Improving Patient Safety for Mom & Baby

Improving Patient Safety for Mom & Baby Data Coaching Call April 22, 2014

Agenda • Review the Patient Safety for Mom & Baby Specific Measures • Review the Data Collection Tool • Review the Data Sharing Agreement • Timelines for Data Submission • Q & A

Data Collection • Project Areas: • Early Elective Delivery (EED) • JC PC-1 • NICU Central Line Associated Bloodstream Infection (CLABSI) • Exclusive Breast Milk Feeding • JC PC-05 • Obstetrical (OB) Harm • C-Section Delivery Rate • C-Section Delivery Rate (AHRQ IQI-21) • Primary C-Section Delivery Rate (AHRQ IQI-33) • The Preterm ICD-9 codes do specify prior to completion of 37 weeks. • OB Hemorrhage • Massive OB Blood Transfusions • K-HEN OB-118 Measure • Adverse Outcomes due to Oxytocin (Pitocin)

Mom & Baby Measures • EED Measure • Joint Commission PC-1 Measure • Will collect from K-HEN • Numerator -Elective deliveries (vaginal or c-section) • Denominator – Deliveries >= 37 weeks and <39 weeks gestation • Definition: Patients with elective vaginal deliveries or elective cesarean sections at >=37 and < 39 weeks of gestation completed • Numerator Statement: Patients with elective deliveries • Denominator Statement: Patients delivering newborns with >= 37 and < 39 weeks gestation completed • Rate (N/D)*100 • NICU CLABSI Measure • NHSN (NICU Level 2 and 3 beds) • Will collect from NHSN if you Confer Rights to KHA • Numerator – Number of central line-associated BSIs • Denominator – Number of central line days

Mom & Baby Measures • Exclusive Breast Milk Feeding • Joint Commission PC-05 measure • Numerator - Exclusively breast milk-fed non -NICU term infants, including those supplemented with human milk • Denominator - # of term infants, including those with medical reasons for supplementation, with certain exceptions • Definition: The Joint Commission defines exclusive breast milk feeding as: “a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines.” Breast milk feeding includes expressed mother’s milk as well as donor human milk, both of which may be fed to the infant by means other than suckling at the breast. While breastfeeding is the goal for optimal health, it is recognized that human milk provided indirectly is still superior to alternatives.

Mom & Baby Measures • OB Harm • C-Section Delivery Overall Rate • AHRQ IQI-21 • Numerator – Number of C-Section Deliveries (excluding hysterectomy procedure code and meeting the inclusion/exclusion criteria of the denominator) • Denominator – All Deliveries (excluding any diagnosis of abnormal presentation, preterm , fetal death, multiple gestation diagnosis codes breech procedure codes; and missing discharge disposition) • The Preterm ICD-9 codes do specify prior to completion of 37 weeks. • Primary C-Section Delivery Rate • AHRQ IQI-33 • Numerator – Number of C-Section Deliveries (excluding hysterectomy procedure code and meeting the inclusion/exclusion criteria of the denominator) • Denominator – All Deliveries (excluding any diagnosis of abnormal presentation, preterm , fetal death, multiple gestation diagnosis codes breech procedure codes; previous Cesarean delivery and missing discharge disposition)

Mom & Baby Measures • OB Hemorrhage – Massive OB Blood Transfusions • ACOG and CMQCC • Will collect from K-HEN (K-HEN OB-118 Measure) • Numerator - Total number of women who received ≥4 units of blood products (including RBCs, FFP, Platelets packs, Cryoprecipitate) • Denominator - All women giving birth ≥20 weeks (birth hospitalization) • Definition: All women who have given birth were transfused with >= 4 units of any blood product

Mom & Baby Measures • Adverse Outcomes due to Oxytocin (Pitocin) • Process Measure • Do you have a protocol in place for the use of Oxytocin that includes at a minimal the following items: • Assessment and documentation for indication for induction/augmentation thru use of the checklist for Scheduling Induction of Labor • Patient understanding of procedure, risk, and informed consent obtained • Appropriate medical and nursing assessment of both maternal and fetal status before the start of induction using the Inpatient Induction of Labor Checklist Continuous evaluation of patient and fetus for complications • Yes – if yes, please indicate the Month and Year of Implementation • No

Data Collection • Baseline Data • Submit six (6) months of baseline data • EED • NICU CLABSI • Exclusive Breast Milk Feeding • OB Harm • C-Section (Primary and Overall Rate) • OB Hemorrhage • Submit monthly data on all outcome measures that are applicable to your hospital • Pitocin Process Measure

Data Collection Tool

Data Sharing Agreement

Data Submission Time Line

Questions Contacts: Melanie Moch mmoch@kyha.com Dolores Hagan dhagan@kyha.com Phone: 502-426-6220

Improving Patient Safety for Mom & Baby