Improving The Grade
Promoting Healthy Birth Outcomes in Ohio
The Ohio Perinatal Quality Collaborative
Dave McKenna
Roni Christopher
Barbara Rose
We have no relevant conflicts of interest to disclose.
…..a statewide improvement collaborative……
Through collaborative use of improvement
science methods, reduce preterm births and
improve outcomes of preterm newborns in
Ohio as quickly as possible. (March 2007)
Key features:
 Focus on population perinatal health = all pregnancies
 Collaboration between obstetrics and pediatrics
 Evidence based decision making
 Collaboration with state policy makers
www.OPQC.net
Our Impact on Ohio
• 47% of all births occurred in OPQC hospitals
• 64% of preterm births (<37 weeks) occurred in
OPQC hospitals
• 82% of births <34 weeks (preterm excluding late
preterm) occurred in OPQC hospitals
• 80% of births 30-33 weeks occurred in OPQC
hospitals and were likely influenced by our
OPQC NICU infection interventions
• 87% of births 22-29 weeks occurred in OPQC
hospitals (target of NICU infection project)
What have we accomplished?
• Focus on population health
 50% of births; 80% of infants 22-29 weeks
 All Level 3
 Target improved care and improved access to care
• Focus on continuum of care
 Prenatal (obstetrics) and neonatal care and decisions
• Collaborations between health care and public health
 Vital Statistics and Medicaid
 HB 197
• National attention
 MOD, VON State Leaders Group, AAP neonatal quality measures group, CMS
HAI research agenda
• Improved care
 ~1000 women per year move from 36-37 weeks to term
 better care of infants with catheters
…..a statewide improvement collaborative……
OPQC NICU Participants
Akron Children's Hospital
MetroHealth Medical Center - Cleveland
Akron Children's Hospital at St. Elizabeth Health Center
Miami Valley Hospital - Dayton
Mount Carmel East Hospital - Columbus
Aultman Hospital - Canton
Mount Carmel St. Ann's Hospital - Columbus
Cincinnati Children's Hospital Medical Center
Mount Carmel West Hospital - Columbus
Cleveland Clinic
Nationwide Children's Hospital (Riverside, Grant,
Doctor’s Campuses) - Columbus
Dayton Children's Medical Center
Riverside Hospital - Columbus
Doctor's Hospital – Columbus
St. Vincent Mercy Children's Hospital - Toledo
Fairview Hospital - Cleveland
Good Samaritan Hospital - Cincinnati
Summa Health System - Akron
The Ohio State University Medical Center – Columbus
Toledo Children's Hospital
Grant Hospital - Columbus
Hillcrest Hospital - Cleveland
University Hospital - Cincinnati
University Hospital - Cleveland - Rainbow Babies
…..a statewide improvement collaborative……
OPQC Obstetric Participants
Akron Children's Hospital - Maternal Fetal Medicine
Akron General
Aultman Hospital - Canton
Fairview Hospital - Cleveland
Good Samaritan Hospital - Cincinnati
Grant Medical Center
Hillcrest Hospital - Cleveland
Mercy Anderson Hospital - Cincinnati
MetroHealth Medical Center - Cleveland
Miami Valley Hospital - Dayton
Mount Carmel East Hospital - Columbus
Mount Carmel St. Ann's Hospital - Columbus
Mount Carmel West Hospital - Columbus
Riverside Methodist Hospital - Columbus St. Elizabeth Health Center - Youngstown St. Vincent Mercy Medical Center - Toledo
Summa Health System - Akron
The Ohio State University Medical Center - Columbus
The Toledo Hospital
University Hospital Case Medical Center - MacDonald Women's Hospital - Cleveland
…..a statewide improvement collaborative……
Goal: Assure that all initiation of labor or
caesarean sections on women who are not in labor
occur only when obstetrically or medically indicated
Key Drivers
Project Aim: In one
year, reduce by 60%,
the number of
women in Ohio of
36.1 to 38.6 weeks
gestation for whom
initiation of labor or
caesarean section is
done in absence of
appropriate medical
or obstetric indication
(Scheduled
delivery)
Awareness of risks &
expected benefit of
near-term delivery by
patients and
consumers
Dating criteria:
optimal estimation
of gestational age
Hospital and physician
practice policies that
facilitate ACOG criteria
Awareness of risks &
expected benefit of nearterm delivery by clinician
Culture of safety
and improvement
Interventions
Inform consumers of risk/benefits of deliveries < 39 weeks
Communicate to patient/clinic/hospital ultrasound results
Promote need for early dating to practitioners and consumers
Public awareness campaign
Promote need for early dating to practitioners and consumers
Promote sonography < 20 weeks to establish dates
Document criteria used to establish EDC
Appropriate use of fetal maturity testing
Empower nurses /schedulers to require dating criteria
Identify a specific contact for authorization dispute re: dating
Provide patient with hard copy results of ultrasound
Empower nurses /schedulers to require dating criteria
Document rationale and risk/benefit for scheduled deliveries
at 36.1 to 38.6 weeks gestation
Document discussion with patient about the above
Both patient and MD sign consent statement for scheduled
delivery between 36.1 and 38.6 weeks
Physician awareness campaign: what are the reason(s) for
scheduled delivery?
Maximize access to Delivery and OR for optimal scheduling
Facilitate scheduling policies that respect ACOG criteria
Prenatal caregivers receive feedback from postnatal caregivers
about neonatal outcomes of scheduled deliveries
Ensure complete and accurate handoffs Ob/OB and Ob/Peds
Document discussion with patient about risk/benefits of near-term
delivery
Promote need for early dating to practitioners and consumers
Continuous monitoring of data & discussion of this effort in
staff/division meetings.
Project outcomes posted on units and websites.
Develop ways to include staff and physician input about
communications and handoffs
Connect with organizational initiatives on safety and use
existing approaches as possible
Empower nurses /schedulers to require dating criteria
OPQC OB Initiative: Our hand
collected data…OPQC hospitals
Gestational age distribution of births at OPQC member hospitals, by month,
January 2006 to March 2010
70
60
40
30
20
10
Points beyond the vertical dashed line are based on preliminary data and are likely to change
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Percent
50
Full term (39-41 weeks)
Near term (36-38 weeks)
OPQC OB Initiative:
Are we making a difference?
Birth Certificate Data for OPQC Hospitals
Ohio births at 36-38 weeks gestation following induction, with no apparent medical indication
for delivery, by OPQC member status, January 2006 to March 2010
25
20
Percent
15
10
5
Points beyond the vertical dashed line are based on preliminary data and are likely to change
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Non-OPQC
Median, non-OPQC
OPQC
Median, OPQC
How we collaborate…
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Monthly review of the data
Monthly action period calls
Site visits
1:1 coaching as needed
Use of the listserv and other
communication methods
Key Changes=Improvement
• 16 teams have a written scheduled delivery policy that outlines
acceptable reasons to delivery before 39 weeks
• We created a consumer flyer to educate on our AIM and it was
translated into 6 languages
• 19 teams have a formal peer review process requiring a physician to
adequately explain why he/she delivered before 39 weeks
• 3 hospitals have actively reached out to the private practice
physicians groups to improve communication processes for
scheduling
• 7 teams changed their scheduling workflow, i.e. dedicated fax
machines, mitigation processes for questionable appointments,
etc…
• All of the teams have, at minimum, adopted a procedural standard
for scheduling inductions
Our Collaborative Makes an Impact
• OPQC wins the SMFM “Award of Research
Excellence” in 2010 and the March 2010 issue
of JCOG detailed this work
• 2009, we were recognized as a best practice for
“Improving the Grade” by the National Office of
the March of Dimes
• We have received a March of Dimes grant to
disseminate this work to non-OPQC hospitals in
2010
• We are presenting our NICU project at PAS next
week
Future Projects
• Prematurity related
• Variation in current
practice
• Existing practice
guideline
• Measurable
outcome
• Enthusiasm by
participants
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Antenatal Steroids
Care of P-PROM
Progesterone
Late Preterm 34-36
Regionalization
Breast Feeding
MgSO4 prophylaxis
Smoking
Substance Abuse
…..a statewide improvement collaborative……
What we are thinking about: How does
OPQC include more Ohio perinatal
providers?
 How do we capture lessons learned?
 Scheduled deliveries at the other 101 Ohio
maternity hospitals?
 NICU-associated infections in other Ohio
NICUs or other NICU populations?
…..a statewide improvement collaborative……
We continue to align our work with
regulations:
Ohio House Bill 197
•
•
•
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Scheduled Births Before 39 Weeks
Antenatal Steroids
Appropriate Birth Site for VLBW Infants
Cesarean Birth Rate in 1st – Time Mothers
Others
…..a statewide improvement collaborative……
Questions?
…..a statewide improvement collaborative……