Merry Medisolving: Electronically Measuring Maternal Care Performance

Maternal health is a big topic in the industry right now. So big that CMS finalized a requirement for all eligible hospitals to publicly report their eCQM rates for PC-02 (Cesarean Birth) and PC-07 (Severe Obstetric Complications) in 2024. But what if you aren’t an eligible hospital and not required to submit these measures? What if you are a Critical Access Hospital with all the limited resources and restraints that usually comes with that type of environment?

For Pella Hospital in Iowa the answer was clear – you do it anyway.

For many years Pella has tracked their Perinatal Care (PC) measure performance. The measures were first released as abstracted measures.

“We were intensely focused on accurately capturing what happened with each mom and baby in our OB unit,” Tory Schrock remembers. “We had a little black book in which we required our staff to manually document every single birth.”

Tory Schrock is the Director of Organizational Excellence for Pella Hospital in Iowa and she and her team run their operations like a military unit with clear processes and procedures outlined for all clinicians and staff. There is reporting up and down the chain and continuous evaluation of performance to better prepare their employees to successfully meet their mission.

“We trained our nursing staff to understand everything about how these measures are calculated,” Tory said. “Once they understood what they needed to capture, it allowed us to feel confident that our data was an accurate reflection of our performance.”

Tory and her team compared their manual results against their abstracted measure performance results. The nurses are essentially abstracting the measure before the patient is even discharged which gives them the ability to further validate the abstracted measure.

Then, in the last few years, the equivalent eCQM PC measures started to roll out.

“Since we already had processes in place to capture and evaluate the abstracted PC measure performance, we took this opportunity to implement the electronic version of the measure and compare our electronic rates to our abstracted rates.”

Pella’s Quality team abstracts the PC measures each month. Once those abstractions are complete, Tory compares their abstracted rates to their electronic rates. They go case by case and review the cases where the results differed between the different measure types.

Using this method of validation, they were able to identify the exact gaps they had that caused their eCQM rates to look different than their abstracted rates.

One discovery they made is that there are differences in the way documentation is captured across their system environments. In a clinic setting, a physician enters details like history of previous birth, breach presentation, and due date, but when a delivering physician went into the hospital setting to perform the delivery, that information was not transferred over to the hospital system. That means someone (the physician or the nurse) should have re-entered that information in the hospital setting so the eCQM could pick it up for calculation.

Pella also discovered that not all breach documentation is equal. There are different kinds of breach presentations that physicians document. When an electronic measure runs a performance calculation, unless all types of breach documentation are mapped to the correct code, you could have patients falling out of the measure because they weren’t properly excluded.

The continuous review between the head of quality and the abstraction team is supplemented with an IT representative. They look for places where they can turn a field into a discrete field for electronic calculation. They also look for places where they can build in a hard stop if necessary. If a physician comes into a hospital setting, they will be stopped from proceeding any further on the screen unless they have certain elements documented. With IT’s involvement they decide on the best way forward as a group.

Pella believes that there are a couple of specific keys to success for their PC measures (and really any eCQMs they track).

“Our first priority is to hit education early and often for both upcoming requirements as well as current performance and areas for improvement (especially on the floor with nursing),” Tory said. “It’s critical to educate on the WHY and not just the WHAT.”

Tory’s team extends the education far and wide in their organization. As the monthly evaluations are completed by the quality team, that information is shared with the OB Director. The director shares that information with the nurses on the floor in their usual communications – such as Friday notes.

The information is also shared with delivering physicians as well, but Pella goes a step further by completing a formal peer review. Each delivering physician is randomly assigned cases of their peers to review. They review how the physician documented and evaluates whether they felt a c-section was justified (i.e., did the mom push for four hours).

Their physicians are incentivized to do this peer review. Pella requires their physicians to participate in a certain number of quality projects each year. Because these PC measures will be publicly reported it is in the interest of both Pella and their physicians to make sure the eCQM results are an accurate reflection of the quality of care.

These physicians are hospital-owned, but rarely work together with their peers. By peer reviewing these cases, physicians also get a chance to see how their peers are documenting compared to their own techniques. It can create great organic growth for the organization.

Every year, Pella does a road show where they travel to all their clinics and complete a “State of the Union.” In this annual report, they explain to their providers the current requirements and what’s coming down the road. They outline the implications for providers in a digital measurement environment. They attempt to educate as many people as possible, so everyone is aware of where Pella is now and where they are trying (or being required) to go.

In addition to excellent and thorough communication to staff, nurses, and providers, Pella ensures that senior management is aware of performance on a regular basis. Once a month they provide updates on measure performance to their board.

“We rely on our Medisolv software for measure calculation of course, but we also use it to generate reports of measure performance for our communication initiatives,” Tory said. “And we rely on the great education we receive from our Medisolv Advisor to make sure we are providing the best and most up-to-date regulatory information to our teams.”