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Description
Meeting Discussion Chart document sample
Document Sample
Pregnancy and Related
Conditions Quality Measures
Benchmark Data:
Core Measures
Agency for Healthcare Research and Quality
National Perinatal Information Center
Project Aim
Improve the PREGNANCY AND RELATED
CONDITIONS CORE MEASURES, AHRQ
and NPIC quality measure performance,
attaining UHC median performer status and
then progress to UHC BEST PERFORMER
Committee:
S.Swanson RN; J.Gianopolous, MD;
R.Beisinger, MD; E.Carroll, MD;
M.Weiss, MD; G.Adams, RN;
M.Chybik, RN; M.Wall, PharmD;
M.Davey, RN; P.Downing, RN;
C.LaPorte, RN; E.Trulis, RN
Barriers and Actions
No internal champion Meeting chaired by AD; case
managers lead work for area
Risk adjustment poorly Reviewed indicators and
understood defined in packets
Benchmark data Case review information for
reviewed in aggregate cases included in the most
9-12 months after care recent data included in
meeting packet
Improvement impact Review expanded to current
slow to be seen and charts looking for
hard to track improvement and continuing
issues.
Percent
2
3
4
5
6
Meeting chaired by AD
Case manager role defined
Quarter
Reviewed definitions
Core Measures
Restructured meetings to have chart
review data available for discussion
Third or Fourth Degree Laceration
Concurrent chart review
LUMC Expected Third and Fourth Degree Laceration Rate
LUMC Observed Third and Fourth Degree Laceration Rate
Chart review by physician with
feedback communication with coding
Documentation education
AHRQ Patient Safety & Quality Indicators
Obstetric trauma - vaginal delivery without instrument
14
Case manager role defined
Documentation education
Meeting chaired by AD
12
Reviewed definitions
Concurrent chart review
10
Restructured meetings to have chart
review data available for discussion
feedback communication with coding
Rate per 100 cases
8
Chart review by physician with
6
4
2
LUHS Rate
UHC Ninetieth Percentile
UHC Median
UHC Tenth Percentile
Quarter (Number of LUMC cases)
This information is confidential and to be used for quality improvement purposes only
AHRQ Patient Safety & Quality Indicators
Obstetric trauma - vaginal delivery with instrument
Concurrent chart review
40
Restructured meetings to have chart
review data available for discussion
Reviewed definitions
Documentation education
35
Case manager role defined
Meeting chaired by AD
30
25
feedback communication with coding
Rate per 100 cases
Chart review by physician with
20
15
10
LUHS Rate
UHC Ninetieth Percentile
UHC Median
UHC Tenth Percentile
Quarter (Number of LUMC cases)
This information is confidential and to be used for quality improvement purposes only
Percent
100
20
40
60
80
Worked with JCAHO to
redefine measure criteria
Developed mechanism
to capture birth weights
Quarter
Core Measures
Began review of all mortality
for co-morbidity accuracy
LUMC Expected Neonatal Mortality Rate (150g - 999g)
LUMC Observed Neonatal Mortality Rate (150g - 999g)
Neonatal Mortality (Birth Weight Range 150g - 999g)
Worked with fellow to
maintain full problem list
Reviewed documentation of
living cohort for accurate
co-morbidity capture
AHRQ Patient Safety & Quality Indicators
Birth trauma - injury to neonate
1.4
1.2
Communication with Coders
1.0
definition clarification
Rate per 100 cases
0.8
Chart review
0.6
0.4
0.2
0.0
LUHS Rate
UHC Ninetieth Percentile
UHC Median
UHC Tenth Percentile
Quarter (Number of LUMC cases)
This information is confidential and to be used for quality improvement purposes only
Next Steps
Utilize UHC coding expertise to identify issues with
injury to neonate.
Continue concurrent chart review for timely
feedback and awareness of practice.
Review a neonatal cohort to assess accuracy of
complications/co-morbidity capture for risk
assessment of surviving cases.
Work with physicians to maintain comprehensive
documentation to facilitate accurate risk capture.
Enhance EPIC use to capture necessary data.
Incorporate education of coders/residents into
orientation to obtain/maintain gains.
