the california maternal data center (cmdc): resources for ...€¦ · ob trauma (3/4th...

The California Maternal Data Center (CMDC):

Resources for your Perinatal Safety Program

Southern California Patient Safety First Collaborative

Anne Castles Project Manager, CMDC

acastles@cmqcc.org

: 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

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: 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

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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.

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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%

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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

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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

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California Maternal Data Center

WebEx Demonstration

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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

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California Maternal Data Center

WebEx Demonstration

PSF and Cal-HEN Reporting

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Hospitals can authorize CMQCC to transfer data to PSF or Cal-HEN on their behalf

Uploading Supplemental Data Files

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Cal-HEN Release Finalized

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Monthly Approvals of Cal-HEN data

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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

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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 acastles@cmqcc.org 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

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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

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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

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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

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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

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Data Edit Tool: to allow fixing of data prior to submission

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Two Security Gates