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Perinatal Quality Collaborative

of North Carolina
2017 – Year in Review

Executive Summary
I. In 2017 PQCNC concluded two initiatives.

A.   In its final year 2017, the Conservative Management of Preeclampsia (CMOP)


Initiative included 21 hospitals accounting for 48% of the deliveries in the state and 6,664
women with a hypertensive disorder of pregnancy. The project had four key aims and all
were met except for one, attaining an antenatal steroid administration rate of 90%. In this
we consistently met a 75% administration rate and reasons for this are discussed below.
Details for individual metrics are discussed below. Overall CMOP resulted in:

1.   A dramatic reduction in deliveries <37 weeks in our collaborative solely for


preeclampsia without severe features or gestational hypertension. The rate decreased
from 7.7% to 0.5% resulting in the avoidance of 180 such deliveries annually. We
estimated the financial savings of this achievement using the Tricare DRG calculator
and the assumption that the majority of these preterm deliveries avoided were 32-36
weeks. Using the hospital charges allowed by Tricare for these DRGs (648, 649, 678,
and 679) we estimated a very conservative cost savings of $2.5M annually (over the
two years of this project) based on NICU admits alone. This does not account for
professional fees. We saw no increase in NICU admits for infants 37 weeks or greater
nor maternal morbidity as our balancing factors.

2.   We did not eliminate all deliveries < 37 weeks for only gestational hypertension or
preeclampsia without severe features but we saw a 93% reduction.

3.   A significant increase in treating hypertensive mothers within one hour. We were


consistently treating 80% of mothers within this time at collaborative conclusion, a
33% increase.

4.   We developed critical tools that demonstrated measureable increased partnership


with patients during this collaborative.

B.   Our second 2017 initiative which was concluded in 2016 and evaluated in 2017 was
the treatment of Neonatal Abstinence Syndrome (NAS). This initiative included 19
hospitals accounting for 44% of the state’s deliveries and enrolled 2012 infants. NAS had
key aims that included the standardization of care at individual hospitals for initial
pharmacologic treatment of NAS (100%), reducing the rate of escalation doses of meds for
NAS by 20%, reducing NICU utilization by 20%, and reducing the length of stay (LOS) by
20%. All these aims were achieved and are discussed in specific detail below.

1.   Overall LOS decreased from a mean of 14.5 to 12 days. (Overall 17% reduction)

2.   Infants requiring medications saw a decrease in mean LOS from 22 to 18 days,


resulting in 4,044 fewer inpatient days. (Overall 27% reduction)

 
 

3.   There was a decrease in the percentage of inpatient days requiring escalation


(increased dosage, rescue doses, or additional agents) from 5.5% to 3% of days. (45%
reduction)

4.   NICU utilization decreased from 67% to 57% including a 25% reduction in NICU
admissions for infants not requiring pharmacotherapy.

5.   Based on these results and the distribution of these avoided days to be newborn
nursery and NICU, we estimate the cost savings attributable to NAS to be $2.4M.

II. In 2017 we have launched two initiatives.

A.   Reducing the morbidity and mortality of Maternal Hemorrhage includes 65 of


North Carolina’s 78 birthing hospitals, comprising 85% of the deliveries in the state.
Teams are focused on strategies to better screen for potential maternal hemorrhage cases,
put in place key response elements for such patients, and build drills for maternal
hemorrhage into the hospital obstetrical practice. Key outcome indicators are a 33%
reduction in the rates of maternal blood transfusion and a reduction in the hospital severe
maternal morbidity and mortality index (SMMI) by 25%. We are diligently attempting to
obtain access to the state administrative hospital data that will allow us to calculate the
SMMI, and that is detailed in comments. Since rollout in September we have seen a 32%
reduction in blood units transfused/1000 patients.

B.   Our second 2017 initiative is Antibiotic Stewardship Newborn Sepsis (ASNS). It


includes 58 teams from 46 hospitals committed to reducing antibiotic exposure of
newborns in the nursery and NICU. These hospitals account for 67% of the deliveries in
the state. The overuse of antibiotics has clear detrimental effects on infants and also
results in overuse of critical resources via extended hospital stays for potentially
unnecessary antibiotic treatment, especially when blood cultures are negative. The goals
of this project are to reduce antibiotic exposure of all infants by 20% and to reduce
antibiotic exposure after a blood culture is negative at 48 hours by 20%. In 2017 this
initiative will have avoided antibiotic exposure for 1100 babies.

C.   Both these projects will continue for the next four months.

III. As 2018 begins we are developing two new initiatives with prework beginning in the fall
of 2018 and kick off in January 2019.

A.   Our new obstetrical initiative will be Safe Reduction of Primary Cesarean Birth.
B.   The new newborn/NICU initiative will be Newborn Hypoglycemia Prevention and
Care.

IV. PQCNC, partnered with DPH and the Birth Defects Monitoring Program, continues to
support the web-based reporting system for North Carolina’s legislatively mandated (SB

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98 in 2013) Newborn Critical Congenital Heart Disease (CCHD) Screening Program. This
system has identified 8 cases of CCHD to date. Details in the report.

V. PQCNC continues to collaborate with the NC State Center for Health Statistics and Vital
Records in our determined effort to improve the accuracy of electronic birth certificate
data reported by hospitals to the state. We identified serious deficiencies in 2013 which we
have been jointly correcting since then. This is an enormous effort to reach birth
certificate registrars at all birthing hospitals to make certain they appreciate the critical
role this data plays in assessing maternal and infant health and allocating resources across
the state. Additionally, we are actively at work trying to make certain registrars have
access to all elements of the maternal record so accurate data can be reported.

A.   PQCNC Funding - PQCNC is grateful for the DMA support in 2018 and 2019
which has allowed this work to thrive. 4.6 FTEs support all the work described in this
report and we estimate our ROI to be 422%. We look forward to continued collaboration
with DMA as we continue to partner to make North Carolina the best place to give birth
and be born. We are requesting additional funding from the NCGA to support the work
needed to ensure that the North Carolina CCHD and Birth Certificate are national models
for the pursuit of excellence in perinatal care.

Results in Detail

Conservative Management of Preeclampsia (CMOP)


CMOP Performance Measures
Overall Performance Measures were:
1.   Partnership with patients and families in creating hospital based teams, Perinatal
Quality Improvement Teams (PQITs), which would oversee execution of the action plan at
their facility.

2.   Adoption of best clinical practice guidelines from the American College of OB GYN
(ACOG) regarding preeclampsia with a focus on eliminating deliveries for preeclampsia
without severe features, or gestational hypertension only, prior to 37 weeks.

3.   Based on ACOG recommendations reducing the time to treatment for mothers


treated for critical hypertension to less than one hour for 80% of mothers.

4.   Increase the administration rates of antenatal steroids to mothers delivering at <


32 weeks due to hypertensive disorders to 90%.

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Evaluation Results for CMOP

CMOP development began with the formation of an Expert Team and the creation of an
Action Plan. The Action Plan is a two-page document which states the initiative aim(s),
details key drivers or contributors to challenges in preeclampsia management, and lists
interventions to be considered for rapid cycle improvement. These interventions are
Planned (P), Done over short periods (weeks) (D), Studied (S) and further Action (A)
taken based on the assessment of the intervention (PDSA). Unique action plans were
developed for each of the phases of CMOP. Each unique Expert Team included members
from across North Carolina that included providers of all types (nurses, doctors, and other
practitioners) and specialties (nursery and neonatal) from hospitals of all sizes. Equally
critical is membership on the Expert Team by patient, hospital executive, North Carolina
Hospital Association, Department of Public Health, Medicaid, Blue Cross Blue Shield
North Carolina representatives. After the Action Plan was developed delivery hospitals
across North Carolina received an invitation to participate in CMOP. A requirement for
participation for hospitals was the creation of a Perinatal Quality Improvement Team
(PQIT) that included at least a physician, nurse, senior administrator and ultimately, a
patient. The PQIT reviewed the Action Plan, performed a local needs assessment and
determined maximal opportunities for improvement using the Action Plan. PQCNC
developed a web based reporting system for hospitals to submit data related to the key
process and outcome measures identified by the Expert Team. The PQITs devised a
system for local collection and entry of data used to support the initiative work.
CMOP Phase One and Two, conducted over 30 months with wrap-up for the final 6
months, was formally structured around quarterly face to face learning sessions, monthly
webinars and weekly email newsletters. In all these interactions, there was sharing of both
challenges and successes from individual PQITs. Learning sessions were day-long face to
face events and included presentations from state and national leaders (Drs. Elliot Main,
Ann Borders, James DeVente, Michael Cotten, Kate Menard and Barbara Murphy) as well
as facilitated, structured table time focused on each facility identifying their next PDSA
cycle and intervention focus for the coming month.

Performance Measures for CMOP

1.   Partnership with patients and families required the development of a reasonably


objective scoring system to track hospital progress in PFE. To this end PQCNC created a
family and patient partnership scoring scale which supported the Patient Family Centered
Care Methodology. This system was developed with input of patients and families in a
formal Patient and Family Engagement (PFE) collaborative that we conducted with 11
facilities. This effort ran over 12 months and included two formal learning sessions and
resulted in the PFE scale as well as a curriculum for leaders at facilities seeking to partner
with patients and families. This was work outside of the CMOP group but carried out in
parallel. Results from this collaborative were reported at all CMOP Learning Sessions.
Below is a sample of the PFE scorecard employed to track facilities progress in advancing

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PFE goals. Of 21 hospitals in the final phase, the median score for PFE was S5. A majority
of teams committed to the PFE concept, selected a team member to serve as the family
liaison, received patient feedback, incorporated that feedback into PQIT activities,
recruited a patient to provide support to CMOP locally, and with the patient member of
the team assessed CMOP practice at the hospital. Our goal was to have the majority of
participating PQITs reach at least S5.

2.   Eliminating deliveries for just preeclampsia without severe features or gestational


hypertension prior to 37 weeks was a critical outcome measure for this grant. The state of
North Carolina regularly reports high preterm birth rates and an opportunity to reduce
these deliveries appeared clear in the development of CMOP. Data reported by hospitals
included the indications for delivery for every patient under 37 weeks. These were
reviewed by the Maternal Project leader for PQCNC, Dr. Arthur Ollendorff and the results
tracked and reported. Rates for deliveries of such infants are displayed below. The first
graph extends from January 2015-February 2016. The second chart displays data from
February 2016 onward. We were able to achieve a dramatic reduction in these deliveries
in our collaborative. The rate decreased from 7.7% to 0.5%. We had stated a goal of
elimination ultimately of such deliveries. We did not achieve that but did reduce such
deliveries by 93%! We saw no increase in NICU admissions for infants 37 weeks or greater
in the initiative. We estimate avoidance of 180 deliveries < 37 weeks annually in our
collaborative.

We estimated the financial savings of this achievement using the Tricare DRG calculator
and the assumption that the majority of these preterm deliveries avoided were 32-36
weeks. Using the hospital charges allowed by Tricare for these DRGs (648, 649,678, and
679) we estimated a very conservative cost savings of $2.5M annually based on NICU
admits alone. This does not include professional fees.

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We saw no increase in NICU admits for infants 37 weeks or greater as our balancing
factor.

3.   Increasing the administration rates of antenatal steroids (ANS) to mothers


needing to deliver at < 32 weeks due to hypertensive disorders is necessary to reduce the
potential morbidities of preterm birth. We targeted a goal of 90% administration. The
evidence for benefit from this treatment in ameliorating effects of preterm birth is so
strong we considered it an outcome measure. The follow-on effect of this intervention
would be reduced incidences of respiratory distress syndrome (RDS), intraventricular
hemorrhage (IVH), and necrotizing enterocolitis (NEC) in preterm infants.

Our measure for ANS was did mother receive two doses of ANS prior to delivery. Many
systems record any steroid exposure as positive. We did not. In selecting a goal of 90% we
realized we were aiming high. Some mothers with hypertensive disorders need to be
delivered quickly and there may not be time to administer one, never mind two doses of
ANS. Our collaborative achieved a consistent rate of 75% administration. We had
occasional peaks into the 90% range. Any 100% periods are during changes in CMOP
phases with low numbers of centers reporting. It may be that a goal of 80% for two doses
of ANS is the target to be aimed for. This issue was discussed at several webinars and one
face to face meeting. We believe the goal of 90% is unreasonable given the need to balance
safety of mother and possibly a distressed baby with the advantages ANS offer a preterm
infant.

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4.   Based on the work done by the California Maternal Quality Care Collaborative
(CMQCC) CMOP sought to reduce the time to treatment for mothers treated for critical
hypertension to less than one hour. We targeted 80% of mothers being treated in this time
frame. There were a variety of system issues that PQITs dealt with in attacking this
challenge, including nurse to physician communication and pharmacy logistics. Baseline
rates were 60% pre-CMOP. By initiatives end we were consistently treating 78-80% of
mothers treated within one hour.

5.   We were challenged to meet the center recruitment numbers we anticipated. We


achieved recruitment of 30 centers but were not able to surpass this. There were several
factors which made larger recruitment challenging. The roll out of other perinatal QI
projects from other organizations clearly forced hospitals to consider local resources and
ability to participate in multiple QI efforts. Specifically, the Health Engagement Network
(HEN) program and QI initiatives developed by expanding health care systems impacted
these efforts in North Carolina. Despite inability to realize our goal of recruiting 40
hospitals we were able to consistently maintain participation of hospitals that accounted
for 45% of North Carolina deliveries.

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Neonatal Abstinence Syndrome (NAS)


NAS Measures and Evaluation

PQCNC NAS included 17 hospitals in NC and 2 hospitals in IL. Baseline


data were collected beginning in April 2013. Program implementation began with Phase
1 from January 2014 through February 2015 followed by Phase 2 through December
2015. Interventions included monthly webinars and four interactive in-person learning
sessions focused on identification and management of NAS and guidance for
implementation of standardized non-pharmacologic and pharmacologic NAS
management bundles. Phase 1 involved initial implementation and individual sites’ needs
assessments and Phase 2 included focused interventions consistent across all sites.

The project enrolled 2,012 infants were included in the intervention. 63% were enrolled in
Medicaid. 50% of infants required pharmacologic treatment. Overall
LOS decreased from a mean of 14.5 to 12 days. Infants requiring medications saw a
decrease in mean LOS from 22 to 18 days (Fig 1), resulting in 4,044 fewer patient
days. Infants who were managed only with non-pharmacologic strategies had decreased
variability in LOS with an average of 6 inpatient days. This is consistent with the AAP
recommendation for monitoring infants at risk for NAS for a minimum of 5 days. Among
infants receiving medications, there was a decrease in the percentage of inpatient days
requiring escalation of therapy (increased dosage, rescue doses, or additional agents) from
5.5% to 3% of days (Fig 2). NICU utilization decreased from 67% to 57% including a 25%
reduction in NICU admission for infants not requiring pharmacotherapy. Infants who
received any maternal breast milk remained stable at 30%.

The standardization of care of NAS at the facility level led to decreases in LOS, NICU
utilization, and medication escalation. There were no increases in readmission rates.
Based on the distribution of these avoided days to be newborn nursery and NICU, we
estimate the cost savings attributable to this to be $2.4M.

Antibiotic Stewardship / Newborn Sepsis (ASNS)

ASNS Overview and Preliminary Evaluation

PQCNC ASNS is a statewide collaborative that includes 58 newborn nursery and NICU
teams from 45 hospitals in North Carolina. The goal of ASNS is to reduce antibiotic
exposure of newborn infants by 20% and reduce the continuation of antibiotic courses in
newborns with negative cultures at 48 hours by 20%. Our desire was to create
collaboration within hospitals between nursery, and if a NICU is present, NICU teams, in
seeking to improve antibiotic stewardship. This would serve not only ASNS but offer
hospitals the opportunity to improve newborn QI capacity. The initiative was developed
by a 54-member state Expert Team. An Action Plan was developed with the outcomes

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above identified, practice recommendations made, key outcome and process measures
identified, balancing measures determined and a web based system created for tracking of
data. Key practice considerations were integrating hard antibiotic stops at 48 hours in
electronic records and the use of the Kaiser sepsis calculator for infants greater than 34
weeks as an adjunct in determining whether antibiotic therapy was warranted. Baseline
data was collected in November and December 2016 with project launch in January 2017.

We have seen a 50% reduction in antibiotic exposure in the newborn nurseries. In the
NICUs we have seen a 30% reduction in antibiotics being continued after 48 hours with a
negative culture. The former represents in most cases. Given that ASNS includes hospitals
accounting for 67% of deliveries in the state we estimate that ASNS will reduce antibiotic
exposure for 1100 babies in 2017.

Alliance for Innovation in Maternal Health (AIM) - Hemorrhage

AIM Overview and Preliminary Evaluation

As a follow on to CMOP PQCNC has been designated the North Carolina organizational
lead for AIM Maternal Hemorrhage. We are one of 11 states engaged in this work. The
success of our efforts in CMOP, and prior success in reducing elective deliveries < 39
weeks, are reasons that the NC Ob Gyn Society, NC ACOG, NC AHONN, NC Hospital
Association, and the NC Midwifery Association were anxious to have us lead this effort.
Through this partnership we have recruited 65 hospitals intending to participate in NC
AIM. There is enormous enthusiasm in the obstetrical community for this work, as well as
amongst healthcare systems. A key attraction of AIM is its reliance on using hospital
administrative coding data to measure the severe maternal morbidity (SMM) index. This
reduces the need for data collection by clinical providers. PQCNC is also measuring blood
transfusions per 1000 patients. Our goal is a 25% reduction in the SMM while reducing
transfusions at participating hospitals.

While extremely successful in recruitment, and PQITs are pursuing PDSA activities,
PQCNC has faced numerous roadblocks in obtaining access to the state level hospital
discharge abstract data. We have explored numerous avenues for solutions including the
NC Hospital Association, NC DHHS, the data contractor (Truven) and the state

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legislature. Discussions are underway with all these entities but interpretation of NC law
by some limits PQCNC access to this data.

PQCNC Critical Congenital Heart Disease (CCHD) Screening Program


Support

In 2013, when legislative funding for the newly mandated CCHD program was removed,
DPH was left without funds needed to create data systems that would support data
collection regarding CCHD screening for every newborn in North Carolina. PQCNC
offered to develop and support such a system given the urgency of the situation. The
members of the statewide CCHD Task Force agreed we were best positioned to do this in
the most efficient and cost-effective manner. We created a reporting system that can be
accessed by the Birth Defects Monitoring Program. The security, monitoring,
maintenance, hosting, updates and reporting for this system costs $25,000 annually.

PQCNC was never funded to support this work and we are appealing to the Child Fatality
Task Force and NCGA to support the costs of maintaining and improving the recruiting,
reporting and support hospitals appear to require to adhere to this reporting obligation.
Currently only 40 of 78 delivering hospitals are reporting their data to the state. It is very
possible that the screening is being done but not reported. We are collaborating with the
North Carolina Hospital Association to determine if this is the case and to educate centers
on the need to report. In requesting additional funding, we seek to add part time
personnel support and reporting capability that will achieve 100% reporting for all births
in the state.

The CCHD screening program in 2017 identified 8 infants prior to hospital discharge with
critical heart lesions. These are infants who otherwise might have died at home after the
normal transition of fetal circulation to newborn circulation over the first week of life.

Improving Data Reported on the North Carolina Electronic Birth Certificate

PQCNC has partnered with the State Center for Health Statistics and Vital Records to
develop strategies to improve accuracy of birth certificate reporting. We held two face to
face learning sessions with hospital Birth Certificate registrars in 2017 to support this
work. A variety of obstacles to accurate data reporting were identified and potential
solutions developed. Regional meetings with Vital Records and registrars have been
sponsored by PQCNC to educate those inputting data on definitions, importance of the
data and to identify opportunities to access data which is not always visible to registrars.
We look forward to continuing this in 2018 and 2019. We have seen clear impact from this
work in the increased reporting of one of the most challenging measures to locate data on
in the medical record. Administration of Antenatal Steroids (ANS) to mothers delivering
at less than 32 weeks was reported as 22% in 2013. It is 63% in 2016. We know based on
individual center data from our CMOP project that the rate is likely at 90%. Our clinical
goal for this metric is 90%.

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We are tracking other measures as well but believe that if ANS rates are reported
accurately, other measures, more easily obtained, will also be more accurately reported.

Additional Successes

We were successful in achieving project goals as described above. We were selected to


participate in the CDC state Perinatal Quality Collaborative program. The Director of
PQCNC, Dr. McCaffrey, has been selected to co-chair the National Network of Perinatal
Quality Collaboratives.

Lessons Learned Through 2017

PQCNC Philosophy

PQCNC is built on an organizational foundation of core principles of leadership, mission


and “knowing your why”, subsidiarity, partnering with patients and families, the proper
role of data, knowledgeable, timely, and continuous support from highly skilled Clinical
Information Managers, and building collaboration through trust, transparency, and value.

1.   Developing a Culture of “Why?”


PQCNC evolution during this grant period has included a determination to incorporate
the concept of “The Why” as described by Simon Sinek. In most organizations workers
know “what” their business does, some “how” the business does it, but they often cannot
state “why” their business does what it does. Employees in the most successful
organizations can state a visionary “why”. PQCNC participants and PQIT members
understand the “why” for each and every initiative. Why are we doing this? “To make
North Carolina the best place to give birth and be born.” Why? “Simple, every patient we
care for deserves the same care we want for our own family member.” “Why” is a critical
ingredient in the PQCNC basket. Identifying and supporting leadership at the local and
state level that models “Why” is a vital PQCNC strategy. Successful QI is not changing
policies and procedures, it is changing culture. The less than perfect systems in place in
many of our hospitals are perfectly designed to deliver the less than perfect outcomes they
deliver. Only leaders armed with a belief in “why,” wielding best practice and evidence,
cloaked in the support of stakeholders can hope to change and sustain the improvements
we need in our perinatal care systems.

2.   Subsidiarity

Subsidiarity refers to the principle that a community of a higher order should not interfere
in the internal life of a community of a lower order, depriving the latter of its functions;

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rather the community of a higher order should support the lower order community in case
of need and help to co-ordinate its activity with the activities of the rest of a system,
always with a view to the common good. The presumption here is that local communities
know best how to address critical issues but may need larger organizational support to
facilitate activities. Too frequently stakeholders in perinatal health, specifically patients,
families and providers, are subjected to organizational decisions that directly impact daily
work and the provision of health care, without an appreciation for the impact such
decisions have at the local level or without input from local communities or teams. There
is often a lack of appreciation of the value of local community needs, variation, and
expertise. Local communities may be individual hospitals within a health system, or units
within a hospital, or specific patient groups receiving care at a hospital. This leads to
burnout, isolation, frustration and a sense of powerlessness. The model of assigning
improvement opportunities from the health system or large professional organizational
level frequently fails to consider that in healthcare every hospital, indeed every unit, is its
own community that has unique cultural characteristics. Additionally, enthusiasm and the
perception of need for improvement on the part of those to engage in the actual work of a
QI project is, in PQNC's experience, necessary for project success. Subsidiarity in QI best
allows for not only the consideration of the variable needs of differing communities, it
recognizes the professionalism of those closest to the work, respects the input of those
experiencing the processes and seeks the opinion of the community regarding disparities
in culture only those stakeholders will appreciate in executing such a project in their
community or unit or hospital. Subsidiarity recognizes the interrelatedness of all in the
healthcare process from individuals to small communities and facilities to larger
organizations. Subsidiarity supports the dignity of all engaged in in this effort.

Subsidiarity is a hallmark of PQCNC work that asks its membership to identify next
initiatives, presents them to a Leadership Team that includes stakeholders from all
communities, that seeks Expert Team members statewide from all stakeholder
communities to develop the seminal documents which will guide the course of thousands
in a clinical project over the ensuing year, that requests PQITs form and then adapt the
previously developed action plan to meet the needs of their unique environment via
PDSAs, and then reports results seeking to give primary authorships to leaders from
varied stakeholder communities across the state.

3.   Taming Data

The focus of QI work often becomes the collection of data. This data collection, when
working across multiple facilities and systems in a state, can often become onerous. In
some facilities EHR data can be accessed and downloaded for transmission to state PQCs
but this is generally not the rule, and it is certainly not the rule when process measures
not typically charted are deemed necessary to analyze effectiveness of an initiative. In
such cases the variable resources able to be dedicated by hospitals to QI activities are

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often consumed with data processes, leaving little opportunity to support the vital work of
small tests of change (PDSA cycles) and meaningful changes in practice and culture. Over
its history PQCNC has demonstrated a commitment to reduce data burden and focus
PQITs on reviewing current care and executing PDSA cycles in areas ripe for
improvement. Expert Teams determine what data is necessary to support the goals of an
initiative. The PQCNC Core Team reinforces the principle that focus should be on the
most accessible and necessary data to achieve desired outcomes. Over the course of an
initiative PQITs not infrequently recognize a need to add or delete data. PQCNC data
systems, discussed below, have evolved to accommodate such critical flexibility.

Our efforts to access and then improve the accuracy of administrative data are a part of
our QI mission. While such data sets are often imperfect, analyzing them in a QI context
leads to their improvement. These data sets offer PQITs and PQCs the opportunity to
identify areas that are challenged in perinatal care, even if currently they might require
other measures to track PQIT progress during a formal initiative. PQCNC has partnered
with the North Carolina Department of Public Health (NCDPH) in numerous realms,
including all our noted projects as well as supporting the state collection of newborn
screening data for Critical Congenital Heart Disease. Our work with one NCDPH division
is critical with respect to improving data accuracy. In conjunction with the SCHS we are
seeking to improve the accuracy of data reporting for the North Carolina Birth Certificate.
PQCNC has sponsored meetings with SCHS and state birth registrars to identify the
challenges in accurate reporting of data, develop plans for improving this reporting and
publicizing the desire of the Vital Records staff to travel to facilities to conduct reviews of
the electronic birth certificate system and definitions related to data fields. PQCNC is
committed to improving this data set and envisions linking it with the hospital discharge
abstract data in creating a perinatal data warehouse that will support perinatal QI work
across the state. PQCNC’s vision is ultimately to conduct state perinatal QI projects which
require no data collection by PQITs. With access to hospital discharge abstract data and
increased accuracy of Birth Certificate data, we anticipate during this grant period that
PQCNC will generate reports from administrative data to support and sustain QI efforts.

The AIM projects offer a unique opportunity to conduct meaningful QI work using
administrative data sets to support PDSAs and identification of areas needing
improvement. There will still no doubt be need for some data collection that is not
contained in this data set but if the administrative data is good enough it will be possible
to significantly reduce data burden on PQITs in the future.

4.   Partnering with Patients and Families

Partnership with patients and families is foundational for PQCNC. Since our inception,
PQCNC has included such partnerships in all initiatives. The contributions of families and
patients have been major reasons for our success in CLABSI, 39 Weeks, SIVB, NAS, NICU
and Newborn Human Milk. In CMOP, NAS and now our ASNS and AIM initiatives we
have continued to explore new and novel ways to engage patients and families in perinatal

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QI. All projects have included videos from families, membership of patients and families
on Expert Teams and presentations at Learning Sessions. We are now employing our
Patient and Family Engagement Scoring system to better track these partnerships.

PQCNC has dedicated considerable resources to support our commitment to patients and
families. In addition to a full time Director of Patient and Family Partnerships we have
conducted two phases of a separate Patient and Family Engagement (PFE) initiative. In
2016 PQCNC developed a training program from PFE work called the Patient and Family
Engagement Certificate Program. This program offers guidance and instruction for
patients and family members partnering with healthcare providers in QI work. The
program identifies and trains attendees in how best to use their input to facilitate the
advancement of care processes in perinatal QI work. We have held multiple classes at our
PQCNC offices and are now offering this program to PQITs and hospitals when we
conduct support visits.

All PQCNC initiatives now require that the hospital PQIT include at least a nurse, doctor,
executive leader support and a patient or family member.

5.   Collaboration

In working with teams from varying facility sizes across the state, the Clinical Initiative
Managers are able to share best practices and resources from both large and small units,
as well as, to connect individual PQIT members with team members at other facilities to
further enhance collaboration and improvement of care. Successfully implemented
process changes meeting initiative goals are identified and highlighted using a recorded
webinar format. These webinars are posted on the PQCNC website for all team and staff
members to access to gain wisdom and lessons learned from other participating PQITs.

Support visits to hospitals have been critical in developing PQCNC collaboration. PQCNC
staff conduct 20-30 PQIT support visits per year. PQCNC Core Staff and Expert Team
members go anywhere, anytime to talk with anyone about PQCNC, initiatives and our
mission. The willingness of PQCNC to travel with its Core Team and bring state experts to
the smallest of rural hospitals on the other end of the state to discuss perinatal care, has
made it clear we are a service organization committed to learning from all collaborators
and supporting all collaborators. PQCNC is non-denominational and exists to identify,
design, launch, execute and sustain perinatal QI projects which serve all stakeholders.
PQCNC has been successful as an organization as a result of our commitment to
collaboration at the local, state and national levels. There is no mandate from the state for
hospitals to join PQCNC. PQCNC succeeds only as a coalition of the willing. This requires
the development of considerable collaborative skills as well as giving careful consideration
to whom the stakeholders are in perinatal care. At the state level the PQCNC Leadership
Team is representative of this reality. Families, patients, providers of all types (nurses,
docs, midwives, and ancillary staff), providers from both maternal and newborn
specialties, legislators, payers and purchasers of care (BCBSNC and DMA), hospital

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administrators from large systems and independent hospitals, NC DPH and the North
Carolina Hospital Association all participate in the PQCNC Leadership Team of 35
individuals have met three times during this grant period to advise on the course of
PQCNC.

In developing initiatives this year PQCNC has recruited Expert Team members from
across the state. Expert Teams from 20-54 members have developed Action Plans for
CMOP, NAS, ASNS and AIM in combinations of web calls and face to face meetings. The
requirement for Expert Team membership is an interest in the topic, a willingness to read
background materials and a commitment to attend 3-4 webinars or face to face meetings
as an Action Plan and measures are developed. The development of Action Plans by a
diverse Expert Team assures ownership of a broad swath of PQCNC membership.

Support visits to hospitals have been critical in developing PQCNC collaboration. PQCNC
staff conduct 20-30 PQIT support visits per year. PQCNC Core Staff and Expert Team
members go anywhere, anytime to talk with anyone about PQCNC, initiatives and our
mission. The willingness of PQCNC to travel with its Core Team and bring state experts to
the smallest of rural hospitals on the other end of the state to discuss perinatal care, has
made it clear we are a service organization committed to learning from all collaborators
and supporting all collaborators. PQCNC is non-denominational and exists to identify,
design, launch, execute and sustain perinatal QI projects which serve all stakeholders.

In leading the AIM team in North Carolina, we are facilitating and coordinating the efforts
of the North Carolina Ob GYN Society, NC ACOG, NC AWHONN, NC DPH, NC DMA,
Blue Cross Blue Shield North Carolina and the North Carolina Hospital Association.
Current recruitment is at 65 centers. It is still possible we will reach our stretch goal of
engaging all 78 birthing hospitals in the state in AIM. PQCNC’s ability to conduct
meaningful and value-based quality collaborative work is testified to in the letters of
support we submit with this grant application.

PQCNC during this grant has partnered with the Duke Clinical Research Institute (DCRI)
to support analysis of all our past work not previously analyzed and published. In the
future DCRI staff will be assisting in the design and statistically reviewing all initiatives.
This collaboration with one of the nation's leading clinical research institutes offers us a
unique opportunity to design, execute and learn from our QI interventions.

6.   Knowledgeable, timely, and continuous support from highly skilled


Clinical Initiative Managers

Clinical Initiative Managers work closely with teams with regular frequent calls to
establish rapport with team members and collaboratively formulate a plan to meet the
initiative goals while addressing each individual unit’s culture. Utilizing QI tools, the
Clinical Initiative Managers work with each PQIT to map out processes and workflows to
better ensure successful implementation of changes and sustainability of desired results.

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The Clinical Initiative Managers routinely review unit data and process and outcome
measures with team members to help identify areas of success and opportunity. The
frequent contact between the Clinical Initiative Managers and individual PQITs allows for
early notification of deviations in process and support for rapid remediation.

In working with teams from varying facility sizes across the state, the Clinical Initiative
Managers are able to share best practices and resources from both large and small units,
as well as, to connect individual PQIT members with team members at other facilities to
further enhance collaboration and improvement of care. Successfully implemented
process changes meeting initiative goals are identified and highlighted using a recorded
webinar format. These webinars are posted on the PQCNC website for all team and staff
members to access to gain wisdom and lessons learned from other participating PQITs.

PQCNC Publishing

PQCNC has published on previous work including 39 Weeks, PQCNC CLABSI and
NCABSI. We presented CMOP disparity data at the Annual VON Meeting in October 2017.
We have submitted CMOP NAS and ASNS abstracts for presentation at 2018 national
meetings. Publications are in the process of being written and we expect submission by
spring.

PQCNC Challenges
Maximizing Recruitment
Individual states clearly seems to define the natural environment for the delivery of
perinatal care. Given this state PQCs seem to be the best solution for exploring
opportunities to improve perinatal care nationally. There are several factors in the current
healthcare setting that make establishing such organizations difficult.
1.   Most state PQCs do not have the luxury of a mandate (Medicaid, other large payer
or the legislature) for hospitals to join such an organization. In effect PQCs are coalitions
of the willing. In this respect, at least initially, there are not hospital resources dedicated
to participation in such work. It becomes the responsibility of the PQC to visit hospitals
and demonstrate a commitment to leadership to support the hospital in its quest to be the
best it can be. It is only by earning the trust over time of hospitals can the PQC expect
hospitals will dedicate significant resources to participation. We are seeing the fruits of
such effort in the increasing enrollment of hospitals in PQCNC initiatives, but this has
been a 10-year journey.

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2.   Hospitals have limited ability to conduct multiple perinatal QI projects. Therefore,


when national, health system or other collaborative organizations (HEN, COIIN, VON)
introduce new QI efforts without partnering with state PQCs for input and guidance on
best projects, the limited perinatal QI resources at hospitals may be diverted to other
projects.

3.   The creation of large health care systems via mergers is a serious challenge.
Corporate offices have established system QI shops which they presume are the best
investment in QI. Given the ability of a healthcare system to analyze its internal data, they
may feel that they have all the tools necessary to maximize perinatal care. There is a belief
in some corporate offices that QI can be managed from the corporate office. What such a
view fails to appreciate is that every hospital is a different environment which requires
unique interventions to examine culture and improve outcomes. Additionally, a corporate
culture may be very insular and would benefit from partnership with outside facilities in
improving care.

4.   Hospitals not infrequently are partnered in quality collaborative efforts with


organizations, sometimes at a significant price, that have become part of culture but do
not necessarily improve outcomes.

5.   It is the duty of PQCs to address all these challenges and demonstrate value that
overcomes the obstacles to enrollment.

Moving Beyond Data Collection to Facilitating Changes in Care

Given limitations in manpower at individual facilities, PQCNC has had to realize that in
such situations submitting data has a tendency to become QI work, though the data may
not be analyzed and care does not change. In CMOP we had to restructure data collection
in order to reduce the demands of data and allow for greater effort to go into actually
making small tests of practice change. The temptation for PQITs to view keeping data up
to date as the primary data has to be pushed back. Data is necessary to identify areas to
improve and note the impact of changes, but ultimately the real work is creating the best
possible care environment for the patient. This is guided by data.

Demonstrating PQCNC Value


PQCNC has been challenged since its inception with demonstrating its value. Many in
2007 thought PQCNC was a good idea, but we were just a good idea, and had not done any
work yet. It was tempting to believe we needed more money to do the work to prove we
were a value but that was not to be. We completed two projects (Eliminating Elective
Deliveries Under 39 Weeks Gestation and Reducing Catheter Associated Blood Stream
Infections - CLABSI) that clearly demonstrated revealed that we would be a good return
on investment. In CMOP, and prior work, we have had to develop methods to estimate the

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impact of our work. While value is not always expressed in dollars, developing projects
which can demonstrate significant cost savings is always advantageous. Over this grant
period we have increasingly used the readily accessible Tricare DRG calculator to estimate
savings as relates to hospital costs.

Accessing State Level Hospital Administrative Data


As noted earlier this has been a huge obstacle in conducting AIM work. We have spent
long hours communicating with DPH, DHHS, NCHA, Truven and the legislature in trying
to work out some agreement to allow PQCNC to access this data in order to support
facilities conducting AIM projects. These conversations are ongoing today.

PQCNC – The Year Ahead


In 2018 we will begin moving to two new projects as we build a structure we hope will
sustain our gains from 2017. The projects on for 2018, decided upon by PQCNC members
across the state are
1.   Newborn Hypoglycemia Prevention and Care: We anticipate participation
that will rival or exceed ASNS. Hypoglycemia is increasingly common in newborns as
diabetes and use of antenatal steroids later in pregnancy has increased. Estimates are just
estimates depending on the maternal population but as many as 3-5% of newborns may
manifest hypoglycemia. Often these babies are separated from mothers, require IV
placement and transfer to an increased level of care, either a special care nursery or NICU.
Once IVs are placed weaning occurs over 1-3 days generally as infants increase their
feedings and better regulate their own blood sugars. The use of oral glucose gel is now
increasingly being published upon and we expect this intervention, just like the Kaiser
sepsis calculator for infection, will reduce the need for treatment for hypoglycemia. This
coupled with standardized hypoglycemia protocols lead us to expect less separation of
mothers and babies, less need for IV fluids and less NICU admissions.

2.   Safe Reduction of Primary Cesarean Birth: This project will be conducted


using the AIM bundle. PQCNC has previously done a similar project in which we reduced
the primary CS rate safely by 19%. Avoiding an unnecessary CS also potentially avoids the
multiple CS down the line for a mother who will be less likely to find providers willing to
perform a vaginal delivery after a CS birth. A key to this intervention will be evaluating
hospital practices regarding labor induction. In our prior PQCNC Supporting Intended
Vaginal Birth - SIVB (Primary CS project), if a mother was admitted for induction not in
active labor her chance for a CS was 3 times higher than a mother in labor admitted to
deliver.

Learn more at pqcnc.org

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