The Ohio Perinatal Quality Collaborative: What Have We Learned in the First 5 Years ?

• Origins

• Goals

• Methods

• Funding

• Projects

• Successes

• Problems

• Lessons

• Future

Jay D. Iams MD

Obstetrics Lead, Ohio Perinatal Quality Collaborative Frederick P. Zuspan Professor Emeritus of Obstetrics & Gynecology The Ohio State University Wexner Medical Center Disclosures: Contracts with Elsevier as an Associate Editor of: Am J Obstet Gynecol Creasy & Resnik’s Maternal Fetal Medicine Research funding from NICHD, CWRU, & CCHMC (for OPQC) No Commercial Affiliations, Speaker’s Bureaus, Consultancies, or Stock

Who Is OPQC?

Ohio Department of Job & Family Services

Ohio Department of Health – Vital Stats

Ohio Medicaid

Ohio AAP, ACOG, MoD

Peds + OB Content & Q.I. Leaders

“OPQC Central”

Secure Central De-identified Data Processing

Staff at Ohio Maternity & Children’s Hospitals

Ohio Families Affected by Prematurity

Start up $$ from CMS ODJFS OPQC

Origins of OPQC - 2007

Ohio PTB 32nd = 13.3%

Ohio Infant Mortality 36th = 7.8% 2007: Ohio VON Neonatologists

Invite Ohio OB’s to Join

2008: Startup Grant $$ from CMS

All 24 of Ohio’s Level III NICUs

20 of Ohio’s largest OB hospitals

~ Half of Ohio Births

March of Dimes’ Ohio PTB Grade: D F !

The OPQC Charter Teams {24 Neo + 20 OB}

• Cincinnati Children’s Hospital Medical Center (NEO) • Good Samaritan Hospital (NEO & OB)

• Aultman Hospital (NEO & OB)

• Akron Children’s Hospital (NEO & OB)

• Akron General Medical Center (OB)

• Cleveland Clinic (NEO)

• Dayton Children’s Medical Center (NEO)

• Fairview Hospital (NEO & OB) • Hillcrest Hospital (NEO & OB)

• Mercy Anderson Hospital (OB)

• MetroHealth Medical Center (NEO &OB)

• Miami Valley Hospital (OB)

• Mount Carmel East (NEO & OB)

• Nationwide Children’s Hospital (NEO) • Doctor’s Hospital (Nationwide NEO) • Grant Hospital (Nationwide NEO)

• Promedica Toledo Children’s Hospital (NEO) • Promedica Toledo Hospital (OB)

• Riverside Methodist Hospital (OB+ Nationwide NEO)

• St. Vincent Mercy Medical Center (NEO & OB)

• Summa Health System (NEO & OB)

• The Ohio State University Medical Center

(NEO & OB) • University Hospital – Cincinnati (NEO & OB)

• University Hospital – Cleveland – Rainbow Babies (NEO)

• University Hospital – MacDonald Women’s Hospital (OB)

• Mount Carmel West (NEO & OB) • Mount Carmel St. Ann’s (NEO & OB)

Cleveland

Akron

Youngstown • St. Elizabeth Health Center(NEO)

Canton Dayton

Cincinnati

Toledo

Columbus

~ HALF OF OHIO BIRTHS OCCUR IN THESE 20 HOSPITALS

Goal:

Through collaborative use of improvement

science methods, to reduce preterm births

and improve outcomes of preterm newborns

and infants in Ohio as quickly as possible.

What is the Mission of OPQC? Reducing prematurity-related poor outcomes for babies in Ohio

The Ohio Perinatal Quality Collaborative 2014

OBSTETRICS

ANCS for women at risk for preterm

birth (240/7- 336/7)

39-Week Scheduled Deliveries

without medical indication

Increase Birth Data Accuracy

& Online modules

Spread to all maternity

hospitals in Ohio

Progesterone for Preterm Birth Risk

NEONATAL

Blood Stream Infection

Highly reliable line maintenance

bundle

Neonatal Abstinence Syndrome

Use of human milk

in infants 22-29 weeks GA

6 OCHA Pilot NAS

Structure & Budget Funding

Project Specific

State, Federal Match, CDC, MoD, in-kind- $600,000/ yr.

Expenditures

Leadership + Administration - 40%

Quality Improvement - 30%

Data Infrastructure & Reporting - 30%

Communication

Weekly Leadership Call + Monthly Executive Oversight Cmte

Stakeholders: ODH, GRC, Medicaid, Regional Balance

Personnel Faculty, Staff, Regional Clinical Leaders, Site Teams / In Kind Services

Support BEACON, ODH (Vital Stats), Medicaid, CDC, MoD, AAP, ACOG, OHA

Quality Improvement in Obstetrics

The system accounts for 85% of unintended consequences

The individual contributes only 15%

Variation = An Opportunity to Improve

IHI: “Plan – Do – Study – Act” Repeat.

OPQC Method

The IHI Model for Improvement

What are we trying to accomplish?

How will we know that change = improvement?

What can we measure?

What can we change to make improvement?

Act Plan

Study Do

The

PDSA Cycle

Sounds Hokey, Doesn’t It?

The Key Driver Diagram

What Do We

Want?

Measurable

Outcome

What Will Make

It Happen?

Key Drivers

How Do We

Change the

Drivers?

Interventions

still sounds weird but …

IHI Breakthrough Series Methods

Create & Sustain Change in Healthcare

Criteria for Project Selection

Population Impact

Clinician Enthusiasm

Benchmark for Best Practice

Solid Evidence for Intervention

Documented Variation in Outcome

Feasible to Implement & Measure

Success Demonstrated Elsewhere

OPQC Process

Simultaneous QI Neo & OB Projects Site Teams = Physician + Nurse + Administrator + Birth Certificate

IHI QI Experts - Key Driver Diagrams & PDSA Cycles

Monthly Webinars & Conference Calls Review Project Goal

Rapid Data Analysis & Return to Sites

Review Aggregate & Site Specific Data

Each site sees aggregate & its own data

Trouble-shoot Systemic & Local Issues w/ PDSA’s

Joint Learning Sessions

Interdisciplinary Review of Process & Goals

OPQC Culture Is not about just working harder

• It’s About:

• Making sure that the right thing happens for every patient every time: reliable health care

• A preoccupation with failure

• Empowering clinical and clerical staff at unit level as the first line of safety

• Recognizing the importance of support from senior medical and administrative leadership

So Just What Does OPQC Do, Anyway?

OPQC Does:

Promote ACOG & AAP

Practice Guidelines

Collect & Report Data

from OPQC Sites

Share Whatever Works

Teach Methods to

Change Care Patterns

Monitor Outcomes

OPQC Does Not:

Tell Doctors & Nurses

How to Practice

“Arrest” Providers &

Report Them to JCAHO

or the Health Department

OPQC is Not The Police.

Share Your Data with

Anyone, Ever. You can share whenever you

want to, but OPQC won’t.

OPQC Initial Projects & Goals Selected by Participating Teams

Neo: 50 % in late onset blood stream & CSF infections in infants 22-29 weeks within 1 year

OB: 60% within 1 year in scheduled births at 360 to 386 weeks that lack a medical indication

The OPQC Scheduled Birth Project Near Term Births Preventable NICU Admissions

Elements of the Key Driver Diagram What did we want to accomplish & when?

Scheduled births lacking a medical indication in 1 year by 60%

What had to change to reach our objective?

Doctor, Nurse, Hospital & Consumer Behaviors

How could we measure & know that change is an actual improvement?

OPQC hand collected data ≈ Ohio BC data

Targets to Reduce Inappropriate

Scheduled Births at 360 - 386 Weeks

Optimal Dating = Ultrasound before 20 Weeks

Schedule births by ACOG criteria

No scheduled births < 39 weeks unless valid medical or obstetrical indication

Scheduled Delivery Form

Confront Risks & Causes of Near-Term Birth Brain Card, Brochures, Infant Morbidity vs. Stillbirth

Soft Stop versus or transition to Hard Stop

Part of a Culture of Safety

Observe

X 2 Months Project ran 9-1-08 11-30-09

%

20 hospitals = 47% of Ohio births 18,384 births between 360 386

4780 (26%) scheduled 13,604 (74%) unscheduled

AJOG 2010

HAND COLLECTED

DATA

Distribution of Ohio Births By Gestational Age And Month January 2006 July 2013

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 Pregnancy Dating Method

Document Reason for Scheduled Birth

OPQC Is Not The Police = Use Soft Stop 1st … then Rapid Data Turnaround

Frequent Group & Site PDSA’s

Enthusiasm from Site Med Leaders AND Hospital Admin

Can You Do This in Your State?

Create A Culture of Change

Learn From All Participants Go to the Sites

Improve Communication Data Collectors, Data Users, Data Analysts

OPQC = Data for You to Use, Not the Police

Birth Certificate = A Q.I. Instrument Enhanced Training Needed

Use Promotes Accuracy Promotes Use

Rapid Turnaround Essential

OPQC Year 3 OPQC + ODH + CDC Year 1

Goals & Outcomes of 2nd Project Cycle: DONE.

Disseminate the 39 Week Project to All Ohio 100% of Ohio Births in Project Sites

60% in Inappropriate Scheduled Births

Antenatal Steroid Project Goal > 90% of Eligible Infants Receive ANCS

Identify & Disseminate Best Practices

BSI - Human Milk Project: Milk Is Medicine ! Increase Reliability of Catheter Care

80% of 22-29 Week Infants Get HM < 72 hrs

≥100 ml/kg/day of Human Milk < 21 days

Different from Charters

Used Birth Registry data instead of hand collected

Site Visits by BEACON QI Coordinators

Monthly Calls

Periodic Learning Mtgs

Collaboration w/ ODH + ODH Office of Vital Statistics + CDC

Dissemination of The 39 Week Delivery Project

Done in Waves

Piloted in 15 Sites 2012

3 Subsequent Waves with

Staggered Start Dates

Jan 2013 Apr 2014

Ohio Birth Registrars are

excited to participate

Henry County

Wood

County Bluffton

Mercy Tiffin

Mary

Rutan

Atrium

McCullough-

Hyde

Fort

Hamilton

Holzer

Medical

Berger Health

Licking

Memorial Doctor’s

Coshocton

East Liverpool

Firelands

Trinity

Fisher-Titus

Samaritan

Wooster

Union

Lakewood

Lake

West

U.H. Geauga

Galion

Toledo

Mercy St.

Vincent

Miami Valley

Hospital

Mercy Anderson

UH Cincinnati

Good Samaritan TriHealth

Aultman

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

Fairview

UH Case

MacDonald

Hillcrest Metro Health

The Christ Hospital

Bay Park

St. Rita’s

Lima

Blanchard

Valley

Southview

Good Samaritan

Premier

Kettering

Bethesda

North

Southern

Ohio

Fairfield

Lancaster

Genesis

Bethesda

Mercy Canton

Lake East

Ashtabula

OPQC Maternity Hospitals 2013

Charter sites XPilot sites Wave 1 sites X Wave 2 sites Wave 3 sites

Community Hospital & Wellness Center

Van Wert

County Hospital

Mercer County Community

Wilson Memorial

Highland District

Madison County

Marietta Memorial

O’Bleness Memorial

SE Ohio Reg. mrd.Ctr

Northside

Medical

Trumbull

Memorial

Pomerene

MedCentral Mansfield

Marion General

Southwest General

St. John

MedCtr

Memorial

Health Care Mercy Lorain

Bellevue

• St. Lukes;

Mercy St. Charles

Adena

HealthSystem

Dublin

Methodist

Grady Memorial

Robinson Memorial

Ravenna

Lima Memorial

Wyandot Memorial

Defiance Regional Medical Center

Memorial Hospital

Memorial Union County

Community Memorial

Knox

Sp

Aultman Orville

East Ohio RegMC

St.Joseph

Clinton Memorial,

Wilmington

Mercy Fairfield

Wayne

Medina

General

Summa Barberton

EMH RMC Parma Community General

Fulton County Health Center

Springfield

Shelby

Can’t Change the Birth Certificate? Revise the Guide for the Birth Certificate Worksheet !

NEW

INFO

• Ask Birth Registrars to Focus on Key Variables in Worksheet • Provide New Focus-Group-Tested Definitions for Key Data

Results of Phase 1 39 Week Dissemination Project

Hospital Birth Certificate Staff STILL Excited !!

Major Misunderstandings on Major Outcomes

Determination of Gestational Age - Rounding Up!

Definition of Preeclampsia

Recognition of Antenatal Steroid Rx

Definition of Breast Feeding at Discharge

Aggregate Rate Declined Significantly

Significant Improvement in 10 of 15 Sites

Effects of the Initial OPQC 39 Week Scheduled Birth Project

September 2008 July 2013

• 36,200 births moved from 37-38 to 39-41 wks • Conservative estimate = 3% fewer “near term”

NICU admissions: N = 1086 • 1086 x $20,000 per NICU Admission $ 21,720 million savings in 5 years

OPQC Is A Voluntary Organization of Ohio

Stakeholders Who Care About Fetal & Infant Health

SMART AIM

To increase the

percentage of infants

born in Ohio at 24 0/7 to

33 6/7 weeks’ gestation

who receive pre-delivery

ANCS to > 90%, by June

2013

Global Aim: Assure that all infants born between 24 0/7 and 33 6/7 weeks’ gestation receive appropriate antenatal corticosteroid treatment to reduce perinatal morbidity and mortality.

Key Drivers

Documentation System

Identification of Appropriate Time for

ANCS Administration

Optimal and Efficient Administration

of ANCS

Awareness of Benefits and Risks

Potential

Interventions

Identification of Appropriate ANCS

Candidate

• Promote public awareness of benefits of ANCS

• Education of parents & non-perinatal providers

• Link to maternal transfer & tocolysis

• General risks and benefits

• Promote consistent use of common algorithm of ANCS

administration for Betamethasone & Dexamethasone

• Practitioners

• Prescribing

• Care Giving / Administering

• Hospitals

• Link to maternal transfer & tocolysis

• Pharmacies

• Distributors

• Pharmaceutical Manufacturers

• CHOOSE an ANCS Strategy or Guideline for your site

• Create an integrated system of recording ANCS

administration among prenatal care sites and delivery

sites encompassing all levels and acuity of care.

• Standardize birth certificate documentation of ANCS

administration

OPQC

ANTENATAL

STEROIDS

PROJECT 2011 2013

FINAL Aggregate Report of the OPQC Project to Improve

Documentation of Antenatal Corticosteroid Use 2011 ‘13

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12

/1/2

011

n=

12

7

1/1

/20

12

n=

15

0

2/1

/20

12

n=

20

2

3/1

/20

12

n=

21

2

4/1

/20

12

n=

20

3

5/1

/20

12

n=

26

2

6/1

/20

12

n=

22

7

7/1

/20

12

n=

23

7

8/1

/20

12

n=

18

7

9/1

/20

12

n=

18

9

10

/1/2

012

n=

24

8

11

/1/2

012

n=

25

3

12

/1/2

012

n=

23

1

1/1

/20

13

n=

20

5

2/1

/20

13

n=

17

5

3/1

/20

13

n=

22

4

4/1

/20

13

n=

20

7

5/1

/20

13

n=

22

4

6/1

/20

13

n=

18

1

ANCS Administration - Aggregate Data

Full Course Partial Course No ANCS and Rupture 32-34 weeks No ANCS

OPQC HAND COLLECTED DATA on 3981 Infants 24 33+6 wks

Blue = Partial Course

Green = Full Course

Concurrent Activities Affecting ANCS Documentation

• 2009: Ohio Hospital Compare Website

Your ANCS Rate Is Going To Be in the Newspaper !

• ODH + CDC Asked OPQC to Disseminate the 39 Week Project to All Ohio Maternity Hospitals

Smaller Hospitals Used Birth Certificate Data

So ODH & OPQC created …

• A Simultaneous ODH Vital Statistics Project to Improve Birth Certificate Accuracy at All Hospitals

Birth Registry Documentation of ANCS Use Aggregate Rate in 19 OPQC Sites 2006 - 2014

Birth Registry Data 2006 2014

Red Arrow:

Ohio Hospital

Compare

Blue Arrow:

OPQC ANCS

Project

Progesterone Prophylaxis of Preterm Birth

Prematurity related - Definitely

Variation in practice - Uncertainty

Existing benchmark – SMFM & ACOG

Measurable outcome – PTB Rates + Inf Mort

Population impact – Definite Potential

Prior success – Many RCT’s but ? population

Enthusiasm by participants – Yes …

Enthusiasm by our supporters - YES

The OPQC Progesterone Project

Goal: Reduce Ohio PTB by 10% in 2 years

Expand Identification of Candidates

Good OB Histories

Cervical Sonography

Make it Easy to Get Progesterone

Create Protocols where the Right Rx is the Default Choice

Outcome Measures

Hand Collected Data at The Big 20 Charter Sites

Medicaid and Private Insurers

Birth Registry Data – Births < 32 and < 37 Weeks

Infant Mortality Rate

Progesterone Rx To Prevent Prematurity

A Repetitive Outpatient Intervention

Process Measures = Women Identified & Rx’d

Proximate Outcome Measures Preterm Birth Rates Before 37 & 32 Weeks of Gestation

Gestational Age at Birth

NICU Admissions & Duration of Stay

Primary Outcomes Are Remote in Time = Neonatal Death - 1st 28 days of life – 75% PTB

= Infant Death – 1st Year of Life – 34% PTB

OPQC Key Steps Maintain Transparency & Confidentiality

Seek Population Impact Infant Mortality & Prematurity Goals, not “quality”

Imperfect Data Can Help If Consistently Gathered

VON Lesson: Keep Data Collection Simple

Quality Improvement & Content Experts

Find and Support Regional Leaders

Listen to the Participants

Rapid Data Turnaround and Reporting

OPQC = Data Collection, Not the Police

OPQC’s Assets & Issues

Assets

Ed Donovan’s Vision Birth Registry QI Health

ODH Vital Stats and Sites

Birth Registrars Are Key!

Ohio’s Army of Leaders Each Metro Area & Beyond

BEACON Q.I. Coordinators

Broad Support Network MoDimes, AAP, ACOG, OHA

Ohio Medicaid

Publications Progress

Issues

Bureaucracy & Oversight

Q.I. or Research ?

IRBs Highly Variable

Rates of Progress Vary 39 Wks vs. Blood Stream Infxn

Progesterone Rx ……. Outcome

Sustaining Outcomes

Topic-Based Funding

Maintenance of Personnel

Publication Policies

The Ohio Perinatal Quality Collaborative 2014

OBSTETRICS

ANCS for women at risk for preterm

birth (240/7- 336/7)

39-Week Scheduled Deliveries

without medical indication

Increase Birth Data Accuracy

& Online modules

Spread to all maternity

hospitals in Ohio

Progesterone for Preterm Birth Risk

NEONATAL

Blood Stream Infection

Highly reliable line maintenance

bundle

Neonatal Abstinence Syndrome

Use of human milk

in infants 22-29 weeks GA

6 OCHA Pilot NAS