BORN is committed to improving the healthcare provided to mothers and children in Ontario. How do we do this? By equipping clinicians and administrators with information (i.e. data, reports, tools) they need to provide high-quality care - check out some examples below.
The BORN Maternal Newborn Dashboard (MND) was implemented in November 2012 in all Ontario hospitals providing maternal newborn services. The MND interface in the BORN Information System (BIS) allows hospitals to view their performance on six standardized Key Performance Indicators (KPIs) in relation to established benchmarks and make comparisons with hospitals of similar birth volume and level of care.
|Maternal Newborn Dashboard Key Performance Indicators|
|1. Proportion of newborn screening samples that were unsatisfactory for testing|
|2. Rate of episiotomy in women who had a spontaneous vaginal birth|
|3. Rate of formula supplementation from birth to discharge in term infants whose mothers intended to exclusively breastfeed|
|4. Proportion of women with a cesarean section performed from ≥ 37 to < 39 weeks’ gestation among low-risk women having a repeat cesarean section at term|
|5. Proportion of women who delivered at term and had Group B Streptococcus (GBS) screening at 35-37 weeks’ gestation|
|6. Proportion of women who were induced with any indication of post-dates and were less than 41 weeks’ gestation at delivery|
During the four years post implementation we’ve seen statistically significant improvements in the provincial rates for KPI 1, KPI 2, KPI 4, KPI 5 and KPI 6. This translates into improved practice and increased quality of care to mothers and babies - fewer unsatisfactory newborn screening samples, fewer elective repeat cesarean section prior to 39 weeks in term low-risk women, fewer inductions for post-dates prior to 41 weeks, a reduction in the rate of episiotomy in women having a spontaneous vaginal birth, and an increase in women having their GBS screening between 35 and 37 weeks gestation.
There were not significant improvements in the rate of formula supplementation in women who intended to exclusively breastfeed (KPI 3). The lack of effect noted with KPI 3 may be related to the practice issue itself. Breastfeeding supplementation is a complex problem that relies on many different care providers giving the same message and consistent support which isn’t always possible.
These results will help to inform the design of future audit and feedback systems created to target other performance issues, as well as support development of specific knowledge translation strategies to support practice change in hospitals. Additional research is currently underway to identify the factors significantly associated with differences in hospital performance before and after implementation of the MND. The results of this research have major implications for policy, practice and future research because we can target clinical issues which are a priority for organizations like Health Quality Ontario. If we want to improve the health system, we need to observe what is happening, identify evidence practice gaps, and track progress and sustainability of practice change.
Non-Invasive Prenatal Testing (NIPT) became available to Ontario women on a private-pay basis in late 2012. This screen analyzes cell-free fetal DNA in a maternal blood sample to detect common aneuploidies (trisomies 21, 13, 18 and sex chromosome aneuploidies), as well as some rare targeted genetic conditions. In January 2014, The Ontario Ministry of Health and Long-Term Care (MOHLTC) began to approve NIPT testing for those women whose pregnancies were deemed to be at high risk for aneuploidy. Initially this test was only done out-of-country but it was eventually patriated to Ontario-based laboratories in late 2015. Women who do not meet the risk criteria outlined by the MOHLTC are able to access NIPT, but must pay privately.
NIPT has been launched in Ontario and other jurisdictions without a great deal of population-based outcomes and performance analyses. As Ontario’s maternal-child registry, BORN is working closely with the NIPT vendors to collect the results of NIPT testing data to-date, which can then be linked to pregnancy outcomes to determine the performance of NIPT in this population setting. The data collection is taking a two-phased approach: BORN has received a limited set of historic (prior to patriation) NIPT testing data; linking and matching of this dataset to the BORN Information System (BIS) aggregate will be ongoing, and will be followed by analysis of outcomes and performance of NIPT as compared to pregnancy outcomes collected in the BIS. In the near future, NIPT vendors will upload regular and more detailed data . Additionally, to enhance the performance analysis, BORN is partnering with Ontario’s cytogenetics laboratories to collect the diagnostic cytogenetics results from both prenatal and neonatal testing.
The NIPT data, combined with the BIS pregnancy outcomes and further cytogenetics data, will allow BORN to assess true population performance of NIPT in Ontario. This analysis will inform the MOHLTC in policy decisions around prenatal screening in Ontario, and more importantly, will allow care providers and women to better understand the best role for NIPT in their pregnancy care.
Data like this is big news! And BORN can claim part of the success. Historically, IVF data was housed in a database called the Canadian Assisted Reproductive Technologies Registry (CARTR). In January 2013, however, BORN assumed responsibility for hosting the database (renamed ‘CARTR Plus’ to reflect the upgrades).
Advantages for Clinics: Data from the 32 IVF clinics in Canada is now entered into the BORN Information System (BIS). The result?
- Immediate access to their own data
- Tools to monitor data quality
- Clinical reports including indicators of performance and quality of care
- The ability to compare their results to the aggregate data of clinics across Canada
- Birth outcome information available for those who have had a successful IVF cycle through a direct linkage to the perinatal data within the BIS (*Ontario clinics only)
In addition, BORN presents a summary of each year’s data at the Annual Meeting of the Canadian Fertility and Andrology Society.
What's Next? BORN is working with the CARTR Plus Reporting and Outcomes Workgroup to develop the CARTR Plus Dashboard. This innovative audit and feedback tool will monitor six key performance indicators (KPIs) of IVF treatment to allow clinics to see their performance ‘at-a-glance’ and to develop strategies for quality improvement when indicated. The dashboard will contain the following KPIs along with targets for meeting the standards of care for IVF:
|CARTR Plus KPIs under Consideration|
|1. Moderate/Severe Ovarian Hyperstimulation Syndrome Incidence (OHSS)|
|2. Blastocyst stage embryo survival rate after thaw by cryopreservation method|
|3. Primary IVF - Pregnancy rate for patient|
|4. Primary IVF -Live birth rate for patient|
|5. Secondary Cycle - Frozen embryo transfer implantation rate by age of oocyte provider at time of embryo cryopreservation when blastocyst stage embryo is transferred|
|6. Multiple pregnancy rate|
Through the CARTR Plus Steering Committee, BORN is committed to providing excellence in data quality and reporting of IVF treatment across Canada.
A bleary-eyed new mom toting her 3-day old baby arrives at the clinic for his follow-up appointment. The physician is asking her questions, but it's hard to concentrate: the baby is fussing - he’ll want to eat soon; she forgot to put change in the meter; she’s worried the car seat might not be in right. She tries to provide as much information as possible, but between exhaustion and distraction, the details escape her.
BORN’s Newborn Profile on Discharge Report can be given to mothers when they’re discharged from the hospital. This concise summary of the labour, birth, and early newborn experience is helpful for families and provides all the information a physician or nurse practitioner will typically need for the first follow-up appointment. Moms can take this report to the appointment and give it to the care provider or just refer to it as needed.
Leanne McCullough, Value Stream Leader, Women and Children’s and Surgical Services at St. Thomas Elgin General Hospital, describes the report as “a comprehensive summary that’s perfect for follow-up visits.” Nurses at St. Thomas used to manually complete a carbon-copy discharge form. Now they print the Newborn Profile on Discharge Report from the BORN Information System (BIS) saving time and money. During their last Maternal Newborn Child & Youth Network (MNCYN) program review, McCullough says the physician group performing the review was impressed with the practicality of the report, commenting ‘The most important information is captured in ONE report’.
Sue Snowden, Manager of the Woman and Child Care Unit at Grey Bruce Health Services in Owen Sound, says the nurses on her unit used to manually complete a newborn summary sheet and fax it to physicians. Problems inherent with faxing (time spent waiting, busy signals, failed transmissions, security of personal health information) made this process inefficient. Now nurses print the Newborn Profile at Discharge Report from the BIS – a process built into their discharge process – and every mom goes home with her info. Snowden says physicians used to struggle to get information from exhausted moms who would arrive at their follow-up appointment in a sleep-induced ‘fog’. Now they have a concise written summary to refer to, making life a little bit easier for everyone.