Improving The GradePromoting Healthy Birth Outcomes in

Ohio

The Ohio Perinatal Quality Collaborative

Dave McKennaRoni Christopher

Barbara Rose

We have no relevant conflicts of interest to disclose.

…..a statewide improvement collaborative……

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

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)

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……

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

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

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 resultsPromote need for early dating to practitioners and consumersPublic awareness campaign

Promote need for early dating to practitioners and consumers Promote sonography < 20 weeks to establish dates Document criteria used to establish EDCAppropriate use of fetal maturity testingEmpower nurses /schedulers to require dating criteriaIdentify a specific contact for authorization dispute re: datingProvide 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 gestationDocument discussion with patient about the aboveBoth patient and MD sign consent statement for scheduled delivery between 36.1 and 38.6 weeksPhysician awareness campaign: what are the reason(s) for scheduled delivery? Maximize access to Delivery and OR for optimal schedulingFacilitate 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 handoffsConnect with organizational initiatives on safety and use existing approaches as possibleEmpower nurses /schedulers to require dating criteria

Awareness of risks & expected benefit of near-term delivery by patients and consumers

OPQC OB Initiative: Our hand collected data…OPQC hospitals

Gestational age distribution of births at OPQC member hospitals, by month, January 2006 to March 2010

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Full term (39-41 weeks) Near term (36-38 weeks)

Points beyond the vertical dashed line are based on preliminary data and are likely to change

OPQC OB Initiative: Are we making a difference?

Birth Certificate Data for OPQC Hospitals

Ohio births at 36-38 weeks gestation following induction, with no apparent medical indication for delivery, by OPQC member status, January 2006 to March 2010

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Non-OPQC Median, non-OPQC OPQC Median, OPQC

Points beyond the vertical dashed line are based on preliminary data and are likely to change

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

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

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

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……

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……

…..a statewide improvement collaborative……

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 1st – Time Mothers

• Others

Questions?

…..a statewide improvement collaborative……