Pregnancy and Related
Conditions Quality Measures
Benchmark Data:
Core Measures
Agency for Healthcare Research and Quality
National Perinatal Information Center
Project Aim
Improve the PREGNANCY AND RELATED
CONDITIONS CORE MEASURES, AHRQ
and NPIC quality measure performance,
attaining UHC median performer status and
then progress to UHC BEST PERFORMER
Committee:
S.Swanson RN; J.Gianopolous, MD;
R.Beisinger, MD; E.Carroll, MD;
M.Weiss, MD; G.Adams, RN;
M.Chybik, RN; M.Wall, PharmD;
M.Davey, RN; P.Downing, RN;
C.LaPorte, RN; E.Trulis, RN
Barriers and Actions
No internal champion
Meeting chaired by AD; case
managers lead work for area
Risk adjustment poorly
understood
Reviewed indicators and
defined in packets
Benchmark data
reviewed in aggregate
9-12 months after care
Case review information for
cases included in the most
recent data included in
meeting packet
Improvement impact
slow to be seen and
hard to track
Review expanded to current
charts looking for
improvement and continuing
issues.
4
3
5
Reviewed definitions
6
Quarter
2
LUMC Observed Third and Fourth Degree Laceration Rate
LUMC Expected Third and Fourth Degree Laceration Rate
Documentation education
Chart review by physician with
feedback communication with coding
Concurrent chart review
Restructured meetings to have chart
review data available for discussion
Meeting chaired by AD
Case manager role defined
Percent
Core Measures
Third or Fourth Degree Laceration
AHRQ Patient Safety & Quality Indicators
Obstetric trauma - vaginal delivery without instrument
4
2
LUHS Rate
UHC Ninetieth Percentile
UHC Median
UHC Tenth Percentile
Quarter (Number of LUMC cases)
This information is confidential and to be used for quality improvement purposes only
Documentation education
Chart review by physician with
feedback communication with coding
6
Concurrent chart review
8
Restructured meetings to have chart
review data available for discussion
Rate per 100 cases
10
Reviewed definitions
12
Meeting chaired by AD
Case manager role defined
14
AHRQ Patient Safety & Quality Indicators
Rate per 100 cases
20
15
10
LUHS Rate
UHC Ninetieth Percentile
UHC Median
UHC Tenth Percentile
Quarter (Number of LUMC cases)
This information is confidential and to be used for quality improvement purposes only
Documentation education
25
Chart review by physician with
feedback communication with coding
30
Restructured meetings to have chart
review data available for discussion
Meeting chaired by AD
Case manager role defined
35
Reviewed definitions
40
Concurrent chart review
Obstetric trauma - vaginal delivery with instrument
Began review of all mortality
for co-morbidity accuracy
Developed mechanism
to capture birth weights
60
Worked with JCAHO to
redefine measure criteria
80
40
20
LUMC Observed Neonatal Mortality Rate (150g - 999g)
LUMC Expected Neonatal Mortality Rate (150g - 999g)
Quarter
Reviewed documentation of
living cohort for accurate
co-morbidity capture
Worked with fellow to
maintain full problem list
Percent
Core Measures
Neonatal Mortality (Birth Weight Range 150g - 999g)
100
AHRQ Patient Safety & Quality Indicators
Birth trauma - injury to neonate
1.2
Chart review
definition clarification
Rate per 100 cases
1.0
0.8
0.6
Communication with Coders
1.4
0.4
0.2
0.0
LUHS Rate
UHC Ninetieth Percentile
UHC Median
UHC Tenth Percentile
Quarter (Number of LUMC cases)
This information is confidential and to be used for quality improvement purposes only
Next Steps
Utilize UHC coding expertise to identify issues with
injury to neonate.
Continue concurrent chart review for timely
feedback and awareness of practice.
Review a neonatal cohort to assess accuracy of
complications/co-morbidity capture for risk
assessment of surviving cases.
Work with physicians to maintain comprehensive
documentation to facilitate accurate risk capture.
Enhance EPIC use to capture necessary data.
Incorporate education of coders/residents into
orientation to obtain/maintain gains.