At BORN we believe in investing in partnerships. Collaboration is beneficial for all; sharing ideas, resources, and responsibilities builds momentum for healthcare change. Below, we highlight some of the ways we support the work of our maternal/child partners in Ontario.
In 2011, the Ontario Ministry of Children and Youth Services (MCYS) established an Applied Behaviour Analysis (ABA)* service and support program to address the needs of autistic children, youth and their families. To evaluate the impact of ABA services and provide feedback to care providers, clients and families, the Child and Adolescent Needs and Strengths – Autism Spectrum Profile (CANS ASP©) tool was selected. This tool is used multiple times during treatment as a measure of progress.
Working in partnership with the CHEO Autism Program, BORN expanded the BORN Information System (BIS) to collect CANS ASP data from 13 lead agencies across the province beginning in fiscal year 2015/16. The reports available in the BIS provide a snapshot of children’s progress based on CANS assessment at the individual and agency level. Provincial level reports are also generated and used to create quarterly reports for lead agencies and MCYS to facilitate evaluation of ABA service and support programs.
Next steps include working with our clinical and research partners to identify further opportunities to facilitate and improve care through this data. Potential projects include:
- Investigating the psychometric properties of the CANS used in Ontario (both full and abridged) at the population level
- Looking for potential associations between an autism diagnosis and data available in the BIS
*Applied Behaviour Analysis (ABA) uses procedures that have been demonstrated to help individuals learn new socially meaningful skills. ABA principles and teaching strategies include: reinforcement, prompting, prompt fading, chaining, shaping, and task analysis. In addition, generalization and maintenance allow new skills to be used in other environments and maintained over time.
Ontario Public Health Standards establish work requirements for public health units (PHUs), and Reproductive and Child Health is specifically called out. The standards include assessment and surveillance, health promotion and policy development, disease and injury prevention, and health protection . PHUs need good quality data to carry out these activities and meet the standards. This is where BORN comes in! Data from the BORN Information System (BIS) reporting portal is available in near real-time and is used by PHU epidemiologists, nurses, and Medical Officers of Health for decision making and program planning and evaluation.
In partnership with PHU subject matter experts, BORN developed a set of reports for PHUs with pre-defined indicators and released them in December 2013. These reports show values and rates for a number of core indicators at the PHU level (i.e. infant feeding, gestational weight gain, alcohol and substance abuse in pregnancy, maternal mental health etc.) and were met with enthusiasm by the public health community.
Building on the success of these reports, BORN then designed a unique tool to help users customize the data to meet their specific needs: the Public Health Unit Data Cube. The PHU data cube allows users to query birth record data from the BIS by specific denominators and outcomes. As an example, a user could query for a relationship between high BMI in a mother and infant outcomes such as birth weight, gestational age, or NICU admission etc. Or, related to health promotion, they could look at smoking rates by neighbourhood to know where to target resources.
BORN granted Public Health Ontario and 17 PHUs access to the new tool in May 2014. Access is contingent on a signed Data Sharing Agreement and completion of a tool that provides guidance on data storage and data handling procedures. By the end of March 2016, 35 PHU’s had access. The Medical Officer of Health (MOH) of each PHU is responsible for ensuring the proper use and protection of the BORN Ontario data.
Response to the data cube has been very positive. Advantages to using data from the BIS include: availability of indicators not captured in other population-level data sources, broad coverage of births in Ontario including those that occur outside of hospitals, and data that is highly relevant for monitoring of reproductive health in Ontario*. We continue to work with our public health colleagues to collect suggestions for future enhancements to these tools.
*Ontario Agency for Health Protection and Promotion (Public Health Ontario). BORN Information System:a data quality assessment for public health monitoring. Toronto, ON: Queen's Printer for Ontario; 2016.
The Baby-Friendly Initiative (BFI) Strategy for Ontario aims to enhance breastfeeding in the province. The Strategy provides hospitals and community health organizations with training, tools, guidance, and educational resources to adopt best practices for breastfeeding to help achieve the World Health Organization’s BFI designation. BORN has been collaborating with the BFI Strategy Implementation Committee since its inception in 2013 to ensure BORN data aligned with the BFI Strategy. BORN also facilitated self-service reporting on BFI outcomes, provided outcome data, and supported quality improvement work.
In April 2014, BORN revised the infant feeding data elements in the BORN Information System (BIS) to more accurately capture infant feeding experience from birth to discharge and to align with the BFI Strategy data requirements.
To standardize data requests and develop user-friendly BFI reports for hospital and midwifery users, BORN created BFI indicator definitions and specifications. Several BFI reports were launched in 2015-2016:
• Baby-Friendly Initiative Stats Report – launched June 16th 2015
• Baby-Friendly Initiative Indicators Status – Comparison Report – launched Oct 7th 2015
Each report provides site-specific rates for the following BFI indicators:
1. Rate of breastfeeding initiation (BI)
2. Rate of exclusive breastfeeding (A)
3. Rate of supplementation with documented medical indications (B)
4. Rate of supplementation with no documented medical indications (C)
5. Adjusted breastfeeding rate (ABF) - Includes infants exclusively breastfed + those supplemented for medical indications
The goal for BFI designation - 75% exclusive breastfeeding or an adjusted breastfeeding rate of 75% - is displayed in each of the reports. The reports are based on live births that occur in the reporting hospital.
Although the reports have been designed to present consistent data and are aligned to support the BFI strategy, each report has a different focus. The BFI Stats Report presents site-specific rates stratified by gestational age groups (37 weeks) and presents data by month, quarter, or fiscal year. The BFI Indicator Status – Comparison Report includes site-specific rates, as well as peer comparison rates for same level of care hospitals, similar volume of birth hospitals and LHIN and Ontario rates.
Data is key for monitoring quality improvement strategies. BORN, in support of the BFI Strategy, designed these reports to help hospitals identify evidence-practice gaps related to breastfeeding support, assess barriers and enablers to BFI best practice, monitor knowledge use and uptake of BFI best practice evidence, evaluate outcomes, and measure sustainability of BFI best practices.
BORN, supported by eHealth Ontario, launched ‘OMama’ in January 2016. OMama is a website and a mobile application (app) that connects women and families to trusted, evidence-informed pregnancy, birth and early parenting information (tailored to the health system in Ontario).
The OMama team, with the help of a project Advisory Committee, surveyed women and care providers about the information its website and app should contain. The response was impressive: 1,100+ people (including over 700 women and several hundred health care professionals) provided recommendations re: the content, functionality, and design of the OMama website and app. Health professionals representing obstetrics and family medicine, midwifery, nursing, pediatrics, social work, and prenatal education provided input.
Several months after launching OMama (spring of 2016), the OMama team reached out to users through a survey and several focus groups to determine: 1) if information on the website and app was easy to access and 2) if using OMama improved their experience and engagement in maternity care. Enthusiastic responses and over 20,000 visits to the website confirm that OMama is making a positive contribution to maternal and newborn care in Ontario.
Healthcare change requires three key ingredients in equal parts: opinion leaders involved in policy setting, high-quality data to help clinicians understand their practice, and local care providers engaged in making change. BORN contributes to each of these important areas through its work with the Provincial Council for Maternal and Child Health (PCMCH), regional maternal-child networks, and Local Health Integration Networks (LHINs).
Opinion Leaders for Policy Setting: In the 2014-16 time period, BORN worked with PCMCH on several initiatives. Members from BORN served on the following committees:
- Hyperbilirubinemia Quality-Based Procedure (QBP)
- Promoting Vaginal Birth QBP
- Low-Risk Birth Strategy
- Prenatal Screening Strategy
- Promoting VBAC
- Revision of the Ontario Perinatal Record
Committee membership is a practical way to effect change; recommendations from these committees frequently result in policy and/or practice change.
Data: Leaders need access to high-quality data to help them make decisions; BORN has it! BORN provided data to PCMCH to support committee work and other ad-hoc needs like the PCMCH Benchmarking report. BORN also granted ‘agent status’ to a PCMCH data analyst, allowing her to access raw data from BORN (improving capacity and efficiency).
Local Care Providers: BORN works with established regional networks including the Champlain Maternal Newborn Regional Program (CMNRP), the Southwest Maternal Newborn Child and Youth Network (MNCYN) and the Greater Toronto Area Obstetric Network (GTA-OBS) as well as LHIN regions with active maternal-child committees. These groups implement provincial recommendations and monitor progress via regular data output from BORN. Networks also determine regional-specific priorities and use data to monitor progress. See below for a snapshot of each regional network.
Champlain Maternal Newborn Regional Program
The Champlain Maternal Newborn Regional Program (CMNRP) is an integrated regional network that promotes evidence-informed, high-quality healthcare and services for mothers, newborns and families in the Champlain and South East LHINs.
One of CMNRP’s strategic directions for 2015-2018 was to increase its utilization of maternal-newborn data to effect system and facility change and to track progress on regional and broader provincial care initiatives. Specific objectives associated with this priority include:
CMNRP gets regular cuts of data from BORN and these are used by the CMNRP team members and CMNRP committees and workgroups as needed, to monitor and evaluate the use of health services, quality of care and trends in patient outcomes in the region of Champlain and South East LHINs.
CMNRP’s first regional report was generated in January 2016, providing hospitals with their data as well as LHIN-level data on the six BORN Maternal-Newborn Dashboard Key Performance Indicators for quarters between October 2012 and October 2015.
In 2012, the Champlain LHIN added one of the KPIs to its hospitals’ accountability agreements - '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' (KPI4). The Champlain LHIN, as well as the South East LHIN, have seen significant improvements in this particular indicator, reaching “yellow” and “green” status during various quarters over the past three years.
Since the mere sharing of data is insufficient to produce significant change, regional performance is discussed at the various CMNRP committees to engage partners and share barriers and facilitators to implementing these best practices. In addition, BORN data is a key agenda item presented and discussed in collaboration with a BORN Coordinator at CMNRP site visits to its regional hospitals. CMNRP also formed a Community of Practice for regional hospitals’ Chiefs of Obstetrics where BORN data and indicators are reviewed and deliberated with sharing of quality improvement strategies.
South Western Ontario Maternal, Newborn, Child and Youth Network
The purpose of the South Western Ontario Maternal, Newborn, Child and Youth Network (MNCYN) is to enable the consistent delivery of safe, quality maternal, newborn, child and youth care across the region. This is achieved by promoting and advocating for a consistent standard of care.
In early 2016, MNCYN launched a regional initiative to address one particular key performance indicator (KPI) – the '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. The MNCYN Quality Improvement Working Group (Perinatal) lead this initiative and has all 15 hospitals with obstetric services in their region on-board (i.e. clinical leaders and physicians from each hospital are engaged).
Felix Harmos, MNCYN Regional Leader, is quick to point out that the strategies being implemented – from physicians championing the change to policy work regarding operating room allocation – come from the organizations themselves. No one is imposing change, it’s coming from within the organizations. Harmos believes this helps the solutions ‘take root’. The MNCYN sub-committee will monitor progress, identify the best-performing sites, and ask these sites to share their knowledge/practice solutions across the region.
Harmos credits other networks like the Champlain Maternal Newborn Regional Program (CMNRP), who have done concerted work on this same indicator (KPI4), for their leadership and hopes the networks will continue to share their successes with each other.
Greater Toronto Area Obstetric Network
In early 2014, obstetric care providers across the Greater Toronto Area (GTA) met to establish the new GTA-OBS network. This group’s aims are to work on quality improvement and standards of care, share data to monitor outcomes and collaborate on research. Throughout 2014 and 2015 the group established and monitored key performance indicators related to NICU admissions, cesarean section in second stage of labour, anal sphincter injuries, postpartum hemorrhage, shoulder dystocia and cesarean section in low-risk nulliparous women.
They learned from their initial look at their data that performance varied among partner organizations so they established a number of quality improvement programs to try and improve practice. Educational modules on postpartum hemorrhage as well as episiotomy and tears were shared among the group. A common protocol for the management of women with gestational diabetes across the GTA was implemented.
Because they determined that diabetes, hypertension and obesity were important clinical issues across the entire GTA, a group of researchers from this network developed a CIHR grant application for descriptive and clinical trial research to learn more about best practices in caring for these women. The network was augmented by the addition of researchers from the Hamilton area and has become SOON (Southern Ontario Obstetric Network). This group is anxious to get started with their research.
The GTA group also recognizes the power of collaboration and sharing beyond their boundaries. They have been networking with the Champlain Maternal Newborn Regional Program in Eastern and Southeastern Ontario, the Provincial Council for Maternal and Child Health and the South West Maternal Newborn Child and Youth Network in London to share indicators and educational initiatives to standardize care across Ontario – a true community of practice.