Tracking quality measures improved perinatal care

SAN FRANCISCO – One California community-based hospital got a head start on tracking core measures of quality in perinatal care that all U.S. hospitals will have to report to The Joint Commission beginning January 2014.

Over the past 2 years, the ob.gyns. found it wasn’t easy, but that tracking core measures of quality significantly improved perinatal care.

Sutter Medical Center in Sacramento, Calif., formed a perinatal data committee in 2010 to identify barriers and develop processes for tracking six quality measures, including the five for The Joint Commission. They worked to overcome doubters on their staff, internally published individual doctors’ rates of cesarean section deliveries and episiotomies, and shared the results for each prenatal obstetrics group.

John Milne/IMNG Medical Media

Their overall rate of elective deliveries at less than 39 weeks’ gestation decreased from 25% of the 4,958 deliveries in October 2010 to 2% of the 5,577 deliveries in December 2012. The cesarean section rate for nulliparous women with a term, singleton fetus in a vertex position dropped from 31% in 2010 to 25% in 2012, Dr. William M. Gilbert reported at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

They also improved significantly in two other core measures of quality mandated by The Joint Commission: The proportion of preterm infants who received antenatal steroids before delivery jumped from 80% to 100%, and the proportion of newborns who were fed exclusively breast milk during their entire hospitalization improved from 58% to 70%. The hospital has begun collecting data on a fifth core measure for The Joint Commission: the rate of health care-associated bloodstream infections in newborns.

Dr. Gilbert and his group also tracked two measures that are endorsed by the National Quality Forum but are not yet required by The Joint Commission. Their episiotomy rate decreased significantly from 5% to 2%, and the proportion of women undergoing cesarean section who received appropriate prophylaxis against deep vein thrombosis increased from 95% to 98% (Jt. Comm. J. Qual. Patient Saf. 2013;39:258-66).

"It took us 1-2 years to get the bugs worked out" in tracking core quality measures, said Dr. Gilbert, regional medical director of women’s services for Sutter Health’s Sacramento-Sierra Region, Sacramento, Calif. The effort required leadership from doctors and nurses, administrative and medical records support, and education for coders.

"If your hospital has done nothing to look at what you’re going to be submitting" to The Joint Commission, he added, "I can guarantee you that even if you think you’re doing great, the data are going to be awful, and you’re going to be scrambling to fix a problem that has occurred."

This kind of attention to quality measures in perinatal care is long overdue, he said. Despite the fact that the 4.2 million normal vaginal deliveries per year represent the No. 1 hospital discharge diagnosis in the United States, and studies show immense variation in perinatal practices between hospitals and geographical regions, efforts to measure the quality of hospital care largely have ignored obstetrics because those efforts have focused on Medicare, and few obstetrical patients are covered by Medicare.

Previous studies show a 10-fold variation in cesarean section rates around the country, and cesarean section rates in low-risk patients vary from 2% to 36%. "I would put to you, if you were making widgets or tanks, and you had such variation in the quality of your tanks that the government was paying for, you’d be out of work and probably in jail, but that’s what we tolerate" in health care, he said. Huge variations also have been reported in rates of induction, episiotomy, breastfeeding, and use of antenatal steroids.

The 40 ob.gyns. affiliated with Dr. Gilbert’s hospital had cesarean rates for nulliparous, term, singleton, vertex pregnancies ranging from approximately 8% to 60% when the tracking efforts began, he said. The committee assigned two-digit alphanumeric codes for each provider and posted individual rates of cesarean sections and episiotomies by provider code for 6 months, to start. It took a year of convincing before getting agreement, but then individual rates were posted in the doctors’ and labor and delivery lounges and were e-mailed to all medical staff.

"It’s amazing – amazing what that did," he said. Doctors with the highest cesarean section rates reduced their use of cesarean sections.

The category of elective deliveries at less than 39 weeks’ gestation excluded cases with medical indications for early delivery, but tracking ran into problems initially because ICD-9 codes did not exist for some exemptions, including prior classical cesarean section or prior myomectomy. "You got dinged for that" in the tracking despite the medical indication, he said. So the committee created tracking categories of "avoidable" and "unavoidable" early deliveries, and doctors didn’t get dinged for unavoidable cases.

Some doctors wrote the reason for early delivery as "intrahepatic cholestasis of pregnancy," which is an appropriate indication, but the medical coders told Dr. Gilbert that having the word "intrahepatic" flagged it as gall bladder disease, which is no reason to deliver early. "We had to work with our coders to help us understand," he said.

Every patient at risk of preterm delivery received antenatal steroids at his hospital, Dr. Gilbert said, "but we weren’t documenting it properly." There had been no uniform spot in the medical record to document administration of antenatal steroids, or to show that they had been given before the current hospitalization. Dr. Gilbert’s team worked with the medical records department to change the electronic health records. Nurses now check off if the patient received a full course of antenatal steroids. If this is missing, the doctor gets a pop-up window where a reason must be given.

"That really was effective," he said.

Tracking of episiotomy excluded cases of shoulder dystocia, but not episiotomy for fetal distress. Despite individual rates being internally publicized, the episiotomy rate seems to be stuck at around 2% because "I do have a couple of old-timers," he said. "Even public embarrassment will not get them to change."

"As an individual and as a hospital, we need to make sure we’re doing the best we can."

Capturing data on whether or not newborns are fed exclusively with breast milk can be difficult, in part because it’s often not clear whether the ob.gyn., the nursing staff, or the pediatrician is responsible for this. Dr. Gilbert’s team analyzed 18 cases at his hospital in which women came in saying they wanted to breastfeed the newborn exclusively, but that didn’t happen. In most cases, the babies received formula after a night nurse moved the baby to the nursery so the mother could sleep, a problem that was addressed. Publicizing exclusive breastfeeding rates for 20 different perinatal obstetrics groups – which ranged from 33% to 93% also helped improve breastfeeding rates.

The perinatal data committee also posted a color-coded "dashboard" showing trends in the hospital’s rates for all these measures over time.

Starting in 2014, The Joint Commission will publish hospital rates for cesarean sections and episiotomies, but not rates for individual doctors. Patient access to individual doctors’ rates of cesarean section, early elective delivery, and episiotomy is likely to come in the future, Dr. Gilbert said, and insurers eventually may select physicians and reimbursement rates based on these outcomes.

"As an individual and as a hospital, we need to make sure we’re doing the best we can," he said.

Dr. Gilbert reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – One California community-based hospital got a head start on tracking core measures of quality in perinatal care that all U.S. hospitals will have to report to The Joint Commission beginning January 2014.

Over the past 2 years, the ob.gyns. found it wasn’t easy, but that tracking core measures of quality significantly improved perinatal care.

Sutter Medical Center in Sacramento, Calif., formed a perinatal data committee in 2010 to identify barriers and develop processes for tracking six quality measures, including the five for The Joint Commission. They worked to overcome doubters on their staff, internally published individual doctors’ rates of cesarean section deliveries and episiotomies, and shared the results for each prenatal obstetrics group.

John Milne/IMNG Medical Media

Their overall rate of elective deliveries at less than 39 weeks’ gestation decreased from 25% of the 4,958 deliveries in October 2010 to 2% of the 5,577 deliveries in December 2012. The cesarean section rate for nulliparous women with a term, singleton fetus in a vertex position dropped from 31% in 2010 to 25% in 2012, Dr. William M. Gilbert reported at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

They also improved significantly in two other core measures of quality mandated by The Joint Commission: The proportion of preterm infants who received antenatal steroids before delivery jumped from 80% to 100%, and the proportion of newborns who were fed exclusively breast milk during their entire hospitalization improved from 58% to 70%. The hospital has begun collecting data on a fifth core measure for The Joint Commission: the rate of health care-associated bloodstream infections in newborns.

Dr. Gilbert and his group also tracked two measures that are endorsed by the National Quality Forum but are not yet required by The Joint Commission. Their episiotomy rate decreased significantly from 5% to 2%, and the proportion of women undergoing cesarean section who received appropriate prophylaxis against deep vein thrombosis increased from 95% to 98% (Jt. Comm. J. Qual. Patient Saf. 2013;39:258-66).

"It took us 1-2 years to get the bugs worked out" in tracking core quality measures, said Dr. Gilbert, regional medical director of women’s services for Sutter Health’s Sacramento-Sierra Region, Sacramento, Calif. The effort required leadership from doctors and nurses, administrative and medical records support, and education for coders.

"If your hospital has done nothing to look at what you’re going to be submitting" to The Joint Commission, he added, "I can guarantee you that even if you think you’re doing great, the data are going to be awful, and you’re going to be scrambling to fix a problem that has occurred."

This kind of attention to quality measures in perinatal care is long overdue, he said. Despite the fact that the 4.2 million normal vaginal deliveries per year represent the No. 1 hospital discharge diagnosis in the United States, and studies show immense variation in perinatal practices between hospitals and geographical regions, efforts to measure the quality of hospital care largely have ignored obstetrics because those efforts have focused on Medicare, and few obstetrical patients are covered by Medicare.

Previous studies show a 10-fold variation in cesarean section rates around the country, and cesarean section rates in low-risk patients vary from 2% to 36%. "I would put to you, if you were making widgets or tanks, and you had such variation in the quality of your tanks that the government was paying for, you’d be out of work and probably in jail, but that’s what we tolerate" in health care, he said. Huge variations also have been reported in rates of induction, episiotomy, breastfeeding, and use of antenatal steroids.

The 40 ob.gyns. affiliated with Dr. Gilbert’s hospital had cesarean rates for nulliparous, term, singleton, vertex pregnancies ranging from approximately 8% to 60% when the tracking efforts began, he said. The committee assigned two-digit alphanumeric codes for each provider and posted individual rates of cesarean sections and episiotomies by provider code for 6 months, to start. It took a year of convincing before getting agreement, but then individual rates were posted in the doctors’ and labor and delivery lounges and were e-mailed to all medical staff.

"It’s amazing – amazing what that did," he said. Doctors with the highest cesarean section rates reduced their use of cesarean sections.

The category of elective deliveries at less than 39 weeks’ gestation excluded cases with medical indications for early delivery, but tracking ran into problems initially because ICD-9 codes did not exist for some exemptions, including prior classical cesarean section or prior myomectomy. "You got dinged for that" in the tracking despite the medical indication, he said. So the committee created tracking categories of "avoidable" and "unavoidable" early deliveries, and doctors didn’t get dinged for unavoidable cases.

Some doctors wrote the reason for early delivery as "intrahepatic cholestasis of pregnancy," which is an appropriate indication, but the medical coders told Dr. Gilbert that having the word "intrahepatic" flagged it as gall bladder disease, which is no reason to deliver early. "We had to work with our coders to help us understand," he said.

Every patient at risk of preterm delivery received antenatal steroids at his hospital, Dr. Gilbert said, "but we weren’t documenting it properly." There had been no uniform spot in the medical record to document administration of antenatal steroids, or to show that they had been given before the current hospitalization. Dr. Gilbert’s team worked with the medical records department to change the electronic health records. Nurses now check off if the patient received a full course of antenatal steroids. If this is missing, the doctor gets a pop-up window where a reason must be given.

"That really was effective," he said.

Tracking of episiotomy excluded cases of shoulder dystocia, but not episiotomy for fetal distress. Despite individual rates being internally publicized, the episiotomy rate seems to be stuck at around 2% because "I do have a couple of old-timers," he said. "Even public embarrassment will not get them to change."

"As an individual and as a hospital, we need to make sure we’re doing the best we can."

Capturing data on whether or not newborns are fed exclusively with breast milk can be difficult, in part because it’s often not clear whether the ob.gyn., the nursing staff, or the pediatrician is responsible for this. Dr. Gilbert’s team analyzed 18 cases at his hospital in which women came in saying they wanted to breastfeed the newborn exclusively, but that didn’t happen. In most cases, the babies received formula after a night nurse moved the baby to the nursery so the mother could sleep, a problem that was addressed. Publicizing exclusive breastfeeding rates for 20 different perinatal obstetrics groups – which ranged from 33% to 93% also helped improve breastfeeding rates.

The perinatal data committee also posted a color-coded "dashboard" showing trends in the hospital’s rates for all these measures over time.

Starting in 2014, The Joint Commission will publish hospital rates for cesarean sections and episiotomies, but not rates for individual doctors. Patient access to individual doctors’ rates of cesarean section, early elective delivery, and episiotomy is likely to come in the future, Dr. Gilbert said, and insurers eventually may select physicians and reimbursement rates based on these outcomes.

"As an individual and as a hospital, we need to make sure we’re doing the best we can," he said.

Dr. Gilbert reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert

SAN FRANCISCO – One California community-based hospital got a head start on tracking core measures of quality in perinatal care that all U.S. hospitals will have to report to The Joint Commission beginning January 2014.

Over the past 2 years, the ob.gyns. found it wasn’t easy, but that tracking core measures of quality significantly improved perinatal care.

Sutter Medical Center in Sacramento, Calif., formed a perinatal data committee in 2010 to identify barriers and develop processes for tracking six quality measures, including the five for The Joint Commission. They worked to overcome doubters on their staff, internally published individual doctors’ rates of cesarean section deliveries and episiotomies, and shared the results for each prenatal obstetrics group.

John Milne/IMNG Medical Media

Their overall rate of elective deliveries at less than 39 weeks’ gestation decreased from 25% of the 4,958 deliveries in October 2010 to 2% of the 5,577 deliveries in December 2012. The cesarean section rate for nulliparous women with a term, singleton fetus in a vertex position dropped from 31% in 2010 to 25% in 2012, Dr. William M. Gilbert reported at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

They also improved significantly in two other core measures of quality mandated by The Joint Commission: The proportion of preterm infants who received antenatal steroids before delivery jumped from 80% to 100%, and the proportion of newborns who were fed exclusively breast milk during their entire hospitalization improved from 58% to 70%. The hospital has begun collecting data on a fifth core measure for The Joint Commission: the rate of health care-associated bloodstream infections in newborns.

Dr. Gilbert and his group also tracked two measures that are endorsed by the National Quality Forum but are not yet required by The Joint Commission. Their episiotomy rate decreased significantly from 5% to 2%, and the proportion of women undergoing cesarean section who received appropriate prophylaxis against deep vein thrombosis increased from 95% to 98% (Jt. Comm. J. Qual. Patient Saf. 2013;39:258-66).

"It took us 1-2 years to get the bugs worked out" in tracking core quality measures, said Dr. Gilbert, regional medical director of women’s services for Sutter Health’s Sacramento-Sierra Region, Sacramento, Calif. The effort required leadership from doctors and nurses, administrative and medical records support, and education for coders.

"If your hospital has done nothing to look at what you’re going to be submitting" to The Joint Commission, he added, "I can guarantee you that even if you think you’re doing great, the data are going to be awful, and you’re going to be scrambling to fix a problem that has occurred."

This kind of attention to quality measures in perinatal care is long overdue, he said. Despite the fact that the 4.2 million normal vaginal deliveries per year represent the No. 1 hospital discharge diagnosis in the United States, and studies show immense variation in perinatal practices between hospitals and geographical regions, efforts to measure the quality of hospital care largely have ignored obstetrics because those efforts have focused on Medicare, and few obstetrical patients are covered by Medicare.

Previous studies show a 10-fold variation in cesarean section rates around the country, and cesarean section rates in low-risk patients vary from 2% to 36%. "I would put to you, if you were making widgets or tanks, and you had such variation in the quality of your tanks that the government was paying for, you’d be out of work and probably in jail, but that’s what we tolerate" in health care, he said. Huge variations also have been reported in rates of induction, episiotomy, breastfeeding, and use of antenatal steroids.

The 40 ob.gyns. affiliated with Dr. Gilbert’s hospital had cesarean rates for nulliparous, term, singleton, vertex pregnancies ranging from approximately 8% to 60% when the tracking efforts began, he said. The committee assigned two-digit alphanumeric codes for each provider and posted individual rates of cesarean sections and episiotomies by provider code for 6 months, to start. It took a year of convincing before getting agreement, but then individual rates were posted in the doctors’ and labor and delivery lounges and were e-mailed to all medical staff.

"It’s amazing – amazing what that did," he said. Doctors with the highest cesarean section rates reduced their use of cesarean sections.

The category of elective deliveries at less than 39 weeks’ gestation excluded cases with medical indications for early delivery, but tracking ran into problems initially because ICD-9 codes did not exist for some exemptions, including prior classical cesarean section or prior myomectomy. "You got dinged for that" in the tracking despite the medical indication, he said. So the committee created tracking categories of "avoidable" and "unavoidable" early deliveries, and doctors didn’t get dinged for unavoidable cases.

Some doctors wrote the reason for early delivery as "intrahepatic cholestasis of pregnancy," which is an appropriate indication, but the medical coders told Dr. Gilbert that having the word "intrahepatic" flagged it as gall bladder disease, which is no reason to deliver early. "We had to work with our coders to help us understand," he said.

Every patient at risk of preterm delivery received antenatal steroids at his hospital, Dr. Gilbert said, "but we weren’t documenting it properly." There had been no uniform spot in the medical record to document administration of antenatal steroids, or to show that they had been given before the current hospitalization. Dr. Gilbert’s team worked with the medical records department to change the electronic health records. Nurses now check off if the patient received a full course of antenatal steroids. If this is missing, the doctor gets a pop-up window where a reason must be given.

"That really was effective," he said.

Tracking of episiotomy excluded cases of shoulder dystocia, but not episiotomy for fetal distress. Despite individual rates being internally publicized, the episiotomy rate seems to be stuck at around 2% because "I do have a couple of old-timers," he said. "Even public embarrassment will not get them to change."

"As an individual and as a hospital, we need to make sure we’re doing the best we can."

Capturing data on whether or not newborns are fed exclusively with breast milk can be difficult, in part because it’s often not clear whether the ob.gyn., the nursing staff, or the pediatrician is responsible for this. Dr. Gilbert’s team analyzed 18 cases at his hospital in which women came in saying they wanted to breastfeed the newborn exclusively, but that didn’t happen. In most cases, the babies received formula after a night nurse moved the baby to the nursery so the mother could sleep, a problem that was addressed. Publicizing exclusive breastfeeding rates for 20 different perinatal obstetrics groups – which ranged from 33% to 93% also helped improve breastfeeding rates.

The perinatal data committee also posted a color-coded "dashboard" showing trends in the hospital’s rates for all these measures over time.

Starting in 2014, The Joint Commission will publish hospital rates for cesarean sections and episiotomies, but not rates for individual doctors. Patient access to individual doctors’ rates of cesarean section, early elective delivery, and episiotomy is likely to come in the future, Dr. Gilbert said, and insurers eventually may select physicians and reimbursement rates based on these outcomes.

"As an individual and as a hospital, we need to make sure we’re doing the best we can," he said.

Dr. Gilbert reported having no financial disclosures.

[email protected]

On Twitter @sherryboschert