Reaching the Best for Floridas Mothers & Babies William M. - - PowerPoint PPT Presentation

William M. Sappenfield, MD, MPH, CPH

Professor & Director Florida Perinatal Quality Collaborative USF College of Public Health

Reaching the Best for Florida’s Mothers & Babies

Conflicts of Interest

No conflicts of interest to report.

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Learning Objectives

• 1. Explain why quality improvement efforts in

maternity care are needed in Florida.

• 2. Learn how quality improvement initiatives and

standardization can improve clinical care.

• 3. Understand that active participation in multi-

hospital quality initiatives can have a larger impact.

• 4. Discuss the potential future directions for quality

improvement efforts.

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Why is QI in maternal health care needed in Florida & the U.S.?

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Florida Health Rankings

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Category State Rank Florida Leading States Health Spending 25th $8,076 $5,982 Infant Mortality 24th 5.8 /1,000 3.7 /1,000 Preterm Delivery 33rd 10.2 /100 7.8 /100 Maternal Mortality 38th 23.8 /100,000 4.5 /100,000 Cesarean 47th 34.7 /100 22.3 /100

US Health Rankings

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Category Country Rank US Leading Peers Health Spending 36 of 36 $9,892 $4,500 Infant Mortality 30 of 39 5.8 /1,000 2.5 /1,000 Maternal Mortality 39 of 40 14 /100,000 3 /100,000

Mothers Assessed for Hemorrhage Risk at Admission, July-August 2013 31 FPQC OHI Hospitals

11% 18% 71% 75%+ 1‐74% None

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Mothers Hospitals

0.1 0.2 0.3 0.4 0.5 0.6 275 300 325 350 375 400 425 450 475 500 525 550 575 600 625 650 675 700 725

Innovators 2.5% Early Adopters 13.5% Early Majority 34% Late Majority 34% Laggards 16%

The Law of Diffusion of Innovation

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Source: E.M. Rogers, 1962

Percent Treated Within 1 hour with Acute Onset Maternal Hypertension, July-August, 2015 32 FPQC HIP Hospitals

7% 50% 43% 75%+ 1‐74% None

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Mothers Hospitals

Percent of All Low Risk Cesarean Deliveries Performed that Met Criteria, July-Sept, 2017 45 PROVIDE Hospitals

45% 48% 7%

Yes No Missing & Other

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NTSV Cesarean Deliveries Met Criteria

Why do we need Perinatal Quality Improvement Efforts?

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Don’t Know

Why Not Follow Practice Guidelines?

Know Intentional Error Unintentional Error Misaligned Incentives System Complexity Inadequate Education

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Don’t Know

Why Not Follow Practice Guidelines?

Know Intentional Error Unintentional Error Misaligned Incentives System Complexity Inadequate Education Quality Improvement Align Incentives

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Florida Pregnancy Associated Mortality Review

• Florida’s process modeled after CDC’s Maternal

Mortality Review & ACOG’s NFIMR Process

• Consistently reviewed cases and collected data since

1999

• Funded through federal Title

V Maternal and Child Health Block Grant funds

• Public/Private collaborative of various organizations,

institutions, providers, & specialties

• Chaired by Dept. of Health and ACOG District

Pregnancy-Related Deaths by Cause Florida, 2006-2015

2.6% 3.4% 4.1% 8.2% 8.4% 9.4% 11.8% 14.4% 14.9% 21.4%

0% 5% 10% 15% 20% 25% 30%

Cerebrovascular accident Unknown Amniotic Fluid Embolism Thrombotic pulmonary embolism Cardiovascular conditions Cardiomyopathy Other Conditions Infection Hypertensive disorders Hemorrhage

Percentage of Deaths

FL PAMR Prevention Strategies

ACOG District Presentations ACOG District Newsletters Peer-Review Journal Publications Hospital Letters Urgent Maternal Mortality Messages

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10 20 30 40 50 60 70

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

PRMR per 100,000 Live Births

Total Non-Hispanic White Non-Hispanic Black Hispanic

Pregnancy-Related Mortality Rate Florida 1999 to 2016

Hernandez, et. al. Florida Pregnancy Associated Mortality Review 2016 Update. 2018 Florida Department of Health

What is quality improvement and what does a Collaborative have to offer?

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Quality Improvement is a Team Sport

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Quality Improvement

The Framework for QI

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What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

Associates in Process Improvement: Model for Improvement

Plan Do Act Study

Quality Collaborative is like a Car…

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Why Participate in a QI Collaborative?

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Toolkit

Data Reporting Materials Education Assistance Technical Learned Lessons Consult Experts Grand Rounds Guidelines Clinical Compare Hospitals Examples Hospital Support Peer

Education is Not Sufficient

Reduction in Elective Delivery by Group, 2007-2009 5 10 15 20

Hard Stop Soft Stop Education

Percent of Elective Deliveries

Baseline Afterwards

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Clark, et. al. Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth. 2010 American Journal of Obstetrics Gynecology

* *

Lee, et al. Implementation Methods for Delivery Room Management. Pediatrics 2014 0.1 1

Series 3 Series 2 Series 1

Hypothermia Intubation at Delivery Surfactant at Delivery 0.2 0.4 0.6 0.8 Collaborative QI Non‐Participants NICU QI

Adjusted Odds Ratios for Post-Intervention & Baseline Neonatal Resuscitation Initiatives, CPQCC

Participating in a Perinatal QI Collaborative Makes a Difference

Severe Maternal Morbidity Rates among Hemorrhage Patients by Hospital Category, CMQCC

Hospitals Baseline Rate Post Rate Percent Reduction Not participating 48 28.6 28.2 1.2% No prior experience 74 22.7 19.2 15.4% Prior experience 25 22.7 16.2 28.6%

Main et al. Reduction of severe maternal morbidity from hemorrhage. Am J Obstet Gynecol 2017.

Participating in a Collaborative More than Once Makes a Difference

Standardizing Clinical Practice Alone Can Improve Quality

“In the absence of evidence-based medicine for a given clinical decision, development of these protocols sometimes may be challenging. However, the use of checklists and protocols has been clearly demonstrated to improve outcomes and their use is strongly encourage.” Clinical Guidelines & Standardization of Practice to Improve Outcomes—ACOG Committee Opinion 629

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• CMQCC. CA‐PAMR (Maternal Mortality Review). Retrieved July 2, 2018.

https://www.cmqcc.org/research/ca‐pamr‐maternal‐mortality‐review

What is the Florida Perinatal Quality Collaborative?

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Vision

“All of Florida’s mothers and infants will have the best health outcomes possible through receiving high quality evidence-based perinatal care.”

• Voluntary
• Population-Based
• Data-Driven
• Evidence-Based
• Value Added

Values

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FPQC Partners & Funders

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AIM States Serious Intent Interested Added OUD State Undecided

National Network of Perinatal Quality Collaboratives

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State PQC Status

PQC Available PQC & CDC Funding Unknown PQC Status

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2017 2016 2015 2014 2013 2012 2011 2010

Maternal Health Infant Health

Early Elective Deliveries OB Hemorrhage Antenatal Steroids Hypertension in Pregnancy Neonatal Catheter Infections Golden Hour Mother’s Own Milk

Data

Perinatal QI Indicators

Past FPQC Initiatives

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Maternal Health Infant Health Data

Ongoing & New FPQC Initiatives

Perinatal QI Indicators Birth Certificate Initiative Pilot Mother’s Own Milk Neonatal Abstinence Long‐Acting Reversible Contraception Primary Vaginal Deliveries

2019 2018 2017

Birth Certificate Initiative

68 Florida Licensed NICUs 115 Florida Delivery Hospitals

FPQC Hospital Participation—2018

Maternal Health Initiatives: 47 FPQC Annual Meeting: 35 Infant Health Initiatives: 25 QI Indicators: 39

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What have we been able to accomplish together as a Collaborative so far?

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Hypertension in Pregnancy Initiative—HIP

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Percent of All Reporting HIP Hospitals that treated women with persistent new-onset severe HTN in 1 hour

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43% 9% 9% 50% 63% 76% 69% 50% 62% 38% 7% 28% 15% 31% 50% 38% 63% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Baseline Q1-16 Q2-16 Q3-16 Q4-16 Q1-17 Apr-17 Perecentage of Hospitals 75 to 100% of women treated within 1 hour 1 to 74% of women treated within 1 hour No women treated within 1 hour

Percent of All Reporting HIP Hospitals where women received discharge education material

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46% 19% 3% 3% 3% 27% 53% 39% 28% 22% 28% 8% 26% 28% 58% 72% 75% 69% 92% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Baseline Q1-16 Q2-16 Q3-16 Q4-16 Q1-2017 Apr-17

Percentage of Hospitals 75 to 100% of women received discharge education material 1 to 74% of women received discharge education material No women received discharge education material

Usefulness of FPQC HIP Resources and Tool 27 of 32 Participating HIP Hospitals

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0% 20% 40% 60% 80% 100%

Collaborative Webinars Email/Phone Technical… In-person Mid-Project Meeting Project Kick Off event Monthly hospital QI data reports HIP Online Tool Box Not Aware Very Useful Somewhat Useful Not at all Useful

Overall Rating of FPQC’s Guidance and Support for the HIP Initiative 27 of 34 Participating HIP Hospitals

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3.7% 22.2% 74.1% 0% 20% 40% 60% 80% 100%

Poor (n=0) Fair (n=0) Good (n=1) Very good (n=6) Excellent (n=20)

Major Barriers to Implementing the Obstetric Hemorrhage Initiative, 175 Individuals from the 35 Participating Hospitals

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Answers %

Lack of physician engagement or leadership 53% Issues with medical record documentation 34% Lack of staff belief/interest in proposed change 21% Other hospital priorities / Lack of time 21% No issues 18% Other 10%

Promoting Primary Vaginal Deliveries (PROVIDE)

Reducing Low Risk Cesareans (NTSV)

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Low-Risk First-Birth (Nulliparous Term Singleton Vertex) Cesarean Rate, 115 FL Hospitals

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Source: FL Vital Records, 2017

0% 10% 20% 30% 40% 50% 60% 70% 80%

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97 101 105 109 113

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Range: 17.9—60.8%

Median: 29.4% Mean: 30.6%

National Target =23.9% 16.5% of FL hospitals meet national target

Percent of All NTSV Cesarean Deliveries Performed that Met Criteria During Baseline

45% 48% 7%

Yes No Missing & Other

45 *Other: Cases in the Induction and Labor Dystocia categories where the cervical dilation at the time of delivery is unknown. Also cases in FHRC category where the FHRC category was Other

Percent of NTSV Cesarean Deliveries Performed Not Meeting Criteria by Category during Baseline

41% 30% 16% 13%

Induction Labor Dystocia FHR Concerns Missing & Other

46 *Other: Cases in the Induction and Labor Dystocia categories where the cervical dilation at the time of delivery is unknown. Also cases in FHRC category where the FHRC category was Other

Percentage of Cesareans Among All NTSV Births For PROVIDE Hospitals, July 2017 to May 2018

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0% 10% 20% 30% 40% 50% 60%

JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY 2017 2018

Percentage of NTSV Cesareans Baseline PROVIDE Rate PROVIDE Rate

• Max. Value

75th Percentile

• Min. Value

25th Percentile PROVIDE Median

What is the future direction for Perinatal Quality Improvement?

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Multiple Pressure Points to Improve Quality

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Professional Organizations Government Reporting Consumer Ratings

QI will be integrated in electronic health records

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Who do we want to be defining health care quality for mothers and babies?

Health Care Systems Professional Organizations Perinatal Quality Collaboratives (national/state) Expert Organizations Private Vendors Quasi-Governmental Entities

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How to Get Involved? (Choose best answer)

• A. Promote your hospital in signing up to participate
• B. Support your hospital’s QI team and efforts
• C. Serve as a physician lead on a hospital QI effort
• D. Promote with other physicians and hospitals
• E. Encourage ACOG District XII to participate
• F. Serve on an FPQC Initiative Advisory Group
• G. Any and all of the above

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Only together can we make Florida the best place for mothers and babies

ARE YOU CONNECTED?

Facebook.com/TheFPQC/ @TheFPQC Join our mailing list at FPQC.org E-mail: FPQC@health.usf.edu

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