lessons from the california maternal quality care ... · 11/28/2017 · t r a n s f or mi n g m a...

QI Leading Practices Series:

Lessons from the California Maternal Quality Care CollaborativeNovember 28, 2017David C. Lagrew, Jr., MD

Executive Medical Director, Women’s Service

St. Joseph-Hoag Health, Providence Health

©2015 PCPI Foundation. All rights reserved.

Today’s Speaker

David C. Lagrew Jr., MD

Executive Medical Director, Women’s Service

St. Joseph-Hoag Health Region of Providence

Healthcare

Executive Committees of the California Maternal

Quality Care Collaborative (CMQCC) and

California Maternal Data Center

Maternal Mortality:

The California Response

David C. Lagrew, Jr., M.D.Regional Executive Medical Director Women’s Services

SJHH

Clinical Professor UC Irvine, Dept Ob-Gyn

T r a n s f o r m i n g M a t e r n i t y C a r e

A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans

What is maternal mortality?





▪ Direct maternal death- due to obstetrical complications during pregnancy, labor or puerperium or from any treatment received

▪ Indirect maternal death- due to a preexisting or newly developed health problem unrelated to the pregnancy

▪ Late maternal death- maternal death occuring42-365 days after delivery

▪ Pregnancy-related death- death of a woman while pregnant or within 42 days of termination of the pregnancy, irrespective of the duration and site of the pregnancy, from any cause

WHO/NCHS-ICD-10





▪ Pregnancy-associated death- All deaths during or within 1 year of

pregnancy

▪ Pregnancy-related death (subset of above)- all deaths during or

within the 1 year of pregnancy due to:

o Complication of pregnancy

o Aggravation of unrelated condition by the physiology of pregnancy

o Chain of events initiated by pregnancy

▪ Using all available data

Maternal Mortality Study Group(CDC/ACOG 1986)





Maternal Mortality Ratio



Maternal Mortality Worldwide





Reducing Maternal Mortality



Yearly rate of decline in Maternal Mortality Ratio 1990–2008





Is US Maternal Mortality Rising?

▪ The estimated maternal mortality rate (per 100,000 live births) for 48 states and Washington D.C. (excluding California and Texas, analyzed separately) increased by 26.6%, from 18.8 in 2000 to 23.8 in 2014. California showed a declining trend, while Texas had a sudden increase in 2011–2012. Analysis of the measurement change suggests that U.S. rates in the early 2000s were higher than previously reported.

▪ Despite the United Nations Millennium Development Goal for a 75% reduction in maternal mortality by 2015, the estimated maternal mortality rate for 48 states and Washington D.C. increased from 2000–2014, while the international trend was in the opposite direction

MacDorman et al Obstet Gynecol. 2016 September ; 128(3): 447–455.





Tip of the Iceberg

▪ Using the New York Data for every

maternal death there are 362 SMM

events

▪New York severe maternal morbidity

measure, New York hospital

deliveries 2008–2013





SMM in the United States 1993-2004





CDC Report: Changes in SMM

▪Compared with the 1993–2004 period, 13 SMM indicators had substantial (50% and more) rate increases in 2013–2014. The largest increases were among the following indicators:

oAcute renal failure at 369%.

oBlood transfusion at 363%.

oShock (body is not getting adequate blood flow) at 233%.

oAdult respiratory distress syndrome at 189%.

oCardiac arrest (sudden loss of heart function) or ventricular fibrillation (heart beats so quickly and irregularly that it stops pumping blood) at 158%.

oAcute myocardial infarction (heart attack) at 133%.

oAneurysms of the aorta (balloon-like bulge in the body’s largest artery) at 1,110%.

https://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html



What’s causing the increase?



17

Berg CJ et al. Obstet Gynecol 2005.

Cause of Death % of All Deaths % Preventable

Cardiomyopathy 21% 22%

Hemorrhage 14 93

PIH 10 60

CVA 9 0

Chronic condition 9 89

AFE 7 0

Infection 7 43

Pulmonary embolism 6 17



Causes in Florida Review



Time After Delivery

‘medicine used to be simple, ineffective and relatively safe; now it is complex, effective and

potentially dangerous”

Cyril Chantler MD

Chantler C. The role and education of doctors in the delivery of health care.

Lancet 1999;353:1178-81



What was our response?





California Maternal Quality Care Collaborative

▪ Multi-stakeholder organization established in 2006: providers, state agencies, hospitals, purchasers, payers and public groups with focus on Maternal Care

Sister organization with CPQCC (neonatal care) at Stanford Univ.

▪ Hosts California Maternal Mortality Review Committee

Launched Maternal Data Center in 2012

Developer of nationally recognized QI toolkits:

oEarly Elective Delivery; OB Hemorrhage; Preeclampsia; CVD in Pregnancy; Prevention of OB VTE; and Supporting Vaginal Birth/Preventing Cesarean

▪Organizer of large-scale learning collaboratives

oLast collaborative engaged 126 California hospitals covering Hemorrhage and Hypertension

oCurrently working with ~100 hospitals on Primary CS

22





CMQCC’s mission is to end preventable

morbidity, mortality and racial disparities in

California maternity care.



Commercial Aviation Worldwide Accident Rate (Boeing, 2000)





Our world (L & D) vs. Their world (Flight deck)

Medicine/OB-Gyn Navy/BHR

Complex /ambiguous terminology/Acronyms

“Fetal distress”,medicationnames,VBAC,LSO,SUI

Port,starboard,aft, forward, RAS, NCO,OD CH46,F18

Equipment Fetal monitors, IV pumps, Laparoscopes, Robots

Helicopters, missiles,radar, sonar, engines

Hazards Infectious diseases,medications, radioactive materials

Ordinance, natural elements, machinery

People Very highly trained with variable experience, some with minimal of both

Younger, intensive system of structured training

Leadership structure Present but loosely defined and team attitude sporadic

Strictly defined but strong team attitude

Work day 24 hour job, some restrictions

24 hour job with restrictions as needed


A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans: Transforming Maternity Care

To achieve this we need to transform maternity care

Guidelines

Communication

Data

Advocacy

QI Capacity



Define and implement best practices for public health, communities, women with quality, safety, and social justice as the clear priorities of every decision and action.

Best Practice Guidelines

Promote communication and collaborationbetween all maternity stakeholders.

Gather, review, and organize maternity data and statistics into actionable information.

Refine Data; Advocate Policy

Build the next generation of California maternal health leaders.





CMQCC’s Key Stakeholders/ Partners

State Agencies

▪ CA Department of Public Health, MCAH

▪ Regional Perinatal Programs of California (RPPC)

▪ DHCS: Medi-Cal

▪ Office of Vital Records

▪ Office of Statewide Health Planning and Development (OSHPD)

▪ Covered California

Membership Associations

▪ Hospital Quality Institute (HQI)/California Hospital Association (CHA)

▪ Pacific Business Group on Health (PBGH)

▪ Integrated Healthcare Association (IHA)

Key Medical and Nursing Leaders

▪ UC, Kaiser (N&S), Sutter, Sharp, Dignity Health, Scripps, Providence, Public hospitals

Professional Groups (California sections of national organizations)

▪ American College of Obstetrics and Gynecology (ACOG)

▪ Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN)

▪ American College of Nurse Midwives (ACNM),

▪ American Academy of Family Physicians (AAFP)

Public and Consumer Groups

▪ California HealthCare Foundation (CHCF)

▪ March of Dimes (MOD)

▪ California Hospital Accountability and Reporting Taskforce (CHART)

28All these groups are represented on the CMQCC Executive Committee



Step 1: Analyze our cases

29



CAMR



Process



Minority Pregnancy Related



Reclassification





1. By all measurement approaches, Maternal Mortality in California has increased

2. Cardiovascular disease has emerged as the number one category for pregnancy related deaths

3. Deaths from hemorrhage, preeclampsia, infection and thromboembolism were judged to have strong chances to alter outcome

4. Obesity, advanced maternal age, cesarean section and African-American race were recognized contributing factors

5. >95% of cases had “opportunities for improvement” for the facilities and the professionals involved

Key Findings CAMR





Maternal Risk Factors IncreasedThe “Big 3”

▪Maternal Age

▪Maternal Weight

▪Prior Cesarean Section



MMR and Age



MMR and Obesity





▪ Death certificate cause of death- ICD codes/key words

▪ Data linkages- death/birth/fetal death certificates

▪ Death certificate- check box

▪ Hospital discharge administrative datasets

▪ Autopsy report

▪ Hospital reporting

Identifying Cases



MMR and CS type



Step 2: Build some tools





▪ Most common preventable causes of

Maternal Mortality

▪ Far and away the most common causes of

Severe Maternal Morbidity (>80%)

▪ Large drivers of maternity costs

▪ High rates of provider

“quality improvement opportunities”

Obstetric Hemorrhage and Preeclampsia:

Summary

42

CDPH/CMQCC/PHI. The California Pregnancy-Associated Mortality Review (CA-PAMR): Report from 2002 and 2003 Maternal Death Reviews. 2011 (available at: CMQCC.org)

Geller SE etal. The continuum of maternal morbidity and mortality: Factors associated with severity. Am J Obstet Gynecol 2004; 191: 939-44.



Hemorrhage Task Force Process

5 meetings in 2008-2009 Developed a Tool Kit for OB services:

Care Guidelines: Step-by-step process in Checklist, Flowchart and Table Chart formats

Compendium of Best Practices: background and rationale for recommendations about preparation for and management of obstetric hemorrhage

Hospital level Implementation Guide: includes QI tools and a sample Policy and Procedure

All resources online at: www.cmqcc.org/ob_hemorrhage

CMQCC sponsored an Implementation Collaborative following the IHI QI Model

http://www.cmqcc.org/ob_hemorrhage



Task Force Membership

David Lagrew, MD

Audrey Lyndon, PhD, RN

Debra Bingham, MS, RN

Elliot Main, MD

Leslie Casper, MD

Maurice Druzin, MD

Sue Faron, RNC, MN, CNS

Nancy Corbett, RN, MS

Kim Gregory, MD

Andrew Hull, MD

Rich Lee, MD

Holly Mason, MD

Jennifer McNulty, MD

Kathryn Melsop, MS

Suellen Miller, PhD, CNM, MHA

Connie Mitchell, MD, MPH

Mark Rosen, MD

Mark Rollins, MD

Larry Shields, M.D.

Jean-Claude Veille, M.D.

Valerie Huwe, RN

James Byrne, MD



Hemorrhage Task Force Objectives

: Transforming Maternity Care

Define the scope of the problem of maternal hemorrhage in California.

Conduct gap analysis to identify opportunities for improvement.

Develop strategies for improvement.

Develop strategies for wide-spread application of selected improvement solutions.



Staged Hemorrhage Emergency Management Response Plan

Copyright California Department of Public Health, 2014; supported by Title V funds. Developed in partnership with California Maternal Quality Care Collaborative Hemorrhage Taskforce Visit: www.CMQCC.org for details

Obstetric Hemorrhage Emergency Management Plan: Table Chart Format version 2.0

Assessments Meds/Procedures Blood Bank

Stage 0 Every woman in labor/giving birth

Stage 0 focuses on risk assessment and active management of the third stage.

· Assess every woman for risk factors for hemorrhage

· Measure cumulative quantitative blood loss on every birth

Active Management 3rd Stage:

· Oxytocin IV infusion or 10u IM

· Fundal Massage-vigorous, 15 seconds min.

· If Medium Risk: T & Scr

· If High Risk: T&C 2 U

· If Positive Antibody Screen (prenatal or current, exclude low level anti-D from RhoGam):T&C 2 U

Stage 1 Blood loss: > 500ml vaginal or >1000 ml Cesarean, or

VS changes (by >15% or HR ³110, BP £85/45, O2 sat <95%) Stage 1 is short: activate hemorrhage protocol, initiate preparations and give Methergine IM.

· Activate OB Hemorrhage Protocol and Checklist

· Notify Charge nurse, OB/CNM, Anesthesia

· VS, O2 Sat q5’

· Record cumulative blood loss q5-15’

· Weigh bloody materials

· Careful inspection with good exposure of vaginal walls, cervix, uterine cavity, placenta

· IV Access: at least 18gauge

· Increase IV fluid (LR) and Oxytocin rate, and repeat fundal massage

· Methergine 0.2mg IM (if not hypertensive) May repeat if good response to first dose, BUT otherwise move on to 2nd level uterotonic drug (see below)

· Empty bladder: straight cath or place foley with urimeter

· T&C 2 Units PRBCs (if not already done)

Stage 2 Continued bleeding with total blood loss under 1500ml

Stage 2 is focused on sequentially advancing through medications and procedures, mobilizing help and Blood Bank support, and keeping ahead with volume and blood products.

OB back to bedside (if not already there)

· Extra help: 2nd OB, Rapid Response Team (per hospital), assign roles

· VS & cumulative blood loss q 5-10 min

· Weigh bloody materials

· Complete evaluation of vaginal wall, cervix, placenta, uterine cavity

· Send additional labs, including DIC panel

· If in Postpartum: Move to L&D/OR

· Evaluate for special cases: -Uterine Inversion -Amn. Fluid Embolism

2nd Level Uterotonic Drugs: · Hemabate 250 mcg IM or · Misoprostol 800 mcg SL

2nd IV Access (at least 18gauge)

Bimanual massage Vaginal Birth: (typical order)

· Move to OR

· Repair any tears

· D&C: r/o retained placenta

· Place intrauterine balloon

· Selective Embolization (Interventional Radiology)

Cesarean Birth: (still intra-op) (typical order)

· Inspect broad lig, posterior uterus and retained placenta

· B-Lynch Suture

· Place intrauterine balloon

· Notify Blood Bank of OB Hemorrhage

· Bring 2 Units PRBCs to bedside, transfuse per clinical signs – do not wait for lab values

· Use blood warmer for transfusion

· Consider thawing 2 FFP (takes 35+min), use if transfusing > 2u PRBCs

· Determine availability of additional RBCs and other Coag products

Stage 3 Total blood loss over 1500ml, or >2 units PRBCs given or VS unstable or suspicion of DIC

Stage 3 is focused on the Massive Transfusion protocol and invasive surgical approaches for control of bleeding.

· Mobilize team -Advanced GYN surgeon -2nd Anesthesia Provider -OR staff -Adult Intensivist

· Repeat labs including coags and ABG’s

· Central line

· Social Worker/ family support

· Activate Massive Hemorrhage Protocol

· Laparotomy: -B-Lynch Suture -Uterine Artery Ligation -Hysterectomy

· Patient support -Fluid warmer -Upper body warming device -Sequential compression stockings

Transfuse Aggressively Massive Hemorrhage Pack

· Near 1:1 PRBC:FFP

· 1 PLT apheresis pack per 4-6 units PRBCs

Unresponsive Coagulopathy: After 8-10 units PRBCs and full coagulation factor replacement: may consult re rFactor VIIa risk/benefit

Blood Loss:

1000-1500 ml

Stage 2

Sequentially

Advance through

Medications &

Procedures

Pre-

Admission

Time of

admission

Identify patients with special consideration:

Placenta previa/accreta, Bleeding disorder, or

those who decline blood products

Follow appropriate workups, planning, preparing of resources, counseling and notification

Screen All Admissions for hemorrhage risk:

Low Risk, Medium Risk and High Risk

Low Risk: Draw blood and hold specimen

Medium Risk: Type & Screen, Review Hemorrhage Protocol

High Risk: Type & Crossmatch 2 Units PRBCs; Review Hemorrhage

Protocol

All women receive active management of 3rd

stage

Oxytocin IV infusion or 10 Units IM, 10-40 U infusion

Standard Postpartum

Management

Fundal Massage

Vaginal Birth:

Bimanual Fundal Massage

Retained POC: Dilation and Curettage

Lower segment/Implantation site/Atony: Intrauterine Balloon

Laceration/Hematoma: Packing, Repair as Required

Consider IR (if available & adequate experience)

Cesarean Birth:

Continued Atony: B-Lynch Suture/Intrauterine Balloon

Continued Hemorrhage: Uterine Artery Ligation

To OR (if not there);

Activate Massive Hemorrhage Protocol

Mobilize Massive Hemorrhage Team

TRANSFUSE AGGRESSIVELY

RBC:FFP:Plts 6:4:1 or 4:4:1

Increased

Postpartum

Surveillance

Definitive Surgery

Hysterectomy

Conservative Surgery

B-Lynch Suture/Intrauterine Balloon

Uterine Artery Ligation

Hypogastric Ligation (experienced surgeon only)

Consider IR (if available & adequate experience)

Fertility Strongly Desired

Consider ICU

Care; Increased

Postpartum

Surveillance

Verify Type & Screen on prenatal

record;

if positive antibody screen on prenatal

or current labs (except low level anti-D

from Rhogam), Type & Crossmatch 2

Units PBRCs

CALL FOR EXTRA HELP

Give Meds: Hemabate 250 mcg IM -or-

Misoprostol 600-800 SL or PO

Cumulative Blood Loss

>500 ml Vag; >1000 ml CS

>15% Vital Sign change -or-

HR ≥ 110, BP ≤ 85/45

O2 Sat <95%, Clinical Sx

Ongoing

Evaluation:

Quantification of

blood loss and

vital signs

Unresponsive Coagulopathy:

After 10 Units PBRCs and full

coagulation factor replacement,

may consider rFactor VIIa

HEMORRHAGE CONTINUES

Blood Loss:

>1500 ml

Stage 3

Activate

Massive

Hemorrhage

Protocol

Blood Loss:

>500 ml Vaginal

>1000 ml CS

Stage 1Activate

Hemorrhage

Protocol

NO

Stage 0All Births

Transfuse 2 Units PRBCs per clinical

signs

Do not wait for lab values

Consider thawing 2 Units FFP

YES

YES NO

On

go

ing

Cum

ula

tive

Blo

od

Lo

ss E

valu

ation

Cumulative Blood Loss

>1500 ml, 2 Units Given,

Vital Signs Unstable

YESIncrease IV Oxytocin Rate

Methergine 0.2 mg IM (if not hypertensive)

Vigorous Fundal massage; Empty Bladder; Keep Warm

Administer O2 to maintain Sat >95%

Rule out retained POC, laceration or hematoma

Order Type & Crossmatch 2 Units PRBCs if not already done

Activate Hemorrhage Protocol

CALL FOR EXTRA HELP

Continued heavy

bleeding

Increased

Postpartum

Surveillance

NO

NO

CONTROLLED

INCREASED BLEEDING

California Maternal Quality Care Collaborative (CMQCC), Hemorrhage Taskforce (2009) visit: www.CMQCC.org for details

This project was supported by funds received from the State of California Department of Public Health, Center for Family Health; Maternal, Child and Adolescent Health Division

Obstetric Emergency Management Plan: Flow Chart Format Release 2.0 7/9/2014

Pre-Admission: All patients-Assess Risk

Stage 0: All birth- Routine Measures

Stage 1: QBL > 500 mL vag or 1000 mL CS or VS unstable with continued bleeding

Stage 2: QBL 1000-1500 mL with continued bleeding

Stage 3: QBL exceeds 1500 mL

Cu

mu

lati

ve Q

BL



Long Beach Memorial OB Hemorrhage Cart

▪Quick access to emergency supplies

▪ Refrigerator for meds

▪ Establish necessary items and par

levels

▪ Label drawers/compartments

▪ Include checklists

▪ Develop process for checking and

restocking

▪ Educate nursing and physician staff





B-Lynch Compression Suture “Belt and Suspenders”

Used with permission from

Christopher B-Lynch



National OB Safety Focuses

1. Obstetrical Hemorrhage

2. Hypertension

3. VTE

4. Cardiovascular Disease

5. Primary Cesarean Section

6. Maternal mental health

7. Reduction in Disparities

8. Support following event

9. Postpartum basics





AIM: Obstetric Hemorrhage Safety Bundle

Readiness: (every unit)

▪ Hemorrhage Cart / with Procedural Instructions (balloons, compression stiches)

▪ Rapid access to hemorrhage medications (kit or equivalent)

▪ Establish a response team: multiple partnerships // unit education, drills, debriefs

▪ Establish MTP and 0-neg/uncrossmatched transfusion protocols

Recognition: (every patient)

▪ Assessment of hemorrhage risk (prenatal, on admission, ongoing in labor & PP)

▪ Measurement of CUMMULATIVE blood loss

▪ Active Management of 3rd Stage (oxytocin after birth)

Response: (every hemorrhage)

▪ Unit-standard, stage-based OB Hemorrhage Emergency Management Plan w/checklist

▪ Support program for patients, families and staff

Reporting / Systems Learning: (every unit)

▪ Establish a culture of Huddles for high-risk patients and post-event debriefings

▪ Review all stage 3 hemorrhages for systems issues

▪ Monitor outcome and process metrics in perinatal QI committee





Prompt medications for HBP





Standardized Labor Response



www.CMQCC.org

Will implementation of a bundle change outcomes?

v2 Released 3/24/15:>4,000 downloads

http://www.cmqcc.org/



Step 3: Collaboratives





40 Active

Mentor Leaders

20Teams of 6-8

Hospitals

126 Participating

Hospitals

13,600 Healthcare Providers

Impacting

288,210Annual Births

MD RN

GOAL: is to ensure that 100% of hospitals with maternity services in California are ready to respond to the two most common obstetric emergencies by implementing patient safety bundles for postpartum hemorrhage and preeclampsia.

Modified IHI Breakthrough Series Collaborative with addition of Mentors

QI Implementation Model





CMQCC OB Hemorrhage Collaborative

CMQCC DIRECTORS AND STAFF

Elliott Main, MD: Medical Director

Barbara Murphy, RN, MSN: Director

Kathryn Melsop: Program and Data Manager

Valerie Cape: Program Assistant

EXPERT PANEL

Obstetrics:

David Lagrew, MD

Bev VanderWal, CNS

Drills & Simulations:

Julie Arafeh, RN, MSN

Quality Improvement:

Paul Kurtin, MD

Anesthesiology:

Mark Rollins, MD

Blood Bank:

Holli Mason, MD






CMQCC OB Hemorrhage Collaborative

COLLABORATIVE AIMS:

Reduce the number of massive hemorrhages and the number of major complications from massive hemorrhage, including transfusions and hysterectomies, for all birthing women in participating hospitals by 50% by December 31, 2011

All collaborative participants develop and implement a multidisciplinary team response to every massive obstetric hemorrhage by December 31, 2011

COLLABORATIVE CONTENT: Collaborative #1: Three in-person Learning Sessions

Collaborative #2: Two in-person Learning Sessions

Monthly All-Collaborative Conference Calls

IHI Extranet Data Entry Portal

Access to Expert Panel or Strategizing, Advising, Planning




Order Sets





Cesarean Hysterectomies SMMC





Asd

Time Period Mean PRBCs Mean Platelets Mean Plasma/FFP Mean Cryo Mean-All Blood

Baseline: 1/09-9/09 82.684 11.3958 56.0977 15.2905 165.468

Year 1: 10/09-10/10 32.5229 5.1276 7.9851 6.8074 52.443

Year 2: 11/10-12/11 23.7254 3.0362 12.3962 1.6728 40.831



Step 4: Feedback the Data




A Toolkit to Support Vaginal Birth and Reduce Primary Cesareans 62

Maternal Mortality

and Morbidity Reduction

Maternity Quality

Measures

Large-Scale Implement-

ationProjects

Maternal Data

Center

CMQCC:Major Areas of Activity



Queries

State Data Warehouse

CMQCC DWH-Data feed

Clarity

Print Group Reports: OBSTAT/BirthCert

MC*21 EpicDelivery Summary/

Flowsheets, etc.

OBSTAT, AVISS

Caché

OSPHD CodedData

BC Data



PDD--Discharge Diagnosis File(ICD9 codes)

Birth CertificateData

Maternal Data Center (MDC) Data Linkage

CMQCC Data Center: Automatically Links

the Data

REPORTSBenchmarks against other hospitals

Sub-measure reports

Calculates all the Measures

Hospital to State Vital Records to CMQCC Hospital uploads to CMQCC

99.5% Linkage RatesBased on:

• Hospital• Maternal DOB• Delivery Date





Reports for California Children’s Services▪ CCS-Certified Hospitals must report overall perinatal stats by GA and BW

▪ MDC provides these data in CCS required format in Hospital Statistics Section





What Drives our NTSV Cesarean Rate?



Some Results





Reducing Maternal Mortality





System-wide Improvement

▪ Comprehensive hemorrhage protocol applied

in Dignity Health System

▪ 60,000 annual births

▪ 2-month baseline and 2-month period 6

months after introduction

▪ Results from 20,890 births

▪ 50% drop in cesarean hysterectomies

Shields, et al SMFM San Francisco, 2/2013





Percent Reductions in Usage

Shields, et al SMFM San Francisco, 2/2013





Reduction in Severe Maternal Morbidity (HEM)



Conclusion and Closing Thoughts





CMQCC’s Mission

▪End preventable morbidity and mortality

and racial disparities in California

maternity care.

▪Build quality improvement capacity among

our units and providers

74





Quality Care Collaborative Skills

Maternal Mortality Review

Toolkit Taskforces

Conducting Collaboratives

Data Center

Leadership Training

Coalition Building



Questions?

lessons from the california maternal quality care ... · 11/28/2017 · t r a n s f or mi n g m a...

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