Improving Perinatal Outcomes: Lessons from Premier s Perinatal Safety Initiative

Transcription

1 Improving Perinatal Outcomes: Lessons from Premier s Perinatal Safety Initiative December 14, 2011 William Riley, Ph.D. Associate Dean, School of Public Health University of Minnesota School of Public Health Kathy Connolly, RN, MSEd, CPHRM KTConnolly & Associates, LLC Rebecca Price, CPHQ PIMS Claims and Quality Improvement Project Manager Premier healthcare alliance Copyright 2011 Premier, Inc. All rights reserved.

2 PPSI PHASE I Kick-off January 2008 Data collection through December hospitals in 12 states Introduced three clinical care bundles Education and transparent benchmarking High Reliability Perinatal Risk Assessment AHRQ Culture of Safety Surveys 2

3 Original participating hospitals Illinois -Methodist Medical Center of Illinois (Peoria, IL) Kentucky -Baptist Hospital East, Baptist Healthcare System (Louisville, KY) Massachusetts -Baystate Medical Center, Baystate Health (Springfield, MA) Minnesota -Fairview Ridges Hospital, Fairview Health System (Burnsville, MN) -Univ. of Minnesota Medical Center, Fairview, Fairview Health System (Minneapolis, MN) New Mexico -Presbyterian Hospital, Presbyterian Healthcare Services (Albuquerque, NM) Ohio - Bethesda North Hospital, TriHealth (Cincinnati, OH) -Good Samaritan Hospital, TriHealth (Cincinnati, OH) -Summa Health System, Akron City Hospital (Akron, OH) Tennessee -Indian Path Medical Center, Mountain States Health Alliance (Kingsport, TN) Texas -Texas Health Harris Methodist Fort Worth Hospital (Forth Worth, TX) -Texas Health Presbyterian Hospital of Dallas (Dallas, TX) Washington -St. Joseph Hospital, PeaceHealth (Bellingham, WA) Wisconsin -West Allis Memorial Hospital, Aurora Health Care (West Allis, WI) 3

4 Building blocks Goals Reduce Harm Increase Patient Centered Care Create High Reliability Perinatal Units Reduce Costs Best Practices Care Bundles (Induction, Augmentation, Devices) Shoulder Dystocia Risk Management (1 st 48 hours response) Foundational Concepts Quality Basics (Reliability Concepts, PDCA model) Team Building & Communication Reliable Metrics and Data Development Situational Awareness & Critical Events Training (Simulation & Debriefing) Cost Analysis (Supply Chain, LOS, Claim/Legal) EFM (Common Interpretation and Communication) 4

5 Building blocks Goals Reduce Harm Increase Patient Centered Care Reduce Costs CREATE HIGH RELIABILITY PERINATAL UNITS 5

6 High reliability characteristics Categories assessed and scored Team work and communication Reliability concepts Situational awareness Fetal monitoring Care bundles Critical event management Risk and liability exposure Scoring criteria all firmly based in HRO principles 6 Copyright 2011 Premier, Inc. All rights reserved.

7 Documents reviewed Policies & procedures Nursing orientation Medical staff credentialing Medical records Induction order sets Quality indicators & trending reports Equipment maintenance records Patient satisfaction history 7 Copyright 2011 Premier, Inc. All rights reserved.

8 Assessment participants Nursing staff Physicians OB/Gyn Anesthesia Pediatrics Neonatology Nurse midwives Quality improvement Risk management Executive sponsor 8

9 Assessment results Scores are used by hospitals to identify existing characteristics of high performing perinatal teams, and to identify other opportunities for improvement in: Clinical processes Team collaboration and communication Risk management Avoidable adverse outcomes Report includes recommendations for improvement in low-scoring areas 9

10 Building blocks RELIABLE METRICS AND DATA DEVELOPMENT Foundational Concepts Quality Basics (Reliability Concepts, PDCA model) Team Building & Communication Situational Awareness & Critical Events Training (Simulation & Debriefing) Cost Analysis (Supply Chain, LOS, Claim/Legal) EFM (Common Interpretation and Communication) 10

11 Process measures Monthly chart audits of: 20 randomly selected elective induction and 20 randomly selected augmentation medical records 20 randomly selected vacuum delivery charts, or all if less than 20 vacuum deliveries that month Review each record looking for compliance with all elements of the respective bundle No credit unless all elements of the bundle have been met 11

12 Harm measures Our teams reported coding data from billing to NPIC NPIC provides quarterly individual and aggregate reports for three metrics: AOI, WAOS, and SI Adverse Outcome Index (AOI) is ten adverse outcomes six maternal and four newborn Maternal death Birth trauma* Uterine rupture Admission to NICU Return to OR / L&D (>2500g & for >24hours) 3º or 4º perineal tear APGAR <7 at 5 minutes Maternal admission to ICU Intrapartum & neonatal death Blood transfusion (>2500g) *Defined differently than the AHRQ Birth Trauma Patient Safety Indicator 12

13 AHRQ patient safety and medical liability grant awarded in 2010 to: University of Minnesota School of Public Health Fairview Health System Premier healthcare alliance/pims 13

14 The Scope of Phase II work of the original 16 PPSI hospitals will continue the work of improving patient safety and developing high reliability teams with these new project components 2011: Additional on-site training for high reliability team development Team STEPPS & In Situ Simulation 2012: Analysis of malpractice claims events and payouts for perinatal injury ( ) : High Reliability Perinatal Assessments to be repeated and compared to baseline scores 2013: AHRQ Culture of Safety to be repeated and compared to two previous scores 14

15 Summary of Phase I ( ) William Riley, Ph.D., Associate Dean, School of Public Health Carmen Parrotta, MPH, Project Coordinator, School of Public health Kathy Connolly, RN, MSEd, CPHRM KTConnolly & Associates, LLC

16 Outline (1) Interventions: Bundle Compliance (2) Harm Measures: AOI, WAOS, SI, (3) Association between Interventions and Harm Measures 16

17 (1) Interventions: Bundle Compliance 17

18 Definition of bundles Elective induction Augmentation Vacuum Elective Induction Augmentation Vacuum Gestational age 39 weeks Normal Fetal status (per NICHD tiers) prior to onset of Oxytocin Pelvic exam prior to the onset of Oxytocin Recognition and management of tachysystole Documentation of estimated fetal weight Normal fetal status (per NICHD tiers) Pelvic exam prior to the onset of Oxytocin Recognition and management of tachysystole Alternative labor strategies considered Patient prepared High probability of success Maximum application time and # of pop-offs predetermined and documented Cesarean and resuscitation teams available at delivery Copyright 2011 Premier, Inc. All rights reserved.

19 Bundle compliance - Success! Significant increase in reliability of the collaborative s bundle compliance rates Increase in reliability is displayed by the process shift circled in each of the bundle graphs

20 Induction bundle compliance Conformity with the elective induction bundle increased from 40 percent to a peak of 91 percent in October of Phase I compliance increased 52 percent. 20

21 Augmentation bundle compliance Conformity began at approximately 24 percent and reached its highest level at 79 percent conformity in March of Phase I compliance increased 118 percent. 21

22 Vacuum bundle compliance Conformity began at approximately 9 percent and increased to 63 percent in April of Phase I compliance increased 467 percent. 22

23 Bundle compliance - Challenges There is substantial variation across the 16 hospitals in trends of bundle compliance performance. The aggregate intervention group has not achieved and sustained criterion compliance. (> or = 4 months of bundle achievement at or above 90 percent) Specific Bundle Components have impeded total compliance rates for each care bundle Estimated Fetal Weight, Gestational <39 weeks/medical Indication, Alternative Labor Strategies and Informed Consent Documented 23

24 Induction Bundle Individual hospitals (n=6) with criterion compliance 24

25 Low-compliance components of care bundles Augmentation Bundle Estimated Fetal Weight Normal Fetal Status Pelvic Exam Tachysystole Bundle Achievements Count Sum Percent Count Sum Percent Count Sum Percent Count Sum Percent Count Sum Percent % % % % % Induction Bundle Gest. Age >=39 Weeks Medical Indication Doc. Normal Fetal Status Pelvic Exam Tachysystole Bundle Achievements Count Sum Percent Count Sum Percent Count Sum Percent Count Sum Percent Count Sum Percent Count Sum Percent % % % % % % Vacuum Bundle Alternative Labor Strategy Informed Consent Doc. EFW, Fetal Pos. and Sta. App. Time & # Pop-Offs Cesarean and Res. Team Bundle Achievements Count Sum Percent Count Sum Percent Count Sum Percent Count Sum Percent Count Sum Percent Count Sum Percent % % % % % % 25

26 What does this mean? While some individual hospitals achieved and maintained bundle compliance at or above 90 percent, the collaboration as a whole has not achieved or maintained the 90 percent compliance for any of the three bundles (the collaborative has not yet reached a level of high reliability ) Raises the question, is 90% compliance the right target? Issues of clinical efficacy and cost/benefit are important with respect to understanding how much standardization is required in order to achieve an improvement in perinatal patient safety. Deeper exploration of the organizational determinants of bundle compliance is needed 26

27 (2) Harm Measures: AOI, WAOS, SI, 27

28 Adverse outcome index: 10 Indicators of harm Complication Maternal death 750 Intrapartum neonatal death of a neonate > 2500 grams (excluding 400 cases with a congenital anomaly or fetal hydrops) Uterine rupture 100 Unexpected internal or external maternal transfer to an ICU for a 65 postpartum complication Birth trauma 60 Return to OR or labor and delivery 40 Admission of neonate > 2500 grams and > 37 weeks to NICU within 35 one day of birth for > 24 hours (excluding cases with a congenital anomaly or fetal hydrops) APGAR 5 < 7 (excluding cases with a congenital anomaly or fetal 25 hydrops) Maternal blood transfusion 20 3rd or 4th degree perineal laceration. 5 Weight 28

29 Calculating the AOI, WAOS, and SI Outcome Measure Formula Phase I Calculation Adverse Outcome Index (AOI) Deliveries with at least 1 AE = x100 Total Deliveries 13, x = ,562 Weighted Adverse Outcome Score (WAOS) = Total Weighted Score Total Deliveries 310,5 263,562 = 1.18 Severity Index (SI) Total Weighted Score = Total Deliveries with Complications 310,575 13,695 =

30 Rates of change for harm measures : Baseline Quarterly Average for Time Period ( ) Follow-Up Average for Time Period (Q ) Change Indices Adverse Outcome Index (AOI) per 1,000 deliveries Maternal AOI Measures Only Newborn AOI Measures (for Inborns Only) (3.1)* (1.9) (1.0) Weighted Adverse Outcome Score (WAOS) Weighted score per delivery Maternal WAOS Measures Only Newborn WAOS Measures (for Inborns Only) (0.05) Severity Index (SI) Weighted score per A.E * Maternal SI Measures Only ** Newborn SI Measures (for Inborns Only) (0.2) * is assigned for moderate change (p-value < 0.05) and ** is assigned for strong change (p-value < 0.01). Interim period not included in Follow-up data Baseline and Follow-up averages for AOI are calculated using quarterly adverse event counts, total deliveries and weighted adverse outcomes scores 30

31 Incremental change: Intervention vs. comparison Baseline Follow-up Incremental Change (Q Q4 2007) (Q Q2 2010) Collaborative Comparison Collaborative Comparison Collaborative Comparison AOI * 0 WAOS SI * *Significant change AOI is presented per 1,000 deliveries 1) 3.1 fewer adverse events for every 1,000 births 2) The Collaborative outperformed the Comparison on all three indices

32 Trending in obstetrical harm measures: Adverse Outcome Index Aggregate Trending of AOI through Phase I: Run Chart AOI Rate per 1,000 Deliveries Q Q Q Q Baseline Q Q Aug/Ind bundles initiated Q Q Q Q Q Q Median = 51.7 Q Q Follow-up Vacuum bundle initiated Q Q Q Q Q Q

33 Trending in obstetrical harm measures: Weighted Adverse Outcome Score Average WAOS per Delivery Q Q Q Aggregate Trending of WAOS through Phase I: Run Chart Q Baseline Q Q Aug/Ind bundles initiated Q Q Q Q Q Q Q Q Follow-up Vacuum bundle initiated Q Q Q Q Median = 1.17 Q Q

34 Trending in obstetrical harm measures: Severity Index Average SI per Adverse Event Q Q Q Q Baseline Q Aggregate Trending of SI through Phase I: Run Chart Q Aug/Ind bundles initiated Q Q Q Q Q Q Q Q Follow-up Vacuum bundle initiated Q Q Q Q Median = 22.7 Q Q

35 Item analysis of AOI scale: Collaborative baseline vs. follow-up Baseline (Q Q4 2007) Follow-up (Q Q2 2010) Maternal Incremental Change Lacerations (4.7) Return to OR (0.11) Mat_death (0.02) Uterine rupt Mat_ICU Blood_Trans Neonatal NICU admit (1.39) Birth Trauma (0.31) Neo_death Apgar *Per 1,000 Deliveries

36 Item analysis of AOI scale: Collaborative baseline vs. follow-up 4.7 fewer lacerations for every 1,000 births 1.39 fewer NICU admissions for every 1,000 births 1 fewer birth trauma event for every 3,226 births 36

37 (3) Association between Interventions and Harm Measures 37

38 Augmentation and Induction Bundles: Multivariate regression analysis Increased Augmentation bundle compliance appears to be associated with: a decrease in AOI, WAOS, and SI scores a decrease in adverse events fewer complications of anesthesia, maternal hypertension, hypoxia and birth asphyxia. Increased Induction bundle compliance appears to be associated with fewer respiratory problems 38

39 Why do Augmentation and Induction Bundle compliance rates AND their relationships to outcomes differ? Induction Controlled environment Pre-determined expectations Planned based on convenience and workload Augmentation Dynamic Requires impromptu decision-making Uncertain outcomes produces heightened situational awareness and increased assessment cognition Increased team engagement 39

40 The High Reliability Perinatal Safety Assessment Higher scores on the High Reliability Perinatal Safety Assessment (HRPSA) tool are associated with a lower incidence of adverse events and improved AOI scores 40

41 High reliability assessment scorecard

42 0.08 Ability of HRPSA Tool (Total Score) to Predicting AOI Outcomes AOI (adverse events per Delivery y = x HRPSA Total Score 42

43 Important to remember? AOI, WAOS and SI are hard to move Time lag -- requires longer time at sustained compliance Causal factors other than bundle compliance impact AOI and are picked up by HRPSA: TeamSTEPPS Use of clinical simulation Changes in the culture of safety

44 Notice of Rights to Data: THIS MATERIAL MAY NOT BE QUOTED IN THE PUBLIC REALM OR REPRINTED IN ANY FASHION WITHOUT THE PERMISSION OF THE PPSI PROJECT TEAM

45 Quality Improvement Certificate Program at Univ. of MN, School of Public Health Benefits your organization by building capacity in Quality Improvement Learn to apply Quality Improvement methods and techniques in Your individual work settings Control charts Change leadership Statistics for health management decision-making 12 credits, distance education format Contact Katy Korchik Program Coordinator at (applications being accepted for Fall 2012) 45

46 Contacts For the Perinatal Safety Initiative Rebecca Price, CPHQ, PIMS Claims and Quality Improvement Project Manager or For perinatal assessments or services Margaret Douglass, MPH, RN, PIMS AVP Risk Management or For information regarding AEIX or PIMS Les Meredith, PIMS Senior Vice President or Kathy Connolly William Riley Carmen Parrotta