Maternal QAPI Program 2252020 St Michael WCS Located

Maternal QAPI Program 2/25/2020

St. Michael WCS • Located in Texarkana, Texas • Serve a multi-state region for NE TX, SW AR, SE OK, and NW LA • NETRAC- F • L&D/OBED • 130 -140 deliveries per month • 16 LDRs, 2 triage, 2 ORs • 9 OB providers along with OB Laborist group • Level III NICU-15 beds • Mother Baby Unit- 20 beds Maternal Designation Survey completed December 18 th & 19 th for Level II. 2

In the beginning… • Hospital Quality department tracked Perinatal Core Measures for the JC • Measures reported out in overall hospital quality meeting and OB/GYN Section meetings • No formal Maternal QAPI reviews initiated at the department level • Chart auditing was limited to high risk events/Midas reporting • Formulated our QAPI Policy • First Maternal QAPI meeting 11/2018 3

Formulating the Agenda • Old Business • Topics that you discuss at each meeting • JC Perinatal Core Measures • Texas. AIM safety bundles • MD quality indicators • Process improvements projects you have been working on • Updates to P&P • Education/Drills • New Business • Needed PI projects based on Midas events, L&D chart audits, or debriefing findings from events or simulations • Open discussion 4

QAPI Presentation • Power. Point presentation • Dashboards • Utilization of graphs to show overall trends 5

QAPI Presentation: Tips • Utilization of tables to present data and case reviews • Create tables from your Excel data 6

Severe M&M In-depth Reviews • Council on Patient Safety in Women’s Health Care • Severe Maternal Morbidity Reporting form • https: //safehealthcareforeverywoman. org/pat ient-safety-tools/severe-maternal-morbidityreview/ 7

Meeting Minutes • QAPI Documentation • PI Opportunity • Identification or recognition • Discussion • Information surrounding the findings • Determination • Steps to desired outcome/goal • Recommendations/Actions • Corrective action plan • Loop Closure Status • Is the desired outcome obtained? • In progress • Continued surveillance • Complete 8

Loop Closure 9

Clear Loop Closure 10

QAPI Tips • • • Proactive program Be inquisitive and ask the WHY Creating a culture of learning and improving Limit PI projects to a manageable number Loop closure – in-progress, continued surveillance, or complete • Involve staff in auditing charts and PI projects • Email minutes with current meeting invite • Value debriefing 11

Contacts Teresa. smith 2@christushealth. org Barbara. wright@christushealth. org Andree. ray@christushealth. org 12

Questions 13

When to Request Your Renewal Designation Survey § § § 14 Request your survey early 6 to 8 months prior to expiration date Expiration dates are on your original letter and on the DSHS website No more than 180 days prior to the designation expiration date and at least 60 days prior to the designation expiration date Submit packet within 120 days of the facility’s survey date Texas. Perinatal. Services. org

to 6 y rve y u s for surve e fram rior to e Tim ths p n mo 180 days prior to the designation expiration date and at least 60 days prior to the designation expiration date 15 Texas. Perinatal. Services. org 8 Paperwork due to state 60 days prior to expiration of designation ate D on i t ira p x E

Birth logs and patient list: Name DOB EGA Ventilation Support LOS MR # Quality Review CR 12. 31. 2019 27 4 days and then b. CPAP 10 days 43 days XXXXX QAPI Committee Name DOB EGA Ventilation Support Surgical interventions LOS MR # Quality Review CR 1. 1. 2020 27 4 days and then b. CPAP 10 days Gastroschisis 43 days XXXXX QAPI Committee BP 29 6 days and then b. CPAP 7 days Diaphragmatic Hernia Return to OR for NEC at 17 dol 64 days XXXXX M&M RCA KC 36 <4 hours Hernia 13 days XXXXX None 16 Texas. Perinatal. Services. org

Texas Perinatal Forum March 2020 St. David’s Medical Center – Social Work ▪ ▪ Policy development Trigger based referrals Community resources Documentation Zoom meeting: March 23, 2020 at 1: 00 p. m. 17 Texas. Perinatal. Services. org

Ask us a question! texasperinatalservices. org Carla Rider, DNP, MBA, RNC-LRN, TETAF Perinatal Program Director crider@tetaf. org 18 Texas. Perinatal. Services. org