentation can be given without any hospital-specific data by deleting the slides that contain green boxes. The notes section of each slide contains talking points for presenting each slide and more details about the data they contain. Overview This tool consists of a PowerPoint presentation that contains national data about perinatal care variation and complications and the need for perinatal patient safety efforts. It also contains template slides that perinatal patient safety leaders can modify to include hospital-specific outcomes data and program analyses. Source: Crimson Continuum of Care interviews and analysis. Access this tool: advisory.com/ccc/PerinatalToolkit

Making the Case for Investing in Perinatal Patient Safety Crimson Continuum of Care Making the Case for Investing in Perinatal Patient Safety

Perinatal Care Plays Prominent Role in Hospitals Consider adding a slide subtitle summarizing your institution-specific data, such as: Births Account for X% of Stays at [Name of Hospital] U.S. Hospitals’ Perinatal Care Volume 3.9M 22% #1 Babies delivered in the United States annually Hospital stays related to perinatal care Where cesarean sections rank among operating room procedures in the U.S. Work with your Crimson Dedicated Advisor to customize this slide with your own data. [NAME OF HOSPITAL] Perinatal Care Volumes ### ##% ## Babies delivered in 2014 Hospital stays related to perinatal care Number of cesarean sections performed annually Source: “National Vital Statistics System Birth Data, 2013,” CDC; Weiss, A, “Overview of Hospital Stays in the US, 2012,” Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, October 2014; Weiss, A, “Characteristics of Operating Room Procedures in U.S. Hospitals, 2011,” Healthcare Cost and Utilization Project, February 2014; Crimson Continuum of Care interviews and analysis. Talking Points: Perinatal care, defined as care of the mother and baby surrounding birth, is top of mind for many hospitals because it’s such a high volume business, and accordingly, because of the visibility it has in the community. Nationwide, there are 3.9 million babies delivered each year and perinatal care contributes to almost one quarter of hospital stays. Moreover, Cesarean sections are the most commonly performed procedure in American operating rooms. With Crimson data we can better understand our hospital’s own perinatal care volume, as well. We can see that perinatal care also plays a prominent role at our institution.

Perinatal Practice Patterns Vary Widely Variation Seen Even among Physicians in the Same Hospital Distribution of C-Section Rates in US Hospitals, 2009 n=593 hospitals with at least 100 births “Initially, our physicians said that the C-section rates varied because of differences in patient population, but then they realized that there were actually differences in how they practiced medicine.” Department Chair Women’s Health Services 500-bed Hospital in the Midwest Source: Kozhimannil, KB et al, “Cesarean Delivery Rates Vary Tenfold among US Hospitals; Reducing Variation May Address Quality and Cost Issues,” Health Affairs, 32, no. 3 (2013): 527-535; Crimson Continuum of Care interviews and analysis. Talking Points: But for something that seems so common and routine, recent research has found that there’s a lot of variation in care provided to women and their babies. One area with stark care variation is C-section rates. Results from one national study, depicted in the graph on the left, found that C-section rates vary tenfold across hospitals. Furthermore, as much as rates vary among hospitals, they also vary within hospitals as well, and not just because of differences in patient populations. Namely, rates vary largely because of difference in practice patterns. [Consider pulling data on C-section rates for providers at your institution and providing an example of the range in rates among your providers.]

20-40% Complication Rates Indicate Room for Improvement Patient Characteristics Explain Only Portion of Variation Complication Rates At “High” and “Low” Quality Hospitals, 2010 Study authors found that while volume and case mix have some impact on complication rates, they do not explain the full difference. Varying outcomes likely resulted from differences in clinical performance. Percent of inter-hospital variation in complication rates that can be explained by patient characteristics, according to another study 20-40% Sources: Glance LG, et al, “Rates of Major Obstetrical Complications Vary Almost Fivefold Among US Hospitals,” Health Affairs, 33, no. 8 (2014):1330-1336; Grobman WA, et al, “Can differences in obstetric outcomes be explained by differences in the care provided? The MFMU Network APEX Study,” Am J Obstet Gynecol, 211, no. 147 (2014):e1-16; Crimson Continuum of Care interviews and analysis. Talking Points: Now I know that variation in practice patterns does not necessarily lead to bad outcomes, so let’s look at the data about complications specifically. The latest data shows that in addition to variation in practice patterns, there is also significant variation in rates of complications, which is often tied to care quality. This indicates that there may be an opportunity to improve perinatal care by reducing unwarranted variation. One study found that nationwide, 13% of women have one or more complications during childbirth, whether a vaginal delivery or cesarean delivery. However, the likelihood that a woman will have obstetrical complications varies substantially from hospital to hospital. As demonstrated by the graph on this slide, complication rates during cesarean deliveries are more than 15 percentage points higher at hospitals that authors deemed “low quality” than at “high quality” hospitals, where complications are less common. [Additional information on the study: For this study, researchers looked specifically at obstetrical complications, including maternal hemorrhage, laceration or operative complication, infection, and all other complications, such as thrombotic complications. The average complication rate for vaginal deliveries was 15.1% and for cesarean deliveries was 8.6%.] Authors found that though volume and case mix may have some impact on these spreads, differences in clinical performance contributed most significantly to varying outcomes. Other studies have come to the same conclusion – patient characteristics explain only a fraction of variation in complication rates across hospitals.

$1.2M 1.3x 5% The Impact of Reducing Variation in Complications Substantial Cost Opportunity with Standardizing Perinatal Care Complications Increase Length of Stay for C-Sections Average annual per-hospital cost opportunity of reducing physician outliers for vaginal and cesarean deliveries $1.2M Increase of 1.4 days to average LOS 3.1 Maternal admissions with complications are more costly than stays without complications 1.3x Average total hospital costs associated with maternity complications, nationwide 5% Source: Elixhauser A, Wier LM, “Complicating Conditions of Pregnancy and Childbirth, 2008,” AHRQ Healthcare Cost and Utilization Project Statistical Brief #113 (2011); Podulka J et al, “Hospitalizations Related to Childbirth, 2008,” AHRQ Healthcare Cost and Utilization Project Statistical Brief #110 (2011); Crimson Continuum of Care data, interviews and analysis. Talking Points: In addition to improving care quality, standardizing perinatal care can also reduce hospitals’ costs. According to data from our Crimson cohort, reducing physician outliers for vaginal and cesarean deliveries can save hospitals, on average, $1.2 million dollars per year. One way to do so is by preventing obstetrical complications. Complications are costly: according to researchers who analyzed a national sample of hospitals (AHRQ’s Healthcare Cost and Utilization Project data set), maternal admissions with complications are 1.3 times more costly than those without complications. Overall, maternity complications are associated with 5% of average total hospital costs. Moreover, further analysis showed that complications during C-sections are associated with a 1.4-day longer length of stay.

Taking a Look at [Hospital’s] Performance Crimson Data Identifies Areas for Improvement This table contains sample data. Work with your DA to customize this slide with data from your own institution by selecting appropriate metrics and filling out table with institution- and cohort-specific data. Measure Number of Cases Hospital Rate /1000 Cohort Average Rate /1000 Performance Birth Trauma Rate – Injury to Neonate (PSI 17) 3/524 5.73 3.60 Below Average Obstetric Trauma Rate – Vaginal Delivery With Instrument (PSI 18) 0/24 118.81 Above Average Obstetric Trauma Rate – Vaginal Delivery Without Instrument (PSI 19) 9/289 31.14 18.67 Cesarean Delivery Rate (IQI 21) 173/459 37.69 33.68 Vaginal Birth After Cesarean Rate, Uncomplicated (IQI 22) 13/109 11.93 13.46 In-line with Average Source: Crimson Continuum of Care. Talking Points: Using Crimson data, we can see how our hospital is doing on complication and patient safety metrics and where we fall within our cohort. This can help us identify where we should focus our perinatal patient safety improvement efforts. [Consider selecting metrics that provide a holistic view of your hospital’s performance, including areas where you are excelling and areas that may need improvement, and explain how your hospital can use this data to chart a plan moving forward and track progress along the way. Tool #2 in the Perinatal Patient Safety Toolkit includes a list of metrics within Crimson Continuum of Care that hospitals can use to evaluate their current performance.]

1st 52% $163 Also Need to Improve OB Emergency Response Sentinel Events Often Preventable, Feed High Liability Costs “Although maternal mortality is a relatively rare event in the United States, each year an estimated 1,000 American women die of pregnancy- related complications such as hemorrhage, embolisms, and hypertension. These deaths are devastating to these women’s families, and they have a profound impact on health care providers and communities. About half of these deaths are believed to be preventable.” Ranking of OB/Gyn among all specialties in claims paid out from 1985-2007 (more than $3B in total) 1st OB malpractice cases involving high-severity injuries, including maternal and infant deaths 52% Projected loss per birth for hospital obstetrics claims in 2015 $163 CDC State Maternal Mortality Review Committee Sources:Bacak SJ et al (editors), “State Mortality Review: Accomplishments of Nine States,” Center for Disease Control and Prevention, 2006, https://www.cdph.ca.gov/data/statistics/Documents/MO-CDC-ReportAccomplishments9States.pdf; Greve, P. “Labor Pains: Liability Trends in Obstetrics,” Medical Liability Monitor, 2009, http://www.scpcf.com/pdf/mlm_laborpains08_09.pdf; “Report: 2015 Hospital and Physician Professional Liability Benchmark Analysis,” AON Thought Leadership, http://www.aon.com/risk-services/thought-leadership/2015-report-hospital-professional-liability-overview.jsp; “Obstetrics,” CRICO, https://www.rmf.harvard.edu/Clinician-Resources/Specialty-Reference-Tag/Obstetrics; Crimson Continuum of Care interviews and analysis. Talking Points: One critical component of reducing complications and adverse outcomes is improving hospital response to perinatal emergencies. In obstetrics, the stakes are high: although rare, each year about 1,000 women die from pregnancy-related complications. And many of these deaths may be preventable. Given these high stakes, it should come as little surprise that Obstetrics and Gynecology typically pays out more malpractice claims than any other specialty, totaling over $3 billion from 1985 to 2007. Just over half of these OB malpractice cases involved high-severity injuries, including maternal and infant deaths. Hospital obstetrics claims contribute to high medical liability premiums and according to one risk management group’s analysis will cost hospitals $163 per birth in 2015. By helping hospitals be better prepared for obstetrical emergencies, perinatal patient safety programs often result in reduced malpractice liability.

Systemic Factors Often Underlie Poor Outcomes Organizational Structures Play a Role in Facilitating Patient Safety Most Common Root Causes for Sentinel Events Reviewed by TJC, 2004-2014 Human Factors (staffing, education) Communication (among providers, with patient) Assessment (clinical assessment, care decisions) Leadership (organizational structures, culture) Source: The Joint Commission Office of Quality and Patient Safety, “Sentinel Event Data: Root Causes by Event Type, 2004-2014,” The Joint Commission, http://www.jointcommission.org/assets/1/18/Root_Causes_by_Event_Type_2004-2014.pdf; Crimson Continuum of Care interviews and analysis. Talking Points: When we consider what it will take to improve perinatal patient safety, we need to look beyond the actions of any specific provider and instead examine systemic factors. The Joint Commission recently published the most common root causes for sentinel events occurring between 2004 and 2014. This graph zeroes in on the Joint Commission’s findings: human factors, including staffing and education, communication, assessment, and leadership are the four leading root causes for perinatal events. We must target these organizational structures to improve safety for our mothers and babies.

Implementing a Comprehensive OB Safety Program Move Follows Risk Reduction Goal Set by Liability Insurer Case in Brief: Yale-New Haven Hospital Key Components of Yale-New Haven Hospital’s Obstetric Patient Safety Program Program evaluation, including an outside expert review and safety attitudes survey 1,500-bed academic medical center in New Haven, CT Roughly 5,000 deliveries annually Developed and implemented a comprehensive obstetrics patient safety program, in collaboration with its malpractice liability carrier, to improve care quality and reduce liability costs Introduced nine interventions over a four-year timespan Results show reductions in both adverse outcomes and liability claims and payments Obstetric patient safety committee, with anonymous event reporting Standardized guidelines for high-risk patient care practices Obstetric patient safety nurse and obstetric hospitalists Required electronic fetal monitoring interpretation certification Obstetric team training Source: Pettker CM et al., “A Comprehensive Obstetric Patient Safety Program Reduces Liability Claims and Payments,” Am J Obstet Gynecol, 211, no. 4(2014):319-325, http://www.ajog.org/article/S0002-9378(14)00434-7/pdf; Pettker CM et al., “Impact of a Comprehensive Patient Safety Strategy on Obstetric Adverse Events,” Am J Obstet Gynecol , 200 (2009):492e1-492e8; Crimson Continuum of Care interviews and analysis. Talking Points: Many hospitals—both large and small—have taken on these systemic problems with striking results. Here we will look at just one example. Starting in 2002, Yale-New Haven Hospital, a 1,500-bed academic medical center in Connecticut, implemented a comprehensive obstetric patient safety program after being challenged to improve outcomes by its malpractice liability carrier. Over the course of four years, leaders implemented nine unique, ongoing interventions, such as an obstetric patient safety committee to review adverse event cases, standardized guidelines for high-risk patient care practices, and required electronic fetal monitor interpretation training and certification for all perinatal providers.

$2.2M $123K OB Patient Safety Program Reduced Complications Also Cut Liability Claims and Payments Adverse Outcome Rates1 Improved Across Implementation Period Total Liability Payments per 1,000 Deliveries $2.2M Prior to patient safety program2 $123K After patient safety program3 First Half Second Half Mean quarterly rate of deliveries with at least one adverse outcome from the adverse outcome index (includes blood transfusion, maternal death, maternal ICU admission, maternal return to OR or L&D, uterine rupture, third- or fourth-degree laceration, Apgar score <7 at 5 min, fetal traumatic birth injury, intrapartum or neonatal death > 2500 g, or unexpected admission to neonatal ICU > 2500 g and for > 24 hours). 1998-2002 2003-2007 Source: Pettker CM et al., “A Comprehensive Obstetric Patient Safety Program Reduces Liability Claims and Payments,” Am J Obstet Gynecol, 211, no. 4(2014):319-325; Pettker CM et al., “Impact of a Comprehensive Patient Safety Strategy on Obstetric Adverse Events,” Am J Obstet Gynecol , 200 (2009):492e1-492e8; Crimson Continuum of Care interviews and analysis. Talking Points: Diving into the program’s results, we see that something that began as an insurer’s effort to reduce liability payments evolved into a multifaceted program that both reduced liability risk and complications. Between the first and second half of the program’s implementation period, the hospital’s rate of deliveries with at least one adverse outcome dropped from 2.9% to 2.1%, cutting the rate by about one-third. Moreover, total liability payments per one thousand deliveries declined from $2.2 million before implementation of the patient safety program to $123 thousand afterward. [Note: Yale measured patient safety via the adverse outcomes index, which has been developed and tested by a number of researchers. It counts the number of deliveries that have at least one of the following adverse outcomes: blood transfusion, maternal death, maternal ICU admission, maternal return to OR or L&D, uterine rupture, third- or fourth-degree laceration, Apgar score <7 at 5 min, fetal traumatic birth injury, intrapartum or neonatal death > 2500 g, or unexpected admission to neonatal ICU > 2500 g and for > 24 hours.]

Nine Elements of a Perinatal Patient Safety Program Best Practices from Leaders in the Field Laying the Foundation Assessment of Potential Perinatal Patient Safety Problems Administrative, Physician Support of Patient Safety Efforts Building Infrastructure Perinatal Patient Safety Nurse Perinatal Patient Safety Committee Process for Standardizing Care Protocols 24x7 Physician Coverage of Labor & Delivery Unit Strengthening Provider and Staff Training Established Team Communication Framework Electronic Fetal Monitoring Training Multidisciplinary Emergency Drills Source: Crimson Continuum of Care interviews and analysis. Talking Points: We can begin to close the gap on perinatal patient safety by learning from hospitals such as Yale and other leaders in the field. Through their interviews and research, the Advisory Board Company identified nine elements of a best practice perinatal patient safety program, organized around three main concepts: laying the foundation, building infrastructure, and strengthening provider and staff training. [You may choose to walk through each of these elements now, or on the next slide when discussing your own institution] Laying the foundation: hospitals assess and prioritize potential safety problems and garner support for patient safety initiatives. Building infrastructure: with an adequate foundation, hospitals can begin to set the plan into motion: hire or designate a perinatal patient safety nurse, create a perinatal patient safety committee, standardize care protocols, and ensure around the clock physician coverage of the labor and delivery unit. Finally, strengthening provider and staff training: ensure ongoing success by establishing a team communication framework, encouraging electronic fetal monitoring training for all perinatal providers, and conducting multidisciplinary emergency drills.

How Does [Hospital Name] Compare? Copy, paste, and delete the Harvey Balls on the right side of the slide to indicate which components of a best practice patient safety program your hospital has fully implemented, partially implemented, or not yet implemented. How Does [Hospital Name] Compare? Evaluating Our Current Perinatal Patient Safety Program 1. Perinatal Patient Safety Problem Identification 2. Administrative, Physician Support of Patient Safety Efforts 3. Perinatal Patient Safety Nurse 4. Perinatal Patient Safety Committee 5. Multidisciplinary Team Focused on Standardizing Perinatal Care Protocols 6. 24x7 Physician Coverage of L&D Unit 7. Common Team Communication Framework 8. Electronic Fetal Monitoring Training 9. Multidisciplinary Emergency Drills Talking Points: Considering these nine elements in the context of our own hospital, we can see that we are on our way to improving perinatal patient safety. [You may go through each of the elements, noting whether it is fully, partially, or not yet implemented.]

Where Do We Start? Modify the suggested next steps below to customize this slide for your institution. Initial Steps Toward Improving Perinatal Patient Safety Suggested Next Steps Designate a clinical and administrative leader for perinatal patient safety Work with IT and department leadership to review current outcomes data and clinical processes to identify the highest-need perinatal patient safety problems Present information about perinatal patient safety trends at labor & delivery department meeting to inform providers and staff of new initiative and identify those who may be interested in contributing Talking Points: [Based on the information on the previous slide, lay out a few steps that your hospital can begin to implement. When laying out first steps, consider not only your needs, but your available resources.]