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Improving Safety of Deliveries --- Reducing Elective Deliveries Prior to 39 Weeks Gestation in Washington State. Washington State Perinatal Collaborative Washington State Department of Health Washington State Hospital Association December 1, 2010.

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Washington State Perinatal Collaborative Washington State Department of Health Washington State Hospital Ass


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    1. Improving Safety of Deliveries --- Reducing Elective Deliveries Prior to 39 Weeks Gestation in Washington State Washington State Perinatal Collaborative Washington State Department of Health Washington State Hospital Association December 1, 2010

    2. Reducing Elective Deliveryat 37 to <39 wks GA Carol Wagner, RN, MBA Vice President, Patient Safety Washington State Hospital Association Amy Bertone, RN, BSN Perinatal Regional Coordinator-Eastern Region Providence Sacred Heart Medical Center and Children’s Hospital Suzan Walker, RN, BSN, MPH Perinatal Regional Coordinator-Northwest RegionDivision of Neonatology, Department of PediatricsUniversity of Washington

    3. Washington State Medicaid Quality Initiative

    4. History: House Bill 2956 • Introduced by hospital request • Increases hospital rates – using dollars from hospitals (assessments) and federal match • Amended by Representative Cody to include a quality incentive • Starting in July 2012, one percent increase in in-patient rates as “pay-for-performance” • Passed in the 2009-2010 legislative session

    5. Principles of Quality Incentive • Measures must be: • Evidence-based. • Consistent with national measures where possible. • Methodology for earning incentive: • Recognize that some measures may not be appropriate to specialty pediatric, psychiatric, or rehabilitation hospitals. • Represent real improvements in quality. • Designed so all hospitals can earn incentive payments if performance is at or above the benchmark.

    6. Additional Framework • Measures need to be of value to Medicaid patients • Hospital Compare with heart attack and pneumonia applies to older population • Consistent with what hospitals are working to improve • Minimal additional data collection

    7. Measures:Adult, Rehab, and Pediatric Acute Care Reduce Hospital Acquired Infections • Healthcare Worker Influenza Immunization Safe Discharges (Reduce Rehospitalizations) • Patient Discharge Information (HCAHPS) Safe Deliveries (acute care only) • Elective Delivery Prior to 39 Weeks Reducing Emergency Department Cost • Reducing Preventable Emergency Department Use

    8. Measures:Behavioral Health Services Reduce Hospital Acquired Infections • Healthcare Worker Influenza Immunization Safe Medications • Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification

    9. Quality Incentive Safe Deliveries (acute care only) • Elective Delivery Prior to 39 Weeks Use The Joint Commission Definition – Modification for more comprehensive sampling process

    10. Point Scale: Elective Delivery Prior to 39 Weeks • Ten Points = 7 percent or less • Five Points = 8 - 17 percent • Three Points = 18 - 30 percent • Zero Points = 31 percent or higher apple side Elective Delivery Between 38 and 39 Weeks Award Table:

    11. Reporting Process • You are welcome to collect the data with any system helpful to you – must match The Joint Commission definition. • Data will be entered into the Quality Benchmarking System each quarter. • Data due by two months following the end of a quarter. • If your hospital is participating in Leapfrog or The Joint Commission, you can transmit the same data to them.

    12. Additional Questions Contact: Carol Wagner, RN, MBA Vice President Patient Safety Washington State Hospital Association CarolW@wsha.org or (206) 577-1831

    13. Reducing Elective Deliveryat 37 to <39 wks GA Data Collection Process A quality initiative of… Amy Bertone, RN, BSN Perinatal Regional Coordinator-Eastern Region Providence Sacred Heart Medical Center and Children’s Hospital Suzan Walker, RN, BSN, MPH Perinatal Regional Coordinator-Northwest Region University of Washington Medical Center

    14. Washington State Perinatal Collaborative A Subcommittee of the Perinatal Advisory Committee • • Washington StateHospital Association • Regional Health Quality Network • • Foundation forHealth Care Quality • • March of Dimes • • American Congress ofObstetrics & Gynecology,WA Section • • Association of Women’s Health, Obstetric & Neonatal Nurses, WA Section • • Insurance providers • • Hospital representatives • Department of Socialand Health Services • Department of Health • Health Care Authority • Washington StateObstetrical Association • Washington Academyof Family Physicians • Midwives Associationof Washington • American College of Nurse Midwives, WA Chapter • Perinatal Regional Network http://www.waperinatal.org/

    15. Data Collection and Reporting(Use The Joint Commission definition)

    16. Denominator Definition = Deliveries 37 0/7 to 38 6/7 weeks gestational age (Joint Commission medical condition exclusions removed)

    17. Numerator Definition = Deliveries 37 0/7 to 38 6/7 weeks gestational age by induction or cesarean who were not in active labor at admission (Joint Commission medical condition exclusions removed)

    18. Joint Commission DefinitionsCurrent v 2010B2 effective through March 31, 2011 Includes: • Denominator Criteria • Medical Condition Exclusion List • Numerator Criteria • Active Labor, Spontaneous Rupture of Membranes, Gestational age http://manual.jointcommission.org/releases/TJC2010B/PerinatalCare.html Next Version (2011A)– released December 1, 2010; Effective starting April 1, 2011

    19. Collecting the Data Denominator Steps Step 1:

    20. Joint Commission GA Definition Gestational Age (GA) = Number of completed weeks elapsed between 1st day of LMP and date of delivery • Abstraction Guidelines for Gestational Age (GA) • GA at delivery rounded off to nearest completed week, (e.g., infant born @ 35 5/7 wks = 35 wks GA, not 36 wks) • Order of records to review: • Prenatal H&P – If GA conflict in chart, use this documentation • Prenatal Forms • Delivery or OR Note • Clinician Admit Progress Note - accepted by MD, CNM, ARNP/physician’s assistant or RN

    21. Step 2After completion of Step One – Exclude the Following Cases • Age <8 or ≥65 yrs of • Length of stay >120 days • Enrolled in OB clinical trial • Medical conditions “possibly justifying elective delivery prior to 39 wks GA” • See Table 11.07, Appendix A of Joint Commission Specifications Manual v 2010B2 http://manual.jointcommission.org/releases/TJC2010B/AppendixATJC.html#Table_Number_11_07_Conditions_Po

    22. OB/Maternal Medical Exclusion Conditions Possibly Justifying Elective Delivery per Joint Commission Definition • HIV disease (042), asymptomatic HIV (V08) • Hypertension—unspecified, pre-existing, transient, benign essentialto severe preeclampsia (642.01, 642.02, 642.11, 642.12, 642.21, 642.22, 642.31, 642.32, 642.41, 642.42, 642.51, 642.52, 642.61, 642.62, 642.71, 642.72, 642.91, 642.92) • Unspecified renal disease in pregnancy (646.21, 646.22) • Liver disorders in pregnancy (646.71) • Diabetes mellitus (648.01) or abnormal glucose tolerance (648.81, 648.82)

    23. OB/Maternal Medical Exclusion Conditions Continued • Maternal congenital cardiac disease (648.51, 648.52) or other maternal cardiac disease (648.61, 648.62) • Coagulation defects complicating pregnancy (649.31, 649.32) • Placenta Previa, Placental Abruption, Ante partum Hemorrhage, Maternal-fetal Hemorrhage, Vasa Previa (vasa previa not on previous Leapfrog exclusion list), 641.01, 641.11, 641.21, 641.31, 641.81, 641.91, 656.01, 663.50, 663.51, 663.53)

    24. OB/Maternal Medical Exclusion Conditions Continued • Premature or spontaneous rupture of membranes (658.11, 658.21) • Polyhydramnios (657.01) or Oligohydramnios (658.01)

    25. Fetal Medical Exclusion Conditions Possibly Justifying Elective Delivery per Joint Commission Definition • Unstable lie or multiple gestation with malpresentation of 1 fetus (652.01, 652.61) • Multiple gestation (651.01, 651.11. 651.21, 651.31, 651.41, 651.51, 651.61, 651.71, 651.81, 651.91) • Post-term pregnancy (645.11, 645.21) • Poor fetal growth/IUGR (656.51) • Central nervous system malformation (655.01) • Chromosomal abnormality (655.11)

    26. Fetal Medical Exclusion Conditions • Suspected damage to fetus from environmental toxins or intrauterine contraceptive device*, viral or other disease, drugs or radiation, other suspected damage to the fetus (655.31, 655.41, 655.51, 655.61, 655.80) • Rhesus isoimmunization (656.11) • Isoimmunization from other blood group incompatibility (656.21) • Fetal distress (656.31), abnormality in fetal heart rate or rhythm (659.71) *Not on previous Leapfrog Exclusion List

    27. Fetal Medical Exclusion Conditions Continued • Intrauterine death (656.41) • Single stillborn (V27.1) • Pregnancy with other poor reproductive history, pregnancy with history of stillbirth or neonatal death (V23.5) *Not on previous Leapfrog exclusion list

    28. Denominator Steps Step 3:

    29. Preliminary Denominator CaseNumber • This number will be among the metrics reported to the WSHA

    30. Step 4 – Optional Random Sampling from Preliminary Denominator • If <= 25 cases identified in preliminary denominator, 100% of these cases go forward for selecting numerator cases for chart review • If > 25 cases meet preliminary denominator criteria there are two options: • A. All cases go forward for selecting numerator cases for chart review in next steps if resources are available (recommended) • OR • B. You may randomly sample a minimum of 25 cases which will go forward for selecting numerator cases for chart review if resources are limited

    31. Optional Random Sampling Example • You have 100 cases in the quarter which meet preliminary denominator criteria • You randomly select every 4th case in sequence by discharge date to obtain 25

    32. Advantages in 100% review option “A” • Your result will be your true rate rather than an approximation • Your result will be more informative regarding quality improvement opportunities • A small change in the numerator has less potential adverse affect on your rate with a larger denominator

    33. Example: Medicaid Incentive Scores with small change of 7 cases in numerator and small vs larger denominators

    34. You Now Have your Preliminary Denominator cases (100% or Optional Randomly Sampled Cases) Next - Identify cases that Will become your Numerator 

    35. Identifying the Numerator Step 5

    36. Step 5 Continued • Use the following codes to filter Preliminary Denominator Cases into Induction and C-Section • **These are the cases you will manually chart review** • Induction: 73.01 Induction of labor by artificial rupture of membranes 73.1 Other surgical induction of labor 73.4 Medical induction of labor • Cesarean: 74.0 Classic Cesarean Section 74.1 Low transverse Cesarean Section 74.2 Extraperitoneal Cesarean Section • 74.4 Cesarean Section of Other Specified Type • 74.99 Other Cesarean Section of Unspecified Type

    37. Step 6Chart Review Cases For the Following • Confirmation that GA at Delivery is 37 0/7 to 38 6/7 weeks • Spontaneous Rupture of Membranes • Presence of Medical Conditions on Exclusion List Documented but NOT coded (must refer documentation to your Coding Department for review and coding corrections) • Participation in OB clinical trial • Active Labor

    38. Step 6 - Continued During manual chart review of cases identified in Step 5Remove the Following Cases from the Numerator and Denominator • Any Case where GA at Delivery is not 37 to < 39 weeks • Any Case with Spontaneous Rupture of Membranes • Any Cases with the Presence of Medical Conditions on Exclusion List Documented (Submit these cases to your coding department for review, correction of codes and updating of your coding and other databases) • Any Case that has documented Participation in OB clinical trial

    39. Continued Numerator FilteringRemove from Numerator but Do Not remove from Denominator • Any cases admitted in Active Labor

    40. Step 7 Calculate final numerator and denominator based on results from chart review by these methods Numerator(chart review) Denominator(chart review not required) Remove:Active labor SROM Remove Medical conditions on exclusion list not coded (refer to Coding for correction) SROMCoding omissions OB Clinical trials Enrolled inOB clinical trial Final Denominator Final Numerator

    41. Step 8 Determining the Rate Final NumeratorFinal Denominator Rate =

    42. Review: With gestational age electronically Quarterly Deliveries Adherence to Joint Commission definitions Singletons ≥37 to <39 wks GA Remove medical conditions on Joint Commission exclusion list (Use codes on Table 11.07), LOS > 120 days and age < 8 or >65 InitialDenominator Identify deliveries with C/S or induction (Use codes on Table 11.05) Initial Numerator(inductionor C/S deliveries) By chart review remove Active Labor, SROM which is not coded and participation in OB Clinical Trial FinalNumerator

    43. Review: Without electronic gestational age Quarterly Deliveries Adherence to Joint Commission definitions Remove medical conditions on Joint Commission exclusion list (Use Table 11.07), LOS > 120 days and maternal age <8 or >65 Deliveries with exclusions removed By chart review, identify deliveries at 37 to <39 wks gestational age InitialDenominator From initial denominator cases, identify deliveries with C/S or induction (Use ICD-9-CM procedure codes from Table 11.05) Initial Numerator(inductionor C/S deliveries) By chart review remove Active Labor, SROM which is not coded and participation in OB Clinical Trial Final Numerator

    44. Active LaborJoint Commission Definition Documentation of regular uterine contractions with cervical change before medical induction or Cesarean • Guidelines for Abstraction: • Cervical dilation  from 1 cm to 2 cm before augmentation and/or Cesarean, or • Previous Cesarean scar, regular uterine contractions and cervical change (e.g.,  from 1 cm to 2 cm or cervix dilated ≥2 cm) before repeat Cesarean)

    45. Spontaneous Rupture of MembraneJoint Commission Definition Documentation of spontaneous rupture of membranes (SROM) before medical induction and/or Cesarean Guidelines for Abstraction: Confirmation before medical induction and/or Cesarean by one of the following methods: — Positive ferning test — Positive nitrazine test — Positive pooling (gross fluid in vagina) — Positive Amnisure test or equivalent — Patient report of SROM prior to arrival at hospital

    46. Assume 500 deliveries / quarter Assume 100 (20%)*Singletons ≥37 to <39 wks GA Assume 50 (50%)*Singletons ≥37 to <39 wks GA w/o medical conditions 10 C/S or induction Example of Data Collection Method Exclude multiples & dels <37 or ≥39 wks GA Exclude medical conditions Cases for ReviewDenominator Identify deliveries w C/S or induction Cases for ReviewNumerator *Based on WA State birth certificate data

    47. Example: Determining the Rate Numerator 10 Denominator 50 Excluded:2 active labor Hypothetical Example 10% SROM by chart review10% med exclusion. not coded20% active labor(Est. based on UWMC review) 8 1 SROM not coded Subtract: 7 1 SROM1 coding omission 1 coding omission 6Final Numerator 48Final Denominator 648 = 12% Rate =

    48. Baseline and Quarterly Data Submissions Baseline: July 1, 2010 – September 30, 2010 (Q3)WSHA secure web-based Quality Benchmarking System (QBS) • Total number of deliveries for the designated time period/Quarter • Total number of deliveries 37 0/7 to 38 6/7 for facilities capable of extracting (eg. from electronic or paper birth log) This will assist with Data Validation • Preliminary denominator -100% of the cases or the Number of Cases prior to doing a Random Sample (cases 37 0/7 to 38 6/7 with The Joint Commission medical exclusions removed)

    49. ContinuedBaseline and Quarterly Data Submissions • Final Denominator • Final Numerator • # of Cases in Active Labor Removed from Numerator Based on Chart Review • # of Cases in Numerator for each of the following medical conditions NOT ON The Joint Commission exclusion list: • Classical Cesarean • Previous Myomectomy • Maternal Medical Condition • Fetal Anomaly • Other

    50. WA State Perinatal Collaborative Timeline • Dec 15, 2010 – Submission of Collaborative enrollment letter to WSHA • Jan 2011 – Webinar Check-in - Baseline data collection • Jan 31, 2011 - Submission of Q3 Baseline data to WSHA • March 1, 2011 – Webinar (additional Webinar’s will be held, dates to be determined) • May 31, 2011 – Q1 2011 data due to WSHA (this also meets Medicaid Initiative) • Aug 31, 2011 – Q2 2011 data due to WSHA (this also meets Medicaid Initiative) • Nov 30, 2011 - Q3 2011 data due to WSHA (this is final quarter for Medicaid Initiative) • February 28, 2012 – Q4 2011 due to WSHA (for WA State Perinatal Collaborative only) • March/April 2012 – Collaborative Evaluation and Wrap-up