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Transforming Perinatal Care:

PQCNC
Making North Carolina the best place to give
birth and be born!

Martin J McCaffrey, MD, CAPT USN (Ret)


Director Perinatal Quality Collaborative of North Carolina (PQCNC)
For the Perinatal Quality Collaborative of North Carolina
martin_mccaffrey@med.unc.edu
984 974-7852
Why Support QI
and Collaboration?
The Role of Quality Improvement

1. Empirical studies that control context …but we live in a world of context!


2. The processes, habits and traditions of local care.
3. Special types of measurement & techniques that include time in the
analysis, as all improvement involves change over time
4. “+”: Employ modalities, including standardization & forcing functions to
apply and adapting generalizable evidence to context
5. The “→” symbol represents the knowledge required for execution—what
you need to know to “make things happen”, the organizational drivers of
change in a particular place.

Batalden PB and Davidoff F. What is "quality improvement" and how can it transform
healthcare? Qual Saf Health Care. 2007;16(1):2-3.
Context and Unexplained Variation:
PQCNC QI Focus
• People
• Expertise
• Communication
• Leadership
• Practices and processes
• Standardization & Compliance
• Technology
• Unit & Hospital
• Organizational structure
• Finances, Volume, Staffing
• Culture
• Beliefs, empowerment, behaviors
• Chain of command
Mission
PQCNC Value Equation
• Partnership with patients and families
• Spread best practice
• Resource optimization
At the PQCNC Table
• Patients and Family Members
• Perinatal providers (65 Hospitals)
• Nurses (Peds, NICU, & OB)
• Practitioners
• Midwives
• Doctors (OB, MFM, Neos, Peds, FP)
• Hospital Executive Leaders
• Lactation consultants, Infection Control, Case Managers, SW
• DPH (Womens and Childrens, State Center for Health Statistics)
• Payers (Medicaid, BCBSNC)
• ORHCC
• State Legislators
• March of Dimes
• NC Hospital Association
• CCNC
PQCNC Core Team

• Project Manager: Keith Cochran (1.0 FTE)


• Clinical Initiative Managers: Susan Gutierrez and Jodi DeJoseph each
1.0 FTE
• Obstetrical Leader: Arthur Ollendorff, MD (0.2FTE)
• Statistical Support: DCRI, Rachel Greenberg MD (0.2 FTE)
• Director: Marty McCaffrey, MD (0.4 FTE)
• Medical Anthropologist (in process) (0.5 FTE)
PQCNC Initiatives-Past, Current and
Future
• Central-Line Associated Blood Stream Infections (CABSI)
• 39 weeks
• Support for Intended Vaginal Birth (SIVB)
• Patient-Family Engagement (PFE)/Patient-Family Engagement
• Exclusive Breastmilk in the NICU and Nursery Key
Past
• Conservative Management of Preeclampsia (CMOP)
Current
• Neonatal Abstinence Syndrome (NAS) Future
• Screening for Critical Congenital Heart Disease (CCHD) Maternal Projects

• Antibiotic Stewardship for Neonatal Sepsis


• Obstetric Hemorrhage (AIM)
• Cesarean Section Reduction (AIM)
• Newborn Hypoglycemia
• Birth Certificate Accuracy
• Next Project…2020?
Conservative Management of Preeclampsia
(CMOP) Data Summary

66% reduction

Rose to 80%

• 23 centers with 42% of deliveries


• 145 deliveries annually
• Hospital cost avoidance $2,374,320 using
Tricare calculator (infants 1500-2500
grams)
• Pro fees not included (estimate $474,866)
18% increase • Increasing use of ANS for infants
requiring delivery at < 34 weeks (from
71% to 85%) impact on reducing RDS,
IVH, and NEC.
• Increasing treatment of HTN moms within
1 hour from 68% to 80%...impact on
stroke, abruption, ICU admits mothers
AIM: Alliance for Innovation on Maternal
Health
NC AIM
• Led by PQCNC
• Leadership team includes NC OB GYN, NC ACOG, NC AWHONN,
NCHA, NC Medical Society, NC IOM, DPH, NC BCBS, DMA
• Participation requires commitment of a team at a minimum including
OB and nursing champion linked to executive leadership
• Improvement is guided by the team using process and outcome data
• Hospital team supported by PQCNC identifies opportunities to
improve care and evaluate impact
• Data sources are hospital administrative data and PQCNC reports
developed by the Expert Team
• AIM Data (Standardized Maternal Morbidity Ratio: SMM developed
by CDC)
• Advantages
• Challenges
Goals of the OBH Project
• Demonstrate 100% compliance with the all AIM
OBH structure metrics
• Demonstrate 98% percent of women have a
hemorrhage risk assessment recorded in the
medical record prior to giving birth
• Decrease by 33% the total units of packed red blood
cells transfused to patients who deliver
• Decrease by 25% the severe maternal morbidity
(SMM) for hemorrhage at the state level
AIM OBH Participating Sites

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Alamance Harris Regional Pardee
Cape Fear Valley Haywood County Park Ridge
Carolina East (Craven) High Point Regional Randolph
CHS Blue Ridge Iredell Rex Hospital
CHS Cleveland Lake Norman Regional Sampson
CHS Lincoln Lenoir Scotland
CHS Northeast Marla Parham Sentara Albermarle
CHS Pineville Martin General Southeastern Health Birth Centers
CHS Stanly McDowell UNC Baby + Co. (Cary)
CHS Union Mission Vidant Baby + Co. (Charlotte)
CHS University Nash General Vidant Beaufort Baby + Co. (Winston-Salem)
CMC-Main New Hanover Vidant Chowan Natural Beginnings (Statesville)
Carteret Northern Hospital Surry Vidant Duplin Women’s Birth and Wellness (Chapel Hill)
Catawba Valley Novant Forsyth Vidant Edgecombe WNC Birth Center (Asheville)
Columbus Regional Novant Huntersville Vidant Roanoke
Cone Women’s Novant Matthews Wake Med
Davis Regional Novant Presbyterian Wake Med-Cary
Duke Regional Novant Rowan Wake Med North
Duke University Novant Thomasville Wayne Memorial
First Moore Regional Outer Banks Regional
Halifax Regional Onslow Memorial
OBH Measures
3.0%
2.5%
2.0%
1.5%
1.0%
0.5%
0.0%
Jan
Sept

Sept
Oct
Nov

Oct
Nov
July
May
April

Aug
March
Dec

Dec
Feb

June

Percent of teams with 50% of patients with Percent of teams reporting 100%
documented QBL documentation of OBH risk assessment
and QBL
Antibiotic Stewardship Newborn Sepsis

• 49 Total teams in 43 hospitals


• Total of 46,480 deliveries in these hospitals over the collaborative period
• 38% of all live births in NC in 2017
• Total of 13,526 NICU admissions (Jan-Dec)
• 681 infants in NBN treated with antibiotics (Jan-Dec)
• 3791 infants in NICUs treated with antibiotics (Jan-Dec)
Birth Certificate Accuracy
• Inspired by CMOP and OPQC work
• Partnership with Vital Records, SCHS and PQCNC
• NCGA funded
• Eight pilot hospitals in Triangle area
• Randolph, WakeMed, WakeMed North, WakeMed Cary, Rex, Duke
Regional, Duke, Central Carolina,
• Approximately 18% of state births
• Goals
• Support efficient and accurate birth information collection in 100% of sites
• Develop a sustainable internal auditing process for data verification at all
sites
• Achieve at least 80% reporting accuracy for all 11 dashboard variables
based on chart audits
• Implement consistent on-boarding practices for new hires and ongoing
training in all sites
Birth Certificate Accuracy
• Birthweight
• Trial of Labor
• Antenatal
Steroids
• Induction of
Labor
• Breastfeeding
at Discharge
• Maternal
HTN
• Previous CS
• Gestational
Age
• Antibiotics
for NB
• Prior Preterm
Del
• Fetal
Presentation
Newborn Project: Newborn Hypoglycemia
Care and Prevention (NHCP)

• Effects 10-15% of newborns


• Teams can standardize care in & across hospitals
• Bring hospital Newborn and NICU teams together
• Reduce separation of mom and baby
• Support breastfeeding and skin to skin care
• Explore newer therapies like glucose gel
• Limit transfers to NICUs
• If recruit all hospitals in NC impact 12,000 (10%) babies & mothers
• If 10% of these infants require IVF and NICU/SCN transfer, we can
potentially avoid 50% of these transfers (500 infants and 1000 NICU
days)
NHCP Action Plan
• Implement a protocol for management and care of symptomatic
newborns > 35 weeks with hypoglycemia and asymptomatic
newborns at risk for hypoglycemia in 100% of participating hospitals
• Decrease the number of newborn transfers to a higher level of care
by 25% solely for the diagnosis of hypoglycemia
• Decrease non-breastmilk supplementation for hypoglycemia by 20 %
• Decrease the number of IV infusions for hypoglycemia by 25%
• Monitor use of weaning protocol to decrease duration of IV infusion
• Systematize clinical care processes of symptomatic newborns with
signs and symptoms of hypoglycemia and asymptomatic newborns
at-risk for hypoglycemia to promote sustainability
• 54 hospitals enrolled
Safely Reducing the Primary CS Rate (RPC)
NC AIM

Unadjusted Primary C/S Rate


40

35

30

25

20

15

10

<200 Primary Deliveries


>1000 Primary Deliveries
Variation in NTSV Rates Among Provider Groups
at a NC Hospital

NTSV by Practice (Q1-Q3 2017)


40

35

30

25

20 Healthy People 2020 Goal

15

10

0
Safe Reduction of Primary Cesarean Birth
(RPC) Initiative
• Statewide QI project to work with all birthing units in NC to
decrease unnecessary primary Cesarean Sections and maintain or
improve the health of the mother and newborn
• Expert team has developed specific goals for the project
• Demonstrate 100% compliance with all AIM RPC structure metrics
• https://pqcnc-documents.s3.amazonaws.com/aimrpc/PQCNCAIMRPCActionPlanFINAL20180905.pdf
• Ensure that all NTSV women having a Cesarean Section have met the
ACOG/SMFM Cesarean Criteria for abnormal labor
• Achieve a statewide NTSV Cesarean rate at or below 20.0% and have
each hospital with an NTSV Cesarean rate at or below the Healthy People
2020 goal of 23.9%
• Demonstrate no change in newborn outcome by route of delivery
measured by 5-minute Apgar score < 7 and admission to the NICU
stratified by reason for admission
• 53 hospitals enrolled
Invitation to the PQCNC

• Currently 53 hospitals signed up for RPC


• Currently 53 hospitals signed up for NHCP
• DMA and BCBS NC supporting both these initiatives
• Still recruiting
• Info at
• https://www.pqcnc.org/node/13902 for RPC
• https://www.pqcnc.org/node/13901 for NHCP