TIPQC THA HEN
OB EED Webinar
August 25, 2014
A TIPQC THA/TCPS Collaborative
Inter-institutional Quality Improvement Project
Faculty
Course Director: Peter Grubb, MD, Assistant Professor of Pediatrics,
Vanderbilt University School of Medicine; Medical Director, TIPQC
Planner/Speaker: Brenda Barker, MEd, Project Director, TIPQC
Planner/Speaker: Chris Clarke, RN, Senior Vice-President,
Tennessee Center for Patient Safety, Tennessee Hospital Association
Planner/Speaker: Jackie Moreland, RN, Clinical Quality
Improvement Specialist, Tennessee Center for Patient Safety,
Tennessee Hospital Association
Speaker: Pam Isom, BSN, RN, MPH, Director of Newborn Screening,
Division of Family Health and Wellness, Tennessee Department of
Health
Speaker: Sara Guerra, BSN, RN, Quality Nurse Consultant, Division
of Family Health and Wellness, Tennessee Department of Health
Welcome!
Agenda for today:
• Data Performance Trends
• Newborn Screening Reports
• Team Successes
• Questions/Answers from Hospital
Teams
OB EED Data Trends
Working toward our goal of 5% or less
HEN OB Data Charts
HEN OB Data Charts
HEN OB Data Charts
HEN OB Data Charts
OB Statewide Data Charts
OB Statewide Data Charts
OB Statewide Data Charts
OB Statewide Data Charts
Questions
State of Tennessee
Newborn Screening Program
Hospital Reports
Pam Isom, BSN, RN, MPH, Director of Newborn
Screening, Division of Family Health and Wellness,
Tennessee Department of Health
~
Sara Guerra, BSN, RN, Quality Nurse Consultant,
Division of Family Health and Wellness,
Tennessee Department of Health
State of Tennessee
Newborn Screening Program
Hospital Reports
Milwaukee Article
Department of Health Process Improvements




Courier Service
Weekend Lab Hours
Weekend Follow-Up Hours
Milwaukee Article
Hospital Reports
 Distribution Date
 Review of Reports
Tennessee Newborn Screening
Follow-Up Program
Pam Isom, Director
 Email: Pam.Isom@tn.gov
Phone: (615) 532-8462
(855) 202-1357
 Newborn Screening Follow-up Program Email:
NBS.Health@tn.gov
Questions
Safe Sleep
Hospital Incentive Bundle
• Free “Sleep Baby, Safe
and Snug” board book for
each birth in your facility
• Free TDH “ABC’s of Safe
Sleep” materials
• Free Recognition on TDH
website
(http://safesleep.tn.gov)
• Signed certificate from TDH
Commissioner
• Press release template
Hospital Requirements
• Identify main hospital contact for communication with
TDH and submit intent pledge
• Develop hospital Safe Sleep policy
• Implement Safe Sleep policy, which at a minimum must
include:
– At least annual education to all perinatal staff (OB,
peri/postpartum, and pediatrics) on safe sleep recommendations
– Requirements for staff to model safe sleep recommendations
– Plan for at least quarterly internal compliance audits with hospital
policy
• Submit annual report on educational activities and staff
compliance in order to receive books
Breastfeeding
The Joint Commission’s Perinatal Care Core Measure PC-03
TIPQC Breastfeeding Promotion
Delivery Project
State AIM: improve the health of infants and mothers in
Tennessee by
• systematically promoting and supporting breastfeeding and
• focusing on high reliability (>90%) implementation of
processes that promote and support breastfeeding in the
delivery setting.
• Immediate aim: Thus, we seek to increase the fraction of
infants who are exclusively fed breast milk at hospital
discharge by 10% by March 2014 (Wave 1 aim & Wave 2 has
just begun)
• Long term aim: To eliminate barriers in birthing facilities to
achieving the Healthy People 2020 goal.
Ten Steps to Successful Breastfeeding:
the Baby Friendly Hospital Initiative
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Have a written breastfeeding policy
Provide staff training in policy implementation
Provide breastfeeding education for pregnant women
Help initiate breastfeeding within 1 hour of birth
Show mothers how to initiate and maintain breastfeeding
(even if separated from infant)
Give no substitutes unless medically indicated*
Practice rooming in 24/7
Encourage breastfeeding on-demand
Give no artificial nipples/pacifiers to breastfed infants
Support and utilize support groups
*Hospitals should accept no free or heavily discounted formulas and/or feeding supplies
Tennessee Breastfeeding Hotline
• 24/7 breastfeeding
hotline!
Dr. Michael Warren, Director, Division
of Family Health and Wellness, TN DOH
Commissioner
John Dreyzehner, MD, MPH
Resource
https://www.cvent.com/Pub/eMarketing/Pages/WebEmail.aspx?m=6048447e-0293-49f5-acdf-6627f13370fe
Resources
• All material will be posted on the THA HEN Community of
Practice (COP) http://www.HealthcareCommunities.org
– Contact aoneal@tha.com for COP questions or if you need
registration and joining instructions.
• THA/TCPS Contacts:
– Chris Clarke, Sr. VP cclarke@tha.com
– Jackie Moreland, QI specialist jmoreland@tha.com
– Jessy Richter, Data Manager jrichter@tha.com
• TIPQC Contact:
– Brenda Barker, M.Ed. Brenda.Barker@tipqc.org
Resources
ACOG Statement
ACOG practice bulletin, "Induction of Labor" updated in 2010
Tool Kit
CMQCC / MOD Tool kit:
http://www.cmqcc.org/resources/1974
Websites
www.tnpatientsafety.com
user name: hospital
password:tnbabies
www.healthytennesseebabies.com
IHI Resources
Elective Induction and Augmentation Bundles
http://www.ihi.org/knowledge/Pages/Changes/ElectiveInductionandAugmentationBundles.aspx
How-to Guide: Prevent Obstetrical Adverse Events @
http://www.ihi.org/knowledge/Page s/Tools/HowtoGuidePreventObstetricalAdverseEvents.aspx
Articles
A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks' gestation
http://www.ncbi.nlm.nih.gov/pubmed/20207241
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Resources
Articles Continued…
Improving Perinatal Care: A Focus on Patient-Centered Care and Evidenced-Based Measures
http://www.ihi.org/knowledge/Pages/ImprovementStories/ImprovingPerinatalCareAFocusonPati
entCenteredCareandEvidencedBasedMeasures.aspx
Reducing Birth-Related Trauma and Liability Exposure
http://www.ihi.org/knowledge/Pages/ImprovementStories/ReducingBirthRelatedTrauma.aspx
Neonatal and maternal outcomes associated with elective term delivery, http://ajog.org
Rationale for a 39-Week Elective Delivery Policy
http://sitesearch.aafp.org/?q=rationale+for+39+Weeks+policy&x=0&y=0&t1search=true&sp_cs=UTF-8
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
http://www.ajog.org/article/S0002-9378(10)00679-4/fulltext
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Resources
Patient Resources
March of Dimes Resources:
Healthy Babies Are Worth The Wait
http://www.marchofdimes.com/professionals/medicalresources_hbww.html
Get ready for labor
“Brain Card”
Why at least 39 weeks is best for your baby
http://www.marchofdimes.com/pregnancy/getready_atleast39weeks.html
AWHONN Resources:
Go the Full 40
http://www.awhonn.org
CMS Innovation Resources
Strong Start Toolkit Link
http://innovations.cms.gov/initiatives/strong-start/what-you-can-do-to-help.html
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IHI Open School 2014
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•
•
•
•
1.
2.
3.
4.
THA is providing free access to the IHI Open School curriculum to employees and
trustees of our safety partner hospitals.
21 online, self-paced courses including 72 lessons and corresponding resources—
videos, case studies, podcasts, featured articles, exercises, networking
Free app for the iPhone and iPad by logging onto iTunes
Over 25 contact hours available for CME, CNE, CPHQ and ACPE credit
Certificate of completion
Register using instructions. Type “Tennessee Hospital Association” as your
facility to receive free membership.
Once registered, go to the course page: www.ihi.org/lms
Click the online learning tab and choose a lesson
Click Begin Lesson
Contact Taelor Barnette at tbarnette@tha.com 615-401-7414 for more information.
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Upcoming Events
• AHA/NICHQ Webinar – Tuesday September 23,
2014; 1:00pm CT. The Baby Friendly Hospital
Initiative: Improving Maternity Care and
Increasing Breastfeeding Rates. Registration is
free – advanced registration required at
https://event.on24.com/eventRegistration/Even
tLobbyServlet?target=registration.jsp&eventid=
840515&sessionid=1&key=AF19B29BDD4B2DA
B560F2A93B54E3AC1&sourcepage=register
Upcoming Events
• Next OB Monthly Team Webinar— Monday
September 29, 2014;10:00am CT. Perinatal Care
Core Measures Overview and Update by Celeste
Milton of the Joint Commission
• 2014 THA Leadership Summit
th
Wednesday November 5 at the Gaylord
Opryland Hotel and Convention Center in
conjunction with THA’s Annual Meeting. Make
plans to showcase your improvement work by
submitting a poster for presentation. Contact
Chris Clarke at cclarke@tha.com for details
Data Due Date!
Monthly data due by last date of following month!