the cmqcc maternal data center (cmdc): resources for your perinatal quality program anne castles,...

The CMQCC Maternal Data Center (CMDC):

Resources for your Perinatal Quality Program

Anne Castles, MPH, MA Kathryn Melsop, MSCMDC Project Managers

Elliott Main, MDCMQCC Medical Director

Presented at Washington State Hospital Association Safe Table 11/19/2013

: Transforming Maternity Care

CPQCC and CMQCCMission: Improving care for moms and newborns

California Perinatal Quality Care Collaborative (CPQCC) Expertise in data capture from hospitals Established Perinatal Data Center in 1996 Data use agreements in place with 130 hospitals with NICUs Model of working with state agencies to provide data of value

California Maternal Quality Care Collaborative (CMQCC) Expertise in maternal data analysis Developer of QI toolkits Host of collaborative learning sessions Established Maternal Data Center in 2011



What is the CMDC?(And how can data help my hospital??)

A low-cost, low-burden, online tool providing hospitals with:

Overall hospital performance measures Drill-down statistics and case review worksheets to identify

quality improvement opportunities—for both clinical quality and data quality

Provider-level statistics—to assess variation within a hospital

Benchmarking statistics--to compare your hospital to regional, statewide, and like-hospital peers

Facilitating reporting to Leapfrog, Cal-HEN and PSF


NEW! CMDC Drill-Down Tools for Primary Cesareans

Background C-section rates continue to rise in CA and

nationwide (2012 CA rate: 33.2%) Tremendous variation in CS rates across hospitals

(and across providers within hospitals) The Nulliparous, Term, Singleton Vertex (NTSV)

population has accounted for the largest portion of the 50% increase in the overall Cesarean birth rate in the last decade and accounts for > 90% of the variation seen among hospital primary cesarean birthrates.


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80% Total CS Rate Among 251 California Hospitals 2011-2012

(Source: CMQCC--California Maternal Data Center combining primary data from OSHPD and Vital Records)

Range: 15.0—71.4%Median: 32.5%Mean: 32.8%

July 24, 2013 5Presented at Washington State Hospital Association Safe Table 11/19/2013

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80% Low-Risk First-Birth (Nuliparous Term Singleton Vertex) CS Rate (endorsed by NQF, TJC PC-02, CMS, HP2020)

Among 249 California Hospitals: 2011-2012(Source: CMQCC--California Maternal Data Center

combining primary data from OSHPD and Vital Records)

Range: 10.0—75.8%Median: 27.0%Mean: 27.7% National

Target =23.9%

July 24, 2013

36% of CA hospitals meet national target

6Presented at Washington State Hospital Association Safe Table 11/19/2013


California Maternal Data CenterWebEx Demonstration


: Transforming Maternity Care 8Presented at Washington State Hospital Association Safe Table 11/19/2013

: Transforming Maternity CarePresented at Washington State Hospital Association Safe Table 11/19/2013


PDD--Discharge Diagnosis File(ICD9 codes)

Birth File(Clinical Data)

Low-Burden Data Collection

CMQCC Data Center

REPORTSBenchmarks against other hospitals

Sub-measure reports

Calculates all the MeasuresLIMITED CHART REVIEW

• Roadmap MetricsOptionally:• ED<39 Weeks• Antenatal Steroids• Bilirubin Screen• DVT Prophylaxis

Hospital to CMQCCHospital to CMQCC



California Maternal Data CenterWebEx Demonstration



Active Track StepsCoordination Complete a Participation Agreement Identify IT staff to upload patient discharge and birth data to

the CMDC on a monthly or quarterly basis: • Patient Discharge Data just like CHARS submission• Birth Data includes 5-10 key data elements (GA, Parity, Birthweight,

Delivering Provider, Apgar Score, ICU admission) Identify staff to complete medical chart review for the

records that require additional information for select “Roadmap” measures and OPTIONALLY:

• Antenatal Steroids• Bilirubin Screening• DVT Prophylaxis for CS cases

Use Results for Clinical and Data QI Participate in training and quality review session with.



CMDC ParticipationCurrent Participation: 45 California hospitals now actively submitting data; 30 more in the pipeline (as of October 2013)

Our CMDC Users Say….This is one of the easiest to use, comprehensive quality improvement tools I have ever seen. David Lagrew MD, Chief Integration and Accountability Officer, Memorial Care Health System

I absolutely love the richness of this data that we can take to our medical staff and administrative teams to see how well we are doing and where we need to focus on our quality improvement. Kristi Gabel, Perinatal CNS, Sutter Roseville Medical Center CMDC has helped us improve our 39 week elective deliveries. We went from 22% to 5% by getting accurate data and this team helped us to keep focused. The CMDC team is excellent. They are quick to answer your questions is a way you can understand. They have a positive, knowledgeable and action oriented team. I am so happy to be part of this.Debbie Groth, Director, Maternal and Child Health, El Camino Hospital, Mountain View We are loving the CMDC! It has truly expanded our quality reporting and ongoing analysis. Cynthia Fahey, MSN, RN, Clinical Quality Coordinator, Community Memorial Hospital, Ventura



Value beyond Joint Commission Reporting

CMDC metrics represent entire population of deliveries Likely to reduce “skew” due to sampling from quarter to quarter

Easy identification of facility-specific QI opportunities Drill-down patient level information

Data quality reports to identify coding issues that impact performance

Case review worksheets

Metrics beyond Joint Commission Perinatal Care set

Statewide, regional and system-wide benchmarks



California Maternal Data CenterScreen Shots


Uploading Data Files• Hospital uploads Discharge Data for one or more months• CMQCC receives Birth Data directly from Vital Records• After both files uploaded, linkage occurs instantaneously. • If additional matching or record review required, notation “Action Needed” appear


Data Entry for Chart Review•Once the data linkage is complete, the system performs the preliminary analysis

for the measures that require chart review .•A worksheet can be printed to give to Medical Records and use for review•Data is entered by clicking into this interactive screen

Each Data Field can be sorted Data

Entry by clicking



CMDC MeasuresLabor and Birth Measures Elective Delivery <39 Weeks (PC-01)* Episiotomy Rate OB Trauma (3/4th Laceration)-Cesarean Delivery (AHRQ EXP-2) OB Trauma (3/4th Laceration)-Vaginal Delivery w/ Instrument (AHRQ PSI 18) OB Trauma (3/4th Laceration)-Vaginal Delivery w/o Instrument (AHRQ PSI 19) Cesarean Section--Nulliparous, Term, Singleton, Vertex (PC-02) Cesarean Section--Nulliparous, Term, Singleton, Vertex, Age Adjusted (PC-02) Cesarean Section--Term, Singleton, Vertex (AHRQ IQI 21) Cesarean Section—Primary (AHRQ IQI 33) Total Cesarean Rate Induction Rate Failed Induction Rate Appropriate DVT Prophylaxis in Women Undergoing C-Section (Leapfrog)* Vaginal Birth After Cesarean (VBAC) Rate, All (AHRQ IQI 34) Vaginal Birth After Cesarean (VBAC) Rate, Uncomplicated (AHRQ IQI 22)

Newborn Measures Newborn Bilirubin Screening Prior to Discharge (Leapfrog)* 5 Minute APGAR <7 Among All Deliveries >39 weeks (HEN) 5 Minute APGAR <7 in Early Term Newborns (HEN) Birth Trauma - Injury to Neonate (AHRQ PSI 17) Unexpected Newborn Complications (NQF)

Prematurity Measures Antenatal Steroids (PC-03) Antenatal Steroids-Leapfrog VLBW (<1500g) NOT delivered at a Level III NICU

*Requires additional limited chart review


Reporting Center

(image) (data file)

•Each measure is displayed graphically and as a data table•Each measure can be downloaded either as an image for use in presentations

or as a data file to be used in reports

Select quality measure to display

Download this measure

Select comparison group(s) for your hospital

Click on rate to “Drill Down” to see the numerator cases


Drill Down Information

• Can drill down to see case-level information• Hover boxes show definitions for ICD-9 codes


Data Quality Reports• Identify discrepancies or missing data in Birth Certificate

and Discharge data files• Use to target data performance/quality improvement

Screen shot from the California Maternal Data Center

Data Quality Reports• Identify discrepancies or missing data in Birth Certificate

and Discharge data files• Use to target data quality improvement

Targeting QI ActivitiesWhat is driving your Elective Delivery<39 Weeks Rate?


Comparative Statistics on:

• Demographic Indicators

• Maternal Conditions• Delivery Methods• Prematurity Rates• Length of Stay


: Transforming Maternity CarePresented at Washington State Hospital Association Safe Table 11/19/2013


Data Edit Tool: to allow fixing of data prior to submission



Two Security Gates


the cmqcc maternal data center (cmdc): resources for your perinatal quality program anne castles,...

Documents

primary data

hospital peers

perinatal data center

data capture

california hospitals

state agencies

ca hospitals

data use agreements