1. Reaching the Best for Florida’s Mothers & Babies
William M. Sappenfield, MD, MPH, CPH
Professor & Director
Florida Perinatal Quality Collaborative
USF College of Public Health

2. Conflicts of Interest
No conflicts of interest to report.

3. Learning Objectives
Explain why quality improvement efforts in maternity care are needed in Florida.
Learn how quality improvement initiatives and standardization can improve clinical care.
Understand that active participation in multi- hospital quality initiatives can have a larger impact.
Discuss the potential future directions for quality improvement efforts.

4. Why is QI in maternal health care needed in Florida & the U.S.?

5. Florida Health Rankings
Category
State Rank
Florida
Leading States
Health Spending
25th
$8,076
$5,982
Infant Mortality
24th
5.8 /1,000
3.7 /1,000
Preterm Delivery
33rd
10.2 /100
7.8 /100
Maternal Mortality
38th
23.8 /100,000
4.5 /100,000
Cesarean
47th
34.7 /100
22.3 /100

6. US Health Rankings Category Country Rank US Leading Peers
Health Spending
36 of 36
$9,892
$4,500
Infant Mortality
30 of 39
5.8 /1,000
2.5 /1,000
Maternal Mortality
39 of 40
14 /100,000
3 /100,000

7. Mothers Assessed for Hemorrhage Risk at Admission, July-August 2013 31 FPQC OHI Hospitals

8. The Law of Diffusion of Innovation
Early Adopters
13.5%
Early Majority
34%
Late Majority
Laggards
16%
Source: E.M. Rogers, 1962

9. Percent Treated Within 1 hour with Acute Onset Maternal Hypertension, July-August, FPQC HIP Hospitals
Mothers
Hospitals

10. NTSV Cesarean Deliveries
Percent of All Low Risk Cesarean Deliveries Performed that Met Criteria, July-Sept, PROVIDE Hospitals
Met Criteria
NTSV Cesarean Deliveries

11. Why do we need Perinatal Quality Improvement Efforts?

12. Why Not Follow Practice Guidelines?
Don’t Know
Know
Unintentional Error
Intentional Error
Inadequate Education
System Complexity
Misaligned Incentives

13. Why Not Follow Practice Guidelines?
Don’t Know
Know
Unintentional Error
Intentional Error
Inadequate Education
System Complexity
Misaligned Incentives
Quality Improvement
Align Incentives

14. Florida Pregnancy Associated Mortality Review
Florida’s process modeled after CDC’s Maternal Mortality Review & ACOG’s NFIMR Process
Consistently reviewed cases and collected data since 1999
Funded through federal Title V Maternal and Child Health Block Grant funds
Public/Private collaborative of various organizations, institutions, providers, & specialties
Chaired by Dept. of Health and ACOG District

15. Pregnancy-Related Deaths by Cause Florida, 2006-2015

16. FL PAMR Prevention Strategies
ACOG District Presentations
ACOG District Newsletters
Peer-Review Journal Publications
Hospital Letters
Urgent Maternal Mortality Messages

17. Pregnancy-Related Mortality Rate Florida 1999 to 2016
Hernandez, et. al. Florida Pregnancy Associated Mortality Review 2016 Update Florida Department of Health

18. What is quality improvement and what does a Collaborative have to offer?

19. Quality Improvement is a Team Sport

20. Quality Improvement The Framework for QI Plan Do Act Study
What are we trying to accomplish? Do
How will we know that a change is an improvement?
Plan
Act
Study
What change can we make that will result in improvement?
Associates in Process Improvement: Model for Improvement

21. Quality Collaborative is like a Car…

22. Why Participate in a QI Collaborative?
Education
Toolkit
Webinars
Data
Reporting
Materials
Technical
Clinical
Lessons
Consult Experts
Learned
Assistance
Guidelines
Hospital
Compare
Hospitals
Peer
Grand
Rounds
Support
Examples

23. Education is Not Sufficient Reduction in Elective Delivery by Group, 2007-2009* *
Clark, et. al. Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth American Journal of Obstetrics Gynecology

24. Participating in a Perinatal QI Collaborative
Makes a Difference
Adjusted Odds Ratios for Post-Intervention & Baseline Neonatal Resuscitation Initiatives, CPQCC
Hypothermia
Intubation at Delivery
Surfactant at Delivery
0.2
0.4
0.6
0.8
Collaborative QI
NICU QI
Non-Participants
Lee, et al. Implementation Methods for Delivery Room Management. Pediatrics 2014

25. Participating in a Collaborative More than Once Makes a Difference
Severe Maternal Morbidity Rates among Hemorrhage Patients by Hospital Category, CMQCC
Hospitals
Baseline Rate
Post Rate
Percent Reduction
Not participating 48
28.6
28.2
1.2%
No prior experience 74
22.7
19.2
15.4%
Prior experience 25
16.2
28.6%
Main et al. Reduction of severe maternal morbidity from hemorrhage. Am J Obstet Gynecol 2017.

26. Standardizing Clinical Practice Alone Can Improve Quality
“In the absence of evidence-based medicine for a given clinical decision, development of these protocols sometimes may be challenging. However, the use of checklists and protocols has been clearly demonstrated to improve outcomes and their use is strongly encourage.” Clinical Guidelines & Standardization of Practice to Improve Outcomes—ACOG Committee Opinion 629

27. CMQCC. CA-PAMR (Maternal Mortality Review). Retrieved July 2, 2018

28. What is the Florida Perinatal Quality Collaborative?

29. Vision Values Voluntary Population-Based Data-Driven Evidence-Based
“All of Florida’s mothers and infants will have the best health outcomes possible through receiving high quality evidence-based perinatal care.”
Voluntary
Population-Based
Data-Driven
Evidence-Based
Value Added
Values
Blue looks fine!

30. FPQC Partners & Funders

31. AIM States
Serious Intent
Interested
Added OUD State
Undecided

32. National Network of Perinatal Quality CollaborativesNJ DE
State PQC Status
PQC Available PQC & CDC Funding Unknown PQC Status

33. Past FPQC Initiatives Maternal Health Infant Health Data 2017 2016
Hypertension in Pregnancy
Maternal Health
Early Elective Deliveries
OB Hemorrhage
Antenatal Steroids
Infant Health
Neonatal Catheter Infections
Mother’s Own Milk
Golden Hour
Data
Perinatal QI Indicators
2017
2016
2015
2014
2013
2012
2011
2010

34. Ongoing & New FPQC Initiatives
Maternal Health
Primary Vaginal Deliveries
Long-Acting Reversible Contraception
Infant Health
Mother’s Own Milk
Neonatal Abstinence
Perinatal QI Indicators
Data
Birth Certificate Initiative Pilot
Birth Certificate Initiative
2017
2018
2019

35. FPQC Hospital Participation—2018
Infant Health
Initiatives: 25
Maternal Health Initiatives: 47
QI Indicators: 39
FPQC
Annual
Meeting: 35
68 Florida Licensed NICUs
115 Florida Delivery Hospitals

36. What have we been able to accomplish together as a Collaborative so far?

37. Hypertension in Pregnancy Initiative—HIP

38. Percent of All Reporting HIP Hospitals that treated women with persistent new-onset severe HTN in 1 hour

39. Percent of All Reporting HIP Hospitals where women received discharge education material

40. Usefulness of FPQC HIP Resources and Tool 27 of 32 Participating HIP Hospitals

41. Overall Rating of FPQC’s Guidance and Support for the HIP Initiative 27 of 34 Participating HIP Hospitals

42. Major Barriers to Implementing the Obstetric Hemorrhage Initiative, 175 Individuals from the 35 Participating Hospitals
Answers %
Lack of physician engagement or leadership
53%
Issues with medical record documentation
34%
Lack of staff belief/interest in proposed change
21%
Other hospital priorities / Lack of time
No issues
18%
Other
10%

43. Promoting Primary Vaginal Deliveries (PROVIDE)
Reducing Low Risk Cesareans (NTSV)
Promoting Primary Vaginal Deliveries (PROVIDE)

44. 16.5% of FL hospitals meet national target
Low-Risk First-Birth (Nulliparous Term Singleton Vertex) Cesarean Rate, 115 FL Hospitals 44
Range: 17.9—60.8%
Median: 29.4%
Mean: 30.6%
National Target =23.9%
16.5% of FL hospitals meet national target
Cesareans are the most common type of major surgery in the U.S. (32.8% of births) and Florida (38.1% of births) in Florida had the 4th highest rate among U.S. states.
Cesareans in Florida have been increasing from a low of 21.9% in 1996 to a high of 38.1% in 2012.
Primary cesareans are driving the increasing rate because virtually all subsequent births will be by cesareans because of few vaginal delivery after Cesarean.
A recent analysis of Florida birth certificates showed that across the 116 delivery hospitals in the state, the primary cesarean rate among low-risk first-birth deliveries ranged from 6.6% to 59.5%; roughly one-fifth of the hospitals (21%) meet the Healthy People 2020 national goal for such deliveries of 23.9% or less.
Source: FL Vital Records, 2017

45. Percent of All NTSV Cesarean Deliveries Performed that Met Criteria During Baseline
*Other: Cases in the Induction and Labor Dystocia categories where the cervical dilation at the time of delivery is unknown. Also cases in FHRC category where the FHRC category was Other

46. Percent of NTSV Cesarean Deliveries Performed Not Meeting Criteria by Category during Baseline
Starting at the bottom of the graph and stacking up:
Met Criteria
10 cm with <3 to 4 hrs
6-9 cm with <4 to 6 hrs
<6 cm with <12 to 18 hrs
*Other: Cases in the Induction and Labor Dystocia categories where the cervical dilation at the time of delivery is unknown. Also cases in FHRC category where the FHRC category was Other

47. Percentage of Cesareans Among All NTSV Births For PROVIDE Hospitals, July 2017 to May 2018
Max. Value
75th Percentile
PROVIDE Median
25th Percentile
Min. Value

48. What is the future direction for Perinatal Quality Improvement?

49. Multiple Pressure Points to Improve Quality
Government Reporting
Health Care Plans
Quality Measures
Professional Organizations
Consumer Ratings
AHCA Medicaid
Joint Commission
Medical Education
Peer Review

50. QI will be integrated in electronic health records

51. Who do we want to be defining health care quality for mothers and babies?
Health Care Systems
Professional Organizations
Perinatal Quality Collaboratives (national/state)
Expert Organizations
Private Vendors
Quasi-Governmental Entities

52. How to Get Involved? (Choose best answer)
Promote your hospital in signing up to participate
Support your hospital’s QI team and efforts
Serve as a physician lead on a hospital QI effort
Promote with other physicians and hospitals
Encourage ACOG District XII to participate
Serve on an FPQC Initiative Advisory Group
Any and all of the above

53. Only together can we make Florida the best place for mothers and babies

54. Are You Connected? Facebook.com/TheFPQC/ @TheFPQC
Join our mailing list at FPQC.org
At FPQC.org you can find information about current and past projects and join our mailing list. We have a facebook page and twitter account as well. You can also us at
is the specific site for PROVIDE