Indiana Perinatal Quality Improvement Collaborative Quality Improvement Committee 11132014 Erica Park Nancy Swigonski MD MPH FAAP Kathleen Frogge Program Director 2 You ID: 174113
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Slide1
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 Slide2
“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 DisneySlide3
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 certificateOverall GOalSlide4
Death Certificate
Indiana Perinatal Quality Improvement Collaborative – Quality Improvement Committee11/13/2014Slide5
Death Certificate ProcessSlide6
Death Certificate Process
1. Funeral home receives a call from the hospital or the parents Slide7
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 Slide8
Death Certificate Process
3. Hospital initiates a burial transit permit Fills out Sections A & BSlide9
Death Certificate Process
4. Person who picks up the body fills out more of the permitFills out Sections CSlide10
Death Certificate Process
5. Funeral home completes the permit - fills out Sections D & E3 copies of this permit 1. Health department by the hospital
2. Crematory or cemetery
3. Health department Slide11
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 hospitalSlide12
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 formSlide13
Death Certificate Process
8. Funeral director fills out demographic informationSlide14
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.Slide15
Death Certificate Process
10. Physician logs onto IDRS and fills out medical information and certifies the death Slide16
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 Slide17
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 Slide18
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 Slide19
Met with funeral director
Discussed the death certificate process and issues with timelinessPhysicians not registered into the system causes delays Time it takes to fill out the death certificate data into IDRS Live birth: ~10 minutesFetal death: ~15-20 minutes
Death Certificate
information gatheringSlide20
N
eonatologist 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 delayPhysicians do not know they are able to initiate the death certificate Ultimately these delays cause delays in burial of the baby
Death Certificate
information gatheringSlide21
https://vrqa.isdh.in.gov/inthin/
indextest.htmlDeath Certificate information gatheringSlide22
Key issue is getting physicians registered into IDRS
Physicians can start the death record, but this was unknownOthers can start the death record with the physician later signing with their personal identification number (PIN), but this was unknown
Death Certificate Data - FindingsSlide23
Online Training
Training manuals Indiana = 78 pages CDC = 65 pagesIDRS system not self-explanatoryWebinar link does not work
Death Certificate Data - FindingsSlide24
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 process –
brainstormingSlide25
Identify the hospitals with highest number of infant deaths and focus efforts on those first
Register and demonstrate IDRS to physicians during hospital orientationsPreload physicians into the system Pilot a program using staff to initiate the certificate
Death Certificate Data - recommendationsSlide26
Birth Certificate
Indiana Perinatal Quality Improvement Collaborative – Quality Improvement Committee11/13/2014Slide27
Birth certificate Process – TheoreticalSlide28
1a. Mother fills out the Mother’s Worksheet section of the CDC-issued 12 page birth certificate form
Birth certificate Process TheoreticalSlide29
1a. Mother fills out the Mother’s Worksheet section (MWS) of the CDC-issued 12 page birth certificate form
1b. Hospital staff fills out the Facility Worksheet section (FWS) of the CDC-issued 12 page birth certificate formBirth certificate Process TheoreticalSlide30
1a. Mother fills out the Mother’s Worksheet section (MWS) of the CDC-issued 12 page birth certificate form
1b. Hospital staff fills out the Facility Worksheet section (FWS) of the CDC-issued 12 page birth certificate form2. Hospital staff logs onto BDRS
Birth certificate Process TheoreticalSlide31
1a. Mother fills out the Mother’s Worksheet section (MWS) of the CDC-issued 12 page birth certificate form
1b. Hospital staff fills out the Facility Worksheet section (FWS) of the CDC-issued 12 page birth certificate form2. 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 TheoreticalSlide32
4. County health department receives birth registration data
Birth certificate Process TheoreticalSlide33
4. County health department receives birth registration data
5. State Department of Health receives birth registration dataBirth certificate Process TheoreticalSlide34
4. County health department receives birth registration data
5. State Department of Health receives birth registration data6. CDC receives birth registration data
Birth certificate Process TheoreticalSlide35
Birth Certificate
information gatheringVital 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 2A: All Birth Worksheet Data Matters Part A
Module 2B: All Birth Worksheet Data Matters Part B
Visited hospitals to outline the birth certificate processSlide36
Birth certificate FindingsSlide37
Findings from the hospital visits
CDC-issued 12 page worksheet was “split” into 5 separate worksheetsHospital has 300 births/dayIf 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 - findingsSlide38
The actual process is much more complex than the 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 - findingsSlide39
The actual process is much more complex than the 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 - findingsSlide40
The actual process is much more complex than the 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 - findingsSlide41
The actual process is much more complex than the 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 CDC-issued 12 page worksheet
Example: choices for “Mother’s Race”
Birth certificate data - findingsSlide42
Variations of the birth certificate registration process in hospitals
Accuracy of the data must be addressedTimeliness of the data must be addressedBirth certificate ProcessFindingsSlide43
What have other states done?
What are best practices?Slide44
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 F
ocused on activities that evaluate and ensure data quality
A
sked 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 Slide45
Birth Quality
WorkgroupRecommendations1. Data must be evaluated on an ongoing basis Importance of rapid cyclingRecommend quick response to poor data quality from birth facilities – weekly or monthly vs. quarterly or yearly Slide46
Birth Quality Workgroup Recommendations
2. Effective communication of data quality is necessary1. Concrete feedback2. Increase awareness about the merit of data quality3. Provide regular trainings and newsletters
4. Publish reports about performance to increase transparency
5. Connect with upper-level clinicians and hospital administrationsSlide47
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 CenterSlide48
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 Slide49
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
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 volumeSlide50
State of Washington
2. “% Unknown” of certain birth data items compared to stateSlide51
State of Washington
3. “% Unknown” of certain birth data items over timeSlide52
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 termsSlide53
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 registrationPhase I: Completing the electronic health record Algorithms to flag incomplete charts
Empowering nursing staff
Increased teaching of hospital staffSlide54
State of Ohio
Phase II: Empowering staffNurses encouraged to contact OB providers if data was missing Emphasized safety benefits to hospital staff peer-to-peerSlide55
State of Ohio
Phase III: Real Time AuditingNursing 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 Slide56
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 agenciesSlide57
State of California
Demonstration site link: https://demo.datacenter.cmqcc.org/hospitals/1
Demonstration site link:
https://demo.datacenter.cmqcc.org/hospitals/1Slide58
What
are the steps that are taken to fill out the birth certificate?Who provides information? What sources are used to fill out the birth certificate (paper, electronic)?
What
if you are unable to find
information?
W
hat
steps do you then take?
Are
there any specific areas on the birth data registration form that are particularly difficult, unclear or usually not able to be filled out? Why is it
difficult?
How
long does it take
to complete 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
long have
you or the person who usually fills out birth
certificate
information been doing this 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
training did
you/they
receive 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 –
what is the process in your hospital?Slide59
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 process –
brainstormingSlide60
1. Provide feedback
Distribute a list of variables that commonly have errors to hospital administrationBirth Certificate Data Recommendations: 4 categoriesSlide61
1. Provide feedback
Distribute a list of variables that commonly have errors to hospital administrationNotify hospital administrative and clinical leadership about the deficiencies in vital records processBirth Certificate Data Recommendations: 4 categoriesSlide62
1. Provide feedback
Distribute a list of variables that commonly have errors to hospital administrationNotify hospital administrative and clinical leadership about the deficiencies in vital records processUse a website to publish performance reports to increase transparency
Birth Certificate Data Recommendations: 4 categoriesSlide63
1. Provide feedback
Distribute a list of variables that commonly have errors to hospital administrationNotify hospital administrative and clinical leadership about the deficiencies in vital records processUse 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 categoriesSlide64
2. Provide training incentives
Recommend hospitals to include completion of training modules in performance review Birth Certificate Data Recommendations: 4 categoriesSlide65
2. Provide training incentives
Recommend hospitals to include completion of training modules in performance review Provide regular trainings and newsletters for birth registration staffBirth Certificate Data Recommendations: 4 categoriesSlide66
2. Provide training incentives
Recommend hospitals to include completion of training modules in performance review Provide regular trainings and newsletters for birth registration staffDevelop a post test and/or a Certificate of Completion for staff completing modules
Birth Certificate Data Recommendations: 4 categoriesSlide67
2. Provide training incentives
Recommend hospitals to include completion of training modules in performance review Provide regular trainings and newsletters for birth registration staffDevelop 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 categoriesSlide68
3
. New systems improvements Add definitions of fetal death and live birth on the electronic birth and death registration systemsBirth Certificate Data Recommendations: 4 categoriesSlide69
3
. New systems improvements Add definitions of fetal death and live birth on the electronic birth and death registration systemsAdd a drop down box with causes of death on the screen that match the CDC codes Birth Certificate Data Recommendations: 4 categoriesSlide70
3
. New systems improvements Add definitions of fetal death and live birth on the electronic birth and death registration systemsAdd 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 categoriesSlide71
4. Extend roles
and approachesCommunicate to physicians that they should register in IDRS and that they can initiate the death record Birth Certificate Data Recommendations: 4 categoriesSlide72
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 orientationBirth Certificate Data Recommendations: 4 categoriesSlide73
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 orientationCommunicate 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 categoriesSlide74
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 orientationCommunicate 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
Birth Certificate Data Recommendations: 4 categoriesSlide75
“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
Steps Towards Effective ChangeSlide76
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 dataIn order for Indiana to successfully reduce the infant mortality rate, the state must have good quality birth and death certificate data SummarySlide77
References
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Jessen
A, Justice D, Madsen-Straight A, Martin J,
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S, Reed P,
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M,
Tretter
E,
Wishart
L. Efforts to improve
b
irth 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
q
uality
q
uery
s
ystem. 2014. Washington State Department of Health. Retrieved July 20,
2014 from https://fortress.wa.gov/doh/bdqq/
bdqq.aspx.
Main E, Castles A, Murphy B. Partnering for maternal data quality improvement. California Maternal Quality Care Collaborative. 2013.