By Tricia Elliott, MBA, CPHQ, Director of Quality Management
The COVID-19 pandemic prompted The Joint Commission to delay plans of publicly reporting two Perinatal Care (PC) performance measures on QualityCheck®, a public facing website. Originally, we planned to begin reporting in July 2020 for the following ORYX® Perinatal Care (PC) measures:
- PC-02—Cesarean Birth
- PC-06—Unexpected Complications in Term Newborns
These measures will now be reported online beginning in January 2021.
According to data from Q4 2019, most hospitals have continued to submit data for the ORYX measures so we’re optimistic this effort can move forward. We believe this will provide meaningful information on the performance of accredited organizations on measures affecting maternal and newborn health.
Cesarean Birth Measure
While it’s important to identify hospitals with high C-section rates, there’s also a broad understanding in the maternal health community that there’s no “magic number” for an ideal C-section rate. As my colleague David Baker, MD, MPH, FACP, Executive Vice President for Health Care Quality Evaluation at The Joint Commission, and I discussed in this USA Today article, hospitals reporting more than 30% of deliveries via cesarean seems far too high, but we also don’t want to encourage inappropriately low rates.
The Cesarean Birth measure, PC-02, calculates the rates of cesarean births among a subset of the general obstetric population of low-risk women having their first birth (nulliparous) with a term, singleton baby in a vertex position (NTSV). The Joint Commission will use data reported by hospitals during 2018 and 2019, along with the following three criteria, to determine a hospital’s PC-02 rating:
- ≥ 30 cases reported in both years
- PC-02 rate > 30% for the current year
- Overall 24-month aggregate PC-02 rate > 30% (see the following note)
Hospitals will be identified on Quality Check with either a plus (+) or minus (-) symbol for the PC-02 measure:
- A plus (+) symbol will signify the hospital has an acceptable rate.
- A minus (-) symbol will signify the hospital’s cesarean rate is consistently high (and has a large enough sample size to make this determination).
For those hospitals identified as having high rates (-), The Joint Commission will show those hospitals’ actual 2019 PC-02 rates. Hospitals with acceptable rates (+) will not have their actual PC-02 rates reported. The Joint Commission believes hospitals should work to reduce unnecessary cesarean births; however, it does not want to differentiate between groups of hospitals whose rates are in the acceptable range. Lower is not always better in these cases, and The Joint Commission does not want to encourage inappropriately low rates that may be unsafe to patients.
Data Submission Changes Due to COVID-19
Data from 2018 and 2019 will be used for the initial release. Moving forward the overall 24-month aggregate rate will be calculated from a rolling eight calendar quarters and refreshed on Quality Check biannually in July and January. Due to the pandemic, the usability of 2020 data will need to be analyzed and a determination will be made as to the methodology to address this time period.
Another complexity due to COVID-19 is that the submission of Q4 2019 data was made optional in March 2020. While most hospitals continued to submit Q4 2019 data, some hospitals did not and will be managed as follows:
Sites that submitted three quarters of data in 2019 and have a plus symbol on Quality Check (acceptable rate) are included in the public reporting as stated above.
Hospitals that meet the criteria for outlier and received a minus symbol on Quality Check (consistently high rate) and did not submit Q4 2019 data will not be displayed and will have the notation “not enough data (number of months of data reporting is below the threshold).”
Unexpected Complications in Term Newborns
It’s important to be as vigilant about potential complications with infants as with their mothers.
The Unexpected Complications in Term Newborns measure, PC-06, which became effective January 1, 2019, measures the number of infants with unexpected newborn complications among full-term newborns with no preexisting conditions.
Term infants represent more than 90% of all births, and this measure assesses the health outcomes of this patient population. Although measures have been developed to assess clinical practices and outcomes in preterm infants, metrics that assess the health outcomes of term infants are lacking. This measure addresses this gap and gauges adverse outcomes resulting in severe or moderate morbidity in otherwise healthy term infants without preexisting conditions.
Importantly, this metric also serves as a balancing measure for other maternal measures such as PC-02, Cesarean Birth, and PC-01, Elective Delivery. The purpose of a balancing measure is to guard against any unanticipated or unintended consequences of other performance measures and to identify unforeseen complications that might arise as a result of quality improvement activities and efforts for these measures. For example, if a cesarean delivery is not done when medically appropriate, there could be a negative effect on the health of the newborn. This measure helps hospitals monitor newborn outcomes.
Data Analysis Changes Due to COVID-19
For calendar year 2020 data on Quality Check, The Joint Commission will analyze all data received to determine the impact of COVID-19 on the data trends and to the public reporting process. Any documents or reports produced with the 2020 data will have notations regarding COVID-19 as data may not be reflective of an organizations’ typical level of performance on measures.
Hospitals will continue to receive their monthly and quarterly measure rates in their Accelerate PI dashboards posted on their extranet site.
For the PC measures, hospitals are encouraged to look at existing tools to assist with improving performance on these measures. Effective tools can be found in the Alliance for Innovation on Maternal Health (AIM) bundles or state collaboratives such as the California Maternal Quality Care Collaborative (CMQCC).
Questions regarding this reporting initiative may be directed to the Performance Measurement Network Q&A Forum on The Joint Commission’s website.
It’s also critical to remind patients that they can play an important role in their care. We were pleased that the Office of the Surgeon General and the U.S. Department of Health and Human Services included materials from The Joint Commission’s Speak Up™ campaign in “The Surgeon General’s Call to Action tTo Improve Maternal Health” report. The campaign, SpeakUp About Your Care was designed to empower patients to ask questions of their health care team. This campaign has free, downloadable posters and infographics to display in patient care settings.
I think we have a real opportunity as a health care community to collaborate and improve maternal and newborn health.
Tricia Elliott, MBA, CPHQ, is director, Quality Measurement at The Joint Commission. Prior to this, she held executive roles in quality and decision support at several Chicago area hospitals.