TIPQC THA HEN OB EED Webinar August 25, 2014 A TIPQC THA/TCPS Collaborative Inter-institutional Quality Improvement Project Faculty Course Director: Peter Grubb, MD, Assistant Professor of Pediatrics, Vanderbilt University School of Medicine; Medical Director, TIPQC Planner/Speaker: Brenda Barker, MEd, Project Director, TIPQC Planner/Speaker: Chris Clarke, RN, Senior Vice-President, Tennessee Center for Patient Safety, Tennessee Hospital Association Planner/Speaker: Jackie Moreland, RN, Clinical Quality Improvement Specialist, Tennessee Center for Patient Safety, Tennessee Hospital Association Speaker: Pam Isom, BSN, RN, MPH, Director of Newborn Screening, Division of Family Health and Wellness, Tennessee Department of Health Speaker: Sara Guerra, BSN, RN, Quality Nurse Consultant, Division of Family Health and Wellness, Tennessee Department of Health Welcome! Agenda for today: • Data Performance Trends • Newborn Screening Reports • Team Successes • Questions/Answers from Hospital Teams OB EED Data Trends Working toward our goal of 5% or less HEN OB Data Charts HEN OB Data Charts HEN OB Data Charts HEN OB Data Charts OB Statewide Data Charts OB Statewide Data Charts OB Statewide Data Charts OB Statewide Data Charts Questions State of Tennessee Newborn Screening Program Hospital Reports Pam Isom, BSN, RN, MPH, Director of Newborn Screening, Division of Family Health and Wellness, Tennessee Department of Health ~ Sara Guerra, BSN, RN, Quality Nurse Consultant, Division of Family Health and Wellness, Tennessee Department of Health State of Tennessee Newborn Screening Program Hospital Reports Milwaukee Article Department of Health Process Improvements Courier Service Weekend Lab Hours Weekend Follow-Up Hours Milwaukee Article Hospital Reports Distribution Date Review of Reports Tennessee Newborn Screening Follow-Up Program Pam Isom, Director Email: [email protected] Phone: (615) 532-8462 (855) 202-1357 Newborn Screening Follow-up Program Email: [email protected] Questions Safe Sleep Hospital Incentive Bundle • Free “Sleep Baby, Safe and Snug” board book for each birth in your facility • Free TDH “ABC’s of Safe Sleep” materials • Free Recognition on TDH website (http://safesleep.tn.gov) • Signed certificate from TDH Commissioner • Press release template Hospital Requirements • Identify main hospital contact for communication with TDH and submit intent pledge • Develop hospital Safe Sleep policy • Implement Safe Sleep policy, which at a minimum must include: – At least annual education to all perinatal staff (OB, peri/postpartum, and pediatrics) on safe sleep recommendations – Requirements for staff to model safe sleep recommendations – Plan for at least quarterly internal compliance audits with hospital policy • Submit annual report on educational activities and staff compliance in order to receive books Breastfeeding The Joint Commission’s Perinatal Care Core Measure PC-03 TIPQC Breastfeeding Promotion Delivery Project State AIM: improve the health of infants and mothers in Tennessee by • systematically promoting and supporting breastfeeding and • focusing on high reliability (>90%) implementation of processes that promote and support breastfeeding in the delivery setting. • Immediate aim: Thus, we seek to increase the fraction of infants who are exclusively fed breast milk at hospital discharge by 10% by March 2014 (Wave 1 aim & Wave 2 has just begun) • Long term aim: To eliminate barriers in birthing facilities to achieving the Healthy People 2020 goal. Ten Steps to Successful Breastfeeding: the Baby Friendly Hospital Initiative 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Have a written breastfeeding policy Provide staff training in policy implementation Provide breastfeeding education for pregnant women Help initiate breastfeeding within 1 hour of birth Show mothers how to initiate and maintain breastfeeding (even if separated from infant) Give no substitutes unless medically indicated* Practice rooming in 24/7 Encourage breastfeeding on-demand Give no artificial nipples/pacifiers to breastfed infants Support and utilize support groups *Hospitals should accept no free or heavily discounted formulas and/or feeding supplies Tennessee Breastfeeding Hotline • 24/7 breastfeeding hotline! Dr. Michael Warren, Director, Division of Family Health and Wellness, TN DOH Commissioner John Dreyzehner, MD, MPH Resource https://www.cvent.com/Pub/eMarketing/Pages/WebEmail.aspx?m=6048447e-0293-49f5-acdf-6627f13370fe Resources • All material will be posted on the THA HEN Community of Practice (COP) http://www.HealthcareCommunities.org – Contact [email protected] for COP questions or if you need registration and joining instructions. • THA/TCPS Contacts: – Chris Clarke, Sr. VP [email protected] – Jackie Moreland, QI specialist [email protected] – Jessy Richter, Data Manager [email protected] • TIPQC Contact: – Brenda Barker, M.Ed. [email protected] Resources ACOG Statement ACOG practice bulletin, "Induction of Labor" updated in 2010 Tool Kit CMQCC / MOD Tool kit: http://www.cmqcc.org/resources/1974 Websites www.tnpatientsafety.com user name: hospital password:tnbabies www.healthytennesseebabies.com IHI Resources Elective Induction and Augmentation Bundles http://www.ihi.org/knowledge/Pages/Changes/ElectiveInductionandAugmentationBundles.aspx How-to Guide: Prevent Obstetrical Adverse Events @ http://www.ihi.org/knowledge/Page s/Tools/HowtoGuidePreventObstetricalAdverseEvents.aspx Articles A statewide initiative to reduce inappropriate scheduled births at 36(0/7)-38(6/7) weeks' gestation http://www.ncbi.nlm.nih.gov/pubmed/20207241 39 Resources Articles Continued… Improving Perinatal Care: A Focus on Patient-Centered Care and Evidenced-Based Measures http://www.ihi.org/knowledge/Pages/ImprovementStories/ImprovingPerinatalCareAFocusonPati entCenteredCareandEvidencedBasedMeasures.aspx Reducing Birth-Related Trauma and Liability Exposure http://www.ihi.org/knowledge/Pages/ImprovementStories/ReducingBirthRelatedTrauma.aspx Neonatal and maternal outcomes associated with elective term delivery, http://ajog.org Rationale for a 39-Week Elective Delivery Policy http://sitesearch.aafp.org/?q=rationale+for+39+Weeks+policy&x=0&y=0&t1search=true&sp_cs=UTF-8 Reduction in elective delivery at <39 weeks of gestation: comparative effectiveness of 3 approaches to change and the impact on neonatal intensive care admission and stillbirth http://www.ajog.org/article/S0002-9378(10)00679-4/fulltext 40 Resources Patient Resources March of Dimes Resources: Healthy Babies Are Worth The Wait http://www.marchofdimes.com/professionals/medicalresources_hbww.html Get ready for labor “Brain Card” Why at least 39 weeks is best for your baby http://www.marchofdimes.com/pregnancy/getready_atleast39weeks.html AWHONN Resources: Go the Full 40 http://www.awhonn.org CMS Innovation Resources Strong Start Toolkit Link http://innovations.cms.gov/initiatives/strong-start/what-you-can-do-to-help.html 41 IHI Open School 2014 • • • • • 1. 2. 3. 4. THA is providing free access to the IHI Open School curriculum to employees and trustees of our safety partner hospitals. 21 online, self-paced courses including 72 lessons and corresponding resources— videos, case studies, podcasts, featured articles, exercises, networking Free app for the iPhone and iPad by logging onto iTunes Over 25 contact hours available for CME, CNE, CPHQ and ACPE credit Certificate of completion Register using instructions. Type “Tennessee Hospital Association” as your facility to receive free membership. Once registered, go to the course page: www.ihi.org/lms Click the online learning tab and choose a lesson Click Begin Lesson Contact Taelor Barnette at [email protected] 615-401-7414 for more information. 42 Upcoming Events • AHA/NICHQ Webinar – Tuesday September 23, 2014; 1:00pm CT. The Baby Friendly Hospital Initiative: Improving Maternity Care and Increasing Breastfeeding Rates. Registration is free – advanced registration required at https://event.on24.com/eventRegistration/Even tLobbyServlet?target=registration.jsp&eventid= 840515&sessionid=1&key=AF19B29BDD4B2DA B560F2A93B54E3AC1&sourcepage=register Upcoming Events • Next OB Monthly Team Webinar— Monday September 29, 2014;10:00am CT. Perinatal Care Core Measures Overview and Update by Celeste Milton of the Joint Commission • 2014 THA Leadership Summit th Wednesday November 5 at the Gaylord Opryland Hotel and Convention Center in conjunction with THA’s Annual Meeting. Make plans to showcase your improvement work by submitting a poster for presentation. Contact Chris Clarke at [email protected] for details Data Due Date! Monthly data due by last date of following month!