1. Instructions to cook up the Baker’s Dozen Made Fresh Daily Kelly Friar, Chief, Office of Health and Vital Statistics and Accreditation Coordinator Ohio Department of Health

2. Significance for Public Health Public Health Accreditation Board PHAB Community Health Assessment Community Health Improvement Plan Dept. Strategic Plan Quality Improvement Plan Workforce Development Plan Performance Management System

3. Category A – Programs with a budget of greater than $250,000 First Place Ohio Department of Health Ohio Perinatal Quality Collaborative (OPQC) The Ohio Perinatal Collaboration to Improve Birth Data and Prematurity Outcomes is a creative approach to using public health surveillance data (birth certificates) as a supplement to data collected from medical records to serve as the metrics that can inform and accelerate perinatal quality improvement initiatives. The Ohio Perinatal Quality Collaborative (OPQC), Ohio’s public/private partnership focused on improving health outcomes using quality improvement science, has documented early successes in reducing late preterm scheduled deliveries without medical indication in 20 delivery hospitals in Ohio. Spreading what works will be essential in reducing prematurity and having a measurable impact on population health. This effort is state administered by investing and partnering in OPQC where the improvement happens. Over many decades Ohio has relied heavily on birth certificates as source of data to measure population-level changes over time, but only recently has turned to them to measure improvements in health care and outcomes. 2012 Vision Awards Achieving Excellence in Public Health Through Innovation

4. The Baker’s Dozen Top Key Variables in IPHIS VariableIPHIS Tab 1. Total number of Prenatal visitsPrenatal 2. Pregnancy Risk Factors: pre-pregnancy and gestational diabetesPregnancy 3. Pregnancy Risk Factors: pre-pregnancy and gestational hypertensionPregnancy 4. History of prior preterm birthPregnancy 5. Induction of LaborLabor & Delivery 6. Augmentation of LaborLabor & Delivery 7. Antenatal corticosteroids (ANCS)Labor & Delivery 8. Antibiotics received by the mother during deliveryLabor & Delivery 9. Birth weightNewborn 10. Obstetrical estimate of gestational ageNewborn 11. Abnormal conditions of the newborn: Assisted ventilation after delivery and NICU admission Newborn 12. Congenital abnormalities of the NewbornNewborn 13. Breast feeding at dischargeNewborn

5. Why Are We Doing This? OPQC’s Mission: Improve Infant Health Through collaborative use of improvement science methods, reduce preterm births and improve outcomes of preterm newborns in Ohio as soon as possible What Causes Perinatal & Infant Mortality?What Causes Perinatal & Infant Mortality? Preterm BirthPreterm Birth Birth Defects SUID et al

6. Our Shared Vision Decrease prematurity and infant mortality in Ohio OPQC, ODH-Vital Statistics and OHA Using the PLAN-DO-STUDY-ACT cycle of continuous quality improvement to facilitate improved data collection to accurately measure progress toward goal of reducing non-medically indicated deliveries prior to 39 weeks gestation

7. Bill Callaghan, MD MPH Centers for Disease Control and Prevention December 1, 2011 “The focus of healthcare for women and infants over the next century depends on the quality of the data collected by those who fill out the birth certificates.”

8. Obstetric Quality 2007 “ There are currently no uniformly accepted measures of obstetrical quality. Many traditional measures of obstetrical quality are flawed and newer measures are still undergoing necessary validation.” - Jennifer L. Bailit, MD, MPH OBG Survey 2007

9. OB Quality Monitoring National Quality Foundation Joint Commission Ohio Hospital Compare Leap Frog CMS Ohio Perinatal Quality Collaborative PCPI PQRS

10. JOINT COMMISION: Perinatal Care Measures PC-01 Elective Delivery PC-01 PC-02 Cesarean Section (NTSV) PC-02 PC-03 Antenatal Steroids PC-03 PC-04 Health Care-Associated Bloodstream Infections in Newborns PC-04 PC-05 Exclusive Breast Milk Feeding PC-05 https://manual.jointcommission.org/releases/TJC2013A/PerinatalCare.html

11. PC -01 Numerator: Patients with elective deliveries Denominator: Patients delivering newborns with >= 37 and < 39 weeks of gestation completed Inductions and cesarean delivery included

12. JOINT COMMISION: Gestational Age ONLY ACCEPTABLE SOURCES IN ORDER OF PREFERENCE: 1. Delivery room record 2. Operating room record 3. History and physical 4. Prenatal forms 5. Admission clinician progress notes 6. Discharge summary

13. JOINT COMMISION: New for July 1, 2013 “It is acceptable to use data derived from vital records reports received from state or local departments of public health if they are available and are directly derived from the medical record with a process in place to confirm their accuracy. If this is the case, these may be used in lieu of the acceptable data sources listed below.” https://manual.jointcommission.org/releases/TJC2013B/DataElem0265.html

14. Promedica Toledo Hospital Mercy St. Vincent Medical Center Miami Valley Hospital Mercy Anderson UH Cincinnati Good Samaritan Aultman Hospital St. Elizabeth Health Center Akron General Akron Children’s MFM Summa Health System Mt. Carmel East Mt. Carmel West Mt. Carmel St. Ann’s Riverside Methodist OSU Wexner Fairview Hospital UH Case MacDonald Women’s Hillcrest Metro Health <39 Week Scheduled Delivery – 20 Charter Hospitals

15. BC Data Varies By: Hospital Hospital Maternal Dis Maternal Dis Credentials Credentials State State

16. Effects of the Initial OPQC 39 Week Scheduled Birth Project September 2008  March 2013 30,000 births shifted to 39-41 weeks Conservative estimate = 3% fewer “near term” NICU admissions: N = 950 $20,000950 x $20,000 per NICU Admission = $19,000,000$19,000,000 savings in 4 ½ years

17. Lessons From the Initial 39 Week Project Create A Culture of Change Learn From All Participants Improve Communication Data Collectors, Data Users, Data AnalystsData Collectors, Data Users, Data Analysts OPQC = Data for You to Use, Not the Police Birth Certificate = A Q.I. InstrumentBirth Certificate = A Q.I. Instrument More Training and More Cross TalkMore Training and More Cross Talk Use  Greater Accuracy  Promotes UseUse  Greater Accuracy  Promotes Use Rapid Turnaround EssentialRapid Turnaround Essential

18. <39 Week Scheduled Delivery and Birth Certificate Accuracy 15 Pilot Hospitals The Christ Hospital Bay Park Promedica St. Rita’s Lima Blanchard Valley Southview Good Samaritan Dayton Kettering Bethesda North Southern Ohio Medical Cent er Fairfield Lancaster Genesis Bethesda Mercy Regional Lorain Mercy Canton Lake East Ashtabula County

19. Team Sharing and Learning Harvard School of Education http://socrativegarden.wordpress.com/2011/08/04/1-2-3-word-cloud/http://socrativegarden.wordpress.com/2011/08/04/1-2-3-word-cloud/

20. Two reasons for inaccurate gestational age entry 1. Sometimes the gestational age is “rounded up” in IPHIS. Gestational age is NEVER TO BE ROUNDED UP; it is recorded in completed weeks. For example, 38 weeks, and 5 days is properly termed 38 weeks. 2. Often there is no agreement re: where in the medical record gestational age should be recorded; in addition, varying gestational ages are found in the medical record. Consistent agreement regarding where in the medical record the IPHIS variable for gestational age is found will greatly increase your accuracy.

21. Remaining 73 Ohio Maternity Hospitals January 2013 thru April 2014 Divided into three separate “Waves” with staggered start dates Differences from Charter and Pilot Sites Updated the report of allowed medical indications from Birth Registry/IPHIS data *Change in measure from 36.0 - 38.6 weeks to 37.0-38.6 weeks gestation; more in harmony with Joint Commission, Leap Frog and Ohio Hospital Care

25. Can You Do This In Your Hospital ? What Are The Keys to Success? Adopt ACOG Guidelines Use a Scheduled Birth Form (ACOG or Site Specific) Document the Pregnancy Dating Method Document the Reasons for Scheduled Birth OPQC Is Not The Police = Start with Soft Stop Rapid Data Turnaround Frequent Group & Site PDSA’s Enthusiasm from Local Leaders

27. PDSA Plan Look at a particular aspect of project Review intervention options Plan implementation of intervention What do you predict will happen? Do Execute the intervention

28. PDSA Study How did the intervention go? Did it go the way you expected? What was the outcome? Was the a measure? Act Accept Adopt Abandon

29. 13 Key IPHIS Variables Handout

30. Is there any way to get gestational age correctly recorded in IPHIS all the time?

31. Essential Data Elements to Accurately Document Gestational Age Earliest Ultrasound that documented GA Ideal CRL Best < 20 weeks gestation documentation by provider estimate of GA what it is based on

32. Second Step-entering Data into IPHIS Make sure everyone agrees where to find best OB estimate of GA and EDD  acquisition of data  Recording of data  Transfer of data  Monitoring of process

33. Photo courtesy of fotolia.com IPHIS to Patient Medical Record Checklist Directions, Data Dictionary, and Examples

34. IPHIS to Patient Medical Record Checklist Hospital: ____________________ Month: ____________ IPHISVariable Chart 1 Y N Chart 2 Y N Chart 3 Y N Chart 4 Y N Chart 5 Y N Total Y Total N Total Y+N Pregnancy tab: Risk Factors Pre-pregnancy and Gestational diabetes Does the data documented in IPHIS match the data found in the patient records? IPHISVariable Chart 1 Y N Chart 2 Y N Chart 3 Y N Chart 4 Y N Chart 5 Y N Total Y Total N Total Y+N Pregnancy tab: Risk Factors Pre-pregnancy and Gestational hypertension Does the data documented in IPHIS match the data found in the patient records? IPHISVariable Chart 1 Y N Chart 2 Y N Chart 3 Y N Chart 4 Y N Chart 5 Y N Total Y Total N Total Y+N Labor & Delivery tab: Characteristics of Labor & Delivery Induction of Labor Does the data documented in IPHIS match the data found in the patient records? IPHISVariable Chart 1 Y N Chart 2 Y N Chart 3 Y N Chart 4 Y N Chart 5 Y N Total Y Total N Total Y+N Labor & Delivery tab: Characteristics of Labor & Delivery Antenatal cortical- steroids (ANCS) Does the data documented in IPHIS match the data found in the patient records? IPHISVariable Chart 1 Y N Chart 2 Y N Chart 3 Y N Chart 4 Y N Chart 5 Y N Total Y Total N Total Y+N Newborn tab: Other Obstetrical estimate of gestation at delivery Does the data documented in IPHIS match the data found in the patient records? Total Y Total N Total Y+N Total “yes” responses divided by total “yes” + “no” responses= %

35. Step 1 Analyze results and dig deeper Is there any difference among data suppliers, documentation, data collectors? What data do you want to work on ?

36. Fishbone Diagram: Design 36 Problem Statement People Policies ProceduresPlace Cause of Primary Cause Primary Cause

37. Fishbone Diagrams: Tips Use Fishbone Diagram on an on-going basis Identify contributing factors to each cause Dig deeply into the causes of the causes May do multiple diagrams to get at the root cause Use data to verify – what is causing the most or worst error of error? Don’t jump to solutions!

38. What We Are Doing Reviewed 10 charts: information in chart, on the ODH facility worksheet and in IPHIS. Discovered: Missing/incorrect data in numerous IPHIS fields. Plan: Change the way data is collected and review data prior to entering in to IPHIS.

39. Scheduled Delivery Form One Page Inclusive: Facilitates information from admitting physician. Variables from IPHIS that are medical indications for elective delivery <39 weeks. Faxed to Maternity Dept. Reviewed by RN prior to scheduling mother for elective delivery.

40. 40 Step 2. Experiment with a solution: improve a specific problem with a specific solution Pilot Run Audit

41. 41 Step 3: Display Results Data Checksheets CCR Gap Sigma= X UCL LCL Sigma= X

42. Hover Function

43. Modules 1.Why is the birth certificate important to the healthcare of women and newborn infants? Use of the birth certificate as a QI tool is discussed in detail in this Module. 2.What are the variables in the Ohio birth certificate and what do they mean? The importance of obtaining the correct gestational age is highlighted as well as the “Bakers Dozen of the Most Important Variables,” with appropriate definitions for each. 3.Where are select birth certificate variables found in the medical record? Select variables are highlighted as well as the need for collaboration between the clinical and data abstraction teams. 4.How can I know if I have accurately entered data into IPHIS? This is the most technical of all the Modules, providing an overview of the IPHIS software and the data checks within it. A suggested quality review of hospital’s submissions is also covered. 5.How can I Improve the data entry processes at my hospital? This Module reviews the Model for Improvement, AIM statements, & PDSA’s.

44. Keys to Success Communication Don’t assume Consensus and key personnel buy-in Grit and determination Monitoring of efforts (DATA)