Improving Patient Safety for Mom & Baby

1. Improving Patient Safety for Mom & Baby Kick-Off Webinar March 28, 2014

2. WelcomeAgenda • Project Overview • Goals for the Project • Data Collection • Website • Tools and Resources • Coaching Call Schedule • Timeline and Next Steps • Questions

3. Project Staff • Nancy Galvagni ngalvagni@kyha.com • Elizabeth Cobb ecobb@kyha.com • Kim Dees kdees@kyha.com • Donna Meador dmeador@kyha.com • Melanie Moch mmoch@kyha.com • Sharon Perkins sperkins@kyha.com • Nick Carricato, MD

4. Overview of the Improving Patient Safety for Mom & Baby Project • Partnership with the Anthem Foundation to improve patient safety and outcomes for mom’s & babies. • Ensuring a healthy population • Raise quality • Lower health care cost

5. Identifying the Need • Our most recent 6 month rate of Early Elective Deliveries is 10.9% - still significantly higher than the CMS goal of 3% or less • Our Ever Breastfed rate is 52.6% compared to the national rate of 76.5% • Kentucky’s overall C-section rate is 34.6% compared to the national C-section rate of 31.8% • March of Dimes 2013 Premature Birth Report Card

6. Identifying the Need • Public attention to hospital performance • Inpatient Hospital Quality Reporting Program • Early Elective Delivery • Breastfeeding Rate

7. About the Project • All KY Birthing Hospitals • Project through December 2014 • Project Areas: • Early Elective Delivery (EED) • NICU Central Line Associated Bloodstream Infection (CLABSI) • Breastfeeding Rate • Obstetrical (OB) Harm • Cesarean (Primary and Overall Rate) • OB Hemorrhage • Adverse Outcomes due to Oxytocin (Pitocin)

8. Commitment for Project

9. Commitment for Project • Submit Commitment Form by April 11th, 2014 to Sharon Perkins at KHA • Identify your Project Team Members • Initiative Leader • Data Coordinator • Quality Leader • Develop a Data Collection Plan • Capture at least six months of 2013 baseline data on all project areas • Submit monthly data on all applicable outcome measures for 2014

10. Goals for the Project The main goal of the project is to reduce harm for Moms & Babies and improve outcomes by: • Reducing EED to < 3%; • Reducing NICU CLABSI < 1 %; • Reducing OB Harm: • Reduce C-Section Rates by 10% • All birthing hospitals adopt best practice protocols for oxytocin • Implementing Best Practice for Human Breast Milk • Reach goals through educational webinars, toolkits and best practices

11. 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 • 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 • Breastfeeding Measure • Joint Commission 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

12. Mom & Baby Measures • OB Harm • AHRQ IQI-21 • C-Section Delivery Rate • Numerator – Number of C-Section Deliveries (excluding hysterectomy procedure code and meeting the inclusion/exclusion criteria of the denominator) • Denominator – All Deliveries (excluding any Dx of abnormal presentation, pre-term, fetal death, multiple gestation Dx codes, breech procedure codes; and missing discharge disposition) • AHRQ IQI-33 • C-Section Delivery Rate • Numerator – Number of C-Section Deliveries (excluding hysterectomy procedure code and meeting the inclusion/exclusion criteria of the denominator) • Denominator – All Deliveries (excluding any Dx of abnormal presentation, pre-term, fetal death, multiple gestation Dx codes, breech procedure codes; previous C-section delivery and missing discharge disposition) • OB Hemorrhage • ACOG and CMQCC • Will collect from K-HEN • 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)

13. Mom & Baby Measures • Adverse Outcomes due to Oxytocin (Pitocin) • ACOG • 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

14. Data Collection • 2013 Baseline Data • Submit at least six (6) months of baseline data • EED • NICU CLABSI • Breastfeeding Rate • OB Harm • C-Section (Primary and Overall Rate) • OB Hemorrhage • Submit monthly data on all outcome and process measure

15. Data Collection Tool

16. Data Collection • Data Sharing Agreement • K-HEN • AHRQ • NHSN

17. Website www.kipsq.org

18. Tools and Resources • Toolkits • Early Elective Delivery (EED) • NICU CLABSI • Breastfeeding • OB Harm: • Cesarean • OB Hemorrhage • Adverse Outcomes (Pitocin Protocol-ACOG) • Resources • Technical Assistance • Hospital Visits • Links on website for multiple resources

19. Coaching Call Schedule • Coaching Call/Training Webinars • April-Data collection coaching call • May 15- EED • May 20- Pitocin Protocol • June 12- Scoring for Birth Readiness • June 17- OB Hemorrhage • July 10- Breast Feeding • September- TBD • November-TBD • December- End of year wrap-up

20. Timeline and Next Steps • Grant cycle January-December 2014 • March 28- Kick-Off Webinar • April 11- Commitment letters due • Coaching Call Schedule • Data Collection Call in April 22nd

21. Questions??