Joint Commission to assess rates of C-sections, punishment possible
Joint Commission to assess rates of C-sections, punishment possible
Perinatal core measures, previously voluntary, now mandatory
The Joint Commission (TJC) will hold hospitals accountable for their cesarean section rates beginning Jan. 1, 2014, and many providers will have to effect an entire culture change within the obstetrical unit by then. Documentation of any cesareans will become especially important.
TJC announced recently that it will expand performance measurement requirements for accredited general medical/surgical hospitals from four to six core measure sets. Four of the six measure sets will be mandatory for all general medical/surgical hospitals that serve specific patient populations addressed by the measure sets and related measures. The mandatory measure sets address acute myocardial infarction (AMI), heart failure, pneumonia, and the Surgical Care Improvement Project (SCIP). These core measure sets are common to several federally legislated programs and selected most frequently by hospitals.
But here is the change that got everyone’s attention: For hospitals with 1,100 or more births per year, the perinatal care measure set will become the mandatory fifth measure set. TJC says it chose the perinatal care measure set because of the high volume of births in the United States — 4 million per year — and because it affects a significant portion of accredited hospitals. TJC will monitor the threshold of 1,100 births over the first four to eight quarters of data collection to reassess ongoing applicability. TJC officials expect that this threshold will be modified over time so that more hospitals are included, and they strongly encourage hospitals to consider adopting this measure set before the required effective date of Jan. 1, 2014.
Strict rules, however, might not be enough, says Robin Kish, MBA, BSN, RN, CPHQ, vice president of Marsh Clinical Healthcare Consulting, in Nashville, TN. It might be necessary to effect a culture change within your hospital, she says.
“It’s not about just how many c-sections you do, but also the general culture of the staff on that unit,” Kish says. “The culture of the staff will be transferred to the patient. If the staff do not have an open mind with regard to vaginal births, the patients can pick up on that. Do you provide enough objective information for the patient to make an informed decision, or is the conversation pretty much swayed to c-sections?”
Voluntary at first
The perinatal measures evolved from just a suggestion to a requirement over several years. In 2007, TJC replaced the old perinatal requirements with a new set of evidence-based measures. At the same time, the National Quality Forum launched a perinatal care project, which resulted in the endorsement of 17 perinatal measures.
TJC then put together an advisory panel made up expert that included neonatologists, obstetricians, certified nurse midwives, and labor and delivery nurses. They reviewed the 17 perinatal measures, and out of those 17 they selected five to make up TJC’s new perinatal core measures: early elective delivery rates, first-time mother c-section rates, prenatal steroids given for preterm birth, bloodstream infections in newborns, and breastfeeding.
The new perinatal core measures were ready for hospitals to use in fall 2009, and data collection began in April 2010, but only 160 hospitals voluntarily adopted the perinatal core measures.
Several stakeholder groups encouraged TJC to make the perinatal core measures mandatory. These groups included the American Congress of Obstetricians and Gynecologists; the Association of Women’s Health, Obstetric, and Neonatal Nurses; the American College of Nurse Midwives; the American Academy of Pediatrics; and the Society for Maternal-Fetal Medicine.
TJC complied by announcing that the perinatal core measures would be mandatory. This is the first time in history that TJC has required a core measure set to be mandatory for a specific scenario — in this case, any hospital with more than 1,100 births per year. (C-sections might be driven partly by fear of malpractice allegations)
May require culture change
Implementing strict policies and procedures can drive down your c-section rate, says Gayle Somerstein, RN, BSN, OCN, MPH, MBA, director of nursing at South Nassau Communities Hospital in Oceanside, NY. South Nassau has been instituting some of the recommendations for reducing c-section rates since 2009. Somerstein won’t release the hospital’s c-section rates because they vary among physicians.
“There has been a reduction since implementing these recommended measures, so we know that these steps work,” she says. “Perhaps some other hospitals that weren’t making this effort earlier will experience some culture shock, because it can be quite a change in how you’ve been doing things over the years.”
The initiative that had the most influence in reducing c-section rates was the scheduling process change for elective inductions, Somerstein says. “Whereas before we had less restrictive rules for scheduling an elective induction, we changed that policy to require a couple of the recommended measures in order to schedule an elective induction. It’s that elective induction between 37 and 39 weeks that often is not successful, and then you have a patient that is half in labor and half not and needs to have a c-section to have the baby successfully.”
The risk manager should take the lead in promoting that culture change, while at the same time collecting the data that will show the effectiveness of your efforts, Kish says.
“One of the first, paramount responsibilities for a risk manager is to stay up to date on the current literature and make sure that the medical staff is staying current,” Kish says. “You also need to start right now collecting baseline data on your current rates and analyze that data very specifically with regard to why the c-sections are happening.”
Sources
- Robin Kish, MBA, BSN, RN, CPHQ, Vice President, Marsh Clinical Healthcare Consulting, Nashville, TN. Telephone: (813) 220-6868. Email: [email protected].
- Gayle Somerstein, RN, BSN, OCN, MPH, MBA, Director of Nursing, South Nassau Communities Hospital, Oceanside, NY. Telephone: (516) 632-4974. Email: [email protected].
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