1. ELIMINATING EARLY ELECTIVE DELIVERIES 1 HRET-FHA HOSPITAL ENGAGEMENT NETWORK (HEN) DATA OVERVIEW September 24, 2012

2. HOSPITAL ENGAGEMENT NETWORK Data Requirements HRET’s Comprehensive Data System (CDS) Overall hospital data Enter numerator & denominator No patient level data Requirement- per focus area One process measure One outcome measure Minimize data entry time burden Entering only 4 numbers in CDS! 1

3. HOSPITAL ENGAGEMENT NETWORK Data Requirements HRET’s Comprehensive Data System (CDS) CDS Encyclopedia of Measures OB Measures: #40-55 May define your own measure & submit it Submit baseline data Preferably prior to 2012 Flexible- baseline can be 1, 3, 6 or 12 months Submit monitoring data monthly (CDS) Submit monthly Progress Report (FHA) 2

4. HOSPITAL ENGAGEMENT NETWORK OB Process Measures- Examples Elective deliveries at >=37 weeks and <39 weeks (EED) Antenatal Steroids DVT Prophylaxis- C-Section OB Outcome Measures- Examples C- Section delivery rate Elective Births <39 week births admitted to the NICU 5 Minute Apgar 39 weeks Neonatal Mortality rate 3

5. HOSPITAL ENGAGEMENT NETWORK CMS Required Reporting- EED All hospitals must report EED rates Final Rule posted August 1, 2012 Data collection begins January 1, 2013 Payment Determination FY 2015 Hospital must report zero if no OB Using the Joint Commission measure PC-01 (EED) Same measure the HEN is using in the CDS Measure #40 in the CDS Encyclopedia of Measures 3

6. Comprehensive Data System HRET’s project data collection system –Web-based –Secure –Flexible https://www.hretcds.org/ 4

7. CDS ENCYCLOPEDIA OF MEASURES 40OBElective Deliveries at >=37 Weeks and <=39 Weeks (JC PC 1) Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed 41OBAntenatal Steroids (JC PC 3)Patients at risk of preterm delivery at 24-32 weeks gestation receiving antenatal steroids prior to delivering preterm newborns 42OBDVT Prophylaxis - C-Section (OB)Measures adherence to current ACOG, SMFM recommendations for use of DVT prophylaxis in women undergoing cesarean delivery 43OBC-Section Delivery Rate (JC PC 2) Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section 44OBElective <39 Week Births Admitted to NICU (March of Dimes) Number of infants admitted to the NICU or transferred to another hospital for care after a scheduled elective induction/ cesarean section between 37 0/7 and 38 6/7 weeks. 5

8. Aim: (Including your How Good and By When statement) Why is this project important?: Aim Statement Changes being Tested, Implemented or Spread Recommendations and Next Steps Lessons Learned Run Charts For each listed change, indicate whether it is being tested (T), Implemented (I) or Spread (S) (Enter summary here) Enter summary here (what do you need from Executive Project Champion, sponsor at this time to move project?) Recommendations Next Steps for testing Project Title _______________ ( Name of Project Champion and Senior Leader Sponsor) © 2012 Institute for Healthcare Improvement Team Members (Names & Roles) Make fonts large, title, labels, dates and notes very simple on graphs prior to shrinking graphs. Should be able to fit 6-8 readable graphs here. If no data are available for a particular measures either create “empty” run list the name of the measure(s) to be collected. Self Assessment Score (1-5) = _____ Date:________

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10. HOSPITAL ENGAGEMENT NETWORK Progress Report 8

11. SUMMARY Implement improvement teams –Rapid Cycle: Small test of change Submit data monthly to CDS –One process measure (EED) and one outcome measure Participate in webinars, calls, meetings, etc. Submit progress reports Collaborate with other facilities Celebrate success!! 9

12. HOSPITAL ENGAGEMENT NETWORK Contacts Sally Forsberg RN, Director of Quality & Patient Safety (407) 841-6230, sally@fha.orgsally@fha.org Kim Streit, VP/Healthcare Research & Information Services (407) 841-6230, kims@fha.orgkims@fha.org Martha DeCastro, VP/Nursing (850) 222-9800, martha@fha.orgmartha@fha.org 10