New York City Health & Hospitals Corporation
CONDUCTING MATERNAL MORTALITY
REVIEW IN AFFILIATE HOSPITALS:
CHALLENGES FOR THE REGIONAL
PERINATAL CENTER (RPC) TEAM
1
Presented by:
Consuelo Dungca, EdD, RN
Marlene Allison, MPH, RN
Juliet Gaengan, MSA, RN
Moftia Aujero, MA, RN
October 28, 2008
American Public Health Association (APHA)
San Diego, Ca
Presenter Disclosures
Consuelo U. Dungca, EdD, RN
(1) The following personal financial relationships
with commercial interests relevant to this
presentation existed during the past 12
months:
“No relationships to disclose”
2
Objectives




3
Discuss challenges for the RPC team in
conducting a maternal mortality review at
affiliate hospitals.
Outline the root cause factors related to
maternal mortality.
Identify system factors related to maternal
mortality.
Discuss quality improvement activities that
impact on perinatal outcomes.
Who We Are
The NYC Health and Hospitals Corporation (HHC) is a
public benefit corporation and the country’s largest
municipal hospital system. It serves 1.3 million patients
annually (more than 400,000 uninsured) in its 11 acute
care, 4 long term care, 6 diagnostic and treatment
centers, a certified home health agency, a managed
care organization and over 80 clinics all over the 5
boroughs. It is affiliated with all major NYC medical
schools providing healthcare services to a large,
economically disadvantaged, multicultural and
multiethnic population; 42% hispanics, 37% african
americans, 7% caucasians, 6% asians, 8% other
minority groups.
4
5
The Role We Play









220,000 annual discharges; 24,000 births
5 million outpatient visits (>2 million primary care)
1 million ED visits; 30% of city’s trauma services
41% of city’s mental health inpatient services
27% of city’s chemical dependency inpatient capacity
1 million skilled nursing facility patient days
11 designated AIDS centers
Inpatient specialty provider for correctional services
Very diverse population, many new immigrants
6
HHC Regional Perinatal
Centers (RPCs)
Prenatal care is provided at 17 HHC facilities across
the City in the boroughs of Brooklyn, Bronx,
Manhattan and Queens. Most of the patients are high
risk due to their co-morbidities, social factors and
late entry into prenatal care. Two of the 11 HHC
hospitals (Bellevue and Jacobi) are designated as
RPCs, the highest designation for a perinatal center
by NY State. The other nine are affiliates of the two
RPCs w/ seven designated as Level III and two as
Level II.
7
Role of the HHC RPCs
The major role of the RPCs is to provide quality
of care oversight to affiliate hospitals and
implement quality improvement activities to
improve perinatal outcomes. RPCs provide
consultation, assist affiliate hospitals with their
quality assurance process (review, identify issues
and opportunities for improvement in the care of
mothers and neonates), and provide staff
continuing education and outreach.
8
Role of the HHC RPCs

RPCs exercise control over the care and
management of 24,000 babies delivered
annually on the 11 HHC hospitals. This is
accomplished through individualized quality
review and consultation, providing mother and
neonate transports to and from RPCs and
affiliates, conducting sentinel review and root
cause analysis and sharing of best practices.
9
Our Data


Over 23,000 deliveries
~ 26% C section rate



10
16% primary C section
10% repeat
2.2 % VBAC
Our Data

Pregnancy Complications



Maternal Complications




11
Hypertension 3%
Diabetes 6%
Blood transfusion 1%
ICU admission 0.37%
Spontaneous still birth > 500 gms 0.39%
Intrapartum fetal demise 0.01%
HARLEM HOSPITAL
12
KINGS COUNTY HOSPITAL
13
Maternal Mortality Review
Process
Maternal
Mortality
Facility Medical
Director
Notified
Risk & Quality
Discuss in
Dept. QA
meeting
RCA
Corp. Medical
Director
Notified
Constitute RCA Committee
Report to NYPORTS
Report
to RPC
Copy sent to Central Office,
CMO, & President
Facility QCEC
Facility QCAC
Facility Quality
Council
14
RPC Site
Visit
Quality QAC
of Board
Full Board
HHC Quality Improvement
Process
The Corporate Quality Assurance Committee (QAC)
of the Board of Directors meets with the HHC 22
facilities quarterly. Each facility Vice President or
Executive Director, Medical Director, Director of
Nursing and other representatives come before the
board to present reports and discuss significant
issues. Reports include maternal mortality and
morbidity sentinel events and Root Cause Analysis
(RCA). The QAC query the facilities on issues
needing clarification, action plans and follow-up.
15
Maternal Mortality Review
Process

Staff from Quality/Risk Management reviews 100%
mortalities and morbidities.

Cases are discussed at the Hospital Sentinel Event Committee
and sub-groups meet to complete RCA, if indicated.

The Corporate Exec. VP/Chief Medical Officer reviews all RCAs

The RPC OB Director reviews all sentinel events and RCAs

RCAs are presented and discussed at the Hospital Executive
QA/PI Committee meetings

RCAs presented and discussed at the QAC of the Board of
Directors meetings

Cases reviewed by RPC team at quarterly site visits
16
ROOT CAUSE ANALYSIS
Why we use it
“Provides a process for identifying
the basic or causal factors that
underlie variation in performance,
including occurrence or possible
occurrence of a sentinel event.”
17
Maternal Mortality Review
Process

Sentinel Event Committee is interdisciplinary; excludes
staff involved or closely associated with case

Involved staff interviewed by assigned member(s) of
Sentinel Event Committee to ensure accurate information

The Committee develops RCA using the NY Patient
Occurrence Reporting and Tracking System (NYPORTS)
RCA framework
18
Maternal Mortality Review
Process

RCA includes:






19
Detailed description of sentinel event
Chronology of event
Pertinent clinical and non-clinical data
Explanation of What and Why of event
Plan of correction (POC)/opportunities for
improvement
POC monitoring to ensure compliance
NYSDOH NYPORTS RCA
Framework
•The Root Cause Analysis framework captures; what
happened, why did it happen, aspect for analysis,
findings including root cause, risk reduction strategies,
and measures of effectiveness. The Why captures
proximate (special cause variance), and systems and
processes underlie those proximate factors (common
cause variation). The framework also requires
breakdown of the causes into; policy or process (system)
in which event occurred, human resource factors &
issues, environment of care including equipment and
other related factors, information management and
communication issues, and leadership culture.
20
NYSDOH NYPORTS RCA
Framework
Standard of Care determination is required. If
standard of care is not met, the Provider is
reported to the State Department of Health. At
the end of every RCA the following are also
required; results of literature review (include
citation(s), executive summary of analysis (note
critical findings) and titles of RCA participants
(e.g. Dir. of Nursing and others).
21
Role of RPC in Maternal
Mortality Review Process

Review maternal mortality cases of its affiliates

Discuss mortality cases at quarterly RPC site visits

Identify opportunities for improvement

RPC OB Director attends RCA meetings
22
Role of RPC in Maternal
Mortality Review Process
Educational Training and QA Monitoring:
 Bi-annual perinatal conferences: topics based on
educational needs identified from site visits and
RCAs, with educational credits
 Quarterly grand rounds to all HHC hospitals by the
RPCs for educational purposes; discuss mortality and
morbidity cases, perinatal indicators and results; and
present performance improvement projects.
 Perinatal task force meetings (cord blood, VBAC,
hemorrhage, pain management, circumcision),
23
24
Definitions: Maternal Mortality

World Health Organization Definition:
The death of a woman while pregnant or within 42 days
of termination of pregnancy, irrespective of the duration
and site of the pregnancy, from any cause related to or
aggravated by the pregnancy or its management, but
not from accidental or incidental causes.
 CDC/ACOG Definition:
The death of a woman while pregnant or within 1 year of
termination of pregnancy, irrespective of the duration and site of
the pregnancy, from any cause related to or aggravated by her
pregnancy or its management, but not from accidental or incidental
cause.
25
Maternal Deaths Within HHC
Hospitals

There were 11 reported maternal deaths across
6 HHC Hospitals in 2004. The causes identified
were: eclampsia and massive brain hemorrhage;
DVT/PE; pulmonary artery malformation; septic
shock; DIC and sepsis; sickle cell; asthma
w/abruptio-placenta; HEELP syndrome; large
renal tumor and amniotic embolism;
hemorrhage
26
Maternal Deaths Within HHC
Hospitals



2004 - 11 maternal deaths
2006 - Six maternal deaths
2007 - Two maternal deaths
Causes: pre-eclampsia, eclampsia, P/E,
necrotizing fascitis (55 days S/P C/S),
HEELP syndrome, thyroid crisis
27
Conclusion

A large number of HHC maternal deaths were
sudden, unexpected and not related to care
provided. By utilizing the RCA process, the RPC
team identified root causes of maternal deaths,
recommended corrective actions for
implementation and opportunities for
improvement. This process of continuous
monitoring and implementation of best practices
contributed to the decrease in maternal deaths.
28
Summary
A thorough and credible RCA shall prevent
future maternal deaths if the most
actionable root causes are identified and
effective risk reduction strategies are
successfully implemented.
29
Future Plans

30
Crew Resource Management to improve
communication amongst providers

Drills and simulations

Team building

Goal: to reach 0 maternal mortality
Descargar

Smoke Cessation Program Quality Assurance/ …