DEVELOPING PERINATAL QAPI Our journey to consistent process

DEVELOPING PERINATAL QAPI Our journey to consistent process improvement

Introductions Stacie Elizondo MSN, RNC § Administrative Director of Women’s & Children’s Services § RN for 26 years § LEAN Instructor Tammy Van Stockum, BSN, RNC-NIC, CD(DONA) § Perinatal Quality Specialist (Full time) § RN for 30 years § Level III NICU Nurse 10 years, Level II 20 years

Background Information • We are located in San Angelo, Texas: Population 100, 000 • Shannon W&C Center is a freestanding facility separate from the main hospital • Our care area covers 10% of Texas’ land 1% of the population (we are rural, closest large city is Abilene) • RAC-K has 2 hospitals in the entire RAC • We have 110 -130 Deliveries per month o 5 delivery room, 4 antepartum rooms, 2 ORs • 10 OB service Providers o Including 8 OB’s and 2 CNMs (No OB Hospitalist or • First Level II Nursery in Texas to be surveyed • Maternal Survey done July 23 -24, 2019 for Intensivist) Level II o Cover their own patients during the day and share • Texas Ten Step call from 1700 -0700 Hospital • Level II Special Care Nursery o 4 intensive care beds, 10 Intermediate care beds • Children’s Miracle Network Hospital and 17 Well baby beds • 9 Pediatricians who cover their own patients (no

Wearing Many Hats • • • Rural facility One person has many roles Not everyone can be at every meeting Huddles crucial to team communication Ad Hoc committees may be needed as situations arise

Where we started 2016: We didn’t know what we didn’t know! • Had a long-standing monthly subcommittee for each service line that included limited QAPI • Created a multidisciplinary operational committee to prepare for Neonatal survey • Only audited neonatal charts based on occurrence reports - No random auditing • Did not have a formal process for loop closure • Did not include Maternal/Perinatal until after January of 2017 • Changed EMR from Paragon to Epic

Neonatal Designation Survey January 2017 • Deficiency • Plan of Correction

Quality vs Perinatal Quality Very early on we recognized the need to shift an FTE to have a full-time Perinatal Quality Specialist with perinatal clinical experience (implemented in October 2018) Hospital Quality already tracking required regulatory data (39 wk inductions, infection rates, etc). Perinatal QAPI is “the rest of the story” Loop closure for Perinatal QAPI through oversight from Hospital Quality and QMC

Neonatal to Perinatal Referred to Maternal TAC for guidelines Developing quality based around the “ 7 pillars” • • HTN PPH MTP Sepsis Behavioral Health Shoulder Dystocia VTE Neonatal to Perinatal to adding Breastfeeding QAPI

Creating a QAPI Program

Create your QAPI Committee • Identify multidisciplinary stakeholders and schedule first meeting • Decide on schedule for meetings and acceptable minimum attendance requirements • Add in additional stakeholders as we needed • Example: EMR Analyst • Expand committee if appropriate • Neonatal+Maternal+Lactation = Perinatal QAPI

Mapping the Basics

Midas follow through process - Neonatal

Midas follow through process - Maternal

QAPI Policy

QAPI Form • Simple Excel form that can be completed and emailed out • Kept in a notebook for follow up by the Perinatal Quality Specialist • Remember to put the confidentiality statement on all forms • Kept notes of progress • Tracked dates to loop closure

QAPI Agenda Template

Agenda: Tips for Success • • • Email the meeting minutes from the last meeting one week before the next scheduled meeting. This will save you valuable time! Once set, keep your agenda consistent at each meeting Old Business - key to loop closure, keep it on until the issue is adequately addressed New Business Open Discussion

Managing PI Projects

Example: Ongoing Project STAT Maternal Imaging � Reporting identified that STAT maternal imaging was not being done within the 30 minutes required. � Began at about 45% in January 2018 � Most recent data 95%

Ongoing Data Analysis Maternal Imaging Within 30 Min. of a STAT Order Ja nu Fe ar br y ua r M y ar ch Ap ril M ay Ju ne Ju Au ly Se g pt ust em O ber c N tob ov e em r D ec be em r be r 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2018 2019 Linear(2018)

Data Monitoring LEAN Cross for ongoing projects

Example: Loop Closure Neonatal Antibiotics initiated within 1 hour of order � Through random chart auditing we found that our policy of starting antibiotic therapy within one hour of the order � In the first quarter 2018, retrospective review revealed that antibiotics were given within 1 hour only 42% of the time QAPI committee reviewed and made the following recommendations: � � � Re-educate nurses AND pharmacy staff regarding the policy Change physician order to STAT for the first dose Trended data monthly on LEAN cross and shared with staff/providers Committee re-evaluated and recommended giving the first dose IM if the IV had not been placed within 30 minutes Numbers steadily improved to 90% for the first quarter of 2019 By the 2 nd quarter of 2019 they had improved to 100% Committee reviewed and determine we could move from the LEAN Cross to monitoring it via the Neonatal Dashboard=LOOP CLOSED

The Proof is in the DATA Antibiotics Started Within 60 Minutes of a Physician Order 120% 100% 80% 60% 40% 2018 2019 Au gu Se st pt em be r O ct ob er N ov em be D r ec em be r y Ju l ne Ju ay M Ap ril Ja nu ar y Fe br ua ry M ar ch 0% Linear(2018)

Data Monitoring Dashboard used for loop closed/continued monitoring

What’s the “Take Home”? Take the TAC as a starting point Consider a data person with clinical experience in the perinatal field as a dedicated FTE for Perinatal Quality Look at the data for trends- Is what you believe to be occurring with patient care happening in reality? Look at basic data: Response time, C/S decision to incision Assure you have loop closure by having consistency in your QAPI meetings HUDDLE often to keep communication moving forward flowing and projects

Contact Us Stacieelizondo@shannonhealth. org Tammyvanstockum@shannonhealth. org

Questions?

TETAF Staff & Support Brenda Putz Carla Rider Kathy Clayton bputz@tetaf. org crider@tetaf. org kclayton@tetaf. org VP of Operations Perinatal Program Director Survey Coordinator Online Resources: texasperinatalservices. org/resources