Birth Death Certificate Indiana Perinatal Quality Improvement Collaborative

Birth & Death Certificate Indiana Perinatal Quality Improvement Collaborative – Quality Improvement Committee 11/13/2014 Erica Park Nancy Swigonski, MD, MPH, FAAP Kathleen Frogge, Program Director 2

“YOU CAN DESIGN AND CREATE, AND BUILD THE MOST WONDERFUL PLACE [SYSTEM] IN THE WORLD. BUT IT TAKES PEOPLE TO MAKE THE DREAM A REALITY. ” WALT DISNEY

OVERALL GOAL Overall goal: Reduce Indiana’s infant mortality rate In order to reach overall goal, Indiana needs good data 2 areas of data: § Birth certificate § Death certificate

Death Certificate Indiana Perinatal Quality Improvement Collaborative – Quality Improvement Committee 11/13/2014

DEATH CERTIFICATE PROCESS

DEATH CERTIFICATE PROCESS 1. Funeral home receives a call from the hospital or the parents

DEATH CERTIFICATE PROCESS 1. Funeral home receives a call from the hospital or the parents 2. If parents decide to use their funeral services, infant will be transferred to the funeral home

DEATH CERTIFICATE PROCESS 3. Hospital initiates a burial transit permit Fills out Sections A & B

DEATH CERTIFICATE PROCESS 4. Person who picks up the body fills out more of the permit Fills out Sections C

DEATH CERTIFICATE PROCESS 5. Funeral home completes the permit - fills out Sections D & E § 3 copies of this permit § 1. Health department by the hospital § 2. Crematory or cemetery § 3. Health department

DEATH CERTIFICATE PROCESS 6. Funeral director logs onto IDRS to initiate the death certificate – generally within 24 -48 hours but may be longer if waiting for the mother’s release from hospital

DEATH CERTIFICATE PROCESS 6. Funeral director logs onto IDRS to initiate the death certificate – generally within 24 -48 hours but may be longer if waiting for the mother’s release from hospital 7. IDRS opens with an initial search § If name is already in the system, it will match the name to the search § If name is not in the system, it will initiate a new death certificate form

DEATH CERTIFICATE PROCESS 8. Funeral director fills out demographic information

DEATH CERTIFICATE PROCESS 8. Funeral director fills out demographic information 9. Funeral director sends death record to the physician § Physician must be registered in the system § Physician will receive an email notifying him/her that a death certification is in queue § Email includes decedent’s name, date and time of death, place of death, etc.

DEATH CERTIFICATE PROCESS 10. Physician logs onto IDRS and fills out medical information and certifies the death

DEATH CERTIFICATE PROCESS 10. Physician logs onto IDRS and fills out medical information and certifies the death 11. Physician sends the death record back to the funeral director § Funeral director receives a similar email notification

DEATH CERTIFICATE PROCESS 10. Physician logs onto IDRS and fills out medical information and certifies the death 11. Physician sends the death record back to the funeral director § Funeral director receives a similar email notification 12. Funeral director finishes certificate

DEATH CERTIFICATE PROCESS Fetal deaths are registered in a separate system § Key differences: § Fetal death report requires more parent demographic information § If the fetus is <20 weeks gestation, the funeral home does not have to report and the hospital can dispose the body

DEATH CERTIFICATE INFORMATION GATHERING Met with funeral director § Discussed the death certificate process and issues with timeliness § Physicians not registered into the system causes delays § Time it takes to fill out the death certificate data into IDRS § Live birth: ~10 minutes § Fetal death: ~15 -20 minutes

DEATH CERTIFICATE INFORMATION GATHERING Neonatologist § Physicians must be registered into the IDRS – if the attending physician is not registered this could cause delays § Recent switch to electronic birth records and lack of training may be causes of delay § Physicians do not know they are able to initiate the death certificate § Ultimately these delays cause delays in burial of the baby

DEATH CERTIFICATE INFORMATION GATHERING https: //vrqa. isdh. in. gov/inthin/indextest. html

DEATH CERTIFICATE DATA - FINDINGS Key issue is getting physicians registered into IDRS Physicians can start the death record, but this was unknown Others can start the death record with the physician later signing with their personal identification number (PIN), but this was unknown

DEATH CERTIFICATE DATA - FINDINGS Online Training § Training manuals § Indiana = 78 pages § CDC = 65 pages § IDRS system not self-explanatory § Webinar link does not work

DEATH CERTIFICATE PROCESS – BRAINSTORMING Where in your hospital/system are there problems with the death certificate process? What ideas do you have to make the system better? What methods at your hospital work well?

DEATH CERTIFICATE DATA RECOMMENDATIONS Identify the hospitals with highest number of infant deaths and focus efforts on those first Register and demonstrate IDRS to physicians during hospital orientations Preload physicians into the system Pilot a program using staff to initiate the certificate

Birth Certificate Indiana Perinatal Quality Improvement Collaborative – Quality Improvement Committee 11/13/2014

BIRTH CERTIFICATE PROCESS – THEORETICAL

BIRTH CERTIFICATE PROCESS THEORETICAL 1 a. Mother fills out the Mother’s Worksheet section of the CDCissued 12 page birth certificate form

BIRTH CERTIFICATE PROCESS THEORETICAL 1 a. Mother fills out the Mother’s Worksheet section (MWS) of the CDC-issued 12 page birth certificate form 1 b. Hospital staff fills out the Facility Worksheet section (FWS) of the CDC-issued 12 page birth certificate form

BIRTH CERTIFICATE PROCESS THEORETICAL 1 a. Mother fills out the Mother’s Worksheet section (MWS) of the CDC-issued 12 page birth certificate form 1 b. Hospital staff fills out the Facility Worksheet section (FWS) of the CDC-issued 12 page birth certificate form 2. Hospital staff logs onto BDRS

BIRTH CERTIFICATE PROCESS THEORETICAL 1 a. Mother fills out the Mother’s Worksheet section (MWS) of the CDC-issued 12 page birth certificate form 1 b. Hospital staff fills out the Facility Worksheet section (FWS) of the CDC-issued 12 page birth certificate form 2. Hospital staff logs onto BDRS 3. Hospital staff uses the CDC-issued 12 page birth certificate form to fill out the electronic birth registration form

BIRTH CERTIFICATE PROCESS THEORETICAL 4. County health department receives birth registration data

BIRTH CERTIFICATE PROCESS THEORETICAL 4. County health department receives birth registration data 5. State Department of Health receives birth registration data

BIRTH CERTIFICATE PROCESS THEORETICAL 4. County health department receives birth registration data 5. State Department of Health receives birth registration data 6. CDC receives birth registration data

BIRTH CERTIFICATE INFORMATION GATHERING Vital Records Training Modules http: //in. gov/isdh/25584. htm § For birth clerks, hospital staff that works with IBRS § 3 modules on the ISDH website § Each take ~30 minutes to complete § Module 1: Improving the Quality of Birth Certificate Data § Module 2 A: All Birth Worksheet Data Matters Part A § Module 2 B: All Birth Worksheet Data Matters Part B Visited hospitals to outline the birth certificate process

BIRTH CERTIFICATE FINDINGS

BIRTH CERTIFICATE DATA - FINDINGS Findings from the hospital visits CDC-issued 12 page worksheet was “split” into 5 separate worksheets Hospital has 300 births/day If no interruptions can get through 20 -25 births into the BDRS/day Time it takes to fill out (ideal) § Ranges from 15 min– 1. 5 hours

BIRTH CERTIFICATE DATA - FINDINGS The actual process is much more complex than theoretical process Obstacles faced by the hospital staff Missing data § Takes time to find sources of missing data and contact the mother for information

BIRTH CERTIFICATE DATA - FINDINGS The actual process is much more complex than theoretical process Obstacles faced by the hospital staff Missing data § Takes time to find sources for missing data and contact the mother for information Variation in data sources (online, paper) § Which source has the correct information?

BIRTH CERTIFICATE DATA - FINDINGS The actual process is much more complex than theoretical process Obstacles faced by the hospital staff Missing data § Takes time to find sources of missing data and contact the mother for information Variation in data sources (online, paper) § Which source has the correct information? Availability of external data § Example: prenatal care if begun in a different hospital

BIRTH CERTIFICATE DATA - FINDINGS The actual process is much more complex than theoretical process Obstacles faced by the hospital staff Missing data § Takes time to find sources of missing data and contact the mother for information Variation in data sources (online, paper) § Which source has the correct information? Availability of external data § Example: prenatal care if begun in a different hospital Changes to the questions and answer choices on the CDCissued 12 page worksheet § Example: choices for “Mother’s Race”

BIRTH CERTIFICATE PROCESS FINDINGS Variations of the birth certificate registration process in hospitals Accuracy of the data must be addressed Timeliness of the data must be addressed

WHAT HAVE OTHER STATES DONE? WHAT ARE BEST PRACTICES?

BIRTH QUALITY WORKGROUP Recently, the CDC formed a Birth Data Quality Workgroup to survey data quality practices among the State Departments of Health § Online survey § Focused on activities that evaluate and ensure data quality § Asked about actions in response to data quality findings § 46/52 completed the survey (88. 4% participation) Results of the study led to 2 specific recommendations

BIRTH QUALITY WORKGROUP RECOMMENDATIONS 1. Data must be evaluated on an ongoing basis § Importance of rapid cycling § Recommend quick response to poor data quality from birth facilities – weekly or monthly vs. quarterly or yearly

BIRTH QUALITY WORKGROUP RECOMMENDATIONS 2. Effective communication of data quality is necessary § 1. Concrete feedback § 2. Increase awareness about the merit of data quality § 3. Provide regular trainings and newsletters § 4. Publish reports about performance to increase transparency § 5. Connect with upper-level clinicians and hospital administrations

BIRTH CERTIFICATE FINDINGS FROM OTHER STATES State Recommendations/Actions Washington “Why Quality Data is Important and Help to Improve Your Data” guide; website comparing data quality of facilities Ohio Real time auditing; development of a new standardized H&P to contain all necessary points California Increased regional trainings; development of a CMQCC Maternal Data Center

STATE OF WASHINGTON The State of Washington has developed a Birth Data Quality Query System (BDQQ) webpage on their State Department of Health website § “The BDQQ is a tool to help you improve your birth data quality” The BDQQ system provides hospital profiles of “percent unknown” for selected items on the birth certificate

STATE OF WASHINGTON There are 4 possible ways to look at the data for each birth facility using the BDQQ system: § 1. “Average % Unknown” compared to facilities of similar birth volume

STATE OF WASHINGTON § 2. “% Unknown” of certain birth data items compared to state

STATE OF WASHINGTON § 3. “% Unknown” of certain birth data items over time

STATE OF WASHINGTON § 4. “Average % Unknown” compared to WA state over time § State also has a PDF link on this site to their guide § Guide explains the reports and the birth certificate in layman’s terms

STATE OF OHIO Ohio Perinatal Quality Collaborative (OPQC) and the Ohio Department of Health Vital Statistics performed a study focusing on 4 phases of birth data registration § Phase I: Completing the electronic health record § Algorithms to flag incomplete charts § Empowering nursing staff § Increased teaching of hospital staff

STATE OF OHIO § Phase II: Empowering staff § Nurses encouraged to contact OB providers if data was missing § Emphasized safety benefits to hospital staff peer-topeer

STATE OF OHIO § Phase III: Real Time Auditing § Nursing supervisors began real time auditing for incomplete medical record § Pregnancy card created for each pregnant women § Phase IV: Real Time Auditing Continued and Expanded to High Risk Groups

STATE OF CALIFORNIA California Maternal Quality Care Collaborative (CMQCC) development of a California Maternal Data Center (CMDC) § CMDC is a statewide data center that collects and reports timely maternity metrics (including data quality) in a way that is “low cost, low burden, and high value for hospitals” § Similar to Washington, but with more detail § CMDC is overseen by a multi-stakeholder Steering Committee composed of clinicians, hospitals, payers, purchasers, consumer organizations, and relevant state agencies

STATE OF CALIFORNIA Demonstration site link: https: //demo. datacenter. cmqcc. org/hospitals/1

BIRTH CERTIFICATE PROCESS – WHAT IS THE PROCESS IN YOUR HOSPITAL? What are the steps that are taken to fill out the birth certifi cate? Who pro vide s information ? What sources are used to fill out the birth ce rtif i cate (pape r, e lectronic )? What if yo u are unable to find information? W hat steps do you then take? Are the re any spe cific areas on the birth data registration form that are part icularly difficult, unclear or usually not able to be filled out? Why is it dif f icult? How lo ng do es it take to comp lete a birth certificate registration form? § How long does a fairly “straightforward” birth take versus a more complicated one? § How many births are entered in 1 day? § How many births per week are entered? § How long from the time of birth to entry into the system (average and range)? How lo ng have you or the person who usually fills out birth certificate in form at ion bee n doing th is job? § Are you/they hired specifically as a birth clerk or do you/they have other duties also? § What other duties? § How many hours per day are dedicated specifically birth data entry? What t raining did you/they r eceive regarding birth certificate? § Have you/they used the birth certificate data training modules on the Indiana State Department of Health website? § If so, did you/they find it helpful?

BIRTH CERTIFICATE PROCESS – BRAINSTORMING Where in your hospital/system are there problems with the birth certificate process? What works well in your hospital? What ideas do you have to make the system better?

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 1. Provide feedback § Distribute a list of variables that commonly have errors to hospital administration

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 1. Provide feedback § Distribute a list of variables that commonly have errors to hospital administration § Notify hospital administrative and clinical leadership about the deficiencies in vital records process

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 1. Provide feedback § Distribute a list of variables that commonly have errors to hospital administration § Notify hospital administrative and clinical leadership about the deficiencies in vital records process § Use a website to publish performance reports to increase transparency

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 1. Provide feedback § Distribute a list of variables that commonly have errors to hospital administration § Notify hospital administrative and clinical leadership about the deficiencies in vital records process § Use a website to publish performance reports to increase transparency § Increase vital records staff to be able to give more immediate feedback

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 2. Provide training incentives § Recommend hospitals to include completion of training modules in performance review

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 2. Provide training incentives § Recommend hospitals to include completion of training modules in performance review § Provide regular trainings and newsletters for birth registration staff

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 2. Provide training incentives § Recommend hospitals to include completion of training modules in performance review § Provide regular trainings and newsletters for birth registration staff § Develop a post test and/or a Certificate of Completion for staff completing modules

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 2. Provide training incentives § Recommend hospitals to include completion of training modules in performance review § Provide regular trainings and newsletters for birth registration staff § Develop a post test and/or a Certificate of Completion for staff completing modules § Pursue CEUs for nurses and CMEs for physicians for completing birth certificate training modules

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 3. New systems improvements § Add definitions of fetal death and live birth on the electronic birth and death registration systems

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 3. New systems improvements § Add definitions of fetal death and live birth on the electronic birth and death registration systems § Add a drop down box with causes of death on the screen that match the CDC codes

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 3. New systems improvements § Add definitions of fetal death and live birth on the electronic birth and death registration systems § Add a drop down box with causes of death on the screen that match the CDC codes § Allow staff to receive email re: death certificate at the same time as the physician

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 4. Extend roles and approaches § Communicate to physicians that they should register in IDRS and that they can initiate the death record

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 4. Demonstrate and implement § Communicate to physicians that they should register in IDRS and that they can initiate the death record § Encourage hospitals to have physicians register in the IDRS during hospital orientation

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 4. Demonstrate and implement § Communicate to physicians that they should register in IDRS and that they can initiate the death record § Encourage hospitals to have physicians register in the IDRS during hospital orientation § Communicate that staff (nurses, clerical staff) can be authorized and trained to complete initial data that is then confirmed by the physician and submitted

BIRTH CERTIFICATE DATA RECOMMENDATIONS: 4 CATEGORIES 4. Demonstrate and implement § Communicate to physicians that they should register in IDRS and that they can initiate the death record § Encourage hospitals to have physicians register in the IDRS during hospital orientation § Communicate that staff (nurses, clerical staff) can be authorized and trained to complete initial data that is then confirmed by the physician and submitted § Communicate that the hospital can initiate the prenatal birth record

STEPS TOWARDS EFFECTIVE CHANGE “Not every change is an improvement, but every improvement is a change; you can’t do anything better unless you can manage to do it differently. You’ve got to let yourself do better than other people. ” Eliezer Yudkowsky

SUMMARY Indiana does very well in the completion of birth and death certificate data However, improvements can still be made to improve the quality of the data In order for Indiana to successfully reduce the infant mortality rate, the state must have good quality birth and death certificate data

REFERENCES 1. 2. 3. 4. Ahuja S, Bakus K, Crawford G, Fontana C, Gambatese M, Jessen A, Justice D, Madsen-Straight A, Martin J, Pagnano S, Reed P, Thoma M, Tretter E, Wishart L. Efforts to improve birth data quality: results from a survey of data quality practices among US vital records jurisdictions. Hyattsville, MD: National Center for Health Statistics. 2014. Ford S, White B. Summary of birth certificate data collection challenges: lessons learned from Ohio and other states. Columbus, OH: BEACON Ohio Department of Health. 2012. Birth data quality query system. 2014. Washington State Department of Health. Retrieved July 20, 2014 from https: //fortress. wa. gov/doh/bdqq. aspx. Main E, Castles A, Murphy B. Partnering for maternal data quality improvement. California Maternal Quality Care Collaborative. 2013.