One commenter. Numerator Statement: Newborns who were fed breast milk only since birth Denominator Statement: o Perinatal measures ZSFG is at or below ZSFG-defined goals and the Vizient median for 5 perinatal core measures: Elective Delivery, cesarean section rate, antenatal steroids, healthcare associated BSI, and exclusive . Women and families should use Leapfrog's Hospital Survey results to consider which hospital they'd like to use for their child's delivery. researchers. /BleedBox [0 0 612 792] G/GqY%]#_$~H"8@ii6T%)`oZ# )F7i'g U@14x?%oH&GsvJg3JC /Border [0 0 0] CMQCC has developed four quality measures that are used by government and quality review agencies such as the Joint Commission and the Leapfrog Group to help measure maternity care performance. Find more COVID-19 testing locations on Maryland.gov. Johns Hopkins Medicine also established a reporting system to track core measure compliance on each unit. /BS 48 0 R hVQo0+~4E#UuQfk4Z4B*B(%g\)B W "J"\DD>H\ A@X@$a*p&>Pv*`ff One of the five core measures includes exclusive breastmilk feeding. /Thumb 30 0 R /Subject () /Rotate 0 vaginal delivery or elective cesarean section before the recommended Learn about the priorities that drive us and how we are helping propel health care forward. a-J&NzNrSCyc|og,jJzJ#6 g)v, ]5jF[7o5iYHP5LFs TBC sB(uZ5F? c Be\?g= t1/;_K'MGwF7Ph}VZMk.42`Ulm6FaekMy9`OtxHp PVn9 '{9BympOo{x~t:]Xc,O_4_ 5z /F 4 /Annots [16 0 R 17 0 R 18 0 R 19 0 R 20 0 R] Center for Academic Medicine, Neonatology, MC 5660, 453 Quarry Road, Palo Alto, CA 94304, CA-PAMR Pregnancy-Associated Mortality Surveillance System Committee, Unexpected Complications in Term Newborns, <1500g Infant Not Delivered at Appropriate Level, COVID-19 Resources for Maternal and Infant Health, Mother & Baby Substance Exposure Initiative Toolkit, OB Hemorrhage Task Force and Update Task Force, Hypertensive Disorders of Pregnancy Toolkit, Hypertensive Disorders of Pregnancy Task Force, Maternal Sepsis Task Force Advisory Group, Support Vaginal Birth and Reduce Primary Cesareans Toolkit, Supporting Vaginal Birth and Reducing Primary Cesarean Delivery Taskforce, Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, Medical School Office Building, 1265 Welch Road, MS 5415, Stanford, CA 94305 USA. << For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. << Using the monthly sampling table for the Mother population, the sample size required is 20% of this sub-population or 80 cases for the month. As a stroke compliance specialist, Meta Phillips, R.N., advocates for a personal touch when reviewing patient charts to help improve processes and patient care. Any party may request reconsideration of any of the 14 endorsed quality measures listed below by submitting an appeal no later than May 3 (to submit an appeal, go to the NQF Measure Database). Eight or more contacts for antenatal care can reduce perinatal deaths by up to 8 per 1000 births when compared to 4 visits. >> Note: District of Columbia state average not available for the cesarean There are no data that higher rates improve any outcomes, yet the CB rates continue to rise. transferred to an acute care facility, or other health care facility expired during the hospitalization Washington, DC the National Quality Forum (NQF) Board of Directors has approved for endorsement 14 quality measures on perinatal care. /Subtype /Link Regardless of the option used, hospital samples must be monitored to ensure that sampling procedures consistently produce statistically valid and useful data. having a vaginal delivery. In all, 22 measures were evaluated against NQFs endorsement criteria by a panel of providers, measurement experts, and consumer representatives; 14 measures were endorsed. The purpose of a balancing measure to is guard against any unanticipated or unintended consequences of quality improvement activities for these measures. /Parent 4 0 R All Records, Calculation, Used in calculation of the Joint Commission's aggregate data. These processes are proven to reduce complications and lead to better patient outcomes. Core Curriculum for Neonatal Intensive Care Nursing - E-Book Lippincott Williams & Wilkins More children born today will survive to adulthood than at any time in history. HtV]oF|'/B%[Au+6yDKH}GZ@-=_^/^R!_R^IZs?{]zKo}#k2rl]W.?Ux~?I??Hns]UZk2l'e eC0(Zp^'7C-9(*0""#/T,0 |'j)W.?Y,>x?r m}\, Learn about the development and implementation of standardized performance measures. /Filter /FlateDecode The measures address a wide range of care concerns, including childbirth, pregnancy and post-partum care, and newborn care. by Purpose. based on a sample of patients and may not reflect the hospitals overall Patients and families should become familiar with the core measures and talk to their health care team if they have any questions or concerns. /Border [0 0 0] NQF operates under a three-part mission to improve the quality of American healthcare by: 1099 14th Street NW Suite 500Washington DC 20005, 202-783-1300 Main202-783-3434 Faxinfo@qualityforum.org. The goal of prenatal care is the birth of a healthy child with minimal risk for the mother. >> /N /NextPage How can patients and families support safety? /BS 44 0 R To provide a benchmark of local health department effectiveness in addressing the core functions and to assess implications for achieving the year 2000 target, a random national sample (stratified by jurisdiction and population base) of local health departments was surveyed to determine self-reported compliance with 10 public health practice . These teams involved partnerships between quality improvement staff, nurse and physician leads, faculty members, IT staff and others to identify barriers to improvement and develop solutions. CMQCC has developed four quality measures that are used by government and quality review agencies such as the Joint Commission and the Leapfrog Group to help measure maternity care performance. Figures do not account for changes in the underlying measure that could break trending. section who have not previously given birth. But back to those of you submitting all four. >> The Compare function compares two years of the measure specifications found in the header of the measure's HTML. Moved the criteria of length of stay (LOS), diagnosis of galactosemia and subject to parenteral nutrition from initial population to denominator exclusion. a diagnosis of galactosemia section measure. by Data. NQF# 0480 Exclusive Breast Milk Feeding, also in electronic measure as 0480e (now managed by The Joint Commission as PC-05). endobj Sample Size: A hospitals performance on some of the core measures is endobj The following indicator sets are considered appropriate and useful for public reports as well: HVYk@~?SqKCB gc@QuVG+q;l\cKwWkEPf`VYg(}8|r%,U|y%KRST@yA,L Wu'MA\kt$c&/B In cases where there is conflicting data, use the document recording the birth weight closest to the start of encounter. Today, the Core Quality Measures Collaborative (CQMC) released four updated core measure sets covering specific clinical areas as part of its mission to provide useful quality metrics as the nation's health care system moves from one that pays based on volume of services to one that pays for value. /Fields [7 0 R] Our mission is to end preventable morbidity, mortality and racial disparities in California maternity care. NQF # Set expectations for your organization's performance that are reasonable, achievable and survey-able. Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this Agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. The annual rankings measure vital health factors, including high school graduation rates, obesity, smoking, unemployment, access to healthy foods, the quality of air and water, income inequality, and teen births in nearly every county in America. Public lists NHS workforce in England [January 2023] Transgender health [September 2022] Weekly additions - 2023-02-26 Financial pressures in the NHS in England [January 2023] Introduction to the NHS in England [February 2023] Devolved National Health Service : the NHS in England, Northern Ireland, Scotland and Wales [March 2022] Adult social . It does not include a comparison of any information in the body of the HTML, e.g., population criteria, Clinical Quality Language, or value sets. The Joint Commissions Advanced Perinatal Care Certification requires the use of this set of standardized performance measures in order to meet the performance measurement requirements for certification. You will be prompted to log in to your NCQA account. A hospital's Mother Population size is 1500 cases during the second quarter. /Ff 65536 As we said above, if you decide to submit these traditionally chart-abstracted measures . /A 13 0 R :K(bX1)6 iNwu+f>J+}~^%1rQX;J/oP1|cMvjSdVE-nE+TS]Pi Q8c0]&DSr+Ku2PImgkEG/]h We looked at how we could improve administration of ACS after 34 weeks. There are no Perinatal Care eCQMs applicable or available for Certification purposes. endobj The Perinatal Center Database A Quality and Utilization Benchmark The Perinatal Center Database (PCDB) has become one of the largest repositories for hospital-based perinatal data in the country. Using the quarterly sampling table for the Exclusive Breast Milk Feeding measure, the sample size required is 109 cases. For an appeal to be considered, the notification must include information clearly demonstrating that the appellant has interests directly and materially affected by the NQF-endorsed recommendations and that the NQF decision has had (or will have) an adverse effect on those interests. P-znw$Z*$iwA EcdxzK4\nG )1s6@rZ6ZkSx7i'8`ab+Iot#v{*]Es cE1!b%55FGe[f/uo ;wVzEqw,*;^^mDJFYZb(8A;)vwX|T$;bKYTAVZKQ^-,0\6f{hCM T;s[ OXSWyz4E-5-uOf`*UH 0vhlEcA+ "+ETf5-kj /Type /Annot ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 11.01.1 Delivery, a Patient Age (Admission Date Birthdate) >= 8 years and < 65 and a Length of Stay (Discharge Date - Admission Date) 120 days. >> %PDF-1.6 % The PC measure set is unique in that there are two distinct Initial Patient Populations within the measure set, mothers and newborns. 21 0 obj >> This field is for validation purposes and should be left unchanged. . /Tabs /W Terms of Use, Patient-Centered Specialty Practice (PCSP), Credentials Verification Organization (CVO), Managed Behavioral Healthcare Organization (MBHO), Health Information Technology Prevalidation Programs, Virtual Seminars, Webinars and On-demand Training, Advertising and Marketing Your NCQA Status, HEDIS Electronic Clinical Data Systems (ECDS) Reporting, CDC Review to Action. Find the exact resources you need to succeed in your accreditation journey. Hospitals with CB rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Gould et al., 2004). All rights reserved. No data is available because Suburban Hospital currently does not When data is translated into useful information, the opportunity to transform quantitative data into qualitative improvements becomes a reality. A hospital's Mother Population size is 125 cases during March. We use cookies to improve your experience and analyze our website traffic. You, your employees and agents are authorized to use CPT only as contained in The Joint Commission performance measures solely for your own personal use in directly participating in healthcare programs administered by The Joint Commission. endobj /S /Named 306 0 obj <>stream No national benchmarking systems existed for gathering or comparing institutional data. << Data show that the majority of newborns with gestational age 37 weeks or more have a birth weight 3000 grams or more. Custom Analytic Interactive Reporting Network, Discuss the Perinatal Care (PC) measures updates, Describe the Perinatal Care (PC) measures, key data elements and recent revisions to the measures, Identify some of the resources available for improving perinatal care. (2018). >> However, very few hospitals chose to adopt the measures because, the measures were optional. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. One commenter. The goal of QualityNet is to help improve the quality of health care . /Subtype /Link The Inpatient Web-based Measure, Elective Delivery, documents the number of patients with elective vaginal deliveries or elective Cesarean sections at greater than or equal to (>=) 37 and less than (<) 39 . PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization. Our team is always trying to make our hospitals processes better to provide the safest care for our patients.. 8 Depressed mothers may have infants that display delayed psychological, cognitive, neurologic, and motor development. Note: Hospitals are encouraged to utilize a data source that reduces unnecessary medical record review e.g., using vital records, delivery logs or clinical information systems as a data source. Added birth weight criteria to the initial population as an alternative to estimated gestational age at birth. /P 10 0 R Learn how working with the Joint Commission benefits your organization and community. Its critical that providers have the right measurement tools to help ensure mothers and newborns receive safe, high-quality care.. 5 0 obj Our comparative Quarterly Report, Perinatal Dashboard and special analyses help member hospitals identify and appropriately focus their quality improvement initiatives and resources. << /MK 15 0 R endstream Eligible Hospital / Critical Access Hospital eCQMs, FHIR - Fast Healthcare Interoperability Resources, QRDA - Quality Reporting Document Architecture, Inpatient hospitalizations for newborns who were with any of the following conditions: LEARN MORE ABOUT PCDB 0 Perinatal Discharges Since 1985 Connecting Through Education Recorded NPIC Events Description. /ArtBox [0 0 612 792] The core measure processes are proven standards of care that reduce complications and lead to better patient outcomes. What is Johns Hopkins Medicine doing to continue to improve? Connected The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization. /Type /Annot In 2011 Johns Hopkins Medicine developed a plan to become a national leader in core measures with a goal of reaching 96 percent compliance. ACOG Committee Opinion No. NQF also endorsed measures dealing with hepatitis B vaccination rates for newborns, neonatal bloodstream infection rates, and exclusive breastfeeding rates during hospitalization. /Type /Page This core set contains several measures NQF endorsed at the facility or health plan level as noted below; core set users should ensure adequate measure denominator size based on their patient population. >> Please refer to the eCQI resource center for more information on the QDM. /BleedBox [0 0 612 792] 225 Chapman Street Suite 200 Providence, RI 02905. /AP 14 0 R /Author () Obstet Gynecol, 131:140-150. Using the quarterly sampling table for the Mothers population, the sample size is less than the minimum required quarterly sample size, so 100% of this sub-population or all 20 cases are sampled. endobj The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization. stream /BS 46 0 R Patients admitted to the hospital for inpatient acute care are included in the PC Mother Initial sampling group if they have: By . We would urge patients to consider more recent performance in combination with historical performance. This product includes CPT which is commercial technical data, which was developed exclusively at private expense by the American Medical Association, 330 North Wabash Avenue, Chicago, Illinois 60611. The ongoing evaluation and updating of endorsed measures ensures the currency and relevance of NQFs perinatal care portfolio. /R 41 0 R |, Prevention and Treatment of Leading Causes of Mortality, Effective Communication and Care Coordination, Maintenance of NQF-Endorsed Performance Measures, 0469: PC-01 Elective Delivery (Joint Commission), 0470: Incidence of Episiotomy (Christiana Care Health System), 0471: PC-02 Cesarean Section (Joint Commission), 0472: Appropriate Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision Cesarean Section (Massachusetts General Hospital/Partners Health Care System), 0473: Appropriate DVT Prophylaxis in Women Undergoing Cesarean Delivery (Hospital Corporation of America), 0475: Hepatitis B Vaccine Coverage Among All Live Newborn Infants Prior to Hospital or Birthing Facility Discharge (Centers for Disease Control and Prevention), 0476: PC-03 Antenatal Steroids (Joint Commission), 1746: Intrapartum Antibiotic Prophylaxis for Group B Streptococcus (GBS) (Massachusetts General Hospital), 0477: Under 1500g infant Not Delivered at Appropriate Level of Care (California Maternal Quality Care Collaborative), 0478: Neonatal Blood Stream Infection Rate (NQI #3) (Agency for Healthcare Research and Quality), 1731: Health Care-Associated Bloodstream Infections in Newborns (Joint Commission), 0304: Late Sepsis or Meningitis in Very Low Birth Weight (VLBW) Neonates (risk-adjusted) (Vermont Oxford Network), 0480: PC-05 Exclusive Breast Milk Feeding (Joint Commission), 0483: Proportion of Infants 22 to 29 Weeks Gestation Screened for Retinopathy of Prematurity (Vermont Oxford Network). >> Using the quarterly sampling table for the Mother population, the sample size required 75 cases for the quarter. By reviewing our patients charts, we can immediately identify what is working and where we can improve. Note however that the calculation may yield a non-whole number and gestational age should be rounded off to the nearest completed week. << Strikethrough text highlighted in red indicates information changed from the previous version. Short Name. NQF# 0471 NTSV Cesarean Birth (now managed by The Joint Commission as PC-02) Nearly all focus on prenatal services received during the last trimester of pregnancy through hospital discharge for both mother and newborn. /Count 2 /MediaBox [0 0 612 792] This should be reflected as such in the newborn's EHR documentation. PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization. Measure Set: Perinatal Care (PC) Set Measure ID: PC-05 Performance Measure Name: Exclusive Breast Milk Feeding Description: Exclusive breast milk feeding during the newborn's entire hospitalization The measure is reported as an overall rate which includes all newborns that were exclusively fed breast milk during the entire hospitalization. << /Metadata 3 0 R /Subtype /Widget Having a baby is one of life's most exciting experiences, but the type of care received in the hospital can vary greatly. /Subtype /Link << = AU?U m!p\;4TPC[H < kIO!0Q)tji Oc2Pe` i)[ XAbRPp&p << /Rect [80 323.2290039062 136.4620056152 307.7850036621] What does this measure mean for quality of care?Breast-feeding provides the best nutrition and health A hospital's PC-Newborn Population size is 100 cases for the month of March. transferred to an acute care facility, or other health care facility endstream endobj 309 0 obj <>stream PPO corresponds to PPO and EPO within Quality Compass. endobj Pediatric Quality Measures Program PQMP Measures SHARE: Search PQMP Measures Center of Excellence (COE) Quality Measurement, Evaluation, Testing, Review, and Implementation Consortium (Q-METRIC) (44) Center of Excellence on Quality of Care Measures for Children with Complex Needs (COE4CCN) (42) Within the PC-Newborn population, there are two baby measures, Exclusive Breast Milk Feeding and Unexpected Complications in Term Newborns. This version of the eCQM uses QDM version 5.6. Drive performance improvement using our new business intelligence tools. The AMA does not directly or indirectly practice medicine or dispense medical services. Please refer to the QDM page for more information on the QDM. Birth weight 3000 grams or more is a proxy to capture term newborns without gestational age recorded in EHR system. This set of measures will help promote the type of high-quality care these populations deserve.. ANA has developed high-impact patient safety measures, with more than two decades of evidence that higher staffing levels are associated with lower rates of patient death and harm. The Joint Commission, Chris Walas, RN, MSN, and Melissa Potts, RN, BSN, CCDS, CDIP. CMS eCQM ID. /Parent 4 0 R QualityNet is the only CMS-approved website for secure communications and healthcare quality data exchange between: quality improvement organizations (QIOs), hospitals, physician offices, nursing homes, end stage renal disease (ESRD) networks and facilities, and data vendors. lz;2[&EPI:+O/A@Fg0{NlAYIS*yIQ6Hfw}I5wMo}#F>juLt!aj-?}a)4g]xo/3sst7o6vso^u|;?=MGmnNgw;{~Kom6:Lc|:;Ow7y}dCy2W79{/]-we33'Wa7i-b| =LNq3d4N'9k{n,~35LWe.cCAX)&I]Ie\E'ZQ+T5.0N=iw]2c3>EZq>-7iNp.~:-Ao>W4e1p0ZTifYg:<6'(>ji{{%6sW L8O;SB&Z:hL:0Mv{(CQE9PCQE9P:`7R8Px&v`i`#fq(bq(>T8%,q`|&f0TAi%Y%y%E%eJ4+H_I4%XelY-o{MlF.I]Rif]lCtcbFSLq|I;%m;*:LQj9o`gKK05o$3;#7 h/?neC%1_}\=wIZn!B4$.Rr\}=O|ikS4@ 9_aMimyT{f7\sB^E@Uo6[Xq2oQr4;w"uFWXr.dK=<. >> Fact Sheet on Maternity Care. EMPOWERED Lower quality care during pregnancy, childbirth, and the postpartum period can lead to unnecessary complications in women and newborns and wasted resources from overused procedures, prolonged hospital stays, and costly neonatal intensive care unit admissions, said Carol Sakala, PhD, MSPH, director of programs at Childbirth Connection and co-chair of the Perinatal and Reproductive Health Endorsement Maintenance Steering Committee. The American Medical Association does not agree to license CPT to the Federal Government based on the license in FAR 52.227-14 (Data Rights - General) and DFARS 252.227-7015 (Technical Data - Commercial Items) or any other license provision. 39 weeks of gestation. This measure tracks the number of term singleton newborns Data shows that the majority of newborns with gestational age 37 weeks or more have a birth weight 3000 grams or more. endobj And a CDC survey found that 8 to 19% of women reported having frequent postpartum depressive symptoms. stream /Type /Metadata 'RelevantDatetime' indicates when the action occurred whereas 'authorDatetime' indicates when the action was recorded. *8XB3+{eI]+(#5Ew){3H hN0dl6BR!b0SVdl RdrgLM}*MIhI5-@I BO!N("(IAMHl"Ua"f:'JFQ;c{,m~%?e- 1uP /CropBox [0 0 612 792] Data Source: The Centers for Medicare and Medicaid Services and Johns The following are Perinatal Care chart abstracted measures used by The Joint Commission. 20 0 obj Perinatal Care (PC) Core Measures: Updates for Fall, 2021. We do not share your information with third parties. endobj RRKd*k2 O! /Type /Catalog *Benchmark Source: National and state averages are the most recent It is acceptable to calculate Gestational Age using the American College of Obstetricians and Gynecologists ReVITALize guidelines, which define Gestational Age as calculated using the best obstetrical Estimated Due Date (EDD) based on the formula: Gestational Age= (280-(EDD-Reference Date))/7. If a hospital uses this method to identify the initial patient population, then the hospital is encouraged to submit all the records of the initial population rather than using sampling to identify the cases for submission. In my experience, good communication is critical to meeting the core measures. /Pages 4 0 R A hospital may choose to use a larger sample size than is required.