The California Maternal Data Center (CMDC): Resources for your Perinatal Safety Program Southern California Patient Safety First Collaborative Anne Castles Project Manager, CMDC acastles@cmqcc.org
CMQCC Maternal Data Center 2013 A one-stop shop to support hospitals obstetric quality improvement initiatives and service line management More quality metrics at your fingertips More benchmarking data New tools to identify the factors underlying a hospital s C-Section rates Automated data transfers to Cal-HEN or Patient Safety First AND Still free guaranteed through 2014 : Transforming Maternity Care 2
What is the CMDC? (And how can data help my hospital??) A low-cost, low-burden, online tool providing hospitals with: Overall hospital performance measures Drill-down statistics and case review worksheets to identify quality improvement opportunities for both clinical quality and data quality Provider-level statistics to assess variation within a hospital Benchmarking statistics--to compare your hospital to regional, statewide, and like-hospital peers Facilitating reporting to Leapfrog, Cal-HEN and PSF : Transforming Maternity Care
NEW! CMDC Drill-Down Tools for Primary Cesareans Background C-section rates continue to rise in CA and nationwide (2012 CA rate: 33.2%) Tremendous variation in CS rates across hospitals (and across providers within hospitals) The Nulliparous, Term, Singleton Vertex (NTSV) population has accounted for the largest portion of the 50% increase in the overall Cesarean birth rate in the last decade and accounts for > 90% of the variation seen among hospital primary cesarean birthrates. 4
1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101 106 111 116 121 126 131 136 141 146 151 156 161 166 171 176 181 186 191 196 201 206 211 216 221 226 231 236 241 246 251 80% 70% Total CS Rate Among 251 California Hospitals 2011-2012 (Source: CMQCC--California Maternal Data Center combining primary data from OSHPD and Vital Records) 60% 50% 40% Range: 15.0 71.4% Median: 32.5% Mean: 32.8% 30% 20% 10% 0% July 24, 2013 5
1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101 106 111 116 121 126 131 136 141 146 151 156 161 166 171 176 181 186 191 196 201 206 211 216 221 226 231 236 241 246 80% 70% 60% Low-Risk First-Birth (Nuliparous Term Singleton Vertex) CS Rate (endorsed by NQF, TJC PC-02, CMS, HP2020) Among 249 California Hospitals: 2011-2012 (Source: CMQCC--California Maternal Data Center combining primary data from OSHPD and Vital Records) 50% 40% 30% Range: 10.0 75.8% Median: 27.0% Mean: 27.7% National Target =23.9% 20% 10% 36% of CA hospitals meet national target 0% July 24, 2013 6
CMDC Goals for CS Tools Identify the population sub-sets undergoing primary CS that are driving an elevated CS rate and link to the appropriate QI bundle Provide ability to drill down to individual cases within the sub-category that can then be sampled for case review using supplied review forms Generate provider level reports for NTSV CS
California Maternal Data Center WebEx Demonstration : Transforming Maternity Care 8
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Low-Burden Data Collection PDD--Discharge Diagnosis File (ICD9 codes) Hospital or OSHPD to CMQCC Birth Certificate File (Clinical Data) Hospital to Vital Records to CMQCC CMQCC Data Center LIMITED OPTIONAL CHART REVIEW ED<39 Weeks Antenatal Steroids Bilirubin Screen DVT Prophylaxis REPORTS Benchmarks against other hospitals Sub-measure reports Calculates all the Measures : Transforming Maternity Care
CMQCC Participation Tracks Active Track Hospitals submit patient discharge data directly to CMQCC for linkage with BC data Rapid cycle data to support QI: monthly/quarterly feedback Overall performance metrics (per JC / NQF standards) Drill-down statistics on clinical and data quality Provider-level statistics Benchmarking data Free through Jan. 2015 View-Only Track Measures based on Patient Discharge Data (PDD) from Office of Statewide Health Planning and Development (OSHPD) & Birth Certificate data Older data (8-14 months old) Overall statistics only for admin-data based measures only : Transforming Maternity Care
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PSF and Cal-HEN Reporting Hospitals can authorize CMQCC to transfer data to PSF or Cal-HEN on their behalf 22
Uploading Supplemental Data Files 23
Cal-HEN Release Finalized 24
Monthly Approvals of Cal-HEN data Hospitals that have authorized CMQCC will receive monthly e-mails to approve each month s final data submission E-mail will have link to approval screen 25
CMDC Participation Tracks Active Track Hospitals submit PDD directly to CMQCC for linkage with BC data Rapid cycle data to support QI: monthly/quarterly feedback Overall performance metrics (per JC / NQF standards) Drill-down statistics on clinical and data quality Provider-level statistics Benchmarking data Ability to authorize data transfer to PSF or Cal-HEN Free through Jan. 2015 View-Only Track Measures based on PDD from Office of Statewide Health Planning and Development (OSHPD) & Birth Certificate data Older data (8-14 months old) Overall statistics only for admin-data based measures only : Transforming Maternity Care
Active Track Steps Coordination Complete a Participation Agreement with CMQCC Data Submissions Identify IT staff to upload patient discharge data to the CMDC on a monthly or quarterly basis: Best to delegate to department responsible for OSHPD PDD submission OPTIONALLY: Identify staff to complete medical chart review for the 3-6% of records that require additional information for: ED < 39 weeks measure Antenatal Steroids Bilirubin Screening DVT Prophylaxis for CS cases Use Results for Clinical and Data QI Participate in quality review sessions with CMQCC staff. : Transforming Maternity Care
View Only Track Steps Initiate Access Contact Anne Castles or your RPPC Director to invite you into the tool. NOTE: Only Active Track participants can authorize CMQCC to report to PSF on their behalf in view-only mode : Transforming Maternity Care
CMDC Participation Current Participation: 45 hospitals now actively submitting data; 30 more in the pipeline (as of October 2013) Our CMDC Users Say. This is one of the easiest to use, comprehensive quality improvement tools I have ever seen. David Lagrew MD, Chief Integration and Accountability Officer, Memorial Care Health System I absolutely love the richness of this data that we can take to our medical staff and administrative teams to see how well we are doing and where we need to focus on our quality improvement. Kristi Gabel, Perinatal CNS, Sutter Roseville Medical Center CMDC has helped us improve our 39 week elective deliveries. We went from 22% to 5% by getting accurate data and this team helped us to keep focused. The CMDC team is excellent. They are quick to answer your questions is a way you can understand. They have a positive, knowledgeable and action oriented team. I am so happy to be part of this. Debbie Groth, Director, Maternal and Child Health, El Camino Hospital, Mountain View We are loving the CMDC! It has truly expanded our quality reporting and ongoing analysis. Cynthia Fahey, MSN, RN, Clinical Quality Coordinator, Community Memorial Hospital, Ventura : Transforming Maternity Care
CMQCC Website For more information on CMDC: Step-by-step participation instructions Data Specifications Interactive Demo Site Go to www.cmqcc.org Select California Maternal Data Center on left-side toolbar Contact Anne Castles at acastles@cmqcc.org or 626-639-3044. : Transforming Maternity Care
Value beyond Joint Commission Reporting CMDC metrics represent entire population of deliveries Likely to reduce skew due to sampling from quarter to quarter Easy identification of facility-specific QI opportunities Drill-down patient level information Data quality reports to identify coding issues that impact performance Case review worksheets Metrics beyond Joint Commission Perinatal Care set Statewide, regional and system-wide benchmarks : Transforming Maternity Care
California Maternal Data Center Screen Shots : Transforming Maternity Care 32
Uploading Data Files Hospital uploads Discharge Data for one or more months CMQCC receives Birth Data directly from Vital Records After both files uploaded, linkage occurs instantaneously. If additional matching or record review required, notation Action Needed appear
Data Entry for Chart Review Once the data linkage is complete, the system performs the preliminary analysis for the measures that require chart review. A worksheet can be printed to give to Medical Records and use for review Data is entered by clicking into this interactive screen Each Data Field can be sorted Data Entry by clicking
CMDC Measures Labor and Birth Measures Elective Delivery <39 Weeks (PC-01)* *Requires additional limited chart review Episiotomy Rate OB Trauma (3/4th Laceration)-Cesarean Delivery (AHRQ EXP-2) OB Trauma (3/4th Laceration)-Vaginal Delivery w/ Instrument (AHRQ PSI 18) OB Trauma (3/4th Laceration)-Vaginal Delivery w/o Instrument (AHRQ PSI 19) Cesarean Section--Nulliparous, Term, Singleton, Vertex (PC-02) Cesarean Section--Nulliparous, Term, Singleton, Vertex, Age Adjusted (PC-02) Cesarean Section--Term, Singleton, Vertex (AHRQ IQI 21) Cesarean Section Primary (AHRQ IQI 33) Total Cesarean Rate Induction Rate Failed Induction Rate Appropriate DVT Prophylaxis in Women Undergoing C-Section (Leapfrog)* Vaginal Birth After Cesarean (VBAC) Rate, All (AHRQ IQI 34) Vaginal Birth After Cesarean (VBAC) Rate, Uncomplicated (AHRQ IQI 22) Newborn Measures Newborn Bilirubin Screening Prior to Discharge (Leapfrog)* 5 Minute APGAR <7 Among All Deliveries >39 weeks (HEN) 5 Minute APGAR <7 in Early Term Newborns (HEN) Birth Trauma - Injury to Neonate (AHRQ PSI 17) Unexpected Newborn Complications (NQF) Prematurity Measures Antenatal Steroids (PC-03) Antenatal Steroids-Leapfrog VLBW (<1500g) NOT delivered at a Level III NICU : Transforming Maternity Care 35
Reporting Center Each measure is displayed graphically and as a data table Each measure can be downloaded either as an image for use in presentations or as a data file to be used in reports Select comparison group(s) for your hospital Select quality measure to display (image) (data file) Download this measure Click on rate to Drill Down to see the numerator cases
Drill Down Information Can drill down to see case-level information Hover boxes show definitions for ICD-9 codes
Data Quality Reports Identify discrepancies or missing data in Birth Certificate and Discharge data files Use to target data performance/quality improvement Screen shot from the California Maternal Data Center 38
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Data Quality Reports Identify discrepancies or missing data in Birth Certificate and Discharge data files Use to target data quality improvement
Targeting QI Activities What is driving your Elective Delivery<39 Weeks Rate?
Comparative Statistics on: Demographic Indicators Maternal Conditions Delivery Methods Prematurity Rates Length of Stay
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Data Edit Tool: to allow fixing of data prior to submission : Transforming Maternity Care
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