Difference between revisions of "Maternal and Perinatal Quality Care Collaboratives"

Revision as of 17:52, 3 May 2023

Perinatal Quality Collaboratives and The Alliance for Innovation on Maternal Health

Perinatal Quality Collaboratives

Perinatal Quality Collaboratives (PQCs) are state level or multi-state networks working to improve outcomes in maternal and infant health by using quality improvement principles to address gaps in evidence-based clinical practices within the state or network they cover.(6) It originated in 1997 with the California Perinatal Quality Improvement Collaborative. Essential elements of a PQC include a multidisciplinary advisory committee, clinical leaders, public health leaders, quality Improvement advisors, family representatives, organizational structure and communication systems, and a data management plan. Their goal is to reduce clinical variation and optimize resources to make evidence-based medicine for maternal and infant health available in all locations. As of September 2022, there are 47 state PQCs in the United States.

The National Network of Perinatal Quality Collaboratives (NNPQC) is an organization supporting the development and maintenance of state PQCs to improve statewide – and thus nationwide – maternal and infant healthcare and health outcomes.(7) The NNPQC was launched by the Centers for Disease Control and Prevention (CDC) and the March of Dimes in 2016. It is now funded by the CDC and coordinated by the National Institute for Children’s Health Quality (NICHQ) since 2017. Coordinating efforts include: PQC intercommunication, development, technical assistance for quality improvement methods.

Current areas of focus for PQCs include efforts to reduce preterm birth, severe complications arising from pregnancy-related hypertension and hemorrhage, racial/ethnic and geographic disparities, cesarean births in low-risk pregnancies, and improve the identification and treatment of neonatal abstinence syndrome.

The NNPQC initiative has several primary drivers at the national level that guide the PQC mission. These are:

1. Getting state or network engagement and buy-in from stakeholders for the PQC vision

2. Launching initiatives

3. Data collection and measurement

4. Quality improvement methods

5. Dissemination

6. Sustainability of the initiative

Some successes of the PQCs as noted by the CDC include:

• Decreased elective deliveries without a medical indication before 39 weeks gestation

• Decreased in cesarean section births in low-risk populations

• Decreased neonatal healthcare-associated sepsis

• Decreased severe maternal morbidity (SMM) from postpartum hemorrhage and hypertension

• Decreased preterm births

• Increased breastfeeding rates

Alliance for Innovation on Maternal Health (AIM)

One area that the CDC collaborates with the Health Resources and Services Administration (HRSA) is through the Alliance for Innovation on Maternal Health (AIM).(8) HRSA and the American College of Obstetricians and Gynecologists (ACOG) formed a $3 million cooperative agreement to develop AIM which is a national, cross-sector initiative to reduce SMM and maternal mortality in the United States. This cooperative agreement is up for renewal and grant consideration as of 2023.

AIM is a voluntary private/public partnership with multidisciplinary and patient representation.(9) The cornerstone of AIM is the development and implementation of patient safety bundles and rapid cycle quality improvement. AIM is in place in 49 states and the District of Columbia collaborating with over 1900 hospitals and birthing centers (comprising over 70% of the national birthing facilities). Through state-based AIM teams, data on core metrics related to processes, structure, and outcomes from collaborating hospitals and birthing centers are compiled into an online national AIM data collection system and analyzed by the AIM Data Team. The AIM Data Center is a free web-based tool to collect, report, and visualize aggregated quality improvement data on patient safety bundle implementation but requires a subaward and data use agreement between AIM state teams and ACOG. It does not collect patient-level data or potentially identifiable patient information. This data is then monitored by HRSA and the national AIM team. It is not publicly available.

The patient safety bundles are a collection of evidence-based nursing and clinical care to target diagnoses that contribute to increased SMM and mortality. The bundles that are in place or have been implemented are:

• Obstetric hemorrhage

• Severe hypertension in pregnancy

• Safe reduction of primary cesarean birth

• Cardiac conditions in obstetrical care

• Care for pregnancy and postpartum people with substance use disorder

• Perinatal mental health conditions

• Postpartum discharge transition

• Sepsis in obstetrical care

• Obstetric care for women with opioid use disorder (retired)

• Maternal venous thromboembolism (retired)

• Postpartum basics: from Maternity to Well-woman care (retired)

• Postpartum basics: from birth to postpartum visit (retired)

• Retained vaginal sponges after birth (retired)

• Reduction of peripartum racial and ethnic disparities (retired)

• Maternal mental health (retired)

An additional important cornerstone of the AIM work was to create the infrastructure for a Levels of Maternal Care (LoMC) system as defined by ACOG and the Society for Maternal Fetal Medicine (SMFM) to address SMM and mortality – similar to levels of neonatal care or trauma care. This established a classification system for basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV) and defined the capabilities and personnel needed for each level. It also sought to develop collaborative relationships between levels in the system for consultation and transfer of care.(10)

(2012)

A Vision for Redesigning Maternal & Perinatal Healthcare Using Health IT

In 2002, Donald Berwick described a framework to plan, discuss, and propose health system redesign. (4) The Vision Team for Transforming Maternity Care(1) applied this framework to maternity and perinatal care to create four levels for change:

A. the experience of women, their families, and support networks

B. the clinical microsystems that provide direct maternity care

C. the hospitals and health care organizations that house and support clinical microsystems

D. the environment of policy, payment, regulation, accreditation, litigation, and other macro-level factors that influence the delivery of maternity care(1)

Application of Health Information Technology: Problems and Goals

Problems: (5)

• Limited interoperability between health IT systems

• Data and health IT systems is not seamlessly linked across time, care settings, and providers

• Data needed by various users is not yet available through health IT systems

• Implementing health IT is expensive

Goals: (5)

1. Create a core set of standardized data elements for electronic maternity care records to facilitate interoperability.

• Accomplish this via a transparent multi-stakeholder process.

• Core data elements are aligned with what is needed for high-quality care and performance measurement that can be implemented in electronic health records (EHRs) or by administrative/clinical data sources.

• Create a data dictionary for internal use by facilities to ensure standardization of the core data elements for optimal clinical care, performance measurement, quality improvement, and research. Benchmarking, reporting, and resources can be made available through creation of a geographic data dictionary for external use (e.g., hospital, geographic, demographic).

• Advocate for policies that promote quality improvement for childbearing women and newborns, specifically CHIPRA provisions that develop a core performance measure set and a model EHR for beneficiaries of Medicaid and CHIP.

• Pilot, evaluate, and refine the electronic maternity care record, and make it an available resource widespread use.

• Encourage employer purchasers and payers to exhibit leadership in advocating for accountability in the expansion of health IT.

2. Ensure security and establish interoperability through identification/authentication tools and accurate patient matching functionalities, and policies that protect patient privacy and security.

• Convene various stakeholders to create strategies that meet needs of patients, the public health, and purchasers.

• Develop and implement methodologies to allow external public health entities to extract data for surveillance and tracking of population health data from EHRs.

• Base secondary data use progress on algorithms within states and voluntary agreements regarding standard methodologies across care settings.

3. Explore ways to use health IT incentives to improve clinical care quality, efficiency, and coordination and to enable corresponding performance evaluation.

• Use standardized, routinely collected data in electronic maternity care records to facilitate research and quality improvement initiatives.

• Include maternal and newborn quality measures in P4P programs, public reporting, and feedback to providers and facilities.

• Improve care coordination and maternity care quality for disparate populations through health IT incentives under Medicaid and safety net providers.

• Develop health IT resources, training and clinical decision support for high-risk maternity events that incorporates regional data and capacity.

4. Increase and improve consumer-based uses and platforms for health IT.

• Use health IT platforms (such as mHealth and social media)to develop accessible, affordable educational resources, methods of communication with caregivers, and personal health record for consumers.

• Use health IT platforms to publicly report results of performance measurement that is user-friendly for consumers to make comparisons among care options. (5)

References

1. Transforming Maternity Care [Internet] 2012 [cited 2012 Nov 24]. [1].

4. Berwick D. A user’s manual for the IOM’s ‘quality chasm’ report. Health Aff. 2002 May;21(3):80-90.

5. Ulmer C, McFadden B, Nerenz DR, editor. Subcommittee on standardized collection of race/ethnicity data for healthcare quality improvement. Race, ethnicity, and language data: Standardization for health care quality improvement Washington, D.C.: National Academies Press; 2009.

6. National Network of Perinatal Quality Collaboratives. National Institute for Children's Health Quality. 2023. Accessed 4/24/2023. [2]

7. Perinatal Quality Collaboratives. The Centers for Disease Control and Prevention. 9/22/2022. Accessed 4/24/2023. [3]

8. Alliance for Innovation on Maternal Health (AIM). Health Resources and Services Administration. October 2022. Accessed 4/24/2023. [4]

9. Alliance for Innovation on Maternal Health. American College of Obstetricians and Gynecologists. 2023. Accessed 4/24/2023. [5]

10. Strategies for Implementation of Regionalized Risk-Appropriate Maternal Care on a National Scale. AIM. August 2022.

Submitted by Katherine Pomeroy, N.D.

Revised by LaPortia Smith, MD 2023