Improving Your Joint Commission Perinatal Care Core Measure of - - PowerPoint PPT Presentation

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Improving Your Joint Commission Perinatal Care Core Measure of - - PowerPoint PPT Presentation

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Improving Your Joint Commission Perinatal Care Core Measure of Exclusive Breast Milk Feeding Through Baby Friendly Implementation of Evidence Based Maternity Practices Ruth Patterson, RNC, BSN, MHSA, Integrated Quality Services Disclosure

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Improving Your Joint Commission Perinatal Care Core Measure of Exclusive Breast Milk Feeding Through Baby Friendly Implementation of Evidence Based Maternity Practices

Ruth Patterson, RNC, BSN, MHSA, Integrated Quality Services

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2 February 6, 2014

Disclosure Statement:

  • I do not work for the Joint Commission
  • I am learning daily about the Core Measures
  • I did not write that title, but I will try to speak to

every part of it!

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3 February 6, 2014

Agenda

Introduction The Who, What, and Why of Joint Commission The Five Perinatal Core Measures Details and Practice with Core Measures for Exclusive Breastfeeding Improvement Process, a PDSA Primer

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4 February 6, 2014

“Who” is the Joint Commission?

TJC – Who, What, and Why

  • Independent not for profit agency.
  • Developers of a nationalized standardized performance measurement

system with input from multiple stakeholders

  • Surveyor for ACCREDITATION of hospitals, inpatient, mental health

care facilities

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5 February 6, 2014

“What” does the Joint Commission do?

TJC – Who, What, and Why

  • Core Measure sets for performance measurement of standardized care

delivered in a focused area

  • AMI, HF, PN, SCIP, IMM, VTE and PC
  • National Patient Safety Goals
  • Designates Top Performer Hospitals (95%)
  • SPEAK UP campaign - Including an excellent patient education

brochure on Breastfeeding

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6 February 6, 2014

“Why” do we care about TJC Core Measures?

TJC – Who, What, and Why

  • Mandate participation for maternity hospitals delivering >1100 infants/year
  • Transparency of Care – BF Measure publically reported starting Jan 1, 2014
  • Health care delivery is shifting to Value-Based Care
  • (CMS can base reimbursement on results)
  • Doing things based on evidence is the right thing to do for our patients.
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Perinatal Core Measures

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8 February 6, 2014

There are five Perinatal Core Measures

  • PC1 – Elective Delivery

– No elective (non-medical inductions) deliveries before 39 weeks.

  • PC2 – Cesarean Delivery

– C/S for primiparous women w/ singleton > 37weeks in vertex position

  • PC3 – Antenatal Steroids

– Women at risk of delivery at 24-32 wks must receive steroid dose pre-delivery

  • PC4 – Blood Stream Infections in Newborns

– Absence of certain strains of bacteria; not limited to central line infections.

  • PC5 and PC5a – the subject of this presentation…

Quick Overview:

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9 February 6, 2014

Breast Feeding Core Measures

  • PC05 – Exclusive Breast milk feeding

from birth until discharge from the hospital

  • f newborns >36 wks gestation.*
  • PC05A – Exclusive Breast milk feeding

from birth until discharge from the hospital

  • f newborns >36 weeks gestation…..

Considering (MINUS) those whose mothers choose to exclusively formula feed.*

* Hospitals with >1100 births per year.

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10 February 6, 2014

The numerator and denominator are specific:

  • Numerator is identical for each:

Exclusive Breast milk feeding from birth until discharge of newborns >36 wks gestation specific denominator

  • Denominator is different:

PC5 Sample from newborns >36 wks gestation born at the facility PC5A Sample from newborns >36 wks gestation born at the facility MINUS newborns in this group whose mothers choose not to breast feed

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Specifications Guidelines

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12 February 6, 2014

Become an expert on the details….

http://www.jointcommission.org

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13 February 6, 2014

CRITERIA FOR BOTH MEASURES

Only Human Milk Exclusion at Sampling

  • From birth until d/c
  • No other liquids or

solids except for drops of vitamins, minerals, or medicines.

  • Includes suckling at

breast, and other feeding with human milk from mother or donor.

  • No formula used for

supplementation.

  • ICD-9 codes for

galactosemia, parenteral infusion, prematurity (Appendix A, Tables 11.20-23)

  • Experienced Death
  • LOS >120 days
  • Clinical Trial
  • Transferred to

another hospital

  • Admitted to NICU for

critical care services at any time during this hospitalization

  • Documented

Reason for NOT exclusively feeding breast milk – mom’s medical reason or mother’s choice to formula feed Exclusion at Abstraction

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Exclusions during Sampling:

Appendix A - excerpt

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Exclusions during Abstraction:

Specifications Manual- excerpts

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Exclusions during Abstraction: Specifications Manual- excerpts

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17 February 6, 2014

There are NO infant-related medical indications accepted for use of formula in normal newborns.

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18 February 6, 2014

Where do you find information when abstracting?

Documentation Source Documentation of Choice If you cannot determine… I&O or feeding records Nursing notes H&P, Admission or D/C Treatment Plans Progress Notes MD, APN, PA, CNM or LC Written PRIOR to feeding

(first entry if < 24/7 duty)

Must clearly tie maternal condition/choice to reason for formula Abstractors cannot assume maternal choice not to breastfeed in the absence of any documentation.

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19 February 6, 2014

Where did I find all of that? http://www.jointcommission.org

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20 February 6, 2014

Let’s Practice Abstracting

  • 1. Included in the population for either measure

and

  • 2. Whether the results will be a “fallout” of

compliance for either measure. Use the algorithms for PC05 and PC05A to determine whether the sampled patient is:

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21 February 6, 2014

Let’s Practice Abstracting

Once the sampling is done... The abstracting begins! Apply the details... DC home, transfer or deceased? Clinical trial? In NICU for critical care services? Apply the details... Did the infant ever have formula? Is there documentation of an acceptable reason for not exclusively feeding breast milk? E = in the numerator D = in the denominator

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22 February 6, 2014

Case One

DETAILS IN BRIEF: Baby Boy Jones,

  • 39.5 wks
  • no clinical trials
  • plans to breast feed
  • rooming in with mother
  • nursed first hour then every few hours
  • second night mom was tired, fed 15 ml EBM

BF newborn, no formula throughout stay.

  • 1. Yes, Included in both measures;
  • 2. NO, Not a fallout. Compliance is met.
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23 February 6, 2014

Case Two

DETAILS IN BRIEF: Baby Boy Smith

  • potential sepsis in NICU for IV antibiotics
  • plan was to breastfeed, hand expression/pumping,
  • slow volume increase, given formula
  • no clinical trials

BF newborn, supplemented with Formula; in NICU for NON-critical care.

  • 1. Yes, Included for both measures;
  • 2. YES, a fallout for both measures. NICU
  • bservation and IV antibiotics does not

meet the “Critical Care” component; baby received both breast milk and formula.

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24 February 6, 2014

Case Three

DETAILS IN BRIEF: Baby Girl Adams

  • decision never to breast feed
  • baby received formula while rooming in with mom
  • admission H&P does specify mother’s preference
  • no clinical trials

Exclusively formula feeding per mother’s choice.

  • 1. Included in both measures.
  • 2. Fallout to PC-05 – NOT exclusively breast

milk fed

  • Not a fallout for PC-05A because provider

notes show link between mother’s choice and formula feeding.

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25 February 6, 2014

Example of results:

PC05 34 = 73.9% Exclusively Breast 46

Let’s say there are 46 newborns in the sample for the month. And we found that 34 of them were exclusively breast milk fed;

  • nly one mother chose to exclusively formula feed.

PC05-A 34 = 75.6% Exclusively Breast 46-1 Considering Mom’s Choice

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Now that you are “expert” in the BF Core Measures….

Is there room for improvement …in exclusive breast milk feeding …… at your facility?

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Performance Improvement Strategies

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28 February 6, 2014

Don’t Re-Invent the Wheel. Use the Evidence!

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Baby Friendly USA recommends 10 Steps

1. Written breastfeeding policy. 2. Train all health care staff in the skills necessary 3. Inform all pregnant women about benefits and management of BF 4. Initiate breastfeeding within one hour of birth 5. Show mothers how to breastfeed and how to maintain lactation 6. Give no food or drink other than breast-milk, unless medically indicated 7. Practice rooming in 8. Encourage breastfeeding on demand. 9. Give no pacifiers or artificial nipples to breastfeeding infants.

  • 10. Foster the establishment of breastfeeding support groups and

refer on discharge

Abbreviated version:

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30 February 6, 2014

Where to start????

How do you decide where to start your improvement efforts?

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31 February 6, 2014

Remember scientific method? Remember the nursing process? Have you ever heard of RIM?

RIM+ is a method used in Performance Improvement that includes goal setting and a process called PDSA.

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32 February 6, 2014

RIM+ uses PDSA – a process that involves lots of “small tests of change”

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33 February 6, 2014

How do you make a plan???

A plan is a made up of many small tests of change to get to an overall goal.  Look at your current practice  Are you using evidence based practices?  Who is your customer and what kind of motivation do they need?  Brainstorm ideas  Identify potential changes to test  Standardize and simplify processes

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34 February 6, 2014

How do you set a goal? Be S.M.A.R.T!

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35 February 6, 2014

Tests of change start small.

Act

  • What changes

are to be made?

  • Next cycle?
  • Analyze data
  • Compare

results to predictions

  • Summarize

what was learned

Study

  • Carry out the plan
  • Document
  • bservations
  • Record data

Do Plan

  • Objective
  • Predictions
  • Plan to carry out the

cycle (who, what, where, when)

  • Plan for data collection

How we test for change.

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36 February 6, 2014

Motivate the Team – professionals AND patients

Education Identify Barriers Reduce Barriers

  • Knowledge is a

wonderful thing!

  • Lactation Education

for professionals

  • Do not assume

patients know where to look for info (or “get it” the first time)

  • Cultural Values and

Norms

  • Heritage and Family

Influence

  • Personal Experiences
  • Staff perceptions of

time involvement

  • Evidence based

information to all.

  • Standardize

language about BF

  • Provide Support
  • Make it easy to do

the right thing!

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37 February 6, 2014

  • Identify ONE potential strategy for improving exclusive breast

feeding rates…. at any of your facilities.

  • What changes can you make that will result in improvement

in ONE aspect of exclusive breast feeding?

Practice in small groups: Find an idea… based on a hunch… test it… plan to celebrate successes

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Final Thoughts:

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39 February 6, 2014

Review:

What are the Numerator and Denominator of PC05 and PC05A? Can you access the Joint Commission Website? What does PDSA represent? What can you take to your home facility as your first test of change? Any questions?

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Thank you!

Contact Info: RUTH.ANN.PATTERSON@KP.ORG

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41 February 6, 2014

Bibliography

  • TJC Website www.jointcommission.org (home page)
  • Kaiser Breastfeeding Toolkit www.kpcmi.org/wp-

content/uploads/2013/03/kaiser-permanente-breastfeeding- toolkit.pdf

  • Pickett, Emma, IBCLC, “A Closer Look at Cultural Issues Surrounding

Breastfeeding,” Lactation Matters, Official Blog of the International Lactation Consultant Association, Oct 30, 2012