1. Pregnancy and Related Conditions Quality Measures Benchmark Data: Core Measures Agency for Healthcare Research and Quality National Perinatal Information Center

2. Project Aim Improve the PREGNANCY AND RELATED CONDITIONS CORE MEASURES, AHRQ and NPIC quality measure performance, attaining UHC median performer status and then progress to UHC BEST PERFORMER Committee: S.Swanson RN; J.Gianopolous, MD; R.Beisinger, MD; E.Carroll, MD; M.Weiss, MD; G.Adams, RN; M.Chybik, RN; M.Wall, PharmD; M.Davey, RN; P.Downing, RN; C.LaPorte, RN; E.Trulis, RN

3. Barriers and Actions No internal champion Risk adjustment poorly understood Benchmark data reviewed in aggregate 9-12 months after care Improvement impact slow to be seen and hard to track Meeting chaired by AD; case managers lead work for area Reviewed indicators and defined in packets Case review information for cases included in the most recent data included in meeting packet Review expanded to current charts looking for improvement and continuing issues.

4. Percent Core Measures Third or Fourth Degree Laceration Quarter LUMC Observed Third and Fourth Degree Laceration Rate LUMC Expected Third and Fourth Degree Laceration Rate 2004 Q1 (n=265)2004 Q2 (n=244)2004 Q3 (n=254)2004 Q4 (n=235)2005 Q1 (n=250)2005 Q2 (n=235)2005 Q3 (n=254)2005 Q4 (n=235)2006 Q1 (n=279)2006 Q2 (n=247)2006 Q3 (n=271) 2 3 4 5 6 Meeting chaired by AD Case manager role defined Reviewed definitions Restructured meetings to have chart review data available for discussion Concurrent chart review Chart review by physician with feedback communication with coding Documentation education

5. Rate per 100 cases AHRQ Patient Safety & Quality Indicators Obstetric trauma - vaginal delivery without instrument This information is confidential and to be used for quality improvement purposes only Quarter (Number of LUMC cases) LUHS Rate UHC Ninetieth Percentile UHC Median UHC Tenth Percentile 2004 Q1 (n=246)2004 Q2 (n=217)2004 Q3 (n=231)2004 Q4 (n=225)2005 Q1 (n=225)2005 Q2 (n=217)2005 Q3 (n=234)2005 Q4 (n=223)2006 Q1 (n=260)2006 Q2 (n=227)2006 Q3 (n=256) 2 4 6 8 10 12 14 Meeting chaired by AD Case manager role defined Reviewed definitions Restructured meetings to have chart review data available for discussion Concurrent chart review Chart review by physician with feedback communication with coding Documentation education

6. Rate per 100 cases AHRQ Patient Safety & Quality Indicators Obstetric trauma - vaginal delivery with instrument This information is confidential and to be used for quality improvement purposes only Quarter (Number of LUMC cases) LUHS Rate UHC Ninetieth Percentile UHC Median UHC Tenth Percentile 2004 Q1 (n=19)2004 Q2 (n=27)2004 Q3 (n=23)2004 Q4 (n=10)2005 Q1 (n=26)2005 Q2 (n=17)2005 Q3 (n=21)2005 Q4 (n=12)2006 Q1 (n=15)2006 Q2 (n=19)2006 Q3 (n=15) 10 15 20 25 30 35 40 Meeting chaired by AD Case manager role defined Reviewed definitions Restructured meetings to have chart review data available for discussion Concurrent chart review Chart review by physician with feedback communication with coding Documentation education

7. Percent Core Measures Neonatal Mortality (Birth Weight Range 150g - 999g) Quarter LUMC Observed Neonatal Mortality Rate (150g - 999g) LUMC Expected Neonatal Mortality Rate (150g - 999g) 2004 Q1 (n=1)2004 Q2 (n=7) 2004 Q3 (n=18)2004 Q4 (n=21)2005 Q1 (n=23)2005 Q2 (n=18)2005 Q3 (n=18)2005 Q4 (n=18)2006 Q1 (n=17)2006 Q2 (n=23)2006 Q3 (n=19) 20 40 60 80 100 Worked with JCAHO to redefine measure criteria Developed mechanism to capture birth weights Began review of all mortality for co-morbidity accuracy Worked with fellow to maintain full problem list Reviewed documentation of living cohort for accurate co-morbidity capture

8. Rate per 100 cases AHRQ Patient Safety & Quality Indicators Birth trauma - injury to neonate This information is confidential and to be used for quality improvement purposes only Quarter (Number of LUMC cases) LUHS Rate UHC Ninetieth Percentile UHC Median UHC Tenth Percentile 2004 Q1 (n=404)2004 Q2 (n=366)2004 Q3 (n=391)2004 Q4 (n=394)2005 Q1 (n=423)2005 Q2 (n=390)2005 Q3 (n=404)2005 Q4 (n=401)2006 Q1 (n=424)2006 Q2 (n=421)2006 Q3 (n=455) 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 Chart review definition clarification Communication with Coders

9. Next Steps Utilize UHC coding expertise to identify issues with injury to neonate. Continue concurrent chart review for timely feedback and awareness of practice. Review a neonatal cohort to assess accuracy of complications/co-morbidity capture for risk assessment of surviving cases. Work with physicians to maintain comprehensive documentation to facilitate accurate risk capture. Enhance EPIC use to capture necessary data. Incorporate education of coders/residents into orientation to obtain/maintain gains.