Some doctors wrote the reason for early delivery as "intrahepatic cholestasis of pregnancy," which is an appropriate indication, but the medical coders told Dr. Gilbert that having the word "intrahepatic" flagged it as gall bladder disease, which is no reason to deliver early. "We had to work with our coders to help us understand," he said.
Every patient at risk of preterm delivery received antenatal steroids at his hospital, Dr. Gilbert said, "but we weren’t documenting it properly." There had been no uniform spot in the medical record to document administration of antenatal steroids, or to show that they had been given before the current hospitalization. Dr. Gilbert’s team worked with the medical records department to change the electronic health records. Nurses now check off if the patient received a full course of antenatal steroids. If this is missing, the doctor gets a pop-up window where a reason must be given.
"That really was effective," he said.
Tracking of episiotomy excluded cases of shoulder dystocia, but not episiotomy for fetal distress. Despite individual rates being internally publicized, the episiotomy rate seems to be stuck at around 2% because "I do have a couple of old-timers," he said. "Even public embarrassment will not get them to change."
"As an individual and as a hospital, we need to make sure we’re doing the best we can."
Capturing data on whether or not newborns are fed exclusively with breast milk can be difficult, in part because it’s often not clear whether the ob.gyn., the nursing staff, or the pediatrician is responsible for this. Dr. Gilbert’s team analyzed 18 cases at his hospital in which women came in saying they wanted to breastfeed the newborn exclusively, but that didn’t happen. In most cases, the babies received formula after a night nurse moved the baby to the nursery so the mother could sleep, a problem that was addressed. Publicizing exclusive breastfeeding rates for 20 different perinatal obstetrics groups – which ranged from 33% to 93% also helped improve breastfeeding rates.
The perinatal data committee also posted a color-coded "dashboard" showing trends in the hospital’s rates for all these measures over time.
Starting in 2014, The Joint Commission will publish hospital rates for cesarean sections and episiotomies, but not rates for individual doctors. Patient access to individual doctors’ rates of cesarean section, early elective delivery, and episiotomy is likely to come in the future, Dr. Gilbert said, and insurers eventually may select physicians and reimbursement rates based on these outcomes.
"As an individual and as a hospital, we need to make sure we’re doing the best we can," he said.
Dr. Gilbert reported having no financial disclosures.
On Twitter @sherryboschert