NPIC Membership Overview and Sample Report Package by jillianstadig

MEMBERSHIP OVERVIEW SAMPLE REPORTS

THE VALUE OF MEMBERSHIP “Why is my cephalohematoma rate so much higher? You ask NPIC to send you the medical records of the babies that have that code, thinking this must have been a baby that was laboring for a long time, and kept hitting their head against the pelvic bones. What we ended up finding out was that a lot of our cephalohematoma rate was associated with physicians who were using a vacuum device even though they did a C-section. You ask them why, and the answer is babies are slippery. These physicians make an incision about three inches long. You're not going to get a baby's head through that. The easy thing to do is to slide in this vacuum device and put it on the kid's head and then start pulling. But now you potentially cause damage. It never would have occurred to me, but so the data was there. “With early deliveries, there's evidence that those children don't do as well. We were fighting the battle to try to get clinicians to recognize this. NPIC data can help us show the incidence of the sequelae in babies who are delivered prior to 39 weeks. We really have a chance to use our own information to convince clinicians it's the right thing to do.” ~Member Story

NPIC Membership can help your hospital/system identify adverse events that could/should have been prevented or mitigated. Data that informs is helpful; data that drives improvement is invaluable.

Table of Contents Membership Overview ................................................................................................................................................................................... 2 Member Hospitals..........................................................................................................................................................................................7 Core Data Set ................................................................................................................................................................................................ 8 Subgroups ................................................................................................................................................................................................... 9 Perinatal Quality Improvement Dashboard ..................................................................................................................................................... 10 Quarterly Report ..........................................................................................................................................................................................13 Quarterly Measure Snapshot ..........................................................................................................................................................................36 Adverse Outcome Index Quarterly Monitoring Report ....................................................................................................................................38 Perinatal Service Line Report ..........................................................................................................................................................................51

INFORMING CHANGE IN PERINATAL OUTCOMES The National Perinatal Information Center (NPIC) is driven by data, collaboration and research to strengthen, connect and empower our shared purpose of improving patient care. With improved outcomes, other metrics of success fall into alignment. For over 30 years, NPIC has worked with hospitals, patient safety organizations, insurers and researchers to collect and interpret the data that drives better outcomes for mothers and newborns. When data is translated into useful information, the opportunity to transform quantitative data into qualitative improvements becomes a reality. “NPIC are the people who have data to show that the work that we're doing was actually having an impact. We were able to see trends with the amount of improvement that you could sell to a physician, so when they say this is never going to work, you could show them the data.” ~Member Testimonial

WORKING TO ACCELERATE IMPROVEMENT Our comparative Quarterly Report, Perinatal Dashboard and special analyses help member hospitals identify and appropriately focus their quality improvement initiatives and resources. “We have to be willing to change at any moment, but change for the right reasons. For me, that’s what the movement is: making sure that we’re creating change where change is necessary, and I can’t do that if I don’t have high quality data.” ~Member Testimonial

The Quarterly Report includes:  Financial, clinical and demographic data  Profiles of obstetrical and neonatal (including special care) services, and offers linked mother/baby analyses, perinatal quality Indicators and five year trends  Comparative Data - Hospital specific data is compared to a peer subgroup, the Perinatal Center Data Base (PCDB) as a whole, to the Trend Data Base, and other national benchmarks. NPIC enhances the value of the comparative data by case mix adjusting variables whenever possible.

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Perinatal Quality Improvement Dashboard displays and tracks key performance indicators from the Quarterly Reports as well as five year trends with indications as to whether your hospital’s metrics are moving in a positive direction. The Dashboard can help identify negative trends that may need corrective action and provides comparison to the peer subgroup and PCDB. “If we see any [negative] changes in our trends and in our quality, then what we’ve done on the financial side doesn’t work. Because at the end of the day, the data that we send to NPIC is why we’re all in business. That’s information about our patient.” ~Member Testimonial

Special Hot Topic Reports are drill down analyses on a “hot topic” which has been identified by the membership as areas of clinical interest. Most analyses have a linked mother/baby component. Recent topics have included maternal diabetes, maternal obesity, preterm deliveries, Neonatal Abstinence Syndrome, etc. Quarterly Measure Snapshot is a mid‐cycle report is a complement to the Quarterly Report which provides internal hospital comparisons for over 20 key metrics using the hospital’s quarterly data submission. The Snapshot displays the current quarter of data to the same quarter last year and the variance between the two quarters. The Adverse Outcome Index (AOI) Report* is designed to measure the volume and magnitude of ten adverse events (6 maternal and 4 neonatal) that may occur during the delivery process and could potentially expose an obstetrical team to malpractice liability. These events were selected because they were deemed definable, and possibly modifiable, through improved team training and communication. Each event is weighted relative to its severity and there are 3 composite metrics that make up the AOI: the Adverse Outcome Index, the Weighted Adverse Outcome Score and the Severity Index. AOI reports profile all three metrics quarterly and in comparison to an NPIC benchmark and target rate. The Perinatal Service Line Report* is intended to help the system leadership quickly assess how the perinatal service line is performing; monitor volume and utilization by level of perinatal care, determine areas of concern or risk exposure; over time, determine whether system-wide initiatives are having an impact at the local level.

*Add-on reports for an additional fee

Peer Subgroup and PCDB Comparisons The PCDB accounts for more than 720,000 perinatal events annually and the five-year Trend Data Base includes more than 3,625,000 events. Greater than 92% of all PCDB records are linked mother/baby records, allowing for analysis of maternal complications and comorbidities and their impact on the newborn.

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Hospitals within the PCDB are assigned to a Peer Subgroup based on responses to the Enrollment Member Survey. The Subgroup provides a meaningful comparison to hospitals with similar practice patterns based on hospital size, teaching status, and volume of perinatal care relative to the entire hospital. “We have had a significant decrease in our number of bad cases, and I do have numbers that show that. We don’t want to become complacent. We utilize that national data to make sure we are still competitive, to make sure that we’re relevant.” ~Member Testimonial

Data Submission The source data set for all reporting is a patient specific administrative data set, also referred to as billing, discharge or UB 04 data. The administrative data has been referred to as the ultimate “green” data set, data collected for another purpose that can be used to support Quality Improvement. Hospitals have the option of programming files to the NPIC specifications or send copies of the administrative data sets submitted to their payers or state discharge database. NPIC writes custom programs to convert state files to the NPIC specifications, further reducing hospitals resources needed to support data submission. “The data has already been collected and aggregated for me, the story is pretty much already told. I didn't have to do all of the number crunching and all that work, and all that compiling data.” ~Member Testimonial

CREATING CONNECTIONS Webinars – Quarterly Report webinars connect member hospitals and help to engage participants in all aspects of information sharing. Hospital specific Member Engagement webinars provide a deeper dive into the hospital/system’s data and reports. All webinars are designed to provide the perinatal team and leaders with critical feedback on how to continue to meet the needs of all stakeholders. Education - Throughout the year, NPIC offers continuing education activities at no cost with the goal of advancing value, quality, safety and best practice in perinatal health. Educational activities serve a wide target audience of physicians, nurses, and allied health professionals.

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Recent Events (full list of events can be found at www.npic.org) Oct. 2, 2019 – Perinatal Care (PC) Core Measures: Updates for Fall 2019* Presenter: Susan Yendro, RN, MSN

Jun. 25, 2019 – Improving Maternal Morbidity and Mortality One Bundle at a Time* Presenter: Camielle Fishel, MSN, RNC-OB Gina Horne, BSN, RNC-OB

Apr. 25, 2019 - Caring for Our Most Fragile Patients with Neonatal Abstinence Syndrome Presenter: Donnalee Segal, MSN, BA, RN *CEU & CME credit available for most activities

EXCLUSIVE OPPORTUNITIES FOR MEMBERS Through NPIC’s relationship with researchers and patient safety organizations, member hospitals have the opportunity to participate in national research studies and QI initiatives. Alliance for Innovation on Maternal Health (AIM): As an AIM System Partner, NPIC is supporting participation of 30 member hospitals in this national effort to reduce maternal morbidity and mortality. Ariadne Labs - "Learning to Safely Decrease Cesarean Section Rates": Through NPIC’s partnership with Ariadne Labs, a joint center for health systems innovation, 51 member hospitals participated on a research project to study the relationship between operational management and institutional cesarean section (C-section) rates. “We had the opportunity as part of NPIC to be in that project with Ariadne labs. I think there was a lot of excitement in being a part of the study.” ~Member Testimonial

HRSA MCH Research Grant "Evaluating maternal and neonatal outcomes: A comparison of 2 models of obstetric care delivery": NPIC partnered with the University of Pennsylvania to study the impact of the laborist model of care on maternal and neonatal outcomes. 32 member hospitals participated.

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MEMBERSHIP REQUIREMENTS Agreements  NPIC Data Sharing Agreement

 Hospital/system BAA Data  On a quarterly basis provide patient specific clinical and billing discharge data as designated in the NPIC Core Data Set for all perinatal discharges.  Provide data in the required NPIC specification/format or submit copies of the administrative data set submitted to the state discharge database.

 Transmit data within 6 weeks after the close of the quarter  Provide timely and accurate correction of data errors Key Hospital/System Contacts  Primary POC(s) to assist and facilitate hospital/system with carrying out the terms and conditions of membership.

 Technical POC to oversee the creation and transmission of the data file(s)  Billing Contact to facilitate invoice approval and timely payment.  Designate clinical, quality, risk management and system leadership to receive Quarterly Reports and related member communication.

To learn more about NPIC Membership, info_req@npic.org

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Novant Health Brunswick Medical Center Bolivia, NC

Abington—Jefferson Health Abington, PA

Grady Memorial Hospital Atlanta, GA

AdventHealth

Hartford Hospital Hartford, CT

AdventHealth Altamonte Altamonte, FL

Inova Health System

AdventHealth Celebration Celebration, FL

Inova Alexandria Hospital Alexandria, VA

AdventHealth Orlando Orlando, FL

Inova Fair Oaks Hospital Fairfax, VA

AdventHealth Winter Park Winter Park, FL

Inova Fairfax Hospital Falls Church, VA

Advocate Christ Medical Center Oak Lawn, IL

Inova Loudoun Hospital Leesburg, VA

AU Health Augusta, GA

Jackson-Madison County General Hospital Jackson, TN

Avera McKennan Hospital & University Health Center Sioux Falls, SD

Lehigh Valley Hospital - Pocono East Stroudsburg, PA

Baptist Memorial Hospital for Women Memphis, TN Beth Israel Deaconess Medical Center Boston, MA

Care New England Health System Kent Hospital Warwick, RI Women & Infants Hospital Providence, RI

Loyola University Medical Center Maywood, IL Medical Center Navicent Health Macon, GA

MedStar Health

Sharp Chula Vista Medical Center Chula Vista, CA

Matthews Medical Center Matthews, NC

Sharp Grossmont Hospital La Mesa, CA

Memorial Hospital Miramar Miramar, FL

Maya Angelou Women’s Health & Wellness Center/Forsyth Medical Center Winston – Salem, NC

Sharp Mary Birch Hospital for Women & Newborns San Diego, CA

Memorial Hospital West Pembroke Pines, FL

Mint Hill Medical Center Mint Hill, NC

Memorial Regional Hospital Hollywood, FL

Presbyterian Medical Center Charlotte, NC

Memorial Health University Medical Center Savannah, GA

Rowan Medical Center Salisbury, NC

Mercy Hospital St. Louis St. Louis, MO Meriter Medical Cetner Madison, WI Newport Hospital Newport, RI

New York– Presbyterian Hospital Allen Hospital New York, NY Lower Manhattan Hospital New York., NY Morgan Stanley Children’s Hospital New York, NY Weill Cornell Medical Center New York, NY

NYU Langone Health

Franklin Square Medical Center Baltimore, MD

NYU Langone-Tisch Hospital New York, NY

Georgetown University Hospital Washington, DC

NYU Langone Hospital-Brooklyn Brooklyn, NY

Harbor Hospital Baltimore, MD

Northside Hospital

Children’s Healthcare of Atlanta Atlanta, GA

Montgomery Medical Center Olney, MD

Northside Hospital–Atlanta Atlanta, GA

Christiana Hospital Newark, DE

Southern Maryland Hospital Center Clinton, MD

Northside Hospital–Cherokee Canton, GA

Cone Health Women’s Hospital Greensboro, NC

St. Mary’s Hospital Leonardtown, MD

Northside Hospital–Forsyth Cumming, GA

Emory University Hospital Midtown Atlanta, GA

Washington Hospital Center Washington, DC

Genesis Medical Center Davenport, IA

Sharp Healthcare

Huntersville Medical Center Huntersville, NC

Memorial Healthcare System

M E M B E R H O S P I TA L S

Sarasota Memorial Hospital Sarasota, FL

Northwestern Memorial Prentice Women’s Hospital Chicago, IL

Thomasville Medical Center Thomasville, NC UVA Haymarket Medical Center Haymarket, VA UVA Prince William Medical Center Manassas, VA

Orlando Health South Lake Hospital Clermont, FL Winnie Palmer Hospital for Women & Babies Orlando, FL OU Medical Center Oklahoma City, OK Parkland Health & Hospital System Dallas, TX

St. Anthony Hospital Chicago, IL St. Charles Hospital Port Jefferson, NY St. Francis Hospital & Medical Center Hartford, CT St. John Hospital & Medical Center Detroit, MI St. Luke’s Hospital of Kansas City Kansas City, MO St. Mary’s Hospital Waterbury, CT St. Peter’s University Hospital New Brunswick, NJ St. Vincent’s Birmingham Birmingham, AL Stamford Hospital Stamford, CT UMass Memorial Medical Center Worcester, MA Unity Point Health—Meriter Madison, WI

UPMC

Phoebe Putney Memorial Hospital Albany, GA

Magee-Womens Hospital of UPMC Pittsburgh, PA

Piedmont Columbus Regional Midtown Columbus, GA

UPMC Altoona Altoona, PA

Presbyterian Healthcare Services

UPMC Hamot Erie, PA

Presbyterian Hospital Albuquerque, NM Presbyterian Rust Medical Center Rio Rancho, NM

UPMC Horizon Farrell, PA UPMC Northwest Seneca, PA

Providence Health & Services Providence Newburg Medical Center Newburg, OR

UT Southwestern Medical Center Dallas, TX

Providence Portland Medical Center Portland, OR

West Penn Hospital Pittsburgh, PA

Providence St. Vincent Medical Center Portland, OR

Winchester Hospital Winchester, MA

CORE DATA SET Core data set* information on all acute inpatient hospital discharges for the NPIC data base. Hospitals are required to submit a patient specific “administrative data set” comprised of Uniform Billing data, along with supplemental perinatal variables. Demographic & Clinical Information Medical Record Number (Patient Identifier) Date of Birth Sex Race Marital Status Primary Payer Zip Code Patient Billing Number (Unique Pt. Episode Identifier) Source of Admission Type Admission Date and Time of Admission Date and Time of Discharge Delivery Date Infant Transfer Principal & Secondary Diagnoses (max-25) (ICD-10) Principal & Secondary Procedures (max-25) (ICD-10) Discharge Status Physician Identifier Weight of Infant APGAR1 & 5 Score (required for AOI) DRG Code (optional) Parity (optional) Gravida (optional) Mother's Medical Record Number (on Baby's Record) Gestational Age (required for AOI) Intensive Care Admit Date (optional) Maternal Blood Transfusion (required for AOI)

Financial Information Routine Adult/Pediatric Days Routine Adult/Pediatric Charges Adult Intensive Care Days Adult Intensive Care Charges Newborn Routine Days Newborn Routine Charges Newborn Intermediate/Convalescent Days Newborn Intermediate/Convalescent Charges Newborn Intensive Care Days Newborn Intensive Care Charges Pediatric Intensive Care Days Pediatric Intensive Care Charges Ancillary Charges: Surgery Charges (OR and Recovery) Labor and Delivery Charges  Radiology Charges  Laboratory Charges  Pharmacy Charges  All Other Ancillary Charges  Total Ancillary Charges  Total Charges

*Many hospitals participate in their State discharge database, which contains most of the variables in our core data set. Hospitals have the option of sending copies of the administrative data sets submitted to their state discharge database or programming files to the NPIC specifications. NPIC.ORG | 8

Subgroup Categories The NPIC Perinatal Center Data Base (PCDB) is comprised primarily of hospitals offering subspecialty perinatal services. Subgroups within the PCDB attempt to account for differences in perinatal practice patterns based on hospital size, teaching status, and volume of perinatal care relative to the entire hospital. Subgroup assignments are based on responses to a survey member hospitals complete when they enroll, or the conditions of special contractual relationships with NPIC.

Eight Subgroup Categories Subgroup AS

Academic Specialty: OB Specialty/Subspecialty; Neonatal Level II and III

Subgroup AR

Academic Regional; OB Regional; Neonatal Level III/IV

Subgroup NB

Non-Academic Basic: OB Basic; Neonatal Level I

Subgroup NI

Non-Academic Intermediate: OB Basic; Neonatal Level II

Subgroup NS

Non-Academic Specialty: OB Specialty; Neonatal Level II/III

Subgroup NR

Non-Academic Subspecialty/Regional: OB Subspecialty/Regional; Neonatal Level III/IV

Subgroup C

CWISH (Council of Women’s & Infants’ Specialty Hospitals)

Subgroup G

Georgia Regional Perinatal Centers

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V17.4 Perinatal Quality Improvement Dashboard

e l p

INTRODUCTION

The NPIC Perinatal Quality Improvement Dashboard tracks key performance indicators from your hospital’s V17.4 Quarterly Report data. The Dashboard can help identify negative trends that may need corrective action and provides useful comparison data. DESCRIPTION OF TABLES

m a S

The tables in this dashboard provide data for selected quality metrics for your hospital as well as data for your NPIC subgroup and the NPIC database average. The report includes data for discharge date range 1/1/17 – 12/31/17. Medical record numbers for the cases contributing to your hospital’s rates are available by request. Table 1: Perinatal Quality Comparative Data

Section A: Total Deliveries displays the count of total deliveries and total inborns for your Hospital, your Subgroup and the NPIC Member Database. Section B: Quality Metrics displays the rate for selected quality metrics for your Hospital, your Subgroup and the NPIC Member Database. The column to the far right of each average illustrates if your Hospital’s rate is significantly above the Subgroup or Database average rate, below that rate, or not significantly different from the Subgroup or Database average rate (see legend). For each metric, the Quarterly Report table/page reference is provided. Table 2: Perinatal Quality Trend Analysis Section A: Total Deliveries displays the count of total deliveries and total inborns for your Hospital for the (trend) years 2013 – 2017. Section B: Quality Metrics displays the rate for selected quality metrics for your Hospital for the (trend) years 2013 – 2017. The column to the far right illustrates if your Hospital’s trend rate is a significant upward trend, a significant downward trend, or stable over time (see legend). For each metric, the Quarterly Report table/page reference is provided.

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V17.4 NPIC Perinatal Quality Improvement Dashboard Table 1: Perinatal Quality Comparative Data NPIC ID: SAMPLE

Table/ Graph Hospital Reference

Section A: Total Deliveries Total Deliveries Total Inborns

Table OB1 Table OB1

2,609 2,661

Subgroup Average

Hospital vs. Subgroup Average 1

4,110 4,208

Hospital

Database vs. Database Average 1 Average

3,509 3,552

Section B: Quality Metrics

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C-Section Delivery Rate (% of total deliveries)

Table OB4

38.4%

32.2%

33.1%

Primary C-Section Rate (% of total deliveries)

Table OB4

21.9%

18.4%

17.7%

AHRQ IQI 33: Primary Cesarean Delivery Rate, Uncomplicated

Table QM1

21.8%

17.3%

18.2%

Repeat C-Section Rate (% of total deliveries)

Table OB4

16.5%

13.9%

15.4%

Induction Rate (% of total deliveries)

Table OB9

NPIC Rate of Inductions resulting in Cesarean Delivery

Table QM1

41.5% 35.7% 37.5% Not displayed, see explanation below a 28.8% 19.5% 18.2%

NPIC Postpartum Hemorrhage Rate

Table QM1

3.1%

5.4%

NPIC Postpartum Readmission Rate (within 42 days post-discharge)

Table QM1

1.3%

1.0%

AHRQ PSI 18: Obstetric Trauma - Vaginal Deliveries with Instruments

Table QM1

14.6%

14.4%

12.9%

AHRQ PSI 19: Obstetric Trauma - Vaginal Deliveries without Instruments

Table QM1

1.7%

1.9%

1.8%

AHRQ PSI 17: Birth Trauma - Injury to Neonate

Table QN1

0.08%

0.69%

Vaginal Deliveries with coded Shoulder Dystocia linked to an inborn â&#x2030;Ľ 2500 grams with birth trauma *

Table QL1

10.7%

16.2%

Total Unexpected Newborn Complication Rate

Table QN2

6.2%

3.5%

3.2%

Special Care Discharges (% of Total Neonates) **

Table N11

32.3%

20.3%

14.4%

Inborn mortality â&#x2030;Ľ 500 grams (% of Total Inborns)

Table N8

0.34%

0.38%

m a S

* This is a linked metric. Please refer to Table QL1: Linked Mother/Baby Indicators for the rate of linked records for your hospital. ** Special Care discharges are those having NICU and/or NINT days/charges > 0.

4.0%

0.51% 16.5%

0.26%

Hospital rate with 95% Confidence Interval: Significantly below Subgroup/DB average rate Significantly above Subgroup/DB average rate

Calculation of induction rates has been suspended. Current ICD-10 coding guidelines may result in overstating the total number of inductions.

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

-- Not significantly different from Subgroup/DB average rate

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

V17.4 NPIC Perinatal Quality Improvement Dashboard Table 2: Perinatal Quality Trend Analysis NPIC ID: SAMPLE

Table/ Graph Reference

Section A: Total Deliveries Total Deliveries Total Inborns

Table OB5

Hospital Trend 1

2013

2014

2015

2016

2017

Graph N1a

2,353 2,409

2,624 2,695

2,658 2,714

2,616 2,688

2,609 2,661

Section B: Quality Metrics C-Section Delivery Rate (% of total deliveries)

Table OB5

35.2%

36.6%

35.1%

35.7%

38.4%

Primary C-Section Rate (% of cases without a prior uterine scar)

Table OB5

23.8%

24.5%

23.9%

24.2%

26.9%

N/A

20.3%

19.6%

18.4%

20.0%

21.8%

N/A

Table OB5

90.6%

88.0%

86.2%

88.1%

89.4%

Graph OB9a

24.8%

20.4%

23.3%

38.7%

40.2%

24.2%

25.2%

23.6%

28.3%

AHRQ IQI 33: Primary Cesarean Delivery Rate, Uncomplicated Repeat C-Section Rate (% of cases with a prior uterine scar) Induction Rate (% of total deliveries)

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m a S

NPIC Rate of Inductions resulting in Cesarean Delivery

Not displayed, see explanation below a

N/A

25.3%

Graph QM1o

2.9%

2.6%

2.8%

3.1%

NPIC Postpartum Readmission Rate (within 42 days post-discharge)

Graph QM1m

1.6%

1.2%

1.3%

1.2%

1.3%

AHRQ PSI 18: Obstetric Trauma-Vaginal Deliveries with Instruments

N/A

19.2%

11.3%

11.5%

12.7%

14.6%

N/A

AHRQ PSI 19: Obstetric Trauma-Vaginal Deliveries without Instruments

N/A

1.7%

1.8%

1.1%

1.9%

1.7%

N/A

AHRQ PSI 17: Birth Trauma-Injury to Neonate

N/A

0.04%

0.08%

0.16%

0.04%

0.08%

N/A

Vaginal Deliveries with coded Shoulder Dystocia linked to an inborn â&#x2030;Ľ 2500 grams with birth trauma *

N/A

1.7%

12.8%

23.1%

20.0%

10.7%

Total Unexpected Newborn Complication Rate

N/A

3.2%Not displayed, 3.7% see explanation 0.0% below b0.0%

6.2%

I N/A

NPIC Postpartum Hemorrhage Rate

Special Care Discharges (% of Total Neonates) **

Table N12

23.4%

25.0%

28.4%

30.6%

32.3%

Inborn mortality â&#x2030;Ľ 500 grams (% of Total Inborns)

Graph N9a

0.13%

0.45%

0.41%

0.37%

0.34%

Trend significance is not displayed for AHRQ measures. Rates based on ICD-10 coding may be different than rates based on ICD-9 coding.

Hospital trend rate:

* This is a linked metric. Please refer to Table QL1: Linked Mother/Baby Indicators for the rate of linked records for your hospital.

Significant Upward Trend

** Special Care discharges are those having NICU and/or NINT days/charges > 0.

Significant Downward Trend

Calculation of induction rates has been suspended. ICD-10 coding guidelines may result in overstating the total number of inductions.

-- Stable over time

UNC rates for 2017 and after are now calculated using updated UNC specifications (Version 2.4, 2018-03-28). As a result,

I - Insufficient data for trend

previous time periods are no longer displayed for comparison. Due to ICD-10 conversion and software availability, the date range of data for 2015 AHRQ measures is 10/01/15 - 12/31/15.

V17.4 QUARTERLY REPORT Date Range 1/1/17 â&#x20AC;&#x201C; 12/31/17 | Comparative Reports This report is proprietary and confidential and constitutes valuable information that must be held in strict confidence. These data are not to be reproduced for use in publication or promotion and are for use solely within its own institution and for its own business purpose only unless written permission has been granted from the National Perinatal Information Center (NPIC). NPIC and their respective agents and employees shall not be held responsible or liable for any error, inaccuracy or omission in any report or analysis prepared in connection with the Quarterly Report or any damage (including but not limited to consequential damages) resulting therefrom or resulting from the memberâ&#x20AC;&#x2122;s use or inability to use its Quarterly Report. ÂŠ2018 NPIC

Quarterly Report Table and Graph Descriptions COMPARISONS

Table OB 1*

Comparative Facility, Subgroup and Database Overview Data on all inpatient discharges for the four quarter period for the database, your subgroup and your hospital. Please note: Some hospitals only submit perinatal discharges.

SECTION I: OBSTETRICAL CLINICAL REPORT APR-MDC 14 Pregnancy, Childbirth and the Puerperium Table OB 2 A utilization and charge analysis for MDC 14 cases.

Peer Subgroup X

NPIC DB X

Trend DB

Table OB 2a

Deliveries by APR DRG Subclass A utilization and charge analysis for deliveries assigned to one of four APR-DRG severity subclasses based on complications, co-morbidities, age or other extenuating circumstance.

Table OB 3

MDC 14 Cases by MS DRG A utilization and charge analysis of all MDC 14 cases by MS DRG.

Table OB 4

Delivery Analysis Comparative data on vaginal and c-section deliveries; c-section delivery data is also subdivided into primary and repeat c-sections. Utilization and charge analyses are provided.

Graph OB 4a

Comparative C-Section Rates: Comparative data display of your hospital's c-section rate with a 95% confidence interval (CI).

Table OB 5

Obstetrical Trend Analysis Your hospital's data compared to the NPIC Trend Database.

Graph OB 5a

C-Section Deliveries with Trendlines

Graph OB 5b*

Primary C-Section Deliveries with Trendlines Rate of primary c-sections as a percent of total cases without a prior uterine scar.

Graph OB 5c

Repeat C-Section Deliveries with Trendlines Rate of repeat c-sections as a percent of total cases with a prior uterine scar.

Table OB 6

Coded Reasons for C-Sections Coded reasons and percent of total for your primary c-section and repeat c-section cases.

Table OB 7

Distribution of Coded Reasons for Primary and Repeat C-Sections Trend Analysis

*Sample Table/Graph included 1

AHRQ comparative metrics have not been published for ICD 10 coded data; they are schedule to resume in the near future.

X X

AHRQ/Other National comparisons1

Quarterly Report Table and Graph Descriptions COMPARISONS

Table OB 8

Operative Vaginal Deliveries Includes forceps deliveries, vacuum extractions and other operative vaginal deliveries. Operative vaginal deliveries are shown as a percent of total vaginal deliveries and each procedure category is displayed as a percent of total operative vaginal deliveries. The database top decile average is also displayed.

Graph OB 8a

Operative Vaginal Deliveries with Trendlines

Table OB 9

Delivery Analysis by Day of Week Total deliveries with induction procedure codes divided into vaginal, primary and repeat c-section deliveries. Includes distribution by day of the week. Table also displays repeat c-section deliveries as a percent of total deliveries and distribution by day of the week.

Graph OB 9a

Peer Subgroup

NPIC DB

X X

Induction Rates with Trendlines

SECTION II: NEONATAL CLINICAL REPORT Table N 1* Neonatal Overview (all cases age 0-28 days old at admission) Total neonates and total inborn neonates (subdivided into singletons, twins, other multiples and unknown), other neonatal admits (subdivided into neonates transferred in, inborn readmissions, all other), inborns and other neonatal admits transferred out.

Trend DB

Graph N 1a

Inborn Twins Birth Analysis with Trendlines

Graph N 1b

Inborn Other Multiples Birth Analysis with Trendlines

Table N 2 Table N 3

Inborn Neonatal Analysis by Birthweight Category Percent of total inborn neonates by birthweight category. Utilization and charge analyses are provided. Neonates Transferred In from another hospital 0-28 days old at admission by Birthweight Category

Table N 4

Neonatal Trend Analysis By Birthweight Category

Graph N 4a

Neonatal Birthweight Analysis with Trendlines: Discharges 500-749 Grams at Admission

Graph N 4b*

Neonatal Birthweight Analysis with Trendlines: Discharges 750-1499 Grams at Admission

Table N 5

MDC 15 Neonate Analysis by MS DRG A utilization and charge analysis of all MDC 15 neonates by MS DRG. Cases 0-28 days old at admission not grouping to an MDC 15 MS DRG are also displayed.

*Sample Table/Graph included 1

AHRQ comparative metrics have not been published for ICD 10 coded data; they are schedule to resume in the near future.

X X

AHRQ/Other National comparisons1

Quarterly Report Table and Graph Descriptions COMPARISONS Peer Subgroup

NPIC DB

A utilization and charge analysis for inborns assigned to one of four APR-DRG severity subclasses based on complications, co-morbidities, age or other extenuating circumstance.

Table N 7

Neonates Transferred In 0-28 days old at Admission by APR DRG Subclass

Table N 8*

Mortality Analysis by Admission Status All neonates at admission, the number who died and percent of total neonates. Also subdivided into inborn ? 500 grams, transferred in and other neonatal admits. Mortality rates at 0-7 days old, 8-27 days old and >= 28 days old.

Table N 6

Trend DB

Inborns by APR DRG Subclass

Graph N 8a

NPIC Inborn Mortality Rate >= 500 Grams

Graph N 8b

NPIC Transferred In Mortality Rate

Table N 9

Inborn Neonatal Trend Analysis: Deaths by Birthweight Category

Graph N 9a

Inborn Neonatal Mortality Analysis (>500 Grams) with Trendlines

Table N 10

Mortality Analysis by Birthweight Category & Admission Status

SECTION III: NEONATAL SPECIAL CARE REPORT Table N 11*

Special Care Analysis Identifies the count and percent of total neonates with a special care discharge (defined as Intermediate Care Nursery or Neonatal Intensive Care Nursery days or charges). Special care discharges are subdivided into inborns, neonates transferred in, inborn readmissions and other neonatal admits. Each category is displayed as a percent of total special care discharges. Utilization and charge analyses are provided.

Table N 12

Neonatal Special Care Trend Analysis

Graph N 12a

Special Care Discharges with Trendlines

Table N 13

Special Care Discharges by Birthweight Category

Table N 14

Special Care Discharges by Discharge Status

*Sample Table/Graph included 1

AHRQ comparative metrics have not been published for ICD 10 coded data; they are schedule to resume in the near future.

X X

AHRQ/Other National comparisons1

Quarterly Report Table and Graph Descriptions COMPARISONS

Table N 15

Special Care Analysis: Complications

Peer Subgroup X

NPIC DB X

Trend DB

AHRQ/Other National comparisons1

Count and rate of selected neonatal complications. The denominator for all rates is the total special care population with the exception of Meconium Aspiration Syndrome (subdivided into inborns in special care with MAS and transfers in to special care with MAS) and Retinopathy of Prematurity with eye procedure (all special care discharges with ROP). Table N 16*

Special Care Analysis: Complication Trends Neonates 500-1499 Grams

Graph N 16a

Special Care Analysis with Trendlines: Proportion of BPD to RDS, Neonates 500-1499 Grams

Graph N 16b

Special Care Analysis with Trendlines: NEC Rate, Neonates 500-1499 Grams

Graph N 16c

Special Care Analysis with Trendlines: IVH (Grade III or IV) Rate, Neonates 500-1499 Grams

SECTION IV: PERINATAL QUALITY INDICATORS Table QM 1* Maternal Indicators

Table QM 2

Coded Reasons for Postpartum Readmissions

Graph QM 1a

AHRQ Perinatal Patient Safety Indicator: Obstetric Trauma - Vaginal Deliveries with Instruments (PSI 18)

Graph QM 1b

AHRQ Perinatal Patient Safety Indicator: Obstetric Trauma - Vaginal Deliveries without Instruments (PSI 19)

Graph QM 1c

AHRQ Inpatient Quality Indicator: Cesarean Delivery Rate (IQI 21)

Graph QM 1d

AHRQ Inpatient Quality Indicator: VBAC Rate Uncomplicated (IQI 22)

Graph QM 1e

AHRQ Inpatient Quality Indicator: Primary Cesarean Delivery Rate (IQI 33)

Graph QM 1f

AHRQ Inpatient Quality Indicator: VBAC Rate All (IQI 34)

Graph QM 1g:

NQF Incidence of Episiotomy

Graph QM 1h

NPIC Third & Fourth Degree Perineal Laceration Rate, with Forceps or Vacuum Extractions

Graph QM 1i

NPIC Third & Fourth Degree Laceration Rate with Forceps or Vacuum Extraction with Trendlines

Graph QM 1j

NPIC Third & Fourth Degree Perineal Laceration Rate, without Forceps or Vacuum Extractions

Graph QM 1k

NPIC Third & Fourth Degree Laceration Rate without Forceps or Vacuum Extraction with Trendlines

Graph QM 1l

NPIC Postpartum Readmission Rate

*Sample Table/Graph included 1

AHRQ comparative metrics have not been published for ICD 10 coded data; they are schedule to resume in the near future.

X X X

Quarterly Report Table and Graph Descriptions COMPARISONS Peer Subgroup

NPIC DB

Trend DB X

AHRQ/Other National comparisons1

Graph QM 1m*

NPIC Postpartum Readmission Rate with Trendlines

Graph QM 1n

NPIC Postpartum Hemorrhage Rate

Graph QM 1o*

NPIC Postpartum Hemorrhage Rate with Trendlines

Graph QM 1p

NPIC Rate of Disruption or Infection of Obstetrical Wound

Graph QM 1q

NPIC Rate of Disruption or Infection of Obstetrical Wound with Trendlines

Graph QM 1r

NPIC Rate of Vaginal Deliveries Coded with Shoulder Dystocia

Graph QM 1s

NPIC Rate of Inductions Resulting in Cesarean Delivery

Table QN 1*

Neonatal Indicators

Graph QN 1a

AHRQ Perinatal Patient Safety Indicator: Birth Trauma - Injury to Neonate (PSI 17)

Graph QN 1b

AHRQ Neonatal Quality Indicator: Neonatal Mortality (NQI 02)

Graph QN 1c

AHRQ Neonatal Quality Indicator: Neonatal Bloodstream Infection (NQI 03)

Table QN 2*

NQF Unexpected Newborn Complications (UNC) (NQF #716 "Healthy Term Newborn")

Graph QN 2a*

Comparative Unexpected Newborn Complication Rates

Table QN 3

Coded Reasons for Inborn Readmissions

Graph QN 3a

NPIC Inborn Readmission Rate

Table QN 4

NPIC Total Inborn Birth Trauma Rate (Trend)

Graph QN 4a

NPIC Total Inborn Birth Trauma Rate with Trendlines

Table QL 1*

Linked Mother/Baby Indicators

Graph QL 1a*

Vaginal Deliveries with Coded Shoulder Dystocia Linked to an Inborn >= 2500 Grams with Birth Trauma

Graph QL 1b

Coded Maternal Conditions with Neonatal Special Care Admission: Hypertension

Graph QL 1c

Coded Maternal Conditions with Neonatal Special Care Admission: Diabetes Mellitus

Graph QL 1d

Coded Maternal Conditions with Neonatal Special Care Admission: Obesity

Graph QL 1e

Coded Maternal Conditions with Neonatal Special Care Admission: Thyroid Dysfunction

Graph QL 1f

Primary Cesarean Deliveries ≥ 37 Weeks with Neonatal Special Care Admission

Graph QL 1g

Repeat Cesarean Deliveries ≥ 37 Weeks with Neonatal Special Care Admission

*Sample Table/Graph included 1

AHRQ comparative metrics have not been published for ICD 10 coded data; they are schedule to resume in the near future.

X X

Table OB 1: Comparative Facility, Subgroup and Database Overview

Total Hospital Discharges Submitted * Total Discharge Days Average Length of Stay Average Charge per Case

Hospital SA1 5,826 24,808 4.3 $19,044

APR DRG Case Mix Index - All Discharges CMI-Adjusted Average Patient Days CMI-Adjusted Average Charge per Case Total Perinatal Discharges** Total APR MDC 14 (APR DRGs 540-566) APR MDC 14 Case Mix Index Total Deliveries (APR DRGs 540-542 and 560) C-Section Rate Vaginal Birth After C-Section (VBAC) Rate Non-Birth Admission Rate

e l p

m a S

MDC 14 Payer Mix % Medicaid % Medicare % Commercial Insurance/TRICARE % HMO % Self-Pay/Free Care % Other/Missing Payers

Total Neonatal Admissions (0-28 Days at Admission) Neonatal Case Mix Index Inborns Inborns, Single Birth Inborns, Multiple Gestation Inborns, Unknown

Other Neonatal Admits (Readmits and Transfers in <= 28 days old)

Subgroup Average 31,310 167,576 5.2 $49,610

Database Average 22,401 102,919 4.3 $37,523

0.6308 6.8 $30,189 5,824 3,033 0.4710 2,609 38.4% 10.6% 13.7%

1.2939 4.0 $38,341 8,945 4,550 0.4592 4,110 32.2% 18.9% 9.3%

0.9669 4.5 $38,807 7,462 3,806 0.4463 3,509 33.1% 14.1% 6.7%

48.2% 1.2% 31.6% 18.6% 0.4% 0.0%

28.3% 1.6% 35.3% 26.9% 0.8% 7.1%

35.7% 0.9% 34.9% 23.0% 2.0% 3.6%

2,791 0.8014 2,661 2,514 138 9

4,395 0.6782 4,208 3,988 210 10

3,657 0.4596 3,552 3,403 142 6

130

186

105

* Subgroup and Database Averages exclude data from hospitals which only submit perinatal discharges. ** Total APR MDC14 and Total Neonatal discharges Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Percent of Cases Without a Prior Uterine Scar

Graph OB 5b: Primary C-Section Deliveries 2013 - 2017 with TrendlinesNPIC ID: SA1 Graph OB 5b: Primary C-Section Deliveries 2013 - 2017 with Trendlines Trend Rate Hosp Numerator NPIC HospID: Denominator Hosp Rate LCI SA1 2013 23.6% 465 1951 23.8% 35.0% 2014 22.8% 520 2123 24.5% 2015 22.2% 520 2180 23.9% 30.0% 2016 22.0% 518 2144 24.2% 2017 22.3% 572 2128 26.9%

UCI 0.018718688 0.01812985 0.017726496 0.017984708 0.018745144

0.019586461 0.018909472 0.01849664 0.018702617 0.019378221

25.0%

e l p m a

20.0%

15.0%

Correl Coefficient:

-0.844338802

709.657% -0.341%

10.0%

Trend Trendline X Vals: 5.0% 2013 2017

23.2% 21.9%

0.0%

2012

2014

2015

2016

2017

Hospital Rate with 95% Confidence Intervals

Trend Hospitals Average Rate

Hospital Rate: Stable Over Time

Trend Rate: Significant Downward Trend, p = 0.000

2013 Trend Rate Hospital Rate Hospital Numerator Hospital Denominator Lower CI Upper CI

S 2013

-1138.013% 0.577% Hosp Trendline X Vals: 2013 23.5% 2017 25.8%

23.6% 23.8% 465 1951 22.0% 25.8%

2014

2015

2016

2017

22.8% 24.5% 520 2123 22.7% 26.4%

22.2% 23.9% 520 2180 22.1% 25.7%

22.0% 24.2% 518 2144 22.4% 26.0%

22.3% 26.9% 572 2128 25.0% 28.8%

Pct Change 13 - 17 -5.5% 12.8%

Table N 1: Neonatal Overview (All cases age 0-28 days old at admission) Hospital: SA1

# of Cases

% of Total Neonates

ALOS

Total Neonates 1 Hospital 2791 100.0% 5.9 Subgroup Average 4395 100.0% 5.4 Database Average 3657 100.0% 4.1 2 Total Inborn Neonates Hospital 2661 95.3% 5.9 Subgroup Average 4208 95.6% 5.2 Database Average 3552 96.9% 4.0 Total Inborn Singletons Hospital 2514 90.1% 5.4 Subgroup Average 3988 90.5% 4.6 Database Average 3403 93.1% 3.6 Total Inborn Twins Hospital 135 4.8% 14.7 Subgroup Average 204 4.7% 15.1 Database Average 138 3.4% 11.1 Total Inborn Other Multiples Hospital 3 0.1% 15.0 Subgroup Average 7 0.2% 32.4 Database Average 5 0.1% 30.6 Total Inborn: Unknown Hospital 9 0.3% 7.7 Subgroup Average 10 0.2% 10.2 Database Average 6 0.2% 7.2 1 - Subgroup and Database averages include all hospitals 2 - Subgroup and Database averages exclude hospitals that do not have inborns

Average Charge

CMI

Adjusted ALOS

Adjusted Average Charge

$24,208 $40,294 $20,489

0.8014 0.6782 0.4596

7.3 7.9 9.0

$30,206 $59,413 $44,583

e l p m

a S

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

$23,902 $37,177 $18,915

0.7852 0.6373 0.4310

7.5 8.1 9.2

$30,442 $58,340 $43,882

$21,279 $31,852 $16,418

0.6995 0.5455 0.3773

7.7 8.4 9.6

$30,419 $58,394 $43,513

$71,232 $126,844 $67,685

2.3355 2.2539 1.5492

6.3 6.7 7.1

$30,500 $56,279 $43,690

$63,736 $330,844 $242,284

2.2830 6.1939 5.4538

6.6 5.2 5.6

$27,917 $53,415 $44,424

$33,379 $79,351 $44,573

1.2837 1.3694 1.0530

6.0 7.4 6.9

$26,002 $57,946 $42,328

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Table N 1: Neonatal Overview (All cases age 0-28 days old at admission) Hospital: SA1

# of Cases

% of Total Neonates

ALOS

Average Charge

CMI

Total Other Neonatal Admits 1 Hospital 130 4.7% 6.5 $30,462 1.1338 Subgroup Average 186 4.4% 9.1 $97,581 1.6864 Database Average 105 3.1% 7.9 $55,281 1.3680 Total Neonates Transferred In (transferred from another hospital) Hospital 15 0.5% 19.7 $115,523 4.2109 Subgroup Average 71 1.8% 21.9 $307,242 3.9097 Database Average 32 1.0% 17.1 $147,795 2.9506 Total Inborns discharged to home (with or without home health) and readmitted within 28 days 2 Readmissions within 7 days post-discharge Hospital 25 1.0% 2.1 $5,772 0.3284 Subgroup Average 30 0.7% 2.3 $15,847 0.3625 Database Average 25 0.8% 2.5 $17,244 0.3509 Readmissions within 28 days post-discharge Hospital 36 1.4% 2.3 $6,157 0.3915 Subgroup Average 47 1.2% 2.8 $22,680 0.4983 Database Average 35 1.1% 2.8 $18,916 0.4321 3 Other Neonates Admitted 0-28 days old at admission Hospital 73 2.6% 5.7 $24,422 0.8832 Subgroup Average 66 1.5% 5.8 $42,171 1.0563 Database Average 37 1.0% 8.6 $60,338 1.6105 1 - Includes neonates born outside the hospital, neonates transferred from another hospital, and cases which were readmissions of previous inborn neonates. 2 - Readmissions as a percent of total inborns discharged to home (with or without home health) 3 - Excludes readmissions and cases identified as tranferred in

Adjusted ALOS

Adjusted Average Charge

5.7 5.4 5.8

$26,867 $57,863 $40,411

e l p m

a S

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

4.7 5.6 5.8

$27,434 $78,585 $50,089

6.5 6.3 7.1

$17,574 $43,722 $49,142

6.0 5.6 6.6

$15,728 $45,514 $43,776

6.4 5.5 5.3

$27,651 $39,922 $37,466

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Table N 1: Neonatal Overview (All cases age 0-28 days old at admission) Hospital: SA1

# of Cases

% of Total Neonates

ALOS

Average Charge

Inborns Transferred Out to Another Facility Hospital 19 0.7% 19.1 $123,578 Subgroup Average 34 0.8% 28.3 $380,281 Database Average 30 1.2% 16.8 $178,619 Inborns Transferred Out to Another Facility within 0-3 Days of Birth Hospital 11 0.4% 1.3 $15,822 Subgroup Average 13 0.3% 1.5 $21,161 Database Average 18 0.9% 1.3 $14,343 Inborns Transferred Out to Another Facility within 4-7 Days of Birth Hospital 3 0.1% 4.0 $51,745 Subgroup Average 6 0.1% 5.5 $81,833 Database Average 3 0.1% 5.2 $47,881 Inborns Transferred Out to Another Facility >7 Days of Birth Hospital 5 0.2% 67.2 $403,742 Subgroup Average 15 0.3% 54.2 $713,567 Database Average 9 0.2% 45.4 $472,256 Other Neonatal Admits Transferred Out to Another Facility within 0-7 Days of Admission Hospital 1 0.0% 1.0 $16,416 Subgroup Average 4 0.1% 2.5 $44,370 Database Average 2 0.1% 2.6 $31,529 Other Neonatal Admits Transferred Out to Another Facility >7 Days of Admission Hospital 2 0.1% 52.0 $352,057 Subgroup Average 5 0.1% 42.9 $555,799 Database Average 2 0.1% 36.9 $372,104

CMI

Adjusted ALOS

Adjusted Average Charge

2.6267 4.9482 3.0759

7.3 5.7 5.6

$47,046 $76,853 $59,346

e l p m

a S

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

0.3921 0.2596 0.2379

3.3 5.6 5.6

$40,348 $81,526 $60,292

0.3799 3.9515 2.4519

10.5 1.4 2.1

$136,207 $20,709 $19,528

8.8910 9.4691 7.8970

7.6 5.7 5.7

$45,410 $75,357 $59,802

0.2602 1.6921 1.5653

3.8 1.5 1.7

$63,090 $26,221 $20,142

13.6448 8.5505 7.6351

3.8 5.0 4.8

$25,802 $65,002 $48,736

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Percent of Total Discharges 500-7000 Grams at Admission

Graph N 4b: Neonatal Birthweight Analysis 2013-2017 with Trendlines:Discharges 750-1499 Grams at Admission NPIC ID: SA1 Graph N 4b: Neonatal Birthweight Analysis 2013-2017 with Trendlines: Trend Rate Hosp Numerator Hosp Denominator Hosp Rate LCI UCI Discharges 750-1499 Grams at Admission 2013 1.7% 61 2398 2.5% 0.00588726 0.007157648 NPIC ID: SA1 2014 1.8% 70 2696 2.6% 0.005704622 0.006692042 4.0% 2015 1.7% 80 2726 2.9% 0.005962897 0.007092894 3.5%2016 1.7% 75 2728 2.8% 0.005815376 0.006841462 2017 1.7% 57 2719 2.1% 0.005084421 0.006075938 3.0%

e l p m a

2.5% 2.0%

Correl Coefficient 1.5%

-0.68273643

1.0%

35.985% -0.017%

Trend Trendline X Vals: 20130.5% 2017

1.8% 1.7%

0.0%

2012

S 2013

Hosp Trendline X Vals: 2013 2017

2014

2.7% 2.4%

2015

2016

2017

Hospital Rate with 95% Confidence Intervals

Trend Hospitals Average Rate

Hospital Rate: Stable Over Time

Trend Rate: Stable Over Time

2013 Trend Rate Hospital Rate Hospital Numerator Hospital Denominator Lower CI Upper CI

149.679% -0.073%

1.7% 2.5% 61 2398 2.0% 3.3%

2014

2015

2016

2017

1.8% 2.6% 70 2696 2.0% 3.3%

1.7% 2.9% 80 2726 2.3% 3.6%

1.7% 2.7% 75 2728 2.2% 3.4%

1.7% 2.1% 57 2719 1.6% 2.7%

Pct Change 13 - 17 -2.9% -17.6%

Table N 8: Mortality Analysis by Admission Status Hospital: SA1

Hospital

Subgroup Average

Database Average

Total Neonates 0-28 days old at admission Neonatal deaths % of total neonates

2791 24 0.86%

4395 28 0.69%

3657 16 0.40%

Inborns (> 500 Grams) Inborn deaths % of total Inborns

2644 9 0.34%

4178 16 0.38%

3525 9 0.26%

7 2 0

11 3 2

6 1 1

15 0 0.00%

71 2 1.27%

32 1 0.94%

0 0 0

1 0 0

115 1 0.87%

115 1 1.52%

73 1 1.16%

1 0 0

e l p m

# died 0-7 days old # died 8-27 days old # died >=28 days old Transferred In Transferred In deaths % of total transfers # died 0-7 days old # died 8-27 days old # died >=28 days old Other Neonatal Admits * Other Neonatal Admit deaths % of total other neonatal admits

a S

# died 0-7 days old # died 8-27 days old # died >=28 days old * Includes readmissions Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Table N 11: Special Care Analysis Hospital: SA1 Total Neonates 0-28 days old at admission Special Care Discharges * % of Total Neonates

Special Care Discharges Only Inborns Hospital Subgroup Average Database Average Neonates Transferred In Hospital Subgroup Average Database Average Inborn Readmissions Hospital Subgroup Average Database Average Other Neonatal Admits Hospital Subgroup Average Database Average

Hospital

Subgroup Average

Database Average

2791 901 32.3%

4395 848 20.3%

3657 560 14.4%

# of Cases

% of Total Special Care Discharges

850 763 546

94.3% 90.6% 90.2%

a S

e l p m

14 57 26

1.6% 6.2% 4.0%

4 11 10

0.4% 1.3% 2.7%

33 18 16

3.7% 1.9% 3.1%

Adjusted Average Charge

ALOS

Average Charge

CMI

Adjusted ALOS

13.9 17.5 14.4

$67,047 $166,205 $98,722

2.1134 2.6681 2.0481

6.6 6.6 7.0

$31,725 $62,294 $48,202

21.1 25.0 18.5

$123,654 $342,982 $155,965

4.5008 4.3410 3.1925

4.7 5.8 5.8

$27,474 $79,010 $48,854

13.8 5.8 8.3

$54,685 $50,935 $64,376

0.8950 0.8685 1.1181

15.4 6.7 7.4

$61,099 $58,646 $57,575

9.5 11.2 13.7

$43,938 $105,005 $97,163

1.4227 1.9331 2.3639

6.7 5.8 5.8

$30,883 $54,320 $41,102

* Special Care discharges are those having NICU or NINT days > 0 or NICU or NINT charges > 0

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Table N16: Special Care Analysis Complication Trends 2013-2017 Neonates with Birthweight 500 - 1499 Grams NPIC ID: SA1 Special Care Cases with Birthweight 500 - 1499 Grams Hospital Trend Data Base Average Proportion of BPD to RDS Hospital BPD Cases RDS Cases Proportion Trend Data Base Average BPD Cases RDS Cases Proportion NEC Hospital Rate Trend Data Base Average Rate IVH (Grade III or IV) Hospital Rate Trend Data Base Average Rate

2013

2014

2015

2016

2017

Pct Change 13 - 17

70 87

91 90

103 88

101 90

67 86

-4.3% -1.1%

16 55 29.1%

27 61 44.3%

27 60 45.0%

11 51 21.6%

8 24 33.3%

-50.0% -56.4% 14.6%

15 60 20.2%

16 63 19.7%

15 62 18.8%

10 62 12.7%

10 60 13.7%

-33.3% 0.0% -32.4%

4 5.7%

8 8.8%

16 15.5%

14 13.9%

10 14.9%

150.0% 161.5%

5 4.4%

5 4.6%

5 4.9%

5 4.5%

5 4.6%

0.0% 4.7%

5 7.1%

4 4.4%

9 8.7%

10 9.9%

4 6.0%

-20.0% -16.4%

5 5.4%

5 4.8%

5 4.6%

6 5.5%

5 4.6%

0.0% -14.8%

m a

e l p

Table QM 1: Maternal Indicators

Numerator Denominator Hospital 3,033 2,609

NPIC ID: SA1 Total APR MDC 14 (APR DRGs 540-566) Total Deliveries AHRQ PSI 2: Death in Low-mortality DRGs ** Observed Rate Expected Rate

LCI *

UCI *

Subgroup Average 4,550 4,110

AHRQ Database Provider Average Rate 1 3,806 3,509

2,995

0.0000 0.0000 0.0010 0.0002 0.0001 -0.0000 0.0000 0.0022 0.0000 to 0.0000 Risk Adjustment data is currently not available from AHRQ due to conversion ICD-10 coding

AHRQ PSI 18: Obstetric Trauma: Vaginal Deliveries with Instruments **

123

14.6%

8.9%

22.1%

14.4%

12.9%

AHRQ PSI 19: Obstetric Trauma: Vaginal Deliveries without Instruments **

1,467

1.7%

1.1%

2.5%

1.9%

1.8%

AHRQ IQI 21: Cesarean Delivery Rate **

744

2,180

34.1%

32.1%

36.2%

27.7%

30.5%

AHRQ IQI 22: VBAC Rate Uncomplicated **

397

11.1%

8.2%

14.6%

19.6%

13.9%

AHRQ IQI 33: Primary Cesarean Delivery Rate **

389

1,783

21.8%

19.9%

23.8%

17.3%

18.2%

AHRQ IQI 34: VBAC Rate All **

479

11.1%

8.4%

14.2%

18.6%

13.7%

e l p

m a 87

1,578

5.5%

4.4%

6.8%

3.4%

5.4%

18 14 4

120 120 120

15.0% 11.7% 3.3%

9.1% 6.5% 0.9%

22.7% 18.8% 8.3%

13.4% 11.2% 2.2%

12.0% 9.8% 2.2%

NPIC 3rd and 4th Degree Laceration Rate, without Forceps or Vacuum Extraction NPIC 3rd Degree Laceration Rate, without Forceps or Vacuum Extraction NPIC 4th Degree Laceration Rate, without Forceps or Vacuum Extraction

25 22 3

1,487 1,487 1,487

1.7% 1.5% 0.2%

1.1% 0.9% 0.0%

2.5% 2.2% 0.6%

2.0% 1.8% 0.2%

1.7% 1.5% 0.2%

NPIC Postpartum Readmission Rate Readmissions within 30 days post-discharge Readmissions within 42 days post-discharge

32 34

2,604 2,604

1.2% 1.3%

0.8% 0.9%

1.7% 1.8%

1.3% 1.3%

1.0% 1.0%

82 2 0

2,609 2,609 2,609

3.1% 0.1% 0.0%

2.5% 0.0% 0.0%

3.9% 0.3% 0.1%

5.4% 0.3% 0.0%

4.0% 0.2% 0.0%

1,607

1.8%

1.2%

2.6%

1.9%

2.3%

NPIC Rate of Inductions resulting in Cesarean Delivery 312 *Lower and upper confidence intervals for all AHRQ indicators are calculated by NPIC. ** AHRQ QIâ&#x201E;˘ ICD-10-CM/PCS Specification Version V7.0. 1 Provider-level rates are not available in the current version of the AHRQ ICD-10 software.

1,082

NQF Incidence of Episiotomy

NPIC 3rd and 4th Degree Laceration Rate, with Forceps or Vacuum Extraction NPIC 3rd Degree Laceration Rate, with Forceps or Vacuum Extraction NPIC 4th Degree Laceration Rate, with Forceps or Vacuum Extraction

NPIC Postpartum Hemorrhage Rate NPIC Rate of Disruption or Infection of Obstetrical Wound NPIC Anesthesia Complication Rate

NPIC Rate of Vaginal Deliveries Coded with Shoulder Dystocia

2 28.8% 31.6% below19.5% Not Displayed.26.2% See explanation

18.2%

Current ICD-10 coding does not allow for a distinction between artificial rupture of membranes (AROM) to induce labor and AROM after onset of labor. As this may result in overstating the total number of inductions, we have suspended the calculation of all inductions rates.

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Graph QM 1m: NPIC Postpartum Readmission RateReadmissions within 42 days post-discharge 2013-2017 with Trendlines NPIC ID: SA1 Graph QM 1m: NPIC Postpartum Readmission Rate Trend Rate Hosp Numerator Hosp Denominator Hosp Rate LCI UCI Readmissions within 42 days post-discharge 2013 1.0% 38 2349 1.6% 0.004727235 0.005937308 2013-2017 with Trendlines 2014 1.0% 32 2616 1.2% 0.003818212 0.00502459 NPIC ID: SA1 2.5% 2015 1.0% 35 2647 1.3% 0.003973534 0.005141436 2016 1.0% 30 2607 1.2% 0.00372311 0.004887366 2017 1.1% 34 2604 1.3% 0.004040944 0.005098263

Rate

2.0%

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1.5%

Correl Coefficient: 1.0%

0.366508333

-23.184% 0.012% Trend Trendline X Vals: 0.5% 2013 2017

1.0% 1.0%

0.0%

2012

Hosp Trendline X Vals: 2013 2017

2014

1.5% 1.2%

2015

2016

Hospital Rate with 95% Confidence Intervals

Trend Hospitals Average Rate

Hospital Rate: Stable Over Time

Trend Rate: Stable Over Time

2013 Trend Rate Hospital Rate Hospital Numerator Hospital Denominator Lower CI Upper CI

2013

140.359% -0.069%

1.0% 1.6% 38 2349 1.1% 2.2%

2017

2014

2015

2016

2017

1.0% 1.2% 32 2616 0.8% 1.7%

1.0% 1.3% 35 2647 0.9% 1.8%

1.0% 1.2% 30 2607 0.8% 1.6%

1.1% 1.3% 34 2604 0.9% 1.8%

Pct Change 13 - 17 6.9% -19.1%

Graph QM 1o: NPIC Postpartum Hemorrhage Rate 2013-2017 with TrendlinesNPIC ID: SA1 Graph QM 1o: NPIC Postpartum Hemorrhage Rate Trend Rate Hosp Numerator Hosp Denominator LCI UCI 2013-2017 with TrendlinesHosp Rate 2013 3.4% 67 2353 2.9% 0.006366125 0.007522176 NPIC ID: SA1 2014 3.4% 69 2624 2.6% 0.005784145 0.00686224 5.0% 2015 3.7% 74 2658 2.8% 0.005877575 0.007026821 4.5% 2016 4.1% 80 2616 3.1% 0.006277864 0.007317489 2017 4.4% 82 2609 3.1% 0.006326189 0.007464071 4.0%

Rate

3.5%

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3.0% 2.5%

Correl2.0% Coefficient:

0.969994436

-544.304% 0.272%

1.5% 1.0% X Vals: Trend Trendline 2013 0.5% 2017

3.2% 4.3%

0.0%

2012

Hosp Trendline X Vals: 2013 2017

2014

2.7% 3.1%

2015

2016

2017

Hospital Rate with 95% Confidence Intervals

Trend Hospitals Average Rate

Hospital Rate: Stable Over Time

Trend Rate: Significant Upward Trend, p = 0.000

2013 Trend Rate Hospital Rate Hospital Numerator Hospital Denominator Lower CI Upper CI

2013

-200.623% 0.101%

3.4% 2.9% 67 2353 2.2% 3.6%

2014

2015

2016

2017

3.4% 2.6% 69 2624 2.1% 3.3%

3.7% 2.8% 74 2658 2.2% 3.5%

4.1% 3.1% 80 2616 2.4% 3.8%

4.4% 3.1% 82 2609 2.5% 3.9%

Pct Change 13 - 17 30.7% 10.2%

Table QN 1: Neonatal Indicators

NPIC ID: SA1 Total Neonates Total Inborns AHRQ PSI 17: Birth Trauma: Injury to Neonate ** AHRQ NQI 02: Neonatal Mortality ** Observed Rate Expected Rate AHRQ NQI 03: Neonatal Bloodstream Infection **

Numerator

NQF #716: Unexpected Newborn Complications 2 Inborn Readmission Rate 3 NPIC Total Inborn Birth Trauma Rate Subdural or cerebral hemorrhage Epicranial subaponeurotic hemorrhage Other injuries to scalp Fracture of clavicle Other injuries to skeleton Injury to spine and spinal cord Facial nerve injury Injury to brachial plexus Other cranial and peripheral nerve injuries Other specified birth trauma Birth trauma unspecified Total Codes Total Cases Total Inborn Birth Trauma Rate 4 1

Denominator

Hospital

2,518

2,791 2,661 0.08%

LCI*

0.01%

UCI*

0.29%

4,395 4,208 0.69%

3,657 3,552 0.51%

-0.45% 0.43% 0.28% Risk Adjustment data is currently not available from0.25% AHRQ due0.00% to conversion to ICD-10 coding 0.00% 0.00% 0.00% -2 142 1.41% 0.17% 5.00% 1.96% 1.89% 118 1,899 6.2% 5.2% 7.4% 3.5% 3.2% 12

2,662

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Subgroup Database Average Average

AHRQ Provider Rate 1

2,614

1.4%

2,661

0 0 48 4 0 0 0 1 0 3 0 56 55 2.1%

1.0%

1.6%

1.9%

1.2%

1.1%

2.7%

1 2 192 8 2 0 1 5 0 24 1 236 227 5.4%

1 1 110 9 2 0 1 4 0 15 0 142 136 3.8%

Provider-level rates are not available in the current version of the AHRQ ICD-10 software. NQF reendorsed this measure in October 2016 as "Unexpected Complications in Term Newborns". 3 Total Inborns discharged to home (with or without home health) and readmitted within 28 days. 4 Total inborn cases with a birth trauma code divided by total inborns. *Lower and upper confidence intervals for all AHRQ indicators are calculated by NPIC. ** AHRQ QIâ&#x201E;˘ ICD-10-CM/PCS Specification Version V7.0. 2

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Table QN 2: Unexpected Newborn Complications (UNC) (NQF #716 “Healthy Term Newborn”) A. Inborns Total Inborns UNC Final Denominator: Inborns in measure population without preexisting complications 1 B. Unexpected Newborn Complication Rates

Hospital SA1

Subgroup Average

Database Average

2,661

4,208

3,552

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1,899

2,796

6.2%

111

3.5%

3.2%

2.1%

1.5%

1.4%

4.1%

2.0%

1.7%

62.7% 9.3%

63 15

56.8% 13.5%

51 9

59.3% 10.5%

24 22

20.3% 18.6%

14 14

12.6% 12.6%

11 11

12.8% 12.8%

Transfer to Higher Level of Care (Severe only)

0.0%

0.9%

3.5%

Neurologic/Birth Injury Severe

4 3

3.4% 2.5%

21 16

18.9% 14.4%

15 12

17.4% 14.0%

Shock/Resuscitation (Severe only)

3.4%

0.9%

1.2%

Long Length of Stay without clear diagnosis (Moderate only)

10.2%

9.9%

5.8%

Total UNC Rate: Inborns with severe or moderate complications

3,193

118

Severe UNC Rate: Inborns with severe complications

Moderate UNC Rate: Inborns with moderate complications

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C. Neonatal Complication Sub-Categories 2 Respiratory Severe Infection Severe

74 11

Includes singletons; birthweight ≥ 2500 grams; gestational age ≥ 37 weeks. Excludes fetal malformations; maternal/fetal complications; exposure to maternal drug use. 2 Excludes neonatal deaths.

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Graph QN 2a: Comparative Unexpected Newborn Complication Rates NPIC ID: SA1 8.0%

7.0%

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6.0% 5.0%

4.0% 3.0%

2.0% 1.0%

0.0%

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Hospital Total UNC Rate with 95% Confidence Interval: 6.2% Hospital Severe UNC Rate (2.1%) Hospital Moderate UNC Rate (4.1%)

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

Subgroup Total UNC Average Rate (3.5%) Database Total UNC Average Rate (3.2%)

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Table QL 1: Linked Mother/Baby Indicators

NPIC ID: SA1 Total Deliveries Total Deliveries linked to an inborn(s) Deliveries linked to an inborn(s) as a percent of total deliveries Vaginal Deliveries with coded Shoulder Dystocia linked to an inborn ≥ 2500 grams with birth trauma Count by Code: Other injuries to scalp Fracture of clavicle Injury to brachial plexus All other birth trauma codes Coded Maternal Conditions with Neonatal Special Care Admission Hypertension

Thyroid dysfunction Primary Cesarean Deliveries ≥ 37 weeks with Neonatal Special Care Admission Repeat Cesarean Deliveries ≥ 37 weeks with Neonatal Special Care Admission

Denominator

Hospital 2,609 2,487 95.3%

LCI

UCI

10.7%

2.3%

28.2%

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m a

Diabetes Mellitus Obesity

Numerator

207

471

152

388

Subgroup Database Average * Average * 4,110 3,578 3,940 3,476 95.9% 97.3% 16.2%

16.5%

4 1 3 1

3 2 2 1

44.0%

39.4%

48.6%

30.0%

22.8%

72.2%

54.8%

85.8%

42.7%

34.8%

39.2%

34.3%

44.2%

24.4%

17.1%

198

34.3%

27.8%

41.4%

21.8%

16.6%

141

407

34.6%

30.0%

39.5%

18.3%

12.9%

344

22.7%

18.4%

27.5%

11.2%

8.0%

* Subgroup and Database Averages are calculated from hospitals with a valid (≥ 70%) mother/baby linking rate.

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

Graph QL 1a: Vaginal Deliveries with coded Shoulder Dystocia linked to an inborn â&#x2030;Ľ 2500 grams with birth trauma NPIC ID: SA1 60%

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50%

Rate

40%

30%

20%

10%

a S Hospital Rate with 95% Confidence Interval (10.7%)

Date Range of Hospital Data: 1/1/2017 - 12/31/2017 Subgroup: AR - Academic Regional

Subgroup Average (16.2%)

Database Average (16.5%)

Date Range of Comparison Data: 1/1/2017 - 12/31/2017

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QUARTERLY MEASURE SNAPSHOT: Q4 2017

The Quarterly Measure Snapshot* provides internal hospital comparisons for over 20 Key Metrics using your quarterly data submission. The Snapshot displays one quarter of data compared to the same quarter of the previous year and the percent change between quarters. This mid‐cycle report is a complement to your Quarterly Report, which will include additional comparisons to your peer subgroup and the NPIC database for the rolling four quarter period.

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*Metric definitions can be found in the Quarterly Report Specifications located on the NPIC Member Portal.

NPIC.ORG | 36

QUARTERLY MEASURE SNAPSHOT NPIC ID: SA1 Date range of discharge data: 10/1/17 ‐12/31/17 COMPARISON Q4 Q4 2017 2016

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OVERVIEW Total Perinatal Discharges Submitted Average Length of Stay Average Charge per Case % Medicaid (MDC 14 only)

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MATERNAL INDICATORS

Total Deliveries (APR DRGs 540‐542 and 560) Total C‐section Deliveries C‐section Rate (% of total deliveries) Primary C‐section Rate (% of cases without a prior uterine scar) Repeat C‐section Rate (% of cases with a prior uterine scar) Vaginal Birth After C‐Section (VBAC) Rate Successful TOL rate (VBAC as a % of total TOL cases) Operative Vaginal Delivery Rate (% of total vaginal deliveries) NPIC Postpartum Hemorrhage Rate NQF Incidence of Episiotomy

Pct Change

1,418 4.2 $19,142 50.1%

1,369 4.5 $19,903 47.9%

3.6% ‐5.2% ‐3.8% 4.7%

638 266 41.7% 30.4% 90.8% 9.2% 91.7% 6.5% 3.5% 6.3%

612 226 36.9% 23.1% 87.1% 12.9% 100.0% 10.4% 2.8% 5.0%

4.3% 17.7% 12.9% 31.6% 4.2% ‐28.3% ‐8.3% ‐37.7% 24.1% 25.6%

686 648 38 1.8% 1.6% 20.4% 0.5% 4.3% 1.1% 3.2%

674 625 49 2.2% 0.5% 18.3% 0.3% 4.2% 1.9% 2.4%

1.8% 3.7% ‐22.5% ‐21.5% 255.6% 11.4% 43.8% 0.7% ‐40.4% 34.0%

NEONATAL INDICATORS

Total Neonatal Admissions (0‐28 Days at Admission) Total Inborns Other Neonatal Admits (includes Readmits and Transfers in) Inborn Readmits as a % of total neonates Inborns Transferred Out to Another Facility (% of total neonates) Special Care Discharges (% of total neonates) Inborn Mortality >= 500 grams (% of total inborns) Total UNC Rate (Inborns with Severe or Moderate Complications) Severe UNC Rate (Inborns with Severe Complications) Moderate UNC Rate (Inborns with Moderate Complications)

©NPIC 2018

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Adverse Outcome Index Quarterly Monitoring Report NPIC ID: SA1 Q4 2015 – Q2 2018

INTRODUCTION

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The Adverse Outcome Index (AOI) Report is designed to measure the volume and magnitude of ten adverse events that may occur during the delivery process and could potentially expose an obstetrical team to malpractice liability. These events were selected by the original developers, because they were deemed definable, and possibly modifiable, through improved team training and communication 1. The introduction of ICD-10 coding in October 2015 required a review of the entire AOI algorithm. Each measure has been updated to ensure alignment with code changes, as well as quality improvement initiatives in Maternal Child Health, and feedback from the field regarding opportunities to make the AOI more responsive to variations in case mix across hospital populations. NPIC worked extensively with Susan Mann, MD, one of the original AOI developers, to refine and update the algorithm to Version 4.0. This report reflects a quarterly monitoring period since the initiation of ICD-10 Coding.

1 Nielson, P., Goldman, M., Mann, S., Shapiro, D., Marcus, R., Pratt, S., Greenberg, P., McNamee, P., Salisbury, M., Birnbach, D., Gluck, P., Pearlman, M., King, H., Tornberg, D., & Sachs, B. Effects of Teamwork Training on Adverse Outcomes and Process of Care in Labor and Delivery: A Randomized Controlled Trial. American College of Obstetrics & Gynecology. 2007; 109 (1): 48 – 55.

NPIC.ORG | 38

AOI EVENTS AND DESCRIPTION OF INDICES

Each type of event has a severity weight associated with it, and there are three indices calculated from the count and weight of the events occurring at your facility. WEIGHTS FOR ADVERSE OUTCOMES

In-hospital Maternal Death

750

In-hospital Neonatal Death ≥ 2500 grams and ≥ 37 Weeks Gestation

400

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Uterine Rupture During Labor Maternal Intensive Care Birth Trauma Unanticipated Operative Procedure

m a

100 65 60 40

Admission to NICU of Neonate Birthweight ≥ 2500 grams and ≥ 37 Weeks Gestational Age for > 1 Day

APGAR 5 < 7

Maternal Blood Transfusion 4th Degree Perineal Laceration

20 5

THE ADVERSE OUTCOME INDEX (AOI): The number of patients with one or more identified adverse events, divided by the total number of deliveries. THE WEIGHTED ADVERSE OUTCOME SCORE (WAOS): The total weights of all the adverse events, divided by the total number of deliveries. THE SEVERITY INDEX (SI): The total weights of all the adverse events, divided by the number of patients with an adverse event. (Note: each delivery is only counted once, but each event is counted.) Note: Due to the limitations of using an administrative data set (the mother and the baby data are not linked), we can only determine the number of patients with an adverse event, not the number of deliveries with an adverse event. This may result in an overstatement in the number of deliveries with adverse events if there are cases where a mother and linked baby each had events.

II.

DATA SUBMISSION AND DISCUSSION

Your AOI report covers the quarterly monitoring period 10/01/15 - 06/30/18 and reflects data files, containing 14,489 perinatal discharges, submitted to NPIC. The source file for this quarter was submitted in the NPIC format for the above period. There were no problems noted with the data. Note: some hospitals submit copies of state database files, in lieu of programming to our NPIC layout specifications. If a hospital does not include numeric gestational age in their data file, then gestational age is calculated for the inborns with missing information using the logic described in the Appendix at the end of this report.

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Please take note of the following: •

The neonatal death, in Q1 2016, was reviewed by the Director of Women’s and Children’s Services and was removed from the indicator due to a congenital anomaly that was not originally coded on the record.

•

There are 5 cases in the “Maternal Intensive Care” indicator, in Q2 2018; the highest number in this reporting period for this metric. The average is 1 for this metric. These cases, contribute to the high AOI and WAOS rates for this time period.

•

There were 4 cases in the “Unanticipated Operative Procedure” indicator, in Q1 2018; the highest number in this reporting period for this metric. The average is 2 for this metric. These cases, in addition to the 1 “Maternal Intensive Care” case in Q1 2018, contributed to the high SI rate for that time period.

•

There is variability in the “Admission to NICU of Neonate” metric. (i.e., the range is from 8 cases to 26 cases, with 19 cases currently in Q2 2018; the average is 14).

III. TABLE AND GRAPH DISPLAYS

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Table 1: Displays a quarter-by-quarter count of cases by adverse event, along with the count of total deliveries, and the average counts for the quarterly monitoring period. Table 2: Displays your hospital’s AOI, WAOS and SI quarterly rates, along with the average rates for the quarterly monitoring period, the NPIC comparative rate, and the target benchmark.

Note: The NPIC comparative rate reflects quarterly monitoring data from 26 NPIC member hospitals that have received AOI reports for the CY 2017 time period. The target benchmark reflects data from 7 of these 26 hospitals. These seven hospitals were selected as part of the target benchmark group, because they were in the top performance quartile for the WAOS score. Graphs 1 - 3: Show a graphic display of each index by quarter, as well as the average rate for your hospital for the quarterly monitoring period. Each data point includes a vertical error bar that represents the margin of error (90% confidence interval). The graph includes a horizontal dashed line that represents the target benchmark value and a dashed dotted line that represents the NPIC comparative rate. If the error bar crosses the horizontal lines representing the target benchmark and/or the NPIC comparative rate, the data point is not significantly different from the line value it crosses. If the error bar does not cross the horizontal lines, the data point is significantly different (higher or lower) than the target benchmark and/or the NPIC comparative rate. These graphs also include a trend line when there are four or more quarters of data, with the analysis of the trend noted in the box on the lower right of each of the three graphs.

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IV. RESULTS OF THE ANALYSIS FOR YOUR HOSPITAL The AOI reflects the overall rate of cases with an adverse event.

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•

Your quarterly monitoring average rate is the same as the NPIC comparative rate and higher than the target benchmark rate.

•

This rate is significantly different from (higher than) the target benchmark.

•

Your trend indicates no significant change.

The WAOS reflects the severity of adverse events relative to all deliveries. •

Your quarterly monitoring average rate is higher than the NPIC comparative rate and higher than the target benchmark rate.

•

This rate is significantly different from (higher than) the target benchmark.

•

Your trend indicates no significant change.

The SI reflects the severity of the events relative to all cases with an adverse event. •

Your quarterly monitoring average rate is higher than both the NPIC comparative rate and the target benchmark rate.

•

This rate is not significantly different from the target benchmark.

•

Your trend indicates no significant change.

This report reflects Version 4.0 of the AOI algorithm. The algorithm logic, and the specific codes associated with each type of adverse event, is available in the Appendix. Note: These data represent one way to interpret the findings from your hospital. Each hospital must determine meaningful goals for their own institution.

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Review of the counts of each measure (Table 1) will clarify the data that are contributing to your hospital’s AOI, WAOS and SI quarterly rates. We strongly encourage case review to verify the accuracy of the AOI metrics and to identify underlying processes that increase the likelihood of errors. We would be happy to provide a list of cases for your review, upon request. Case list requests or questions regarding this report may be directed to your hospital’s NPIC Hospital Liaison, via email: mservices@npic.org

ACKNOWLEDGEMENT

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The AOI Report was developed by the National Perinatal Information Center (NPIC) in conjunction with the Team Performance Plus (TPP™) Training Program. The specific measures profiled in this report were developed, beginning in 2001, by a panel of experts from the American College of Obstetrics and Gynecology (ACOG), the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN), The Society for Obstetric Anesthesia and Perinatology (SOAP), the Armed Forces Institute of Pathology (AFIP), the US Navy Bureau of Medicine and Surgery (BUMed), the Office of the Surgeon General - US Army, TRICARE Management Activity (the US military health system), and participants from the hospitals selected for a team training study co-sponsored by the Department of Defense, the Risk Management Foundation of the Harvard Medical Institutions, and the Beth Israel Deaconess Medical Center Obstetrics/Gynecology Foundation. The types of events, and the weights associated with them, were developed by this panel of experts through a rigorous consensus process to determine appropriate “weights”. For example, it was agreed that “maternal death” should have the highest severity weight (750); the sum of the weights of all other events is equal to the severity weight for maternal death.

ADVERSE OUTCOME INDEX (AOI) REPORT Table 1: Count of Adverse Events by Indicator Q4 2015 663 675

Q1 2016 610 625

Q2 2016 636 665

Q3 2016 681 700

Q4 2016 680 698

Q1 2017 634 648

Q2 2017 649 659

Q3 2017 723 737

Q4 2017 594 617

Q1 2018 623 623

Q2 2018 667 682

Avg. For Period 651 666

In-hospital Maternal Death

In-hospital Neonatal Death, ≥ 2500 grams and ≥ 37 weeks gestation

Uterine Rupture During Labor

Maternal Intensive Care

Birth Trauma

Unanticipated Operative Procedure

Admission to NICU, Neonate ≥ 2500 grams and ≥ 37 Weeks Gestation, for > 1 day

APGAR 5 < 7, Inborn Neonate, ≥ 2500 grams and ≥ 37 Weeks Gestation

Maternal Blood Transfusion

4th Degree Perineal Laceration

Total Adverse Events

Total Patients with one or more Adverse Events

NPIC ID: SA1 Total Deliveries Total Inborns

AOI Report ©NPIC 2018

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Version V4.0 Run date: 11/30/2018 12:03 PM

ADVERSE OUTCOME INDEX (AOI) REPORT Table 2: Indices by Quarter

Q4 2015

Q1 2016

Q2 2016

Q3 2016

Q4 2016

Q1 2017

Q2 2017

Q3 2017

Q4 2017

Q1 2018

Q2 2018

Avg. for Period

Adverse Outcome Index (AOI)

0.056

0.036

0.039

0.040

0.025

0.024

0.026

0.050

0.046

0.034

0.051

0.039

0.024

Weighted Adverse Outcome Score (WAOS)

1.75

1.27

1.29

1.67

0.80

0.85

0.83

2.03

1.77

1.32

1.85

1.40

1.38

0.78

Severity Index (SI)

31.35

35.23

32.80

42.22

32.06

36.00

31.76

40.69

38.89

39.05

36.32

36.03

35.18

32.22

NPIC ID: SA1

Target Benchmark

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*NPIC Comparative Rate Range: AOI: 0.011 - 0.071 WAOS: 0.30 - 2.80 SI: 29.22 - 44.24

Adverse Outcome Index (AOI) -- Number of patients with an adverse event divided by total number of deliveries Weighted Adverse Outcome Score (WAOS) -- Total weights of all adverse events divided by total number of deliveries Severity Index (SI) -- Total weights of all adverse events divided by number of patients with an adverse event

AOI Report Â©NPIC 2018

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NPIC Rate*

Version V4.0 Run date: 11/30/2018 12:03 PM

ADVERSE OUTCOME INDEX (AOI) REPORT The Adverse Outcome Index (AOI): (Number of Patients with an adverse event divided by the total number of deliveries)

NPIC ID: SA1 0.080

0.070

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0.060

0.050

0.040

0.030

0.020

0.010

0.000 Q4 2015

Q1 2016

a S Q2 2016

Q3 2016

Q4 2016

Q1 2017

Q2 2017

Q3 2017

Q4 2017

Q1 2018

Q2 2018

Avg For Period

NPIC Comparison Rate (.039)

Quarterly Average

Average for Period

Error Bars represent Margin of Error (90% Confidence Interval).

AOI Report Â©NPIC 2018

Target Benchmark (.024) Hospital Trend: No Significant Change

Version V4.0 Run date: 11/30/2018 12:03 PM

ADVERSE OUTCOME INDEX (AOI) REPORT The Weighted Adverse Outcome Score (WAOS): (Total weights of all adverse events divided by the total number of deliveries)

NPIC ID: SA1 2.50

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2.00

1.50

1.00

0.50

0.00 Q4 2015

Q1 2016

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Q2 2016

Q3 2016

Q4 2016

Q1 2017

Q2 2017

Q3 2017

Q4 2017

Q1 2018

Q2 2018

Avg For Period

NPIC Comparison Rate (1.38) Quarterly Average

Average for Period Target Benchmark (.779)

Error Bars represent Margin of Error (90% Confidence Interval).

AOI Report Â©NPIC 2018

Hospital Trend: No Significant Change

Version V4.0 Run date: 11/30/2018 12:03 PM

ADVERSE OUTCOME INDEX (AOI) REPORT The Severity Index (SI) (Total weights of all adverse events divided by the total number of patients with an adverse event)

NPIC ID: SA1 60.00

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50.00

40.00

30.00

20.00

10.00

0.00 Q4 2015

Q1 2016

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Q2 2016

Q3 2016

Q4 2016

Q1 2017

Q2 2017

Q3 2017

Q4 2017

Q1 2018

Q2 2018

Avg For Period

NPIC Comparison Rate (35.18) Quarterly Average

Average for Period

Error Bars represent Margin of Error (90% Confidence Interval).

AOI Report Â©NPIC 2018

Target Benchmark (32.22)

Hospital Trend: No Significant Change

Version V4.0 Run date: 11/30/2018 12:03 PM

APPENDIX: Adverse Outcome Index (AOI) Algorithm (V4.0) The ICD-10 code tables used to determine each indicator count for the Adverse Outcome Index can be found on the NPIC website: http://www.npic.org/Services/AOI_4.0_Definitions_Codes.pdf

Event Populations

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Deliveries: Cases assigned to any of the following MS DRGs: 765-768, 774-775, or > 981 with an ICD-10-PCS delivery code, and also assigned to any of the following APR-DRGs: 540-542, 560 (Appendix M.1.1) Inborns: All neonates born in your hospital (Appendix B.1.1)

Event Definitions In-hospital Maternal Death {Case Weight: 750} Deliveries and discharge disposition = died Exclusions: None

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In-hospital Neonatal Death ≥ 2500 grams and ≥37 weeks Gestation {Case Weight: 400} Inclusions: Inborns with birthweighti ≥ 2500 grams and ≥ 37 weeks gestationii with discharge disposition of died within 28 days of birth Exclusions: Cases with congenital anomalies and other disorders (Appendix B.2.1) Uterine Rupture During Labor {Case Weight: 100}

Inclusions: Deliveries with diagnosis code O71.1 (rupture of uterus during labor) in the primary, first or second diagnosis code position only Exclusions: None

VERSION 4.0 Effective: 7/1/2017

Maternal Intensive Care {Case Weight: 65} Inclusions: Deliveries with AIMiii Severe Maternal Morbidity (SMM) diagnosis and/or procedure codes (Appendix M.3.1) OR Deliveries with the NPIC Blood Transfusion Indicator = 1 on submitted file; AND  with an ICU day or charge OR  discharged to another hospital (UB04 disp=02) Exclusions: Cases with placental disorders (Appendix M.3.1) or any AIM SMM diagnosis code(s) with Present on Admissioniv (POA) indicator = Y

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Birth Trauma {Case Weight: 60}

Inclusions: Inborns with birthweight ≥ 2500 grams and ≥ 37 weeks gestation with UNCv severe birth trauma diagnosis codes (Appendix B.3.1) Exclusions: Cases with osteogenesis imperfecta (Appendix B.3.1) Unanticipated Operative Procedure {Case Weight: 40}

Inclusions: Deliveries with unanticipated operative procedure codes (Appendix M.4.1) in the first or second procedure field

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Exclusions: Cases with placental disorders or cervical cancers; Also excludes hysterectomy cases with an ICU day or charge or discharged to another hospital (UB04 disp=02) (Appendix M.4.1) Admission to NICU of Neonate Birthweight ≥ 2500 grams and ≥ 37 weeks Gestational Age (GA) for > 1 day {Case Weight: 35} Inclusions: Inborns with birthweight ≥ 2500 grams and ≥ 37 weeks gestation; AND  NICU admission within one day of birth for greater than one day; OR  transferred to another hospital (UB04 disp=02 or =05) within one day of birth

Exclusions: Cases with congenital anomalies and other disorders (Appendix B.2.1) or neonatal drug/alcohol exposure (Appendix B.5.1) APGAR 5 < 7 {Case Weight: 25} Inclusions: Inborns with birthweight ≥ 2500 grams and ≥ 37 weeks completed gestation; APGAR 5 < 7 Exclusions: Cases with congenital anomalies and other disorders (Appendix B.2.1) or neonatal drug/alcohol exposure (Appendix B.5.1)

VERSION 4.0 Effective: 7/1/2017

Maternal Blood Transfusion {Case Weight: 20} Inclusions: Deliveries with AIM Severe Maternal Morbidity (SMM) blood transfusion procedure codes (Appendix M.5.1); OR  additional select code for transfusion of non-blood products (Appendix M.5.1); OR  NPIC Blood Transfusion Indicator = 1 on submitted file Exclusions: Delivery cases that are included in the “Maternal Intensive Care” event (see definition above). 4th Degree Perineal Laceration {Case Weight: 5}

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Inclusions: Deliveries with fourth degree perineal laceration diagnosis code (Appendix M.6.1) Exclusions: Cases with shoulder dystocia (Appendix M.6.1)

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Birthweight is determined by numeric value or ICD-10-CM coding Gestational Age is determined by numeric value or ICD-10-CM coding. Cases missing gestational age information default to ≥ 37 weeks if birthweight is ≥ 2000 grams. iii Alliance for Innovation on Maternal Health (AIM) iv Present on Admission (POA) indicator Y = diagnosis was present at time of inpatient admission v Unexpected Complications in Term Newborns (UNC) NQF Measure #0716 ii

VERSION 4.0 Effective: 7/1/2017

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V17.4 Perinatal Service Line Report PURPOSE

Executives at the system level are working hard to manage population health and insure the appropriate alignment of patient risk with location of care. That task is critical when managing perinatal services across multiple hospitals at different levels of care since OB claims can be one of the most expensive exposure areas. This report includes data for all your delivery facilities that are members of NPIC. Our hope is that seeing utilization and quality metrics across your service line will help you better manage the population health of your mothers and infants.

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The Perinatal Service Line Report (PSL) allows executives to: •

Quickly assess each perinatal service in the system.

•

Monitor volume and utilization by level of perinatal care.

•

View quality and outcome metrics to determine areas of concern or risk exposure.

•

Insure the risk profile of the hospital’s population matches its clinical capabilities.

•

Insure transfer patterns are appropriate and timely.

•

Over time, determine whether system-wide initiatives are having an impact at the local level.

I. OVERVIEW OF THE TABLES

Data are displayed in the following four tables for all participating hospitals in your system, organized from the facility providing the highest level of care in this system (e.g., Regional Perinatal Center) to the facility providing the lowest level of care (e.g., Basic/Level I). The System Total/Average is provided in the first column followed by each of your system hospitals with their NPIC peer comparison subgroup next to the appropriate level hospital(s). The System Average is the average of the values for each hospital included in the report. The tables in this report display data for the period 1/1/17-12/31/17.

NPIC.ORG | 51

Please note: within each display of APR DRG subclasses (in maternal as well as neonatal tables) the % of “ungroupable” cases is displayed but is not included in the calculation of total % of cases in subclasses .1 (minor complications) to .4 (extreme complications). Table 1: Maternal Utilization and Acuity Analysis includes maternal utilization data and acuity information (e.g., case mix index, and subclass) for antepartum, delivery and postpartum discharges from each of your hospitals and their respective subgroup. The payer mix for MDC 14 is also displayed.

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Table 2: Maternal Quality Analysis includes delivery discharges for each facility, and percent of cases for 19 maternal indicators (e.g., C-section with LOS >5 days, Admissions to AICU, Severe Maternal Morbidity). Table 3: Neonatal Utilization and Acuity Analysis includes utilization data and acuity information (e.g., case mix index, subclass) for all neonates, all inborns, all transfers in and all transfers out (at 0 – 3 days of birth).

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Table 4: Neonatal Quality Analysis includes 7 indicators for all neonates (e.g., % admitted to the special care nursery, % Died), and 16 indicators for all inborns (e.g., % readmitted within 28 days, % Total UNC subdivided into moderate and severe). Data Definitions Indicator definitions can be found in the Quarterly Report Specifications located on the NPIC Member Portal under “Resources” or “Quarterly Reports”. Member Portal Registration: https://portal.npic.org/member/index.php?id=455 Member Portal Login: https://portal.npic.org/member/index.php?id=456

Questions regarding this report should be directed to Sandra Boyle, Director of Data Services (sboyle@npic.org) or Janet Muri, President (jmuri@npic.org) at 401-274-0650.

V17.4 Perinatal Service Line Report Hospital System ID: SA1 Date Range of Data: 1/1/2017 - 12/31/2017

Table 1: Maternal Utilization and Acuity Analysis

Total MDC 14 - Pregnancy and Related Conditions Antepartum Discharges (APR DRGs 563, 565, 566) % of System Total Case Mix Index ALOS Subclass .1 Minor Complications (column %) Subclass .2 Moderate Complications Subclass .3 Major Complications Subclass .4 Extreme Complications Ungroupable Delivery Discharges (APR DRGs 540, 541, 542, 560) % of System Total Case Mix Index ALOS Subclass .1 Minor Complications Subclass .2 Moderate Complications Subclass .3 Major Complications Subclass .4 Extreme Complications Ungroupable Postpartum Discharges (APR DRG 561) % of System Total Case Mix Index ALOS Subclass .1 Minor Complications Subclass .2 Moderate Complications Subclass .3 Major Complications Subclass .4 Extreme Complications Ungroupable MDC 14 Payer Mix Medicaid Medicare Commercial Insurance/TRICARE HMO Self-Pay/Free Care Other/Missing Payers

Subgroup NS*

Subgroup AR*

Subgroup NI*

Subgroup NB*

System Total/ Average

Hospital A

AR Average

Hospital B

NS Average

Hospital C

NI Average

Hospital D

NB Average

5,410 431 100.0% 0.3572 2.4 36.4% 45.5% 17.1% 1.0% 0.0% 4,807 100.0% 0.4402 2.6 51.5% 37.3% 11.0% 0.2% 0.0% 100 100.0% 0.4663 2.4 18.5% 57.4% 23.2% 0.8% 0.0%

2,949 245 56.8% 0.4282 3.5 29.0% 42.5% 26.5% 2.0% 0.0% 2,603 54.2% 0.4597 2.6 53.2% 34.8% 11.6% 0.4% 0.0% 59 59.0% 0.4900 2.7 11.9% 57.6% 28.8% 1.7% 0.0%

4,216 317 -0.4003 3.6 26.8% 50.7% 21.8% 0.8% 0.0% 3,759 -0.4566 3.2 48.5% 38.6% 12.6% 0.3% 0.0% 73 -0.4970 2.9 23.6% 46.6% 26.2% 3.7% 0.0%

1,135 126 29.2% 0.3418 2.9 42.1% 48.4% 9.5% 0.0% 0.0% 963 20.0% 0.4592 3.2 48.6% 40.6% 10.7% 0.1% 0.0% 29 29.0% 0.3872 2.6 37.9% 51.7% 10.3% 0.0% 0.0%

2,328 82 -0.3749 2.6 40.3% 41.4% 17.5% 0.8% 0.0% 2,205 -0.4222 2.6 65.9% 29.4% 4.6% 0.1% 0.0% 21 -0.4934 2.6 27.8% 46.0% 21.7% 4.5% 0.0%

645 35 8.1% 0.3251 1.6 45.7% 48.6% 5.7% 0.0% 0.0% 596 12.4% 0.4202 2.2 51.2% 38.9% 9.9% 0.0% 0.0% 8 8.0% 0.4576 2.1 12.5% 62.5% 25.0% 0.0% 0.0%

1,542 43 -0.3605 2.1 39.3% 46.4% 13.7% 0.6% 0.0% 1,474 -0.4205 2.5 57.2% 37.6% 5.2% 0.1% 0.0% 12 -0.4348 3.0 32.9% 40.8% 26.3% 0.0% 0.0%

681 25 5.8% 0.3335 1.5 29.0% 42.5% 26.5% 2.0% 0.0% 645 13.4% 0.4217 2.3 53.2% 34.8% 11.6% 0.4% 0.0% 4 4.0% 0.5303 2.0 11.9% 57.6% 28.8% 1.7% 0.0%

516 16 -0.3769 1.7 35.3% 49.2% 14.4% 1.1% 0.0% 491 -0.4251 2.4 60.9% 32.8% 6.2% 0.2% 0.0% 4 -0.4563 2.1 8.9% 68.3% 22.8% 0.0% 0.0%

50.6% 0.6% 28.2% 18.1% 1.1% 1.4%

46.2% 1.0% 30.7% 21.6% 0.5% 0.0%

26.5% 0.7% 37.2% 24.3% 0.8% 10.5%

49.2% 0.8% 28.8% 17.1% 1.4% 2.8%

35.3% 0.4% 46.8% 13.7% 2.2% 1.6%

44.4% 0.6% 31.6% 19.8% 1.5% 2.1%

33.7% 0.5% 31.7% 26.8% 0.7% 6.6%

62.6% 0.0% 21.6% 14.0% 1.0% 0.9%

37.2% 0.4% 37.8% 22.5% 0.9% 1.2%

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*Subgroups: AR - Academic Regional Perinatal Centers; NS - Non-academic Specialty; NI - Non-academic Intermediate; NB - Non-academic Basic

V17.4 Perinatal Service Line Report Hospital System ID: SA1 Date Range of Data: 1/1/2017 - 12/31/2017

Table 2: Maternal Quality Analysis Subgroup AR*

Subgroup NS*

Subgroup NI*

Subgroup NB*

System Total/ Average

Hospital A

AR Average

Hospital B

NS Average

Hospital C

NI Average

Hospital D

NB Average

4,807 100.0%

2,603 54.2%

3,759 --

963 20.0%

2,205 --

596 12.4%

1,474 --

645 13.4%

491 --

Admitted from another hospital

0.2%

0.3%

2.0%

0.2%

0.1%

0.0%

0.5%

0.3%

0.0%

Multiple gestation

2.9%

3.3%

3.1%

3.8%

1.4%

1.0%

1.3%

3.3%

1.1%

C-sections with LOS > 5 days

2.2%

2.0%

4.1%

4.8%

1.0%

0.2%

0.8%

2.0%

0.7%

VBAC

13.8%

12.9%

19.0%

15.0%

10.0%

19.5%

10.4%

7.9%

8.4%

5.6%

10.2%

5.8%

4.7%

6.4%

5.6%

6.2%

2.1%

5.2%

5.3%

7.7%

4.0%

7.7%

10.1%

2.1%

8.7%

3.5%

4.4%

15.7%

9.7%

14.1%

27.3%

8.8%

19.1%

9.0%

6.8%

15.2%

1.3%

1.7%

1.3%

1.6%

0.9%

1.6%

1.2%

2.4%

7.8%

14.8%

11.2%

7.8%

6.0%

2.1%

5.9%

6.8%

3.9%

2.3%

2.9%

4.9%

2.4%

2.3%

2.2%

2.7%

1.6%

3.4%

0.2%

0.0%

0.3%

0.1%

0.2%

0.5%

0.2%

0.0%

0.2%

0.4%

0.3%

0.7%

0.3%

0.5%

0.3%

0.4%

2.1%

2.2%

2.0%

0.8%

2.2%

2.7%

2.4%

2.7%

3.2%

4.4%

4.2%

4.4%

5.2%

3.7%

4.0%

3.1%

4.2%

3.5%

0.3%

1.6%

0.5%

0.6%

0.0%

1.2%

0.3%

0.1%

0.00%

0.01%

0.00%

0.03%

0.00%

0.05%

0.00%

0.53%

1.2%

1.4%

1.3%

1.9%

0.6%

0.8%

0.5%

0.4%

2.3%

2.9%

1.5%

1.9%

1.5%

2.9%

2.0%

Total Delivery Discharges % of System Total

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Overview: Maternal Quality

Operative Vaginal Deliveries Episiotomy PSI 18: OB Trauma with Instruments PSI 19: OB Trauma without Instruments Delivered < 37 weeks GA Coded with a postpartum hemorrhage (PPH) Coded with a PPH and red blood cells transfusion Coded with PPH and hysterectomy Coded with shoulder dystocia Coded with gestational diabetes Admitted to Adult Intensive Care Unit (AICU) Died Transferred out within 1 day Readmitted within 42 days Severe Maternal Morbidity (SMM)

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*Subgroups: AR - Academic Regional Perinatal Centers; NS - Non-academic Specialty; NI - Non-academic Intermediate; NB - Non-academic Basic

V17.4 PSL REPORT ÂŠ2018 NPIC

V17.4 Perinatal Service Line Report Hospital System ID: SA1 Date Range of Data: 1/1/2017 - 12/31/2017

Table 3: Neonatal Utilization and Acuity Analysis

All Neonates % of System Total Case Mix Index ALOS Subclass .1 Minor Complications (Col. %) Subclass .2 Moderate Complications Subclass .3 Major Complications Subclass .4 Extreme Complications Ungroupable All Inborns % of System Total Case Mix Index ALOS Subclass .1 Minor Complications Subclass .2 Moderate Complications Subclass .3 Major Complications Subclass .4 Extreme Complications Ungroupable All Transfers In % of System Total Case Mix Index ALOS Subclass .1 Minor Complications Subclass .2 Moderate Complications Subclass .3 Major Complications Subclass .4 Extreme Complications Ungroupable Inborns Transferred Out (0-3 days of birth) % of System Total Case Mix Index ALOS Subclass .1 Minor Complications Subclass .2 Moderate Complications Subclass .3 Major Complications Subclass .4 Extreme Complications Ungroupable

Subgroup NS*

Subgroup AR*

Subgroup NI*

Subgroup NB*

System Total/ Average

Hospital A

AR Average

Hospital B

NS Average

Hospital C

NI Average

Hospital D

NB Average

5,169 100.0% 0.5875 4.4 68.3% 22.3% 7.5% 1.8% 1.4% 4,927 100.0% 0.3852 3.5 69.1% 21.8% 7.5% 1.6% 0.2% 36 100.0% 3.6632 27.6 7.7% 61.5% 11.5% 19.2% 30.9% 10 100.0% 0.1882 1.2 30.0% 30.0% 26.7% 13.3% 0.0%

2,805 54.3% 0.8890 5.8 60.4% 25.2% 11.1% 3.3% 2.8% 2,664 54.1% 0.8260 5.5 61.1% 25.2% 10.9% 2.8% 0.3% 34 94.4% 6.3756 19.7 15.4% 23.1% 23.1% 38.5% 61.8% 5 50.0% 0.2795 1.4 20.0% 20.0% 40.0% 20.0% 0.0%

4,059 -0.7314 5.7 68.1% 20.7% 8.9% 2.4% 1.1% 3,883 -0.6794 5.4 69.3% 20.3% 8.4% 2.1% 0.5% 69 -3.8281 18.5 18.3% 31.1% 26.5% 24.1% 17.9% 16 -0.3201 1.4 15.4% 26.3% 29.5% 28.8% 1.0%

1,074 20.8% 0.4426 4.4 72.8% 20.5% 5.9% 0.8% 0.0% 1,025 20.8% 0.4362 4.4 73.4% 19.8% 6.2% 0.7% 0.0% 2 5.6% 0.9508 35.5 0.0% 100.0% 0.0% 0.0% 0.0% 0 0.0% --------

2,264 -0.2525 3.1 76.8% 17.8% 5.1% 0.3% 1.9% 2,227 -0.2450 3.0 77.1% 17.6% 5.0% 0.3% 1.8% 7 -1.6908 17.4 42.1% 25.2% 30.6% 2.2% 7.2% 17 -0.2920 1.4 11.8% 32.2% 33.6% 22.5% 1.3%

631 12.2% 0.1295 1.8 79.7% 18.4% 1.9% 0.0% 0.0% 598 12.1% 0.1293 1.8 80.9% 17.1% 2.0% 0.0% 0.0% 0 0.0% -------2 20.0% 0.1358 1.0 50.0% 50.0% 0.0% 0.0% 0.0%

1,515 -0.2032 2.7 76.7% 17.9% 5.2% 0.2% 1.0% 1,494 -0.1964 2.7 77.0% 17.7% 5.1% 0.2% 1.0% 3 -3.2519 13.0 37.4% 46.2% 16.4% 0.0% 2.0% 15 -0.1943 1.3 38.2% 35.2% 19.9% 6.7% 1.6%

659 12.7% 0.8890 5.8 60.4% 25.2% 11.1% 3.3% 2.8% 640 13.0% 0.1491 2.4 61.1% 25.2% 10.9% 2.8% 0.3% 0 0.0% -------3 30.0% 0.1494 1.3 20.0% 20.0% 40.0% 20.0% 0.0%

500 -0.1436 2.2 81.5% 15.2% 3.2% 0.1% 2.6% 494 -0.1416 2.2 81.7% 15.1% 3.1% 0.1% 2.5% 0 --------10 -0.1632 1.2 42.5% 43.4% 12.3% 1.9% 3.8%

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V17.4 Perinatal Service Line Report Hospital System ID: SA1 Date Range of Data: 1/1/2017 - 12/31/2017

Table 4: Neonatal Quality Analysis System Total/ Average All Neonates Special Care nursery %

Subgroup AR* Hospital A

AR Average 4,059

1,074

2,264

631

1,515

659

500

20.5%

13.5%

6.0%

9.7%

0.0%

2.3%

0.4%

0.9% 21.6%

Died (≥ 500 grams)

0.34%

0.64%

Severe birth asphyxia

1.0%

1.6%

0.6%

Coded with Neonatal Abstinence Syndrome

0.7%

1.4%

0.9%

Singletons Birth Trauma (PSI 17) Special Care nursery % Transferred out within 3 days of birth Hypothermia Hyperbilirubinemia Died (≥ 500 grams) Severe birth asphyxia Coded with Neonatal Abstinence Syndrome (NAS) Unexpected Newborn Complications (UNC) UNC - Moderate UNC - Severe Readmitted within 28 days

NB Average

20.0%

19.9%

Delivered by c-section

Subgroup NB* Hospital D

2,805

0.3%

< 2500 grams

NI Average

27.7%

15.5%

< 1500 grams

Subgroup NI* Hospital C

5,169

Hypothermia

Readmitted within 28 days

NS Average

13.6%

Hyperbilirubinemia

All Inborns

Subgroup NS* Hospital B

2.3%

1.3%

1.1%

4,927

2,664

3,883

7.3%

14.3%

11.5%

1.6%

3.9%

2.6%

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95.2%

93.7%

94.0%

32.3%

33.5%

31.2%

0.1%

0.2%

0.3%

0.4%

0.2%

11.0%

24.4%

11.1%

19.3%

19.9%

16.7%

0.56%

0.13%

0.00%

0.06%

0.15%

0.09%

0.7%

0.4%

0.2%

0.3%

1.6%

0.3%

1.3%

0.0%

1.3%

1.4%

1.3%

2.5%

0.9%

4.1%

0.8%

1.3%

0.6%

1,025

2,227

598

1,494

640

494

8.3%

6.3%

1.3%

5.3%

4.3%

2.3%

0.8%

0.0%

0.2%

0.0%

0.1%

91.7%

97.1%

98.0%

97.3%

97.5%

97.1%

37.1%

33.3%

25.3%

29.4%

33.5%

30.2% 0.42%

0.7%

0.32%

0.5%

0.34%

0.1%

16.7%

11.9%

0.8%

9.0%

0.0%

6.8%

0.0%

0.8%

0.3%

1.0%

0.5%

2.1%

0.3%

0.1%

0.59%

11.0%

26.5%

17.6%

0.2%

0.4%

0.3%

0.8%

0.1%

0.2%

0.3%

0.2%

13.0%

18.4%

20.7%

9.0%

23.5%

6.4%

18.7%

18.4%

16.5%

0.19%

0.41%

0.36%

0.20%

0.09%

0.00%

0.16%

0.00%

0.9%

1.4%

0.5%

0.6%

0.4%

0.2%

0.3%

1.4%

0.4%

0.5%

1.0%

0.7%

0.2%

1.1%

0.0%

1.3%

1.0%

1.2%

3.9%

4.7%

4.6%

6.0%

3.4%

2.5%

4.7%

2.3%

3.9%

2.4%

2.7%

3.2%

4.3%

2.3%

0.8%

2.9%

1.9%

2.1%

1.4%

2.0%

1.4%

1.7%

1.1%

1.7%

1.8%

0.4%

1.8%

2.4%

1.2%

1.1%

2.6%

0.9%

4.4%

0.7%

1.6%

0.4%

* Subgroups: AR - Academic Regional Perinatal Centers; NS - Non-academic Specialty; NI - Non-academic Intermediate; NB - Non-academic Basic

V17.4 Perinatal Service Line Report Hospital System ID: SA1 Date Range of Data: 1/1/2017 - 12/31/2017

Table 4: Neonatal Quality Analysis (continued) System Total/ Average All Transfers In

Subgroup AR* Hospital A

AR Average

Subgroup NS* Hospital B

Subgroup NI*

NS Average

Hospital C

Subgroup NB*

NI Average

Hospital D

NB Average

Special Care nursery %

47.8%

91.2%

83.2%

100.0%

82.1%

0.0%

75.9%

0.0%

Hypothermia

0.0%

2.0%

0.0%

Hyperbilirubinemia

27.9%

55.9%

47.9%

Died (≥ 500 grams)

0.0%

0.00%

2.48%

Severe birth asphyxia

4.4%

8.8%

4.4%

Coded with Neonatal Abstinence Syndrome

11.8%

23.5%

9.8%

Readmitted within 28 days

0.0%

0.7%

Inborns Transferred Out (0-3 days of birth) < 2500 grams < 1500 grams Singletons Delivered by c-section Special Care nursery % Hypothermia Hyperbilirubinemia Severe birth asphyxia Coded with Neonatal Abstinence Syndrome (NAS) Unexpected Newborn Complications (UNC) UNC - Moderate UNC - Severe Readmitted within 28 days

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0.0%

27.7%

0.0%

4.6%

100.0%

85.2%

53.3%

80.0%

33.1%

40.0%

60.0%

83.3%

0.0%

0.8%

0.0%

12.1%

0.0%

7.2%

0.0%

0.3%

66.7%

100.0%

0.0%

66.7%

100.0%

0.0%

51.0%

31.1%

0.00%

1.30%

0.0%

2.1%

1.4%

0.0%

16.6%

0.7%

0.0%

0.5%

0.0%

10 25.9%

0.0%

37.3%

0.0%

26.3%

0.0%

17.3%

0.0%

5.3%

0.0%

0.7%

94.5%

100.0%

85.9%

100.0%

90.1%

41.4%

0.0%

50.4%

80.0%

48.8%

80.4%

0.0%

44.1%

60.0%

5.0%

0.5%

0.0%

1.9%

13.8%

0.0%

12.3%

0.0%

4.8%

7.4%

0.0%

5.0%

0.0%

12.0%

6.6%

0.0%

0.6%

0.0%

7.7%

79.3%

86.8%

100.0%

88.2%

0.0%

80.6%

15.0%

2.9%

0.0%

11.1%

0.0%

4.2%

64.3%

83.9%

100.0%

77.1%

0.0%

76.4%

12.5%

7.8%

0.0%

11.4%

0.0%

4.8%

* Subgroups: AR - Academic Regional Perinatal Centers; NS - Non-academic Specialty; NI - Non-academic Intermediate; NB - Non-academic Basic