PQCNC 2024…How We Got Here

and How We Get There

Making North Carolina the Best Place to Give Birth and Be Born
 PQCNC Value Equation
• Partnership with patients and families
• Spread best practice
• Identifying and reducing disparities
• 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 Administrators
– Lactation consultants, Infection Control, Case Managers, SW
• North Carolina Medicaid/DHB
• DPH (Womens and Childrens, State Center for Health Stats, Vital Statistics)
• Other Payers (BCBSNC)
• Multiple medical organizations (NC ACOG, NC AWHONN, NC Ob Gyn, NC Peds, NC Midwives, NC FP)
• Major Healthcare Systems (ECU, Novant, Atrium, Cone, WakeMed, UNC, Duke, Catawba Valley)
• State Legislators
• Child Fatality Task Force
• NC Hospital Association
• Perinatal Nurse Champions
• NC Matters
• March of Dimes
 PQCNC From 50,000 Feet (2009-2024)
• Central-Line Associated Blood Stream Infections (CABSI) 11 NICUs
• Reducing Early Elective Deliveries (39 weeks) 33 Hospitals
• Support for Intended Vaginal Birth (SIVB) 34 Hospitals
• Exclusive Breastmilk in the NICU and Nursery 42 Hospitals
• Neonatal Abstinence Syndrome (NAS) 31 Hospitals
• Screening for Critical Congenital Heart Disease (CCHD) All Hospitals
• Conservative Management of Preeclampsia (CMOP) 24 Hospitals
• Obstetric Hemorrhage (AIM) 65 Hospitals
• Antibiotic Stewardship for Neonatal Sepsis (ASNS) 47 Hospitals
• Primary Cesarean Section Reduction (AIM) 52 Hospitals
• Newborn Hypoglycemia (NHPC) 54 Hospitals
• Birth Certificate Accuracy
• Comprehensively Lessening Opioid Use Disorder Impact on Moms and Babies (AIM) 54
Hospitals
• Cardiac Care in Obstetrics (AIM) Pilot with 3 Centers
• Sepsis in Obstetrics (AIM) 42 Hospitals
• Care of the Late Preterm Infant 53 Hospitals
 PQCNC Work: At the Ground Level
• Conservative Management of Preeclampsia (CMOP) (2014-2016)
• 32 % reduction in non-indicated deliveries for mothers with only gestational
hypertension or preeclampsia without severe features
• Avoiding 156 non-indicated preterm births annually in this collaborative group
• Estimated annual cost avoidance $3.9M using conservative gestational age estimates
and Tricare DRG Payment calculator at www.health.mil/drg
• Antibiotic Stewardship and Newborn Sepsis (ASNS) (2018)
• Eliminated antibiotic exposure for 792 NBN babies annually
• Reduced continuation of antibiotics after 48 hours of negative cultures for 110 NBN
babies
• Reduced NICU antibiotic days by 22%, 442 days a month or 5,304 annually
• Ended antibiotic exposure after negative cultures at 48 hours for an additional 27
NICU infants per month, 324 annually.
• Trend to reducing continuation of antibiotics after 48 hours in 22-31 week infants by
36%...avoided antibiotic continuation in 72 infants < 31 week infants per year.
 PQCNC Work: At the Ground Level
• Newborn Hypoglycemia Prevention and Treatment (NHPC) (2019)
• Introduced standardized weaning protocols for IVF in the NICU
• Introduction of glucose gel statewide
• Reduction in length stay of 48 hours for 1056 NICU babies
• Avoided 2112 NICU days, estimated cost avoidance of $4.2M
• Reducing the Primary CS Rate (RPC) (2019-2020)
• 60% of deliveries in the state
• Collaborative CS rate reduced from 25% to 22%
• Eliminated estimated 756 Primary CS each year
• Cost avoidance estimated $3.8 M each year
 PQCNC Work: At the Ground Level
• Maternal Patients in clOUDi (2021-2023)
• 1% of maternal patients with OUD
• 1021 identified by validated verbal screening in clOUDi
• 330 mothers accepted referrals for treatment
• Referral rate increased over clOUDi from 25-45%
• Depression screening 26% in Jan ’23, 54% in August ‘23
• Naloxone at discharge for all moms…0% in Jan ‘23…12% in August ‘23
• Newborn Patients in clOUDi (2021-2023)
• 1% of newborn patients with NASNOWS
• Formal education regarding NAS/NOWS infant care pre-delivery: 65% to 90%
• ESC as methodology: 40% to 90% of hospitals
• Transfer of infants requiring narcotics for NOWS decreased 25% to 10%
• ALOS reduced from 21 (Finn) to 17 (ESC) days for NOWS in NICU
 Strengthening Partnerships
• Medicaid/DHB
• Continued financial support
• Pediatric and Maternal Advisory Groups to assist Medicaid re transition issues
• Maintain the PMH CCNC regional obstetrical leadership
• RSV prophylaxis
• Partnering to access data key to AIM projects (Severe Maternal Morbidity)
• Approval of payment for three prenatal high risk screens
• Impact? 11% with a known prenatal screen Jan 1.0 to 43% in August 3.0
• DCRI
• Data partnership to prep and advise re publications
• Prep of quarterly DHB reports
• Translation and formatting of SMM data
• NNPQC
• Regional QI collaboration being discussed with PQCs in VA, TN, AL, GA, FL.
 PQCNC AIM Leadership
(Alliance for Innovation on Maternal Health)
• PQCNC was approved as state AIM lead organization in 2017 by AIM national leadership
• AIM is a HRSA/ACOG sponsored national program, now includes 49 states.
• NC AIM team
• DMA
• DPH
• NC Ob GYN
• NC AWHONN
• NC ACOG
• NC Midwives
• NC FP
• NCHA
• AIM Initiatives
• 39 Weeks (2009), Primary CS (2010-2012) pre-AIM
• CMOP…Hypertensive Disorders in Mothers
• Obstetrical Hemorrhage (OBH)
• Safely Reducing the Primary CS Rate (RPC)
• Opioid Use Disorder (clOUDi)
• Cardiac Care in Obstetrics
• Sepsis in Obstetrics
 PQCNC Leads AIM in North Carolina
• Critical element of AIM is state level discharge abstract data reported as
Severe Maternal Morbidity (SMM)
• 21 hospital ICD codes for 21 indicators to identify delivery hospitalizations with SMM
• Renal failure, MI, DIC, eclampsia, heart failure, shock etc.
• This data received by state PQCs and transmitted to AIM TC for
benchmarking and review by individual hospitals, all deidentified
• Offers PQCNC teams opportunity to track vital outcomes seamlessly
• Green data
• Reduce data collection for centers, focus on PDSA cycles and improvement
• Allows PQCNC a means to better sustain prior initiatives
• PQCNC has worked for 7 years to get this data
• Legislation passed in 2023 with support of DHHS/DHB gave us this access
• We are now receiving this data from DPH
 PQCNC Leads AIM in North Carolina
• The data we are now receiving from DPH needs to be reviewed, translated
and transmitted to the AIM TC
• In 2023 we applied for and were awarded a HRSA/AIM Capacity Building
Grant
• 4 year grant to develop and build on our new access to hospital level SMM data.
• Gratitude for support letters from DHB, DPH, NC Ob Gyn Society, NC AWHONN, and
leaders in our largest systems in NC
• This SMM data will report on key measures for Sepsis and Cardiac Care
• We also propose to explore this data set beyond SMM data
• Develop a Newborn Morbidity Measure to assist hospitals in improving care
delivered to newborns
 So How Did We Get Here?
• Multiple state partners committed to making North Carolina the best place
to give birth and be born have supported and steered PQCNC
• A determined PQCNC core team on a mission to recruit, coach, facilitate
and mentor PQCNC Perinatal Quality Improvement Teams (PQITs)
• High touch projects which PQCNC members identify, present and select
• JC measures
• MOC
• CMS Birthing Friendly designation
• Payment incentives
• Voluntary, tireless PQITs committed to improving care in their hospital
• No mandates for hospitals to join these initiatives
• Hospital supports personnel
 The PQCNC 2023 QI Award Winner
• Regular participant in Initiatives since 2009
• Selected for outstanding clOUDi work
• Through their use of PDSAs
• Expanded their PQIT to include pharmacy and are moving forward with
offering Naloxone to maternal patients at discharge
• Have navigated initial physician resistance to Naloxone distribution
• Used patient feedback to updates NAS and safe sleep education
• 100% screening of maternal patients since January 2022
• 100% of maternal patients with OUD receive education re care NAS/NOWS
• 100% referral rate for mothers with OUD since
How Will We Get There?
PQCNC 2024
 Report from NNPQC
• CDC National Network Perinatal Quality Collaboratives (PQCs) 2023
• Breakout sessions focused on challenges to PQCs
• How can PQCs in states without legislative or payer mandates encourage voluntary
hospital participation?
• More focus on hospital executive leadership…JC Measures, Birthing Friendly, Blue Distinction
• Emphasizing executive uplink for hospital teams
• Demonstrate success….publications, site visits, media
• Convincing health systems they need PQCs
• Overcoming centralization of QI
• Recognizing the importance of subsidiarity…tailoring QI locally…the PQC wheelhouse
• Team construct is a key to success
• Recruiting patient and family partners
• Challenging to get docs to lead initiatives locally (especially inpatient/outpatient)
• Supporting local team leaders challenging culture
• Data collection often stalls teams…simplify data, green data
The Double Edged Data Sword:
Waiting on an EMR Friend?

• Dats is needed, but the data is not

THE work
• Data supports the work
• The EMR can be good
• The EMR can be bad when we do
nothing while waiting in the queue for
adding a new data field to the EMR
 Can We Partner Better With Patients and
Families?

• Overcoming stigma & prejudice

• “Its hard to find patients or families.”
• System barriers…HIPPA, other training
• Creating safe environment where input
valued

Breaking prejudices
• Follow AAP guidelines
• Breastfeeding is an evidence based practice that reduces withdrawal
symptoms
• Mothers with marijuana unable to breastfeed
 Addressing Disparities
• PQCNC initiatives seek to identify disparities based on race & payer
• Published on disparities in ANS use
• Bias and stigma training
• Conversation with PQITs to address potential causes
• In clOUDi we note, as have others, disparities in black and Hispanic patients
vs white patients in accepting treatment referrals
• 21%, 33% and 54%
• Causes identified include workforce shortage, access and cost of care, discrimination,
and fear of the child protection system
• Topic weekly emails, monthly coaching meetings and quarterly learning sessions
• Monitor for disparities in upcoming initiatives
How Do We Get There?
 How Will We Get There?
• PQCNC exists to support hospital and clinic teams as they pursue
excellence
• Achieving this requires accountability on the part of PQCNC and
Perinatal Quality Improvement Teams (PQITs)
• To this, PQCNC constantly evolves its approaches to supporting teams
• 2023 saw us revamp and standardize monthly coaching calls
• Meeting as PQITs, not individuals
• Teams present their Leadership Report
• Process and outcome measure progress
• Identification of successes and opportunities
• PDSAs identified
 How Will We Get There?
• In 2024 at enrollment we have requested
• Team roster
• Completion of pre-work
• Completion of facility snapshot
• Attendance at meetings by at least 2 team members
• We will continue to conduct monthly coaching calls as Team Leadership
Report Updates
• We as the Core Team are available to go anytime, anywhere, to talk with
anyone to support our teams
• Sepsis and Care of the Late Preterm are ideal projects to support the
creation of even stronger teams
• Use AIM data to guide facilities and reduce data collection burden
• Focus on identifying opportunities to improve care
• Implementing PDSAs, small tests of change
• MOC Credit for Boards…attendance at least 1 in person meeting
 PQCNC Core Team Accelerates:30-60-90
• 30 Day Review
• Team formation
• Data acquisition and submission
• Identifying opportunities
• Conducting PDSAs
• 60 Day Review
• Team formed
• Data submitting
• PDSA underway
• 90 Day Review
• PDSA evaluated, action taken
• Next opportunity and PDSA identified
Culture
Alone we can do
so little, together we
can do so much.
Helen Keller