Aim

Kickoff!
Making North Carolina the Best
Place to Give Birth and Be Born!
Martin J McCaffrey, MD, CAPT USN (Ret)
For the Perinatal Quality Collaborative of North Carolina
Who Needs QI and
Collaboration?
NIH Consensus Statement Antenatal Steroids
1994
 Antenatal Steroid Use in CA 2005-2007

Lee HC et al. Antenatal steroid administration for premature neonates in California From 2005-2007. Obstet
Gynecol. 2011 Mar;117(3):603-9.
Making North Carolina the Best Place to Give
Birth and Be Born
Defining Value
Partnership with patients and families
Spread best practice
Resource optimization
 Hospitals (65) Participating in

PQCNC Initiatives
Cape Fear Valley
Albemarle Women's Center

Granville Medical Birthing Center

Carolinas Medical Center
Halifax Regional Medical Center
CMC-Pineville
Maria Parham Medical Center Maternity Services
Columbus
Nash Health Care Special Care Nursery
Cleveland
Nash Health Care Women's Center
Duke
Wilson Medical Center

Granville Carteret General Hospital Brady Birthing Center and Nursery

New Hanover Outer Banks Hospital

Novant Forsyth Bladen County Hospital Birth Center

Novant Huntersville Johnston Health Women's Pavilion

Wake Med Cary

Novant Presbyterian
Southeastern Regional Women's Healthcare
Rex
Vidant Edgecombe
UNC
Alamance Regional Medical Center
Vidant (ECU) Greenville
Brenner Children's Hospital
Womack
Davis Regional
WakeMed
Morehead Memorial Hospital

Caromont Randolph Hospital

Catawba Valley CMC Lincoln

Central Carolina Grace Hospital

CMC-NorthEast High Point Regional Culp Women's Center

Iredell Memorial Hospital

FirstHealth - Moore
Novant-Matthews
Grace
Rowan Regional Medical Center
McDowell
Stanly Regional Medical Center
Mission
Lenoir Memorial Hospital
Onslow
Watauga Medical Center
Transylvania
Wilkes Regional Medical Center
 PQCNC Initiatives
CABSI
39 Weeks
SIVB
National CLABSI
Exclusive Human Milk Well
Exclusive Human Milk NCCC
Patient and Family Engagement (PFE)
Neonatal Abstinence Syndrome
CCHD Screening Reporting System
Accuracy in the Birth Certificate
Conservative Management of Preeclampsia (CMOP)
ASNS
AIM OB Hemorrhage
 Supporting Public
MD MOC Advocates

Quality
Clinical Measures
Leaders

Making North
Carolina the Best Payment
Evidence
Place to Give Birth Incentives
and Be Born

Public Public
Policy Reporting
Pay for
Quality
Collaborative
Performance
Improvement
 Who are our PQCNC Partners?
Co-Leads for National Network
Perinatal Quality Collaboratives
CDC PQC Project AHA/HRET
NCGA and CFTF BCBSNC

DPH Maternal NCHA and NCQC

And Infant Health

Division Medical
NC March of Dimes PQCNC Assistance & CCNC

Office Rural Health NC Partnership for

Community Care Maternal Safety

62 Hospitals Family Support

Network Joint Commission
13 States 171 NICUs in PQCNC Perinatal
Led NCLABSI Core Measures Panel
 Initiative Design
Select initiative topic
Identify Expert Team
Expert Team Develops Aim Statement and Charter
Problem, intervention, defined goal
Expert Team Develops Action Plan (Key Driver Diagram)
Identify key challenges
Identify recommended interventions
Outcomes desired
Expert Team Defines Key Measures
Process and outcome
Create Web Based Data Reporting System
Hospital Perinatal Quality Improvement Teams Formed
Face to face Learning Sessions, Monthly Webinars, Weekly Newsletters, QI
Facilitation
 PQCNC Initiatives
2009-2016
Reduction of Early Elective Deliveries (<39 Weeks) (2009)
Reduction of First Birth Cesarean Delivery Rate (Support for Intended Vaginal
Birth SIVB) (2010-2012)
Reducing Central Line Associated Blood Stream Infections in NICUs (CLABSI)
(2009, 2010-2011)
Increasing Breastfeeding Rates in Well Nurseries (2010-2012)
Increasing Maternal Milk Use in NICUs (2010-2012)
Conservative Management of Preeclampsia (2014-Present)
Neonatal Abstinence Syndrome (2014-Present)
 2017 PQCNC Initiatives
Phase 1/2 (Post-Pilot): Conservative Management of Preeclampsia (CMOP)
(includes 23 Hospitals)
Antibiotic Stewardship Newborn Sepsis (48 hospitals, 56 teams)
AIM (Alliance for Innovation on Maternal Health)
Prevention of morbidity and mortality associated with maternal hemorrhage
2018 Newborn Initiative: Hypoglycemia
 39 Weeks Project

Decrease of
43%

Berrien K et al. The perinatal quality collaborative of North Carolina's 39 weeks project: a quality improvement program to decrease elective deliveries before
39 weeks of gestation. N C Med J. 2014 May-Jun;75(3):169-76.
 PQCNC Support for Intended Vaginal Birth
(Reduction of Rate of NTSV CS)

50.0%
45.0%
40.0%
35.0%
Cesarean Rate

30.0%
25.0% All Patients
20.0%
High-Risk Patients
15.0%
Low-Risk Patients
10.0%
5.0%
0.0%
Baseline
February
March
April
May

July
August
June

September
October
November
December

Phase I Phase II/III

In nine months we saw a 15% increase in the likelihood of first-time

mothers delivering vaginally in 24 participating centers
Mothers may have
more than one risk
factor
 INITIATIVE-WIDE CESAREAN RATES
50.00% OVERALL C/S RATE

C/S RATE - NO C/S RISK FACTORS

45.00%
38 to 26%...33% increase in likelihood of SIVB
20 to 16%...24% C/S RATE - 1+ C/S RISK FACTORS
40.00% 38.01%
36.34% Linear (OVERALL C/S RATE)
34.62% 35.06%
34.07%
35.00% 32.60%
30.20% 29.74% 30.41%
30.00% 28.00% 27.62%
26.42%
25.11%
23.99% 24.12% 23.67% 23.95%
25.00% 22.16% 22.80%
21.98%
21.02% 21.29%
20.37%
19.11%
20.00%
20.25% 20.74%
19.32% 18.66% 19.06% 19.19% 18.83%
18.23% 18.47% 18.27%
15.00% 16.95% 16.59%

10.00%

5.00%

0.00%
 Conservative Management of Preeclampsia
(CMOP) 2013-Present
New ACOG and CCNC guidelines related to classification and management of
HTNsive disorders
CMQCC toolkit for hypertensive disorders of pregnancy
Key metric of time to treatment
Advocacy groups for mothers with preeclampsia
Interest from payers
23-32 centers actively participating, 42% of NC births
Likely consideration by JC of measures related to maternal hypertension
Aims
1) Eliminate deliveries 37 weeks for GHTN and Preeclampsia Without Severe Features
2) Increase Time to Treatment or BP Control < 1 hour to 90%
3) Increase antenatal steroid rates to 90%
4) Increase rates of maternal postpartum education
 Antibiotic Use in the NICU
When different
physicians are
recommending
different things
for essentially
the same
patients, it is
impossible to
claim that they
are all doing the
right thing."
(Eddy DM)

Schulman J et al. Neonatal intensive care unit antibiotic use. Pediatrics. 2015 May;135(5):826-33.
 AIM
By January 2018, PQITs in NC hospitals will utilize defined best practices for evaluating risk
for sepsis to demonstrate a decrease of 20% in the number of patients exposed to any
antibiotic and a decrease of 20% in duration of antibiotic administration past the first 48
hours of life with a negative blood or CSF cultures.

Action Plan Recommendations

Kaiser sepsis calculator
Antibiotic Time Out
Parent partnership Focus is acute infection
Targets mother-baby units and NICUs

www.pqcnc.org
 UNC Experience

Process Change

A 70% reduction in antibiotic exposure to infants in UNC NBN

From 7.5% to 2.3% of newborns receiving antibiotics
 ASNS in NC

122,719 births in NC (2016)

85,903 infants participating in

PQCNC ASNS nearly 70% of
births in NC
 PQCNC ASNS
By the numbers
44
Hospitals Participating

85,903 6,442
Infants Currently Being
North Carolina Exposed
Newborns

1,288 (3,221)
Infants per year
protected from
unnecessary exposure
to antibiotics
 ASNS NBN

Reduction from 2.3% to 1.6%...30%

ASNS NBN
ASNS NICU

23% to 13%...44% reduction

 ASNS NICU

Reduction from 33% to 24%...28%

 = PQCNC Projects

ETD, CS Rates, Neonatal Mortality

32.3 32.9 32.8 32.8 32.8 32.7 32.2
31.8
31.2 31.3 31.7 31.4 32 31.9
30.3 31.1
30.3 30.4 30.6 30.3
29.1 29.8 29.5 29.3 29.4
28.8
27.8
27.5 27 27
26.8
26.1 26
25.3 25 24.6
24.4 39 Weeks 24
23 22.9
15% reduction in early term deliveries
SIVB SIVB CMOP
8% reduction in overall CS rate
6% reduction in neonatal mortality PMH PMH
14% reduction in 32-36 week deliveries
HEN

11.2 11.4 11.4 11.1 10.8 11.1 10.6 10.1 9.6 9.5 9.5 9.8

6 5.6 5.7 6 6.1 5.6 5.7 5.3

5.2 4.9 4.9 4.9 5 4.9

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
CS Rate NC CS Rate US Neo Mortality Early Term Deliveries 32-36 Week Deliveries
 Partnering in Public Health Monitoring
CCHD Screening
Accuracy in Birth Certificate Reporting
State Center for Health Statistics (Kathleen Jones-Vessey, Matt Avery and NC
Birth Certificate Registrars)
Vital Records (Tamma Hill, Field Services Manager for Vital Records)
 PQCNC Return On Investment
2009-2016
Savings
$29,928,000 for SIVB/39 Weeks
$11,854,498 for massive reductions in 37-38 week deliveries and newborn costs
$1,400,000 for CMOP avoiding preterm births
$3,500,000 for NAS avoiding NICU and hospital days
None of these savings include estimated 20% professional fees
Additional $9,336,499
$23,400,000 for CLABSI
Total savings estimated = $79,418,997
Cost
CMS Transformation Grant ($650K over three years)
UNC Innovations Grant ($600K over three years)
ORHCC/BCBSNC ($1M) one time support
NCGA Approved DPH Maternal Block Grant ($250K x 3 years, $350K x 2 years)
NCGA (2016) $475K
CDC Grant ($200K/year x 2 years)
Total funding (2006-2014): $4,575,000
ROI
1735% over last six years
Stakeholders
Non-Denominational
On the Road
Data
Were making changes, are we changing culture?
Think Big
TEAMWORK

Alone we can do
so little, together we
can do so much.
Helen Keller
 CMOP Phase 2

66% reduction

Rising to 85%

Hospital cost avoidance $2,374,320 using

Tricare calculator (infants 1500-2500 grams)
Pro fees not included (estimate $474,866)
Increasing use of ANS for infants requiring
18% increase delivery at < 34 weeks (from 71% to 85%)
impact on reducing RDS, IVH, and NEC.
Increasing treatment of HTN moms within 1
hour from 68% to 80%