Upload
others
View
7
Download
0
Embed Size (px)
Citation preview
The California Maternal Data Center (CMDC):
Resources for your Perinatal Safety Program
Southern California Patient Safety First Collaborative
Anne Castles Project Manager, CMDC
: Transforming Maternity Care
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
2
: Transforming Maternity Care
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
NEW! CMDC Drill-Down Tools for Primary Cesareans
4
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.
0%
10%
20%
30%
40%
50%
60%
70%
80%
1 6
11
16
21
26
31
36
41
46
51
56
61
66
71
76
81
86
91
96
10
1
10
6
11
1
11
6
12
1
12
6
13
1
13
6
14
1
14
6
15
1
15
6
16
1
16
6
17
1
17
6
18
1
18
6
19
1
19
6
20
1
20
6
21
1
21
6
22
1
22
6
23
1
23
6
24
1
24
6
25
1
Total CS Rate Among 251 California Hospitals 2011-2012
(Source: CMQCC--California Maternal Data Center combining primary data from OSHPD and Vital Records)
Range: 15.0—71.4%
Median: 32.5%
Mean: 32.8%
July 24, 2013 5
0%
10%
20%
30%
40%
50%
60%
70%
80%
1 6
11
16
21
26
31
36
41
46
51
56
61
66
71
76
81
86
91
96
10
1
10
6
11
1
11
6
12
1
12
6
13
1
13
6
14
1
14
6
15
1
15
6
16
1
16
6
17
1
17
6
18
1
18
6
19
1
19
6
20
1
20
6
21
1
21
6
22
1
22
6
23
1
23
6
24
1
24
6
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)
Range: 10.0—75.8%
Median: 27.0%
Mean: 27.7% National
Target =23.9%
July 24, 2013
36% of CA hospitals
meet national target
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
: Transforming Maternity Care 8
California Maternal Data Center
WebEx Demonstration
: Transforming Maternity Care 9 9
: Transforming Maternity Care 10
: Transforming Maternity Care 11
: Transforming Maternity Care 12
: Transforming Maternity Care
PDD--Discharge Diagnosis File (ICD9 codes)
Birth Certificate File (Clinical Data)
Low-Burden Data Collection
CMQCC Data Center
REPORTS Benchmarks against other hospitals
Sub-measure reports
Calculates all the Measures LIMITED OPTIONAL CHART REVIEW
• ED<39 Weeks • Antenatal Steroids • Bilirubin Screen • DVT Prophylaxis
Hospital to Vital Records to CMQCC Hospital or OSHPD to CMQCC
: 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 21
California Maternal Data Center
WebEx Demonstration
PSF and Cal-HEN Reporting
22
Hospitals can authorize CMQCC to transfer data to PSF or Cal-HEN on their behalf
Uploading Supplemental Data Files
23
Cal-HEN Release Finalized
24
Monthly Approvals of Cal-HEN data
25
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”
: Transforming Maternity Care
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 [email protected] 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 32
California Maternal Data Center
Screen Shots
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
: Transforming Maternity Care
CMDC Measures Labor and Birth Measures Elective Delivery <39 Weeks (PC-01)* 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
*Requires additional limited chart review
35
Reporting Center
(image) (data file)
•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 quality measure to display
Download this measure
Select comparison group(s) for your hospital
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
38 Screen shot from the California Maternal Data Center
39
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
: Transforming Maternity Care 43
: Transforming Maternity Care
Data Edit Tool: to allow fixing of data prior to submission
: Transforming Maternity Care
Two Security Gates