The Alliance for Innovation on Maternal Health

The Alliance for Innovation on Maternal Health


— Ladies and gentlemen
thank you for standing by. Welcome to the CDC Perinatal
Quality Collaboratives Webinar. During the presentation
all participants will be in a listen only mode. Afterwards we will conduct a
question and answer session. At that time if you have a
question please press star followed by the number 1
on your telephone keypad. You may also enter questions at
any time throughout the webinar by using the chat
feature located in the lower left hand
corner of your screen. If you need to reach an operator
at any time please press star 0. As a reminder this
conference is being recorded, Thursday, June 2, 2016. I will now like to
turn the conference over to Dr. Henderson. Please go ahead. — Good afternoon. My name is Zsakeba Henderson
and I lead the activities and support of state based
perinatal quality collaborative in the Division of
Reproductive Health here at CDC. And I’d like to welcome
you to today’s presentation for the CDC Perinatal Quality
Collaborative webinar series. Today’s webcast will be an
informative presentation of current activities to
address maternal mortality and severe maternal
morbidity and the development, collaborative nature and
natural scope of the Alliance for Innovation on
Maternal Health, also known as the AIM Program. At the end of the presentation
you will have the opportunity to ask questions and participate in the discussion
with the presenter. A recording of this webinar will
also be archived on our web page at www.cdc.gov/
reproductivehealth /maternalinfanthealth/pqc. Handouts were made available
with your reminder email after registering
for the webinar and will be made available
again to register for the follow-up communication
act for today’s webinar. Our presenters for today are
Elliott Main and Jeanne Mahoney. Dr. Elliott Main is
the Medical Director of the California Maternal
Quality Care Collaborative and has led multiple state and national quality
improvement projects. He is also a Chair of the California Pregnancy
Associated Mortality Review Committee since its
inception in 2004. He is currently Clinical
Professor of Obstetrics and Gynecology at
both University of California San Francisco
and Stanford University. Dr. Main has been
actively involved or chaired multiple
national committees on maternal quality measurement
including those sponsored by the American College of
Obstetricians and Gynecologists, the American Medical
Association, the Joint Commission, LeapFrog,
and Centers for Medicare and Medicaid Services. In addition he has
co-led a number of national quality
initiatives with ACOG, the CDC and the Maternal
Child Health Bureau. In 2013 Dr. Main received the
ACOG distinguished Service Award for his work in quality
improvement. Our next speaker will be
Jeanne Mahoney who is a nurse by training and currently
is the Senior Director of Providers Partnership,
American College of Obstetricians and Gynecologists,
also known as ACOG. ACOG’s Providers Partnership,
supported in part by the College’s Annual Funds, tackles
many issues related to Maternal Safety
and allows the college and the Federal Department
of Health and Human Services to coordinate Maternal and
Child Health Activities between Federal and State
Maternal Child Health Programs. Jeanne Mahoney is
also coordinator of the National Partnership for
Maternal Safety and Director and Development Leader
of the AIM Program. I will now turn the presentation
over to Dr. Elliott Main. — Good afternoon and good
morning here in California. On behalf of Jeanne
Mahoney and myself we want to do this presentation in
honor of all the other partners that we have in this project. So we are engaging the
Nursing Association, the Midwife Association, AIM,
many, many other partners around the country are
engaged in this as well as obviously the CDC and
Maternal Health Bureau. And this really is
the representation of many partner’s activities. What I’d like to cover today
is some of the U.S. data for maternal mortality
and severe morbidity and the evolution then through
the National Partnership for Maternal Safety and the
Council for Patient Safety in Women’s Healthcare in which
the Alliance for Innovation in Maternal Health, the AIM
project, sits and resides. We’ll go through the resources, how we’re doing data-driven
quality improvement of some of the measures for the
project, our data center and our national staff. This slide shows the
disturbing trend that has been in the newspaper a lot, have
been in our journals a lot over the last five years
which is in contrast to all the other developed
countries in the world who have seen declining
maternal mortality rates, the U.S. has stood out. In 1990 we were at
the head of the pack but by 2013 we’re lagging behind
all other developed countries. And this is certainly a
concern to every provider of medical care for woman
in the United States as well as for our government agencies. There’s some debate as to
whether the rise is related to administrative data but in any case, i.e. we’re
either identifying cases better but in any case it’s much
higher than it should be and in comparison to every
other industrialized country in the world. Furthermore, there’s
great disparity. The black/white disparity is
three to four times higher in African American women
for maternal mortality. This is in contrast to other
measures of pregnancy outcomes where there’s also disparity. But those in contrast are one
and a half to two halves prior. Prematurity is in that
range. Infant mortality and even cancer deaths are in
the one and a half to two times higher, which everyone agrees is
much greater than it should be. Here it’s three to
four times higher but probably the
greatest disparity of any public health
measure in the United States. Mortality is a rare event in
today’s world in even countries like the United States. But maternal morbidity occurs
100 fold more commonly. So instead of per hundred
thousand, now we’re talking about per hundreds here. And as you see in this same
time period from the 90’s up until the mid 2000’s you’ve
seen a doubling of the rate of severe maternal morbidity which is characterized
essentially by transfusions, by ICU admissions and severe
complications of pregnancy going from seven tenths of a
percent to 1.6 percent. Obviously, our pregnancy
population has been changing. We are working with mothers
who are older, more obese, have more underlying medical
conditions, hypertension, diabetes and there are many
more who have a prior C-section which carries its own
set of complications. In short we’re not
in the best of shape when starting pregnancy. However, age and obesity
are risk factors, they’re not causes of death. So the implication here is that
we need to bring our A game when we’re taking care
of today’s pregnant woman and we need to practice
medicine not in isolated one-on-one fashion but in
a fully developed team. This is actually the U.S. and
California’s actual numbers. What you see here in red
is the rate of maternal mortality from CDC databases
for United States as a whole going
from nine to 15ish. California with 500,000
annual births, which represents 1/8
of all U.S. births. is neck in neck with the U.S.
as a whole, a little bit more, a little bit less, but lies
within the same exact pattern. As was noted, I chaired on
the maternal mortality review committee for California, and
when we started reviewing the deaths after the state noticed
a rise in 2005-2006, we wanted to look beyond just
the epidemiology of the death but look at the opportunities
for improvement, trying to turn the mortality
reviews into a driver for change. When you look at
maternal mortality, at the specific underlying
causes, in the red column here you
see that embolic disorders, infection, hemorrhaging,
preeclampsia, all are in that 10
to 15 percent range. Some studies a little bit more,
some studies a little bit less. Many of them combine
inappropriately vinous thromboembolism and amniotic
fluid embolism. Very different disorders. But they often end up
being joined together. What you see and what’s
found in California was that the number one disorder is
cardiac disease. This is both cardiomyopathy and underlying
cardiac disease and that just reflects
the increasing burden of obesity and hypertension. And in our finding it was
even more of a concern in the African American
population. Now when you go to the
next column though, in the orange header, which is
one measure of severe morbidity which is ICU admission. This is now one to two per
1,000 or 10 fold higher than the mortality rate. Here the hemorrhage and preeclampsia now
are becoming dominant with some 50 percent of
cases admitted to the ICU or from these two causes. The CDC definition of
severe maternal morbidity, which includes transfusions
and a variety of diagnosis, pretty severe, but a little more
common ones at two per 100 now, now again 10 fold higher
than ICU admissions. Hemorrhage and preeclampsia
now account for some 80 percent of cases. So this is quite
directive in terms of where we need to
focus our efforts. When you look at preventability for maternal deaths there’s
been three good studies, types of studies,
The CDC working with North Carolina data
tried to identify causes that were presentable,
identify hemorrhage and preeclampsia is the
most preventable causes. In our California reviews, we
looked at a little bit differently. It was hard to retrospectively
judge preventability and we chose to grey the chance
to alter the outcome as good, very strong, good
or some or none. And here we’ve combined
the strong and good chance to alter the outcome
and again hemorrhage and preeclampsia are
the most important ones. The UK looks at it differently
again with substandard care that has a major contribution
to the maternal death and preeclampsia was the
most common cause fitting that category with hemorrhage
in a close second place. They had done previously a fair
amount of work on hemorrhaging which is why perhaps that was
somewhat a lower cause there. The cost of hemorrhaging
hypertension are actually also pretty dramatic here. These were two cost analysis
studies done recently at UCLA Center for Health
Policies Research indicating that for our Medicaid and
Medi-Cal the annual cost, annual cost, for
maternal hemorrhage was over $100 million. The annual cost for hypertension
disorder was $107 million so combining the mother and
the NICU cost to the baby. So these are real numbers. Now California has
500,000 births. You have to prorate
that for the state. Half of our births are Medi-cal. This was just the Medi-cal
births saving, costing, excuse me $200
million each year for each of these two causes. Significant maternal
morbidity is a significant driver for cost and morbidity. So to summarize we have
the most preventable causes of maternal mortality are
hemorrhaging and preeclampsia. The most common causes of
severe maternal morbidity, a large driver of cost
and they have high rates of provider quality improvement
opportunities so to summarize like denial and delay. Denial indicating that that
providers were assuming that the condition was
going to improve on its own and they just needed
to give it more time and delay is increasing passage of time before you get the
medicine for the treatments that are really going to do
the job such as interventions like balloons or
a little further surgery. This has been shown in several
studies, California, Illinois, in the Chicago area
several times and in other countries as well. Our approach in California was
to reduce maternal mortality and severe maternal morbidity
by concentrating first on these two causes of
morbidity mortality. So in 2009 we did a hemorrhage
multidisciplinary taskforce with everyone we could
think of in labor and delivery including
obstetricians, anesthesiologists, nurses, midwives
and hospital leaders. That turned into a
quality improvement toolkit which was then tested
through three multihospital collaborative at
20 to 30 hospitals. And now it’s in a statewide
implementation project with 125 hospitals. The same pattern was used for
preeclampsia … and to a taskforce a QI toolkit in a multihospital collaborative here. I’m getting feedback here.
It looks like … — Elliot, this is
Zsakeba Henderson. I just wanted to inform you
that the sound is pretty low. If you could just speak up or
come closer to the receiver so we can hear you a bit better. — Fine. Going back to where we
were with maternal mortality, this is where we were when we
started all these processes in California. And then over the next years
we’ve seen a significant spreading of where
we are in California with the rest of
the United States. With the U.S. going
up to the 19 range and California dropping
into the seven. There are multiple things that
can account for this change but certainly the focus
on obstetric safety on our units was a particular
contributor of actually focusing on hemorrhage and preeclampsia. improves outcomes for other
causes of maternal mortality as well which were developed
in the same structure and the safety elements that
can apply to all causes. The National Partnership for
Maternal Safety was organized as people started seeing
the fall in maternal safety and the increase in maternal
mortality throughout the country and represented the union
of efforts from the Society of Maternal Fetal Medicine
and ACOG represented here by Barbara Levy and Kate
Menard, and Mary D’Alton, the past President of the
Society of Maternal Fetal Medicine and my role as leader of California Maternal Quality Care
Collaborative working with ACOG. We called for a national
commitment to decrease maternal mortality and morbidity by better monitoring severe
morbidity, introducing bundles for hemorrhaging and
hypertension and VTE prevention and really trying to equip all
obstetrics units and providers with education and
resources needed. We did recognize
that half the births in the United States occurred
in hospitals with fewer than 1,000 deliveries. This really also then led us to
focus on identifying women at highest risk for
maternal morbidity to ensure access to
appropriate care. So it’s one thing to call for
national efforts, the other is to put it into play and
how do you mobilize all the organizations needed? And the answer to that is
the Council on Patient Safety in Women’s Health Care. This engages vice
presidents or above leaders from all the organizations
seen on this screen here which is essentially every
professional organization that’s engaged in women’s
healthcare from ACOG to the Osteopathic colleges for
obstetrics and gynecologists, to the anesthetic anesthesiology
society to Nurses Society to midwives society and
the gynecological society for family practice
and our board. So this is a critical group
of people to engage in focusing on these elements. So if we’re going to
introduce bundles we have to define what we’re
talking about. And what we’re looking at with the
national safety bundles is a collection of the best
practices for improving safety in maternity care that
have been vetted previously in large quality
improvement collaboratives. So the goal here is to
move establish guidelines in the practice with
the standard approach within your institution. These are not meant to be
a national protocol where, you know, one size
fits every facility. That would not work given the
different level of resources and the different approaches
that are available in all of our 4,000 maternity hospitals in the U.S. They’re
not new science. They’re not new randomized
controlled trials. They’re really putting
what we’ve learned from previous studies
into practice. The safety bundles
that have gone through the vetting processes
all have the same format. They are structured
into four domains. They’re called the four
R’s: readiness, recognition, response and reporting. Every unit is for readiness, Is your team ready
for emergency? And then recognition: how does
your team identify patients at risk for experiencing
deterioration? And how do you respond
then to an emergency? You know often times safety
bundle in the past have focused on a response.
But we really wanted to focus additionally on making
them unit ready and have some early warning or prevention
activity as well as response. Above all though we have to have
an element involving reporting. How are we going to learn and
improve some events in our unit? So this is data driven
quality improvement. This is debriefing. This is schooling. And learning from our events. So this is a pretty
critical R in our structure. The first bundle approved was
the obstetric hemorrhage bundle, and again these were all
multidisciplinary in their construct
and in their writing. This was put on the patient’s
safety council website and actually published
in four journals at the same time: The Green
Journal for Obstetrics, the Nursing Journal, JOGNN,
the Midwifery Journal for ACNM, and Anesthesia Journal,
Anesthesia and Analgesia for SOAP and the Editorial
and Family Practice Journal A detailed description was vetted and published in all four
journals in July 2015. So with bundles then we’re
also talking about toolkits. And when we talk about toolkits for quality improvement
this is really a repository, if you would, of
detailed examples of all the safety bundle elements.
Example policies, procedures, pathways, instructions so that
a unit can go to the toolkit, fix what it needs and really
jumpstart their quality improvement process. The goal here is for a guide
for bundle implementation. There are several states
that have led the way early on in these: California
and New York, and now we have additional
support from many other states
in this area. These are some examples of each of our respective
websites. CMQCC.org. The ACOG District 2, the
ACOG website. The Florida perinatal
Quality Collaborative, through their website. All these are easily Googleable. And Playbook for the
Successful Elimination of Early Elective Deliveries
was one that was a follow up playbook now for those
states that still had trouble with early elective
deliveries that we helped work on to the National Quality Form. So the National Goals set by
the council are that we want to have three bundles
implemented in every hospital over the next three years with the initial one being
hemorrhaging, preeclampsia and VTE prevention
with additional targets of first birth c-sections
and inter-conceptional care. How can we possibly reach
all of the hospitals and all the providers
in the United States? Part of the answer is
with this group on the phone, on this webinar and with all
the people that we talk to. And it’s engaging
every organization that we can think
of in this quest. And that’s where the
Alliance for Innovation in Maternal Health
comes into play. And this is a cooperative agreement between Maternal Child
Health Bureau and the Council on Patient Safety
in Women’s Healthcare. And it is administrated by
the Senior Director of ACOG which is Jeanne Mahoney. And the goal of the Alliance
for Innovation of Health is over the next four years to
prevent 1,000 maternal deaths and 100,000 cases of severe
maternal morbidity as we look at the CDC definition. Again we have to engage all
our professional organizations but that’s not going
to be enough. So the key partners for AIM
to put all this together, and here they’re in
alphabetical order, include the Hospital
Association, AMCHP, ASTHO, most of which engage
our State Health Partners. Various parts of
The Center for CMS that involves CHIP Services and
Innovation such as the HENs, The CDC, the joint commission
and the March of Dimes. So this is really an effort of
all these types of organizations with all our professional
colleagues. Where we stand with safety
bundles now is we’ve grown and published obstetric
hemorrhage, severe hypertension and VTE and they’re
all on the same website that we’ll show in a moment. We also have a key bundle
on patient and family and staff support,
which is supportive for all the other bundles,
recognizing that someone who has an illness or
severe maternal morbidity or in the worst case
a death, the family and the staff also
need support as we work through these processes. One of the later bundles
is the Safe Reduction of Primary Cesarean Births and that’s a whole
project on its own. There are safety tools
that have been published in this project including
Maternal Early Warning Criteria, which again is supportive
for all the bundles. As well as a guidance
for reviewing cases of Severe Maternal Morbidity. Coming soon are two new
bundles on Reducing Disparities in Maternity Care, which
is a critical piece that underscores again all of
our efforts in all the bundles. And the last bundle
illustrated here is looking at what we can do between
pregnancies, pre-pregnancy, to optimize women’s health
prior to conception. So you have bundles,
you have toolkits, but how are you going
to get them done? How are you going to
get them implemented? And this is a key role of
a quality collaborative. In here we have groups
of providers and hospitals working together
in an improvement project. And/or a group of diverse
organizations all working together on a topic typically where one alone would
be much less successful. The model we have with AIM is to
have the state health department with its resources
working with organizations that represent all the
providers and all the hospitals. This is essentially a three-
legged stool bringing together hospitals, hospital
associations, all the professional
organizations that we spoke of together with state
health departments that are generally the source
of their own set of programs as well as their
own sources of data. So where we are now with AIM
is engaging actively a series of states, Oklahoma,
Maryland, Florida and Illinois. We’re engaging some very large
health systems through NPIC and its organization of
hospitals and Premier and Trinity, both of those have
independently large data systems that can support such
a project as well. We’ve enrolled, we have
four additional states that are enrolled and actively
moving towards data submission and program development,
including Michigan, Mississippi, Louisiana
and New Jersey. We’re also looking at some
of the territory supported by AMCHP including some
of the Pacific Islands. And a special project through
ACOG trying to see if some of the main principles can apply to our partner countries
in Africa. We have, we’re anticipating
in the next six months or so that additional states
will join, South and North Carolina
we’re having extensive conversations with. And the two states that started
for mother support, New York and California, already have a
lot of progress in these areas, already have a lot of data,
we’re looking to integrate them in in a grandmother type
of role in the project. Now there are other states that are actually quite
interested as well. All the states on this slide and all the organizations
represent 2.6 million births in the United States, which is
about 60 percent of the births. I’m going to hand the baton
over to Jeanne at this point. — Ok thank you. And just to say that all of these states have
been contributing to our knowledge base as
we move ahead with AIM and so we really want to
be thankful, particularly of our grandmother
and grandfather states and those states that have
been working on bundles and these processes
for quite a while, that we don’t start
the initiative, we just work with it. How does AIM
work or why does it work? And we think about this
because number one we have a national focus. It’s not just one state or
one system or one hospital. It’s not a one off. We’re really looking across
the country and trying to build that tipping point
across the country of maternal safety as we go. We build, as I said,
on existing structures. We’re not trying
to reinvent wheels. We’re just trying to take what’s
available and to integrate it in across the country. And we really provide
cross facility, system and state sharing
for mutual support. It’s a big, huge thing. And as we go along I’ll
talk a little bit more about that mutual and peer
support that we’re doing. We have an expanding library of
resources and you’ll see those. And then really looking on the one-on-one technical
assistance that we can provide. So. What’s our process? We’ve recognized that
every single hospital in this country is different. There is no single
task that seems to work for any one particular hospital, one particular system,
one particular state. And so what we’re
trying to do is build on what’s already existing. We don’t try to make
it all look vanilla. We do like rocky road. So we expect that adoption of bundles is going
to be incremental. It certainly isn’t feasible
to just take all the bundles and do them at the same time
and expect that you’re not going to drive the world crazy. So just taking one step at a
time, one of those bullet points in a bundle at a time
and seeing how that goes. And then building on
a success from there. As I say we learn
from each other. We definitely involve
patients and families and you’ll see a little bit more
about that as we move along. And we like to keep everybody
informed of what’s going on. What do we have
available and I’m going to go through these a little bit. So we have lots of resources,
as I mentioned before. We have safety bundles,
we have sample protocols, checklists, algorithms, a lot
of patient information systems. We have our partner teams
and we schedule TA calls. There’s now eight of them
a month that are happening for various groups of
people and various systems in various hospitals across
the country that we continue to try and keep up with. And these TA calls are,
although we facilitate them, it’s really those on the phone
that are helping each other to build on what
they’re going on. We take every, all the
information that we get from these calls and try to find
out what it is that AIM can do to help break through
some barriers. And it’s been really
exciting to be on them. As I say, we do these facility
level peer-to-peer support. We have e-learning modules. And if you haven’t been on the website I
encourage you to do so. The website is
safehealthcareforeverywoman and there’s a special
spot there for AIM. So that’s the council website
address that I’m giving you but AIM is right on
the council website. And in those are
E-learning modules. Right now we have one on early
warning systems, hemorrhage and hypertension, the
one on safe reduction of primary c-sections is
just about finished and ready to go up, VTE prevention
is right behind it and we’ll have others
as we move along. And we have the data
for those data manager that Elliott is going
to talk to you about. We have a safety action series. It’s usually twice a month. We help with the council to put
on these webinars that go along and we have experts
that have been involved with the bundle development
or bundle implementation that are talking on the
webinar about how they’re doing and what they’re doing. So they’re very specific
to the bundles. And we are working
on doing drill and team training resources and that’s coming
in the near future. — Thank you, Jeanne. This is a picture of the website
that has many of the resources that Jeanne spoke about. It’s all laid out. All publicly available. This scrolls down
to show you some of the further details
on the website. Here are the e-modules. Again, anybody can download
them to get these going. We really are excited
about these e-modules. And lastly this is log in to
support for, if you’re a member, a member of AIM, you
can get a lot of support through this kind of a portal. Each section, every
bundle, has direct links to the tools needed
for implementation. So we talked about
obstetric hemorrhage. Here you see the
readiness piece. And here are a set of resources
that you can immediately link to and download so support
to the highlights of other states’ toolkits. We have a series of
longer presentations that are 45 minutes to an hour
that are expert discussions on the bundles or
pieces of the bundles. And again these are downloadable
including the slide sets for these, which is a
very exciting piece. So a question on the
table is, “Are CEU’s offered on the e-module courses?”
I think Jeanne can answer that. — On the e-modules, no, we do not
have CE’s but what we do have on the e-modules,
they’re very short. They’re like little TED talks. And what we do have on them
is after each of the domain, so after readiness for
hemorrhage we have a set of questions that staff,
hospital staff, can print out and then get a certificate
that they’ve accomplished this for their competency
requirements within their unit. So we don’t have CEU’s or
CME’s but we do have these that are very important
for the joint commission when they’re coming around
to look at staff education. We are also working, or are
about to work, with HealthStream which is an organization that helps hospital
education training. And they also give out
certificates and this is going to be connected with
HealthStream to make it even more seamless within a hospital
for staff education. — So what’s even more
important than CMA’s for physicians nowadays is
actually help in the making of certification process. And we and others on the program
have been working with ABOG, the American Board of Obstetrics
and Gynecology for their, to make it easy to get credit
for QI activity for that part of the maintenance
of certification. This has been done
for pediatrics and many other specialties and
ABOG is getting on board here and our partner organization in Illinois has gotten
this organized and we’re spreading this around. So that is the hallmark
of quality improvement is to share all the
materials far and wide. — Just along with that
I’ve just been talking with the American
College of Nurse Midwifes and they have a similar
process and we’re going to work with them to see
how we can help them to also get this certification. — So I spent just a few
moments on the data side of AIM because that’s how you
can measure progress and that’s how you
can measure success. And these are a combination
of outcome, process and structure measures. You really have to have data
to drive quality and safety. On the other hand you want
to minimize the effort to minimize the burdens
on hospitals and states so we strove to strike a balance
on that with our experience in multiple quality improvement
projects over the last decade. So the overarching outcome
measures, and consistent with the goals I spoke of
at the beginning, are severe maternal morbidity
using the CDC definition which is calculated using
patient discharge diagnosis data alone. So that’s no additional
data collection at the hospital level. Of course we want
maternal mortality but that’s a whole process
in itself that we have to get working with states
departments of health. For bundle specific outcome
measures we have three bundles that we’re starting with right
now, hemorrhage, preeclampsia and cesarean section reduction. These also can be collected
with administrative data. Severe maternal morbidity
among hemorrhage cases, among preeclampsia cases and
then the NTSV C-section rate which can be calculated
with birth certificate data. Hospitals themselves can get through our AIM data
portal a limited group of structure & process measures
that are focused on education and especially only one
process measure per bundle. That would be collected and
recorded on a quarterly basis. The datacenter has
built on the experience of sending the other
quality collaborative to use run charts illustrated
here showing your hospital compared to other like
hospitals and where it stands within the different quartiles. Data can be sent in
a tabular portion, and again this is
a sample hospital, and it would be compared
against the state of Oklahoma versus other like
hospitals in Oklahoma. Hospitals are De-Identified
in this process. Hospitals can see their own
name and how they compare but other hospitals cannot
see each other’s name or even their numerator
and denominator so there’s good anonymity here. We do categorize hospitals
into the quartiles, the U.S. quartiles so a
quarter of U.S. hospitals are under 500 births, a quarter
of U.S. hospitals are within 500 and 1,000, etcetera. State coordinators, as we work
with different state projects, can see the hospital name
to help move them along in a state collaborative
but as we sit at our national levels we
can’t see any hospital names and no one else can
see the hospital names. So this is an example of a hospital seeing how it
compares to other hospitals. The different shades of purple
here represent the different types or the different levels
of births at each hospital. And so hospital here at Tillman
Care Center would see its own name and its own rank
and its own rate. And it could, at
the bottom here, select or deselect
various hospitals to narrow the process down. So now we’re really looking
at 1,000, 2,000 and over 2,000 and that allows you to do
the comparisons a little more clearly. We are very interested in
disparity, as I mentioned at the beginning of
our discussion today and we’re following that
both at the hospitals, which probably only can be done at the annual basis given
the sample sizes engaged. And collaborative wide
so we’re looking to try and reduce not only
maternal morbidity overall but maternal morbidity
among African Americans and reduce that disparity. Here’s an example of a process,
one of the few process measures that we have, which
would be nurse education on a given bundle in
increments of 10 percent. And again you can
compare yourself to the different strata of hospitals
and you can see in this, at this point about half
the hospitals are engaged and completely from
their nursing education. But when you look at provider
education they’re lagging a bit behind. Here we’re asking that they
have at least a grand rounds or attendance at a grand rounds or other educational activity
related to the specific bundle. Implementation is hard
though and it is one thing to have a bundle, one
thing to have a toolkit and even data collection but
the actual implementation is where most folks struggle. And so what we see
here is the ability to put together resources that
have been very recently done. The CDC has done a very
nice project of Developing and Sustaining Perinatal
Quality Collaboratives that was released a two months
ago that is helpful for states but also is very helpful for implementation
of specific projects. The Council on Patient Safety
Women’s Healthcare has a bundle about bundles, if you
would, a bundle of how to implement bundles
released a toolkit on that and that was released just
two days ago on our website and that has a lot of very
practical information. CMQCC has also in the last days
released an implementation guide for supporting the Vaginal Birth and Reducing Primary
Cesareans toolkit and our collaborative on that. So these are great
resources to go through as you’re working
either at the state level or the hospital level to work
on the implementation phase. Just as we’re closing I’d
like to recognize the staff for AIM national staff. Jeanne Mahoney on
our line today. Kisha Semenuk is
our Program Manager, does a lot of the day
to day interaction. Martha Ngoh is Program Associate
that gets all our materials up and a lot of the communications. I’m working on the
implementation side. Andrew Carpenter
and his associates at Critical Juncture has
developed a datacenter and they’re managing that and
are working with state agencies to get birth certificate data and the patient’s
diagnosis data. But we could not do this without
all the national state leaders from ACOG, AWHONN,
ACNM, AMCHP and ASTHO and other related organizations
to make this really fly. So what we covered
today was U.S. data for maternal mortality
and severe morbidity. The National Partnership
for Maternal Safety and how that’s come
under the umbrella of the Council Patient Safety
which is now contracted with AIM to roll this out nationally. We talked about how we’re
in eight states right now, looking for funding for more and hopefully we’ll get more
states and more funding. And all the resources that
we’ve already developed that are available on
the council website, on the AIM portion of
the council website. We have a datacenter
up and running and we’re collecting data
now from multiple states. And we’d like to end
with a thank you for all of our partners and encourage
everyone to get engaged. And I think we have a few, we
have seven or eight minutes left that we can handle
questions as we go along. — Hello Elliott, this
is Zsakeba Henderson. I just want to let everyone know
that we are taking questions in the chat and we will also
be taking live questions. I’d also like to ask the
operator to open the lines for questions for
those who would like to actually engage the
speakers through the audio line. And I also want to ask
if you are not speaking to make sure your
phone is on mute. So Elliot there are some
questions we already have in the queue and I will just
start with those questions. We actually do have
longer than a few minutes. We have time for question
and answer until 3:30. But we’ll take the questions
that we have already lined up. The first question is
what went into determining or selecting the health
conditions, for example, hypertension or obstetric
hemorrhage? — So those were identified,
hemorrhage and hypertension, as that they were the
leading preventable causes of maternal mortality. That they were far and away
the most important causes of severe maternal morbidity
accounting for over 80 percent. And they had a high
degree of preventability. We also contributed a lot to extra
costs for labor and delivery. Those were all wrapped up
into the highest, creating them as the highest priority. In California we’re also
working on a toolkit for cardiovascular disease, which as you noted was
the number one cause of maternal mortality but it actually encompasses
a whole range of conditions. It’s not a single, even cardiomyopathy is
actually breaks down into four or five different types
of cardiomyopathy, hypertensive cardiomyopathy, pregnancy related
cardiomyopathy, hypertrophic cardiomyopathy,
for example. And so it gets complex very
quickly and it involves a lot of people outside
of the hospital which is just a trickier
part to reach. So we’re working on
different strategies for that that we can use for
hypertension and preeclampsia which are largely
focused on the hospital and the prenatal care needed
prior to the hospital. — Thank you very much. Our next question is, “Would
HealthStream access require a purchase by the facility? Or is access to HealthStream
adequate?” Thank you. — Hi. This is Jeanne.
I’ll answer that question. We are just contracting
now with HealthStream but from what I understand, if a facility is already using
HealthStream, it will just be part of the package
that comes with it. So it’s not a specific
separate package. And HealthStream will be doing
webinars and other things to help promote AIM
once it gets started. So we’re really excited
to be working with them. — Fantastic. Thank you. The next question is in
relation to the bundles. And the question is, “Are we
collecting neonatal outcome during the bundle use time? I assume this is in regard to
the maternal project. The maternal project,
are neonatal outcomes being collected?” — The state health departments
are collecting that for states as a whole, neonatal
mortality rates, of course. But we’re not collecting
additional neonatal morbidity issues. This has been a focus largely
on the maternity outcomes. In California we focus
on cesarean section. In our collaboratives we
are looking at a variety of neonatal morbidity outcome
as a balancing measure. We’re looking at ways
of extending that up for other states to use
as administrative data. — Fantastic. And then the last chat question that we currently have is,
“How will you make sure that data isn’t double counted? For instance in Maryland,
the largest birthing hospital with approximately 10,000 births
a year, was a Trinity facility and Trinity is also
participating.” — Ok well we have some
hospitals that are both in a state and in
a health system. We are looking to encourage
them to be primarily counted in their state, if they’re
in a state like Maryland, they will be displayed in both
but we are counting them for, if they’re in a state,
in the state. The data portal can display them
again in both so they can participate in both but the actual counts
will be limited to the states, unless they’re in a system that doesn’t have a
state home as well. There was a chat question I
saw about the definition of severe maternal morbidity, Maternal morbidity is obviously
a spectrum of gradation from almost died, near
miss, to morbidity that could be just
vaginal lacerations. And so where you actually
make that cut point in between is recognized
to be arbitrary. We wanted to have two goals. We wanted to have it
be severe morbidity and not very milder morbidity. We wanted it to be measurable. One of the definitions of near
miss that we use for case review for the joint commission
is four units of blood transfusion
or ICU admission. Neither of those
is easily captured with administrative
data, in fact both of those could be very
hard even for a hospital to identify internally. It’s sort of interesting
how difficult it is because blood transfusions
count for many hospitals. So we partnered with the
CDC to use their measure that Bill Callaghan developed
a number of years ago. It was Elena Kuklina. And is done on administrative
data which is severe maternal
morbidity CDC index, if you would. We actually just did
a validation study that was published
in May suggesting that it was a very
adequate measure. It’s not perfect. We felt that there was
severe maternal morbidity which probably not just
defined by a single unit of blood transfusion which
would be counted in the CDC. But on the other hand families and patients might consider
any blood transfusion of proof. So it was a test of
specivity and specificity if, if you did include one unit
blood transfusion in the mix. It is collectable and it
is, and we have worked with a collaboration of four or
five state projects with the CDC to validate a transition to ICU10. And that involves some tweaks
of the definition in the code and that will be
released shortly. So we do have an
IC9 and IC10 version of severe maternal morbidity
that has a track record that has 10 or 15
publications on it. That’s the one we’re
using for this project. — Fantastic. I’d just like to
remind participants that we are still
accepting questions through the chat function and I believe the operator
has opened the lines for audio questions. I also would like to remind you that handouts were made
available in the reminder email for those who registered and
will be made available again to those who registered for this
webinar after the presentation. There will be handouts with
the slides made available and the presentation will
also be posted on our webpage. The link to our webpage is on the last line that’s
currently presented. And you can also sign up on our
webpage to get notifications for any updates or
changes to that page. We’ll go ahead to
the next question. And the next question is, “Is maternal mortality data
collected in U.S. territories, for example Puerto Rico and
the U.S. Virgin Islands?” — I actually don’t
know the question. I’m assuming it must be because
that it is a basic public health measure. — Yes, I can answer that. The answer is yes. — I’m sorry. — Go ahead, finish. — No, I was just saying the simple answer is yes. — So looking at the list
in acute care settings of what gestational age should
fetal demise be investigated? That’s a little off of our
topic today but generally at hospitals we often
investigate 20 weeks or more. There’s a big move nationally
to move that down to 16 weeks. — The Northern Mariana
Islands is one of our… — Yeah. That’s… There’s some very good new
data on stillbirths that has come out of the NICHD
Collaborative on stillbirth. [ someone talking in the background ] Jean, I think we’re hearing
you talk in the background. — Yes, please mute your phone
if you’re not answering the question. — And the next question here is,
“Will you be counting all blood product in the four unit count
with the recent discussion about plasmas versus packed cells?” Any blood transfusion count as a
severe maternal morbidity. The four unit count was for the
joint commission. And the joint commission wanted
folks to look at a basically it’s considered a special event
with a plural investigation, formally known as a root cause
analysis. Now a little bit more broadly defined. But it was a
multidisciplinary review of the potential systems improvement.
That’s what the four unit count is. Working with the joint
commission in ACOG we revised it to be essentially four units of
red cells, easier to collect, easier to collect, easier to count,
because platelets come in 10 packs. Is that 1 or is that 10?
And cryo can come similarly. So it was really
focused on red cells, just as an arbitrary item. We do strongly recommend fresh
plasma but this gets away from all those other issues. — Thank you. I just wanted to let
participants know if you’d like to ask an audio question
you can just press star 1 in order to be queued up for
an audio question. Are there any additional
questions at this time? — There are no audio
questions at this time. — Thank you. So if there are no further
questions at this time I’d like to thank… Sorry.
Was that a question? We would like to thank
Elliott Main and Jeanne Mahoney for giving us an excellent
presentation on the Alliance for Innovation on Maternal Health.
We’d also like to thank you all for participating
in this webinar and we’d like to invite you to provide feedback
about this presentation and this webinar series as a whole.
We will be contacting you after this webinar for your input.
We hope and our webpage in this webinar series will facilitate
exchange of information and promote visibility of perinatal
quality improvement activities throughout the country.
You may also visit our webpage at www.cdc.gov/reproducetivehealth/
maternalinfanthealth/pqc to learn more about CDC support
of Perinatal Quality Improvement Collaborative. Thank you again and have
a wonderful afternoon.

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