Perinatal Care (PC) Core Measures: Updates for MHA OB Constituency Group and OB Improvement Initiative Updates

Transcription

1 January 27, 2015 Perinatal Care (PC) Core Measures: Updates for 2015 Celeste Milton, MPH, BSN, R.N. Associate Project Director Department of Quality Measurement MHA OB Constituency Group and OB Improvement Initiative Updates Missouri Hospital Association Sharon Burnett, Vice President of Clinical and Regulatory Affairs Alison R. Williams, Vice President of Clinical Quality Improvement

2 How To Ask a Question You may use the Questions pane to submit questions.

3 Perinatal Care (PC) Core Measures: Updates for 2015 Celeste Milton, MPH, BSN, RN Associate Project Director Department of Quality Measurement January 27, 2015

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5 Perinatal Care (PC) Project Overview 2007 Board of Commissioners recommendation Use current evidence 2008 National Quality Forum project Technical Advisory Panel (TAP) appointed 2009 TAP meeting Measure specifications completed Manual released 2010 Data Collection began

6 PC Core Measures PC-01 Elective Delivery PC-02 Cesarean Section PC-03 Antenatal Steroids NQF Endorsed PC-04 Health Care-Associated Bloodstream Infections in Newborns PC-05 Exclusive Breast Milk Feeding PC-05a Exclusive Breast Milk Feeding Considering Mother s Initial Feeding Plan

7 Current ORYX Requirements Perinatal Care set mandatory for hospitals with 1,100 or more births per year (fifth mandatory measure set)

8 Reporting Requirement for Centers for Medicare and Medicaid Services (CMS) IPPS Final Rule posted August 2014 Continue collecting & reporting PC-01: Elective Delivery FY 2017 to be used in Value Based Purchasing Program 1 of 3 proposed process measures: MRSA Bacteremia C. difficile infection PC-01 Elective delivery

9 Additional EHR Based Measures Hospital IQR Program FY 2017 Electronic Health Record (EHR) Based (voluntary reporting) Hearing Screening Prior to Hospital Discharge PC-05 Exclusive Breast Milk Feeding and the subset measure PC-05a Exclusive Breast Milk Feeding Considering Mother s Choice CAC-3 (Children s Asthma Care-3) Home Management Plan of Care (HMPC) document given to patient/caregiver Healthy Term Newborn

10 FY 2015 Proposed IPPS Rule Hospital IQR Program Future Electronic Clinical Quality Measures for FY 2018 payment determination: Hepatitis B Vaccine Coverage Among All Live Newborn Infants Prior to Hospital or Birthing Facility Discharge NQF #0475 PC-02 Cesarean Section NQF #0471 Adverse Drug Events Hyperglycemia Adverse Drug Events Hypoglycemia

11 In Development: Perinatal Care Certification WHAT Strong focus on improving quality of care for normal physiologic birth through use of standards, clinical practice guidelines, and performance measures WHEN PROCESS POINT QUESTIONS? Timeline under review Current projection: Mid 2015 Standards and onsite review process currently in development and pilot testing Contact us at

12 PC Core Measure Set Two Distinct Populations: Mothers Newborns Consists of Five Measures Representing the Following Domains of Care: Assessment/Screening Prematurity Care Infant Feeding

13 PC-01 Elective Delivery Original Performance Measure/Source Developer: Hospital Corporation of America- Women's and Children's Clinical Services

14 Rationale American College of Obstetricians and Gynecologists (ACOG) and American Academy of Pediatrics (AAP) standard Significant short-term newborn morbidity Elective inductions result in more cesarean sections

15 Numerator and Denominator Patients with elective deliveries Patients delivering newborns with >=37 and < 39 weeks of gestation completed

16 Denominator Populations Included Populations: Diagnosis Codes for pregnancy- Appendix A, Tables 11.01, 11.02, 11.03, Diagnosis Codes for planned cesarean section in labor- Appendix A, Table

17 Denominator Populations (Cont.) Excluded Populations: Diagnosis Codes for Conditions Possibly Justifying Elective Delivery Prior to 39 Weeks Gestation- Appendix A, Table11.07 < 8 years of age >= to 65 years of age LOS >120 days Enrolled in clinical trials Gestational Age < 37 or 39 weeks or UTD

18 Denominator Data Elements Admission Date Birthdate Clinical Trial Discharge Date Gestational Age Principal or Other Diagnosis Codes

19 Gestational Age (PC-01, 02 & 03) Completed weeks of gestation Days < 6 are always rounded down UTD should be documented if no prenatal care (effective 1/1/15) Clarification added for conflicting documentation Document closest to time of delivery Vital records reports, delivery logs or clinical information systems acceptable data sources

20 Numerator Populations Included Populations: Procedure Codes for one or more of the following: Medical induction of labor- Appendix A, Table Cesarean section- Appendix A, Table and all of the following: not in Labor and no history of Prior Uterine Surgery Excluded Populations: None

21 Numerator Data Elements Principal & Other Procedure Codes Labor Prior Uterine Surgery Spontaneous Rupture of Membranes has been removed

22 Labor Documentation taken at face value Descriptors not required to be present Descriptive Inclusions: Active Labor Spontaneous Labor Early Labor Descriptive Exclusions: Prodromal Labor Latent Labor

23 Prior Uterine Surgery Inclusions: Prior classical cesarean section (vertical incision into upper uterine segment) Prior myomectomy Prior surgery with perforation (result of accidental injury) Hx of uterine window (prior surgery or via ultrasound) Hx of uterine rupture Hx of a cornual ectopic pregnancy

24 Prior Uterine Surgery (Cont.) Exclusions: Prior cesarean section without specifying type Prior low-transverse cesarean section

25 Lessons Learned from the Field Coders and clinical staff DO NOT have a shared understanding of PC-01 expectations: Some coders only review provider documentation & others also review RN documentation in EHR Providers DO NOT have a clear understanding of documentation requirements: using ACOG terminology but abstractors adhering to manual specifications= differing interpretations

26 Lessons Learned from the Field (Cont.) Very few hospitals have a hard-stop policy Team division: Nursing taking the lead in accountability enforcing PC-01 resulting in disharmony with providers Further divide between quality/coding teams and nursing/provider teams

27 How can we improve performance for PC-01? Adopt a hospital wide policy establishing criteria for performing early term medical inductions and cesarean sections Require review of requests not meeting criteria Clear, concise documentation by all clinicians Coder & clinical education as needed

28 PC-02 Cesarean Section Original Performance Measure/Source Developer: California Maternal Quality Care Collaborative

29 Rationale Skyrocketing increase in rates Most variable portion of a primary CS rate Performance improvement opportunity

30 Why are there no exclusions to the measure such as maternal cardiac conditions, fetal distress, etc.? Variation of a primary CS rate which does not allow for exclusions Designed to measure complications that largely arise in labor and not exclude them Some medical practices during labor lead to the development of indications that were potentially avoidable

31 Numerator and Denominator Patients with cesarean sections Nulliparous patients delivered of a live term singleton newborn in vertex presentation

32 Denominator Populations Included Populations: Diagnosis Codes for pregnancy- Appendix A, Tables 11.01, 11.02, 11.03, Nulliparous patients With Principal or Other Diagnosis Codes for outcome of delivery as defined in Appendix A, Table And with a delivery of a newborn with 37 weeks or more of gestation completed

33 Denominator Populations (Cont.) Excluded Populations: Diagnosis Codes, for multiple gestations and other presentations- Appendix A, Table < 8 years of age >= to 65 years of age LOS >120 days Enrolled in clinical trials Gestational Age < 37 weeks or UTD

34 Denominator Data Elements Admission Date Birth Date Clinical Trial Discharge Date Gestational Age Principal or Other Diagnosis Codes Principal or Other Procedure Codes Parity

35 Parity Vital records reports, delivery logs or clinical information systems acceptable data sources Clarification added for conflicting documentation Definition includes only previous live deliveries Do not count current delivery in EHR

36 Numerator Populations Included Populations: Principal or Other Procedure Codes for cesarean section- Appendix A, Table Excluded Populations: None

37 Numerator Data Elements Principal or Other Procedure Codes

38 Direct Standardization (Risk Adjustment) Maternal Age Bands

39 Stratification by Ages PC-02a Cesarean Section - Overall Rate PC-02b Cesarean Section - 8 through 14 years PC-02c Cesarean Section - 15 through 19 years PC-02d Cesarean Section - 20 through 24 years PC-02e Cesarean Section - 25 through 29 years PC-02f Cesarean Section - 30 through 34 years PC-02g Cesarean Section - 35 through 39 years PC-02h Cesarean Section - 40 through 44 years PC-02i Cesarean Section - 45 through 64 years

40 How can we improve performance for PC-02? Reduce admissions in latent labor Eliminate elective labor induction before 41 weeks Improve diagnostic and treatment approaches for labor disorders (dystocia and failure to progress)

41 Improving Performance (Cont.) Standardize diagnosis and management of fetal heart rate abnormalities while in labor Reduce uterine hyper-stimulation associated with oxytocin Follow oxytocin safety protocols

42 Improving Performance (Cont.) Encourage patience in the active phase of labor and in the second stage of labor (pushing) Encourage easy operative vaginal delivery as alternative to cesarean delivery in appropriate cases

43 PC-03 Antenatal Steroids Original Performance Measure/Source Developer: Providence St Vincent s Hospital/Council of Women and Infant s Specialty Hospitals

44 Rationale National Institutes of Health 1994 recommendation Neuro protective benefits Reduces the risks of respiratory distress syndrome, prenatal mortality, and other morbidities

45 Numerator and Denominator Patients with antenatal steroid therapy initiated prior to delivering preterm newborns Patients delivering live preterm newborns with =>24 and <34 weeks gestation completed

46 Denominator Populations Included Populations: Diagnosis Codes for pregnancy- Appendix A, Tables 11.01, 11.02, 11.03, 11.04

47 Denominator Populations (Cont.) Excluded Populations: < 8 years of age >= to 65 years of age LOS >120 days Enrolled in clinical trials Documented Reason for Not Initiating Antenatal Steroid Therapy Principal or Other Diagnosis Codes for fetal demise- Appendix A, Table Gestational Age < 24 or >= 34 weeks or UTD

48 Denominator Data Elements Admission Date Birthdate Clinical Trial Discharge Date

49 Denominator Data Elements (Cont.) Principal or Other Diagnosis Codes Gestational Age Reason for Not Initiating Antenatal Steroid Therapy

50 Reason for Not Initiating Antenatal Steroid Therapy Documentation why therapy was not initiated Examples of implied reasons include: Chorioamnionitis Fetal anomalies incompatible with life Imminent delivery (within 2 hrs. after admission)

51 Numerator Populations Included Populations: Antenatal steroid therapy initiated- Appendix C, Table 11.0 Excluded Populations: None

52 Numerator Data Elements Antenatal Steroid Therapy Initiated: 12 mg betamethasone IM or 6mg dexamethasone IM

53 Antenatal Steroid Therapy Initiated Only initiation versus full course Initiation prior to hospitalization acceptable

54 PC-04 Health Care-Associated Bloodstream Infections in Newborns Original Performance Measure/Source Developer: Agency for Healthcare Research and Quality

55 Rationale Rates range from 6% to 33% Increased mortality, length of stay & hospital costs Effective preventive measures available

56 Numerator and Denominator Newborns with septicemia or bacteremia Liveborn newborns

57 Denominator Populations Included Populations: Other Diagnosis Codes for birth weight between 500 and 1499g- Appendix A, Table 11.12, 11.13, or OR Birth Weight between 500 and 1499g OR

58 Denominator Populations (Cont.) Other Diagnosis Codes for birth weight > 1500g- Appendix A, Table 11.15, 11.16, & OR Birth Weight > 1500g who experienced one or more of the following: Experienced death Principal or Other Procedure Codes for major surgery- Appendix A, Table Principal or Other Procedure Codes for mechanical ventilation- Appendix A, Table Transferred in from another acute care hospital within 2 days of birth

59 Denominator Populations (Cont.) Excluded Populations: Principal Diagnosis Code for septicemias or bacteremias- Appendix A, Table Other Diagnosis Code for septicemias or bacteremias- Appendix A, Table OR Principal or Other Diagnosis Codes for newborn septicemia or bacteremia- Appendix A, Table with Bloodstream Infection Present on Admission Other Diagnosis Codes for birth weight < 500g- Appendix A, Table OR Birth Weight < 500g LOS < 2 days Enrolled in clinical trials

60 Denominator Data Elements Admission Date Birthdate Birth Weight Bloodstream Infection Present on Admission Clinical Trial

61 Denominator Data Elements (Cont.) Discharge Date Discharge Disposition Principal or Other Diagnosis Codes Principal or Other Procedure Codes

62 Birth Weight If BOTH pounds & ounces AND grams recorded-use grams Vital records reports, delivery logs & clinical information systems acceptable data sources Admission weight if transfer ok Data sources prioritized: NICU Admission Assessment or Notes Delivery and/or Operating Room Record

63 Bloodstream Infection Present on Admission Suspected or confirmed within 48 hrs. Positive or inconclusive blood cultures drawn within 48 hrs. (Negative not included) POA indicator present with codes for septicemia or bacteremia R/O, work up or evaluate for sepsis not included Clinical signs & symptoms must be documented

64 Bloodstream Infection Present on Admission (Cont.) Signs & symptoms: body temperature changes respiratory difficulty diarrhea hypoglycemia reduced movements reduced sucking seizures bradycardia swollen/distended abdomen vomiting and/or jaundice

65 Numerator Populations Included Populations: Other Diagnosis Codes for newborn septicemia or bacteremia- Appendix A, Table OR Other Diagnosis Codes for sepsis- Appendix A, Table Excluded Populations: None

66 Numerator Data Elements Other Diagnosis Codes

67 Risk Adjustment Birth Weight: 3 birth weight categories ( , , grams) Congenital Anomalies: 3 different types (gastrointestinal, cardiovascular, other specified) identified through diagnosis codes Out-born birth Death or transfer out

68 PC-05 Exclusive Breast Milk Feeding Original Performance Measure/Source Developer: California Maternal Quality Care Collaborative

69 Rationale Goal of World Health Organization (WHO), Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) Numerous benefits for the newborn & mother

70 Numerator and Denominator Newborns that were fed breast milk only since birth Single term newborns discharged alive from the hospital

71 Denominator Populations Included Populations: Principal Diagnosis Code for single liveborn newborn

72 Denominator Populations (Cont.) Excluded Populations: Admitted to the Neonatal Intensive Care Unit (NICU) Other Diagnosis Code for galactosemia Principal or Other Procedure Code for parenteral infusion Experienced death

73 Denominator Populations (Cont.) Excluded Populations (Cont.) LOS >120 days Enrolled in clinical trials Documented Reason for Not Exclusively Feeding Breast Milk Patients transferred to another hospital Other Diagnosis Codes for premature newborns- Appendix A, Table 11.23

74 Denominator Data Elements Admission Date Admission to NICU Birthdate Clinical Trial Discharge Date Discharge Disposition

75 Denominator Data Elements (Cont.) Principal & Other Diagnosis Codes Principal & Other Procedure Codes Reason for Not Exclusively Feeding Breast Milk

76 Admission to NICU Not defined by level designation or title AAP definition used Not necessary to look for critical care services provided Excludes newborns admitted for observation/transitional care Transitional care defined as LOS < 4 hrs. If no order, look for supporting documentation

77 Numerator Populations Included Populations: NA Excluded Populations: None

78 Numerator Data Elements Exclusive Breast Milk Feeding: Drops of water or formula dribbled on breast to stimulate latching ok

79 PC-05a Exclusive Breast Milk Feeding Considering Mother s Initial Feeding Plan

80 Numerator and Denominator Newborns that were fed breast milk only since birth Single term newborns discharged alive from the hospital excluding those whose mothers initial feeding plans were not to exclusively feed breast milk

81 Reason for Not Exclusively Feeding Breast Milk Allowable values (AVs): 1.Maternal medical conditions 2.Maternal initial feeding plan 3.None of above or UTD Maternal conditions + formula must be clearly documented- do not assume Clarification added for lactation consultant : IBCLC or CLC only; CLE not acceptable

82 Reason for Not Exclusively Feeding Breast Milk (Cont.) Initial feeding plan discussion prior to first feeding must appear in newborn s record RN documentation requires additional validation- check box, standing orders NOT acceptable alone as validation Feeding both should be rare & requires education on risks Mother s record alone cannot be used if linked via EHRs

83 Reason for Not Exclusively Feeding Breast Milk (Cont.) Bottle cannot be used as formula Admission defined as birth Discussion prior to birth acceptable: must be timed and dated & must appear in newborn s record Mother changes to formula later: AV 3 Newborn medical conditions: AV 3

84 How can we improve performance for PC-05 and PC- 05a? Adopt a hospital wide feeding policy promoting breast milk feeding as the default method of feeding Clear, concise documentation key to aid coders in identifying prematurity problems Make sure mother understands choice of feeding for hospitalization ONLY

85 Improving Performance (Cont.) Skin to skin contact immediately Rooming-in to recognize early feeding cues Utilize The Joint Commission s Speak Up Campaign materials Posters Brochures Buttons Share your mpinc scores with staff

86 FAQs What are the national rates for the PC measures?

87 The Joint Commission s Annual Report on Quality and Safety 2014 Measure Number Measure Name 2013 Rate Perinatal Care Composite 74.1% PC-01 Elective Delivery 4.3% PC-02 Cesarean Section* 25.9% PC-03 Antenatal Steroids 89.7% PC-04 Health Care-Associated Bloodstream Infections in Newborns* 2.5% PC-05 Exclusive Breast Milk Feeding 53.6% PC-05a Exclusive Breast Milk Feeding Considering Mother s Initial Feeding Plan * Denotes outcome measure 69.2%

88 Resources

89 March of Dimes Perinatal Care Resource Toward Improving the Outcome of Pregnancy III (TIOP III): sionals/medicalresources_tiop.html

90 Resource for Elective Delivery March Of Dimes (MOD)/California Maternal Quality Care Collaborative (CMQCC) <39wk Toolkit Available at: marchofdimes.com or CMQCC.org to download your free copy of the toolkit.

91 Resources for Cesarean Section California Maternal Quality Care Collaborative white paper: Cesarean Deliveries, Outcomes, and Opportunities for Change in California: Toward a Public Agenda for Maternity Care Safety and Quality : wnload

92 Resources for Cesarean Section (Cont.) ACOG Obstetric Care Consensus #1: Safe Prevention of the Primary Cesarean Delivery blications/obstetric_care_consensus_ Series/Safe_Prevention_of_the_Primar y_cesarean_delivery

93 Resources for Antenatal Steroids ACOG clinical-practice guideline, Management of Pre-Term Labor : =38621&search=antenatal+steroids March of Dimes Preterm Labor Assessment Toolkit: als/preterm-labor-assessmenttoolkit.aspx#

94 Resources for Preventing Bloodstream Infections CDC guideline for the prevention of intravascular catheter-related infection: bsi-guidelines-2011.pdf Joint Commission CLABSI Toolkit: absi_toolkit.aspx

95 Resources for Breast Milk Feeding Promotion The Centers for Disease Control and Prevention (CDC) guide: guide.htm. The Academy of Breastfeeding Medicine (ABM) protocols: spx. The United States Breastfeeding Committee toolkit: The Joint Commission s Speak Up Campaign:

96 View the manual and post questions at:

97 The Joint Commission Disclaimer These slides are current as of (1/27/2015). The Joint Commission reserves the right to change the content of the information, as appropriate.

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99 MHA OB Constituency Group and OB Improvement Initiative Updates January 27, 2015 Missouri Hospital Association Sharon Burnett, Vice President of Clinical and Regulatory Affairs Alison R. Williams, Vice President of Clinical Quality Improvement

100 Perinatal Regionalization Legislation Bill to define neonatal and maternal levels of care and create a system for referral to ensure high-risk pregnancies and low birth weight, preterm, or otherwise at-risk neonates receive consultation and access to riskappropriate care The MHA Board voted to remain neutral, bill has not been filed ACOG/SMFM consensus paper on designations for levels of maternal care March of Dimes legislative fact sheet and FAQs Posted under Jan. 27 Webinar Materials at

101 You ve come so far in such a short time!

102 Obstetric Hemorrhage Improvement Initiative Best Practices Adopted MO HEN Mar 2014 MO HEN Dec 2014 Not HEN Dec 2014 Survey Question % Yes N=32 % Yes N=35 % Yes N=19 A1. Have you implemented standardized OB hemorrhage policies, procedures? 72% 97% 95% A2. Have you implemented standardized order sets for general and massive OB hemorrhage? 62% 83% 74% A3. Do you have an obstetric hemorrhage rapid response team? 31% 57% 39% A4. Do you have an obstetric hemorrhage cart or kit? 66% 97% 68% A5. Do your physicians perform a hemorrhage risk assessment prenatally? 41% 54% 42% A6. Do you perform a hemorrhage risk assessment upon admission? 59% 77% 58% A7. Do you have protocols/checklists/charting tools for on-going objective quantification of actual blood 48% 86% 68% loss? A8. Do you have protocols/checklists/charting tools to objectively assess maternal deterioration during and 66% 83% 72% after all births? A9. Do you hold regularly scheduled standardized training on formal quantitative measurement of blood 37% 60% 68% loss? A10. Do you regularly hold on-site inter-professional hemorrhage drills? 31% 60% 50% A11. Do you hold post OB hemorrhage debriefs? 47% 63% 72% A12. Do you have standardized definitions and documentation to ensure consistency in coding and 43% 69% 63% reporting of maternal hemorrhage? A13. Do you track your progress on maternal hemorrhage reduction with process and outcome measures? 56% 60% 47%

103 AWONN Practice Briefs Quantification of Blood Loss /pdf Guidelines for Oxytocin Administration after Birth /pdf

104 Obstetric Preeclampsia Improvement Initiative Best Practices Adopted MO HEN Mar 2014 MO HEN Dec 2014 Not HEN Dec 2014 Survey Question % Yes N=32 % Yes N=35 % Yes N=19 B1. Do you use a preeclampsia early recognition tool? 19% 46% 26% B2. Have you adopted protocols/checklists for treating severe hypertension including the use of 78% 86% 89% magnesium sulfate? B3. Have you adopted order sets for treating severe hypertension? 59% 74% 84% B4. Do you track the percentage of mothers who received timely treatment (within 60 minutes) for severe hypertension (Systolic >= 160 or Diastolic >=100)? 3% 31% 16% B5. Do you educate patients on signs and symptoms of preeclampsia? B6. Have you educated ED staff on signs and symptoms of postpartum preeclampsia? B7. Do you track your progress on preeclampsia harm reduction with process and outcome measures? 100% 100% 100% 25% 35% 37% 28% 31% 16%

105 Interest Survey Not Very Important Not Important Neutral Important Very Important Total Weighted Average Electronic fetal monitoring 0% 0% 1.79%(1) 28.57%(16) 69.64%(39) Rapid response for perinatal 0% 0% 3.51%(2) 17.54%(10) 78.95%(45) safety Safe medication 0% 0% 0% 10.53%(6) 89.47%(51) administration including oxytocin and magnesium sulfate Safe cesarean section 0% 0% 1.75%(1) 28.07%(16) 70.18%(40) including reduction of unnecessary primary, low risk C/S. Implementation of the 0% 0% 3.51%(2) 15.79%(9) 80.70%(46) Hemorrhage Guidelines Implementation of the 0% 0% 0% 22.81%(13) 77.19%(44) Preeclampsia Guidelines VTE prophylaxis safety 0% 0% 10.71%( %(22) 50%( bundle ) Use of simulation 0% 0% 10.71%( %(18) 57.14%(32) ) Preventing baby drops and 0% 0% 7.14%(4) 28.57%(16) 64.29%(36) other adverse consequences of rooming in Maternal and newborn addiction to prescription and illicit drugs 0% 0% 3.51%(2) 45.61%(26) 50.88%(29)

106 OB Harm Reduction 2015 Continued adoption of best practices and protocols preeclampsia OB hemorrhage Oxytocin Bundles implementation-updated versions HEN 2.0-Safety Across the Board early elective deliveries all OB Harm as part of Total Harm Cesarean Section rate Readiness Recognition Response

107 Education & Networking in 2015 MHA Strategic Quality tab: Webinars & Conference Calls-specific topics and support Regional meeting (May/June): call for planning team members call for hosts call for speakers

108 Contacts Missouri Hospital Association Sharon Burnett, Vice President of Clinical and Regulatory Affairs 573/ , ext Alison Williams, Vice President of Clinical Quality Improvement 573/ , ext March of Dimes Greater Missouri Chapter Trina Ragain, State Director of Program Services 314/