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Welcome! Wave 2 - Group Webinar #7
Decreasing births < 39 weeks gestation without
medical indication and improving birth
registry accuracy project
Ohio Perinatal Quality Collaborative
Ohio Department of Health, Office of Vital Statistics
Ohio Hospital Association
December 16, 2013
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Agenda
Time Topic
Presenter
12:00 pm Welcome, roll call, and review of Agenda Susan Ford
12:10 pm
Data Review –
• Aggregate Quarter 3 data chart
• Monthly Aggregate Chart Review
Jay Iams, MD
12:15 pm ODH-VS Data Warehouse and Updates to IPHIS John Paulson
Judy Nagy
12:25 pm Sharing our Success
All Teams
12:55 pm Wrap up…
Susan Ford
<39 Week Scheduled Delivery and Birth Registry Accuracy
Wave 2 Hospitals
• Madison County
Hospital
• Highland
District
Hospital
• Wilson
Memorial
Hospital
• O’Bleness
Memorial
Hospital
• MedCentral
Health
System -
Mansfield • East Ohio
Regional
Medical
Center
• Marietta
Memorial
Hospital
• Memorial Health Care System
• Van Wert County Hospital
• Trumbull Memorial
• Southwest
General • St. John Medical Center
• Pomerene
Hospital
• Northside Medical
• Marion
General
Hospital
• Mercy
St Charles
• Promedica
Flower
Hospital
• Promedica
St. Luke’s
• Community
Hospital &
Wellness
Center
• Bellevue
Hospital
• Mercer
County
Community • Upper Valley
Medical
Wave 2 teams
• Bellevue Hospital
• Community Hospitals and
Wellness Centers
• East Ohio Regional Medical
Center
• Highland District Hospital
• Madison County Hospital
• Marietta Memorial Hospital
• Marion General Hospital
• MedCentral Health System –
Mansfield
• Memorial Health Care System
• Mercer County Joint Township
Community Hospital
• Mercy St. Charles Hospital
• Northside Medical Center
• O’Bleness Memorial Hospital
• ProMedica Flower Hospital
• ProMedica St. Luke's Hospital
• Pomerene Hospital
• Southwest General Medical
Center
• St. John’s Medical Center
• Trumbull Memorial Hospital
• Upper Valley Medical Center
• Van Wert County Hospital
• Wilson Memorial Hospital
In 9 months,
reduce to 5% or
less, the number
of women in Ohio
of 37.0 to 38.6
weeks gestation
for whom delivery
is scheduled in the
absence of
appropriate
medical indication
OPQC: Decreasing births < 39 weeks gestation without medical indication and improving birth registry accuracy project
Awareness of risks & expected benefit of scheduled delivery
prior to 39.0 weeks by patients and other
consumers
Dating criteria: optimal estimation of
gestational age
Hospital and physician practice
policies that facilitate ACOG criteria
Awareness of risks & expected benefit of near-term delivery
by clinician
Culture of safety and improvement
• Inform consumers of risk/benefits of deliveries < 39 weeks
• Communicate to patient/clinic/hospital ultrasound results
• Promote need for early dating to practitioners and consumers
• Public awareness campaign
Promote need for early dating to practitioners and consumers
Promote sonography < 20 weeks to establish dates
Document criteria used to establish EDC
Appropriate use of fetal maturity testing
Empower nurses /schedulers to require dating criteria
Identify a specific contact for authorization dispute re: dating
Provide patient with hard copy results of ultrasound
• Empower nurses /schedulers to require dating criteria
• Document rationale and risk/benefit for scheduled deliveries at 37.0
to 38.6 weeks gestation
• Document discussion with patient about the above
• Both patient and MD sign consent statement for scheduled delivery
between 37.0 and 38.6 weeks
• Physician awareness campaign: what are the reason(s) for
scheduled delivery?
• Maximize access to Delivery and OR for optimal scheduling
• Facilitate 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
• 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 handoffs
• Connect with organizational initiatives on safety and use existing
approaches as possible
• Empower nurses/schedulers to require data criteria
Aim
Key Drivers
Interventions
Goal: Assure that all initiation of labor or caesarean sections on women who are not in labor occur only when obstetrically or medically indicated
Revised: 1.31.13
OPQC: Decreasing births < 39 weeks gestation without medical indication and improving birth registry accuracy project
In 9 months,
improve birth
registry
accuracy so that
focused
variables**
will be transmitted
accurately in
95% of records
(** Pre-pregnancy and
Gestational Diabetes; Pre-
pregnancy and Gestational
hypertension; Induction of
Labor; ANCS;
OB estimate of GA)
Key Drivers Interventions
Aim
IPHIS (BR) fields include
essential and specific
information/definitions
• Identify a key clinical contact for birth data
team
• Identify all sources of birth data
• Identify process for flow of data into the birth
registry (IPHIS) system
• Ensure birth data team has access to
necessary clinical data
• Utilize ODH and OPQC online education
modules for training of birth data and nursing
staff
• Ensure clear understanding of birth registry
variables
• Ensure clear understanding by birth data team
of medical terminology related to birth registry
variables
• Group and individual webinars and
1:1 support by state quality
coordinators to identify key changes
Identification and spread
of best practices for data
entry and verification
Trained clinical and birth
data teams
Audit Process for data
verification
• Coaching/reinforcement by OPQC and state
quality coordinators
• Clarify IPHIS definitions and instructions
Appreciation of the
Importance of the Birth
Registry information
• Use medical record to IPHIS quality review
feedback to identify gaps
• Continuous monitoring of Birth Registry data
reports
Strong communication
between clinical team and
birth data staff
Revised: 1.31.13
Month 7 in Review
Wave 2 IPHIS to Patient Medical Record Chart Reviews Induction of Labor
Induction of Labor:
June data: 90%
July data: 93%
August data: 98%
September: 99%
October: 97%
November: 97%
Wave 2 IPHIS to Patient Medical Record Chart Reviews Antenatal Corticosteroids
ANCS:
June data: 98%
July data: 97%
August data: 99%
September: 98%
October: 97%
November: 98%
Wave 2 IPHIS to Patient Medical Record Chart Reviews Pre-Pregnancy & Gestational Hypertension
Pre-pregnancy &
Gestational Hypertension:
June data: 90%
July data: 95%
August data: 98%
September: 98%
October: 99%
November: 99%
Wave 2 IPHIS to Patient Medical Record Chart Reviews Pre-Pregnancy & Gestational Diabetes
Pre-pregnancy &
Gestational Diabetes:
June data: 93%
July data: 98%
August data: 100%
September: 98%
October: 100%
November: 100%
Wave 2 IPHIS to Patient Medical Record Chart Reviews Obstetrical Estimate of Gestation at Delivery
Obstetrical Estimate of
Gestation at Delivery:
June data: 84%
July data: 91%
August data: 92%
September: 93%
October: 95%
November: 95%
0
5
10
15
20
2520
06-Q
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n=
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20
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n=
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Pe
rce
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wit
h n
o m
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ica
l in
dic
ati
on
Births induced at 37-38 weeks with no apparent medical indication for early delivery,
by quarter, 2006-2013 Aggregate of Wave 2 sites
Quarterly Percent Baseline Average Percent Control Limits
Source: Ohio Department of Health, Vital Statistics
Sep. 2008: Charter teams 39-Week project begins May 2013
Wave 2: 39 week project begins
SPECIAL CAUSE!
Goal
Have you obtained YOUR site specific data?
https://opqc.net
“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.”
Bill Callaghan, MD MPH
Centers for Disease Control and Prevention
December 1, 2011
Abnormal Assist Vent County of Birth Live Born OPQCElective
Admission NICU CyonoticHeart Low Birth Weight Indicator OPQCSmallGestAge
Anencephaly Delivery Method Maternal Transfer Payor Delivery
Anesthesia Diaphragmatic Hernia Maternal Transfer Facility Perinatal Region
ATB duing labor/del Down Syndrome Medical Record Numbers Plurality
Assisted Ventilation 6hours Eclampsia Hypertension Meningomyelocele Poor Preg Outcomes
Augment Labor FacilityID Month Prenatal Care Began Prem Rupt Membrane
Breast Feeding at Discharge Gastroschisis Month Prenatal Care Began Prenatal Care
Birth Injury Gestation Mother's Age Prenatal Care Code
Birth State Gestational Diabetes Mother's Age Group Pre-Preg Diabetes
Birth Weight Gestational Hypertension Mother's Ethnicity Pre-preg Hypertension
Birth Weight Category Hospital City Mother's First Name Prev CSection
Birth Year Hospital County Mother's Last Name Prev Live Births Dead
BirthMonth Hospital Level Mother's Marital Status Prev Live Births Living
BirthPlace Code Hospital MAT License No Mother's Middle Initial Prev Preg Outcomes
CertificateNo Hospital Name Mother's Race Prev Pre-term Births
Child's First Name Induct Labor Mother's Race Category Residence State
Child's Last Name Infant Living Newborn Antibiotics Set Order
Chorioamnionitis Infant Transfer Newborn Seizures Sex
Chromosomal Disorder Infant Transfer Facility Newborn Surfactant Steriods
Clinical Estimate Gestation Infertility Asst. Technology No of Prev CSection TimeofBirth
County of Birth Infertility Drugs Non-Vertex Presentation
Number of Prenatal Visits
Export to Excel
Pregnancy Tab - Risk Factors:
• e.) hypertension, gestational
(include pre-eclampsia)
• o.) hydramnios/oligohydramnios
change to:
polyhydramnios/oligohydramnios
• Removal of “Unknown” as a box
to be checked
Newborn Tab:
• Obstetrical Est of
Gestational Age
• Include boxes for
both weeks AND
days
• Breastfeeding at
Discharge
• if Yes, drop down
box: if
exclusive/no
supplementation
Proposed Clarifying Variables in IPHIS
Proposed New Variables in IPHIS
Pregnancy Tab - Risk Factors:
• IUGR (suspected prenatally)
• Renal (kidney) disease
• Cholestasis
• Blood group Allo-immunization
• Prior non-pregnant uterine
surgery
Pregnancy Tab – Infections
Present and/or Treated:
• HIV
Pregnancy Tab – Obstetric
Procedures:
• Progesterone – did the mom
receive progesterone in any
form to prevent prematurity
• Newborn Tab – Pulse
Oximetry:
• Newborn Critical
Congenital Heart Disease
Screening
Proposed New Variables in IPHIS
Prenatal Tab - Pregnancy
Dating (which will be next to
LMP)
• Ultrasound BEFORE or = to 20
weeks gestation
• Ultrasound AFTER 20 weeks
gestation
• Unknown OR no ultrasound
performed
Pregnancy Tab - Risk Factors:
K. Mother had a previous
cesarean delivery?
Check YES___ How
many?____
• C/S Incision Type: Which of the
following has the mother had?
prior Classical C/S
prior Uterine Rupture
prior Uterine Window
NONE of the above
IPHIS information….
Wave 2:
Sharing
Our
Success
Photo courtesy of: redbubble.com
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #1
Show us one of your PDSA cycles
• We discovered that multiple statistics from the Birth Certificate
worksheet were not being included or discovered on admission.
• In order to increase the capture of necessary statistics, all of the
pregnancy risk factors, infections present/and or treated during
the pregnancy, and obstetric procedures from the worksheet were
added into our computer documentation system, OBIX.
• All of the data can be found on
the Triage and Admission form.
• This has improved the registry
project and has prompted the
nurses to obtain a more detailed history.
Lessons Learned
• We learned that people are visual and it
takes something as simple as this to
improve compliance!
• Patient’s EDC must be on or after _______ to be
scheduled
• What advice would we give other teams?
Changing one thing at a time improves
acceptance and resistance to change.
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #2
Changes implemented
from our PDSA cycles • The project was discussed at OB/Peds Committee
meeting in July.
• It was decided that the delivering physicians would record
a final EDC on the prenatal record within the first 1-2
prenatal visits.
• That date is used when scheduling inductions.
• That date is recorded as the final EDC on the admission
form.
• That date is entered in IPHIS as the Obstetrical Estimate
of Gestation at delivery.
Lessons Learned
• Establishing a process for documenting the final EDC early in
the pregnancy has eliminated changing the due date at the end of
the pregnancy when an induction is scheduled for convenience.
• Knowing that the final EDC is the date that everyone is looking at
has improved accuracy in reporting the Obstetrical Estimate of
Gestation at delivery.
• Getting key players educated and on the same page has greatly
improved accuracy.
• Physicians, nurses, and the abstractors ALL have a stake in
whether or not the birth certificate is accurate.
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #3
Show us one of your PDSA cycles • Plan- More accuracy with EDC
• Do- Staff education & Physician/CNM
Education
• Study- Continue to audit for compliance-ongoing
process
• Act- Have one to one when fall out occurs-adapt,
adopt, or abandon – be open and flexible • EDC dating was not consistent
• Staff educated – OB Service support – Induction/Consent form
changed for exact weeks/days
• Improvement with audit – will continue to monitor
Lessons Learned • What did we learn?
• Consistency is KEY!! Be sure to give staff the
education and autonomy to do what is right.
• What advice can we give?
• Allow yourself to make mistakes, re-evaluate and
move forward.
• Suggestions?
• Possibly to have face to face meeting at the end to
see all results.
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #4
• Plan: review chart and compare to information on birth certificate for accuracy
• Do: 10 births less than 39 weeks were pulled from medical records and were reviewed and
compared
• Study: look at results and determine change in process needed made so accurate data
was being transmitted to IPHIS
• Act: RN’s began completing L&D and newborn data on Facility WS as of July 23, 2013
• Tell us about it: • Why it was chosen? Because documentation was incomplete, items incorrectly
identified, and entered. HIM struggling to complete records for IPHIS
• How was it received? A little grumbling at first but after discussions and the
presentation nursing staff understood the need. There has been a back slide lately
and forms are being sent to medical records blank, or with missing data. Reminders
have been sent.
• Did you results match your predictions? Yes, our accuracy has improved
considerably.
• What would you do differently next time? Try and get more nursing participation in
the original project so maybe more buy in on the importance of completing the forms.
Show us one of your PDSA cycles
Lessons Learned
• That we have room to improve always. There
are still several places where items are
charted(gestational age) leading to room for
errors. More standardized documentation
would help alleviate duplication, this will
happen when our HER goes live
• Advice? Educate, educate, educate
• Future projects: Maternal addiction, increasing
resources for treatment.
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #5
Lessons Learned
• With staffing challenges at our
hospital, our team primarily was
able to participate as observers and
appreciated “learning from others."
Decreasing births < 39 weeks gestation without medical
indication and improving birth registry accuracy project
Storyboard #6
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #7
Improving the Accuracy reporting of GA
• Tell us about it:
• A number of staff were using the wrong date.
• We have had 100% correct dating for the last 2
reporting periods.
• Staff did better than expected.
• We would use the same techniques for any
further changes.
Show us one of your PDSA cycles
Lessons Learned
• We learned that we were using the incorrect
date for IPHIS. We now have the 39 week
date on the scheduling book so inductions are
not scheduled before that date with out
reason.
• Don’t assume that everyone is completing the
worksheets the same. Educate everyone on
how it must be done and then check that it is
being done.
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #8
Show us one of your PDSA cycles
• In progress - small test of change
• Tell us about it:
• At present we are trialing a new Induction
Scheduling sheet which is dated and verifies the
date for 39 weeks gestation, thus easing the
confusion for the scheduler.
• This has been an adjustment for both the nurses
and the physicians with the use of this method of
scheduling as it removes an old idea of “the
schedule book” transitioning to scheduling for
quality and best practice.
Lessons Learned
• Having a physician champion
definitely eases the initiation and
transition of the project. It helps
enable other physician by-in.
• Once the change and transition has
occurred, be vigilant in maintaining
the change so with time, it does not
revert back to the old practice.
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #9
Tests of Change: PDSA • Our PLAN: Have nurses use the appropriate information to complete the facilities
worksheet. Nurses will appreciate the importance of the Birth Registry information.
We will see an improvement in Birth Registry information.
• What we did : Education to staff was completed and the importance of accurate
obstetrical gestation information reinforced.
• STUDY: Evaluation of medical records and IPIHS.
June: 80% Sept : 100%
July : 90% Oct : 100%
August: 95% Nov 100%
Education gave a clear understanding of expectations and there is improved accuracy.
• Act: Adopted changes that included a new birth certificate registrar. This along with
an improved understanding by the staff has drastically improved our accuracy
Lessons learned
•It was good to involve our nursing staff for a better understanding of the process.
•We found a very supportive network to assist us in making the changes necessary to adopt the 39 week guidelines .
•The adventure was worthwhile directly leading to more accurate information being recorded in both the medical record and IPHIS
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #10
Work related to our PDSA cycles
• Chart and Audit tool were utilized every
month
• Plan to educate Staff at every Department
Meeting
• Participate in the monthly calls from OPQC
• Data Collection was performed by myself
and a staff member
Lessons Learned
• Educated physicians- worked well
• Continue 1:1 counseling with staff
• Re-educated staff on Birth Certificate
definitions
• Biggest improvement is the
documentation consistency of the
gestational age
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #11
Sharing Our Successes
• Our hospital continues to have < 5% of scheduled
deliveries less than 39 weeks and has increased our IPHIS
submission accuracy to 100%. In the month of November
we did not have any scheduled deliveries less than 39
weeks.
• During the IPHIS to Patient Medical Record Checklist we
also tracked 2 additional variables: Breastfeeding at
Discharge and Antibiotics during Labor. We have been
tracking these 2 variables since July. For the variable
Breastfeeding at Discharge we have had 100% accuracy the
last 5 months. We have gradually increased our submission
accuracy for Antibiotics during Labor from 30% to 90%.
IPHIS to Patient Medical Record
Monthly Data
0
10
20
30
40
50
60
70
80
90
100
July August September October November
Perc
en
tag
e c
orr
ect
Antibiotic use in Labor
Lessons Learned
• Through this project staff is very cautious when it comes to
scheduling inductions. They are receiving the patient’s EDC and
reason for induction. If the patient is less than 39 weeks and is
without a medical reason the OB Supervisor is notified.
• Birth Certificate Abstractors feel they have increased their knowledge
with what is expected in data abstraction by ODH/Vital Statistics due
to the information that has been presented throughout the project.
• Birth Certificate Abstractors are no longer indicating induction and
augmentation, they are indicating one or the other.
• Our team feels this has been a positive collaboration that has
implemented change for the well being of our community.
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #12
PDSA Cycle
Complete and Accurate Completion of Birth Certificate Worksheets Why: Information from the conference calls identified
information that the Unit Director and other team members were not interpreting correctly on Facility Worksheet
Two mandatory education sessions for nurses using the same questions from our conference calls for assessment and education (Gestational Age, Induction, NICU, “Unknown”) were held
Prediction: Items such as gestational age and NICU admission were being filled out inconsistently
Pretest/Chart Review revealed that the prediction was correct. Education was completed in beginning of November. First month’s results showed improvement in correct documentation (73% to 90%)
Lessons Learned Awareness is Key
Education, Awareness, and Clear
Communication of the expectations
strongly impacts positive outcomes
People in general want to do well; however
processes to hold individuals accountable helps.
Our Hospital
Our Team
Storyboard #13
PLAN:
RN entering the BirthCertificate Data will file the Birthcertificate Data, then She will have another
nurse review the information entered into IPHIS and compare it to the facility worksheet printed.
Once the information is validated then the FINAL Birthcertificate will be printed.
How will you know that the change is an improvement?
The data that is entered generated Facility worksheet will match the data entered
into the State Vital Statistics IPHIS system.
What driver does the change impact?
Data entry verification for accurate data collection and comparison:
Best Practice for Facility=Accuracy
What do you predict will happen? Data Entry errors into the IPHIS system will be identified and
can be corrected in order to assure accurate BirthCertificate Data.
PLAN
Prenatal Data collected by: Admitting RN On Admission and Form Initiated
2. Delivery Data is collected/entered by Delivery RN After Delivery BC Info Form
3. BC Form Printed by Any RN Prior to DC Printed
4. BC Form Verified and signed by the mother: Can be completed by Any RN
Prior to DC On the unit
5. Enter Info for validated BC worksheet into IPHIS by IPHIS RN Clerk Within 10 days On the unit
6. Have another RN validate entered data (Any RN) Within 10 days On the Unit
Plan for collection of data:
Verify thru use of the IPHIS Medical Record Data Collection sheet that all information is correct
on the BirthCertificate as verified by the mother on the Facility Worksheet.
DO:
Test the changes.
Was the cycle carried out as planned? X Yes No
Record data and observations.
Some BC Worksheets not printed prior to the patient D/C
Some BC Worksheets not signed after printed prior to D/C
BC Worksheets have incomplete data- IPHIS nurse must search medical record.
What did you observe that was not part of our plan?
1. 1. Worksheet not printed
2. 2. Worksheets not validate
3. Incomplete Data Collection prior to patient Discharge
STUDY:
Did the results match your predictions? Yes X No
Compare the result of your test to your previous performance:
Data at 98% overall, but 90% in some variables such as gestation and induction
What did you learn?
Need to identify specific time frames in order to assign accountability and responsibility in an
area where Any RN could perform the duty. (Assign a task and a Time Frame)
ACT:
Decide to Adopt, Adapt, or Abandon.
X Adapt: Improve the change and continue testing plan.
• Adopt: Select changes to implement on a larger scale and develop an implementation plan and plan for sustainability
• Abandon: Discard this change idea and try a different one
Team Name:
Date of test:
6-1-13 to 7-31-13
Test Completion Date: 7-31-13 (Will adapt plan and retest)
Retested: Process adopted in September of 2013 for all BirthCertificate Data.
Overall team/project aim: improve birth registry accuracy at 95% or greater on 100% of BirthCertificate Data Variables
What is the objective of the test? Improve accuracy of data entered into IPHIS for data collection and comparison as well as assuring accurate birthcertificate information to
decrease hospital liability related to probate associated with birth certificate error
Do
Study Act
Plan
Lessons Learned
In Summary:
• We learned that things may not be what you think.
• We thought we had a good process for Birth certificate Data
Collection, but really, we had lots of room for improvement.
• Think outside the box
• Learn from others
• Other teams have great ideas- don’t reinvent the wheel
• Thanks to OPQC and Vital Statistics for the time and
effort invested in this project
Storyboard #14
Our Focus Increase IPHIS submission accuracy , especially
gestational age • Plan: Determine where staff is obtaining information for IPHIS forms
and developing a workflow for more accurate documentation.
• Do: Staff was observed while documenting for one week or questioned where they obtained information.
• Study: Found that staff and abstractor were both getting gestational age from gestational age assessment. Nurses were also “rounding up” for gestational age.
• Act: Education was given through email and at staff meeting. Any incomplete IPHIS forms were to be brought to a clinical leader for completion if information was missing.
Lessons Learned Reporting accurate information was needed to determine the extent of elective inductions under 39 weeks.
Working with the OPQC team gave us supporting information for administration to implement new policies.
Working closely with all areas involved and continued education produced the best results.
Decreasing births < 39 weeks gestation without medical
indication and improving birth registry accuracy project
Storyboard #15
PDSA Cycle PDSA WORKSHEET
Team Name: Date of test: 8/23/2013 Test Completion Date: In process.
Overall team/project aim: Increase accuracy of birth registry data into IPHIS by 95% focusing on key variables.
What is the objective of the test? Increase accuracy of reporting breastfeeding at discharge.
PLAN:
Briefly describe the test: Confirm with HUCs about their view in Epic for OB
Nursery report can be located & shows recent feeding history of infant.
How will you know that the change is an improvement? Our chart audits with
comparison of IPHIS should show breastfeeding at discharge & not the
intention to breastfeed on admission.
What driver does the change impact? The key variable of breastfeeding at
discharge in the birth registry data in IPHIS.
What do you predict will happen? There will be an improvement in the
breastfeeding variable in medical record & IPHIS entry.
PLAN
Plan for collection of data: Monthly medical record comparison with IPHIS
data entry.
DO: Test the changes. HUCs can see the infant feeding record in the OB
Nursery report.
Was the cycle carried out as planned? Yes No
Record data & observations. Initial observation of the plan met goal as
expected.
What did you observe that was not part of our plan? Changes in personnel.
STUDY:
Did the results match your predictions? Yes No
Compare the result of your test to your previous performance: Noted slight
increase in variation with the change in personnel.
What did you learn? Learned that those who do data entry into IPHIS can
access the information needed. They can also confirm the process by asking
if still breastfeeding during their interview process when they confirm
Hepatitis B vaccine & hearing screen. Implement IPHIS entry into
orientation process.
ACT: Decide to Adopt, Adapt, or Abandon.
Adapt: Improve the change & continue testing plan.
Plans/changes for next test: Monthly plan medical record & IPHIS entry
comparisons.
Adopt: Select changes to implement on a larger scale & develop an
implementation plan & plan for sustainability.
Abandon: Discard this change idea & try a different one.
Lessons Learned • Most important things we learned:
• Communication between clinical & nonclinical staff is essential.
• Medical Record audits assist in best place to find information
needed to input into IPHIS & provide competency assessment.
• Advice to other teams:
• Do Medical Record audits from months prior to starting the
OPQC project. This will help the team see where improvements
need to be made.
• Educate collaboratively to decrease nonmedical inductions prior
to 39 weeks gestation.
• Advice to OPQC & ODH/Vital Statistics:
• Continue the collaborative group meeting with ample time to
share storyboards. Great networking!
Decreasing births < 39 weeks gestation without
medical indication and improving birth registry
accuracy project
Storyboard #16
Plan: Decrease the
number of “99”s and “unknowns”
in IPHIS data entry
Do: Collaborate with
provider offices to ensure data needed
is provided consistently
Study: Continue chart
audits of medical records that data
is available
Act: Without improvement the team will review
plan and make changes for reimplementation
Show us one of your PDSA cycles:
Lessons Learned
Next Steps…
• Complete the final Monthly Progress Report for December
(including your team’s 10 chart review results)
• Link will be sent from ODH-VS 12/20; DUE 1/10/14
• Plan to complete Post Project Systems Inventory
• Link will be sent from OPQC Central to ALL team members
• Quarter 4 (2013 year) data charts will be available
mid January and will be posted on opqc.net
Thank you for your participation
• So long…but not farewell
Photo courtesy of goodlightscraps.com
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