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PERINATAL QUALITY
COLLABORATIVE
Obstetric and Neonatal Metrics from the
Administrative Data Set
January 24, 2019
Janet H. Muri, MBA, President
Providence, RI
• Samples analyses
• Unexpected Complications of the Term Newborn (PC 06)
• Severe Maternal Morbidity (AIM metrics)
National Perinatal Information Center
• Industry-wide data set: every patient discharged from the hospital has
a hospital discharge record
• The data elements are fairly standard (CMS) and because it is used for
billing of hospital based services, the clinical and financial details
require accuracy
Jeffrey Gould, MD
Director, Perinatal Epidemiology and Outcomes Unit
Department of Pediatrics
Stanford University School of Medicine
PI, CMQCC, CPQCC
~ Speaking at the MA Neonatology Quality Forum, June, 2015 ~
State Administrative Data
• Reporting selected metrics back to all birth hospitals “pulls” them into the
conversation: value of the data, need to improve the data, opportunities for
statewide or region-wide QI projects
• Each state will have a different level of agreement with their hospitals
regarding reporting hospital identifiers and patient PHI (protected health
information)
• Hospital identifiers can be masked with numbers/letters to preserve
anonymity but also show multi-site comparisons
• Identify outlier status allowing you to drill down and validate provider
documentation and coding of the data
Provider ID
Additional Variables Sometimes Available
Joint Commission Severe Maternal Morbidity: A patient safety event that occurs intrapartum
through the immediate postpartum period (24 hrs), that requires the transfusion of 4 or more
units of blood products (fresh frozen plasma, packed red blood cells, whole blood, platelets)
and/or admission to the intensive care unit (ICU). Admission to the ICU is defined as admission
to a unit that provides 24-hour medical supervision and is able to provide mechanical
ventilation or continuous vasoactive drug support. These events are to be reviewed by the
hospital to determine if they rise to the level of a sentinel event. Reporting to the JC is optional
but they must have the disposition of their findings available during their JC Survey.
***AIM Severe Maternal Morbidity (SMM): Delivered women who experience at least one of
the 21 CDC defined morbidities during their delivery hospitalization. (Blood transfusion is the
largest driver of SMM so SMM is calculated two ways: with and without cases with ONLY a
blood transfusion event.)
AIM Severe Maternal Morbidity
(SMM)
• Rate of cases with at least one morbidity increased 75% between 1998/1999 and
2008/2009; Greatest increases in shock (+100.7%); blood transfusions (+183.2%); and acute
renal failure (+97.3%)
• SMM with and without transfusions are the two universal outcome metrics being used by
Alliance for Innovation in Maternal Health (AIM)
• SMM with and without transfusions for cases coded with a PP Hemorrhage are the two
outcome metrics specific to the implementation of the AIM Hemorrhage Bundle
1
Callaghan, W.M., Creanga, A.A., Kuklina, E.V. Severe Maternal Morbidity Among Delivery and Postpartum Hospitalization in
the United States. American Journal of Obstetrics and Gynecology 2012; 120:5. 1029-1036.
Severe Maternal Morbidity Defined
CDC metric profiled in 2012 article by William Callahan et. al.*
Denominator: Deliveries
Numerator: Any case with a severe morbidity code as defined by latest CDC ICD 9/ICD 10 code list
(www.safehealthcareforeverywomen.org)
* Callaghan, W.M., Creanga, A.A., Kuklina, E.V. Severe Maternal Morbidity Among Delivery and Postpartum Hospitalization in the United States.
Obstetrics and Gynecology 2012; 120:5. 1029-1036.
SAMPLE SMM (HEM) TABLE
6.9%
6.4%
PCT Change=
-7.24%
UNEXPECTED COMPLICATIONS OF THE TERM
NEWBORN
Joint Commission PC 06.0, 06.1 and 06.2
Required reporting starting1/1/2019
Unexpected Complications
of the Term Newborn
(NQF # 716 and PC 06)
• Regionalization Analysis
• Match level of care with acuity of population delivered at
that facility
• Analysis of maternal and neonatal transfer patterns
• Analysis by payer to determine efficient use of resources
Jmuri@npic.org
www.npic.org