Utilizing Quality Improvement Methods to Address Low Birth Weight Births in Pierce County

Summary

Impact Statement:

This local health department addressed an unacceptable rate of low birth weight births by standardizing their referral process and timeframes; successfully making pre-natal care referrals earlier in the gestation period to ultimately improve the health of newborns in their county.

Summary:

The Pierce County low birth weight (LBW) rate for singletons was worse than the Washington State rate. We elected to work on improving our internal process for providing Maternity Support Services (MSS) to Medicaid eligible women in our county. MSS includes public health nursing home visits for prenatal/postpartum education and referrals. Our theory for improvement was: If we engage MSS-eligible women early (first trimester) in pregnancy for health promotion education and referral for behaviors and conditions associated with LBW, such as smoking, drug-use, poor nutrition, and lack of medical and dental care, then we can impact positive birth outcomes. Our aim for this project was to increase by 20% the number of referrals who received a Public Health Nurse (PHN) office or home visit within 20 working days from referral (baseline 60%).

Quality improvement (QI) tools utilized for this project included root-cause analysis (fishbone diagram) and also line and Pareto charts. We developed a standardized referral process, a nursing practice standard that all referred clients would be contacted within 10 working days of referral, and created new data collection fields in our existing database to better track trends in contact, referrals, and care. Review of the data became part of weekly staff meetings. Targets were established, and at the sixth and final quarterly review for this project, we exceeded both targets for contact within 10 days and home visit within 20 days of referral. Mean gestation at time of first home visit went from 23.2 weeks to 21.6 weeks, failing to reach the target of 13 weeks. Toward the end of the project period, there were changes in the MSS program, and the project team (Black Infant Health; BIH) refocused to a targeted population. The aim for this project was to increase African American (AA) enrollment in MSS by 10%.

Organization that conducted the QI initiative:

Tacoma-Pierce County Health Department

Citation:

Pfeifer, S. Public Health Quality Improvement Exchange. Utilizing Quality Improvement Methods to Address Low Birth Weight Births in Pierce County. Mon, 12/11/2017 - 14:06. Available at http://www.phqix.org/content/utilizing-quality-improvement-methods-address-low-birth-weight-births-pierce-county. Accessed April 19, 2024.

Background and Aim

Planning and Execution Details

QI Implementation:

To better understand the process for referrals to MSS, the project team first developed a flow chart depicting the multiple steps in the referral process. Through that exercise, we discovered there was no standardized process, creating great variability on how fast nurses received referrals and the length of time before contacting clients. We then used a fishbone diagram to understand barriers to early referrals to MSS. After identifying root causes of barriers, we looked at best or promising practices for referral networks and engagement of pregnant women into services. We also identified data that were needed to monitor improvement and incorporated new data fields into an existing client information database. Line charts were developed to enter quarterly data for monitoring progress toward targets. Our project focused on internal processes 1. Developed standardized referral process. 2. Developed practice standard: PHNs to contact clients within 10 days of referral. 3. Created new data collection fields. 4. Revised dispostion codes (closure or not-engaged clients).

Focus activities

Maternal and Child Health Services:

MCH home visits

Non-WIC nutrition assessment and counseling

Prenatal care

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

Rapid Cycle Improvement

QI Tools:

Other QI tools:

Work Process Analysis

Initiative Dates:

1/1/09 to 12/31/10

Initiative Duration:

Between 18-24 months

Methods of evaluation:

Targets established and line charts utilized to monitor progress toward goals.

Other Information:

• Informal data collection within an RCI process was helpful for quickly gathering data such as asking clients about barriers for engaging in MSS. • Added staff outside of Maternal Child Health for different perspective and skills. • Brought in staff person from tobacco prevention who had experience developing referral networks with community groups and churches.

Supplemental Materials:

Storyboard

Supplemental Files:

Attachment	Size
TPCHD MLC LBW final story board.pptx	177.7 KB

Results

Measurable QI Outcomes:

• Mean gestation at time of first home visit went from 23.2 weeks to 21.6 weeks, failing to reach the target of 13 weeks. • Mean gestation at time of referral went from 21.6 weeks to 18 weeks. • The percentage of referrals opened within 20 working days from time of referral went from 60% to 84%, exceeding the target of 75% (20% increase). • The percentage of referrals contacted within 10 working days of referral stayed above 90% for all quarters except one during the project period.

Other QI Outcomes:

• Data reviews are now part of weekly supervisor meeting-work processes. • Data reviews now capture number of referrals that received telephone consultation but did not open for services (non-billable). • After observing an increase in later gestation referrals, we learned that one referral source was holding referrals then sending a "batch," delaying early referrals. • Outreach was made to referent to educate on importance of early enrollment of clients and encouraged more timely faxing of referrals. Referent complied, and positive feedback was given periodically to reinformce timely referrals.

Lessons Learned, Observations and Insights:

• When addressing an issue as large as LBW, it was realistic to start where we were—ensuring our internal processes for MSS referrals were understood and effective. • Programs change, but we learned to adapt and continue to utilize QI concepts and tools for improvement. • QI takes time but it has become the way we do our work not the work we do. • Before concluding a trend, look at multiple data points over time to determine normal variation. • Having a QI infrastructure helped support our project. • Budget and staffing challenges are also continuous! • Incorporating data reviews into staff meetings engaged staff beyond the project team in our efforts. • MLC collaboration model: experience and knowledge shared, technical support, and iLincs all enhanced our learning!

Future Plans:

Initial project was revised and database was replaced; not all fields were kept. Data reports were incorporated into general meetings, and performance measures were established. Future goals at time of project closure for the second project: Process measures: 1. Number of women enrolled and tracked through BIH project. 2. Recruit and support two additional BIH project referral churches/organization sites. 3. Facilitate networking meetings with community partners working toward elimination of health disparities in AA births. 2010 targets for these measures were met or approached.

Utilizing Quality Improvement Methods to Address Low Birth Weight Births in Pierce County

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

QI Spotlight

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Utilizing Quality Improvement Methods to Address Low Birth Weight Births in Pierce County

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

QI Spotlight