Redesigning the Perinatal Morbidity and Mortality Review Process: Improving Outcomes for Moms and Babies

The goal of morbidity & mortality reviews (M&Ms) is to identify correctible deficiencies in provider practices, system failures, and patient behaviors in order to improve future patient outcomes. It is widely recognized that M&Ms lack standardization and formal guidelines which ultimately negatively impacts the care moms and babies receive. The UIC Perinatal Center mapped the current process and conducted a process improvement initiative to improve M&M reviews.

Anna Calix received her BA from Augustana College and her MPH from the University of Illinois at Chicago. She has devoted most of her career to the perinatal field. Anna worked as a research specialist for the UIC Perinatal Center, where she collected and analyzed perinatal morbidity and mortality data for 8 network hospitals, prepared cases for morbidity and mortality reviews, and coordinated hospital accreditation visits. She founded Gifts from Liam after her first child was stillborn unexpectedly at 40 weeks’ gestation. Additionally, Anna is the cochair of the Perinatal Alliance of Bereavement Care Providers of Illinois, a peer companion and support group facilitator for the Star Legacy Foundation, and has conducted and participated in several pregnancy and stillbirth research studies.  She has shared her experience at numerous conferences and workshops educating providers on improved perinatal bereavement practices.

Joanne Sorce received her BA from DePaul University, her BSN from the University of Illinois at Chicago, and her MSN from Benedictine University.  Her clinical experience includes working in labor and delivery, postpartum, and neonatal intensive care units.  She worked as a Nursing Outcomes Improvement Facilitator in the labor and delivery, postpartum, and nursery units at Memorial Medical Center in Springfield, IL.  In this role, Joanne guided new nursing staff through orientation and encouraged their professional development. She wrote and implemented evidence based nursing policies for the units. She also taught basic fetal monitoring for residents and nursing staff.  She joined UIC as the Director of Outreach Education for the UIC Perinatal Center and then became the Network Administrator.  As the educator, Joanne was responsible for developing and implementing educational offerings on a variety of obstetric and neonatal topics.  As Administrator, she is responsible for providing oversight of the perinatal care at the 8 member hospitals. Joanne has co-authored two articles on perinatal bereavement and delayed bathing which have been published in the Journal of Neonatal Nursing. 

Ms. Calix and Ms Sorce have disclosed that they do not have any real or perceived conflicts of interest in making this presentation.

Dr. Terrell Hatzilias: My name is Dr. Terrell Hatzilias, and it’s my privilege to introduce Anna Calix and Joanne Sorce. Anna Calix received her BA from Augustana College and her MPH from the University of Illinois at Chicago. She has devoted most of her career to the perinatal field. Anna worked as a research specialist for the UIC Perinatal Center, where she collected and analyzed perinatal morbidity and mortality data for 8 network hospitals, prepared cases for morbidity and mortality reviews, and coordinated hospital accreditation visits.

She founded Gifts from Liam after her first child was unexpectedly stillborn at 40 weeks gestation. Additionally, Anna is the co-chair of the Perinatal Alliance of Bereavement Care Providers of Illinois, a peer companion and support group facilitator for the Star Legacy Foundation, and has conducted and participated in several pregnancy and stillbirth research studies. She has shared her experience at numerous conferences and workshops educating providers on improved perinatal bereavement practices.

Joanne Sorce received her BA from DePaul University, her BSN from the University of Illinois at Chicago, and her MSN from Benedictine University. Her clinical experience includes working in labor and delivery, postpartum, and neonatal intensive care units. She worked as a Nursing Outcomes Improvement Facilitator in the labor and delivery, postpartum, and nursery units at Memorial Medical Center in Springfield, Illinois. In this role, Joanne guided new nursing staff through orientation and encouraged their professional development. She wrote and implemented evidence-based nursing policies for the units. She also taught basic fetal monitoring for residents and nursing staff.

She joined UIC as the Director of Outreach Education for the UIC Perinatal Center and then became the Network Administrator. As the educator, Joanne was responsible for developing and implementing educational offerings on a variety of obstetric and neonatal topics. As Administrator, she is responsible for providing oversight of the perinatal care at the 8 member hospitals. Joanne has co-authored two articles on perinatal bereavement and delayed bathing which have been published in the Journal of Neonatal Nursing.

Anna and Joanne’s presentation is titled, Redesigning the Perinatal Morbidity and Mortality Review Process: Improving Outcomes for Moms and Babies. Thank you very much.

Joanne Sorce: Hello and welcome. Today we are presenting our business process improvement project conducted at the University of Illinois Administrative Perinatal Center, which we will refer to as the APC thereafter. Our project is redesigning the perinatal morbidity and mortality review process, improving outcomes for moms and babies.

We have divided our presentation into two parts. The first part is a general overview of our project, and the second part is a deep dive into the steps of our process improvement. Let’s begin.

The UIC APC is one of 10 perinatal centers in Illinois. Every hospital in Illinois belongs to a perinatal center. The perinatal centers are required by the Illinois Department of Public Health or IDPH to conduct M&M reviews at their hospitals based on the volume of deliveries. There is no standardized format for executing M&M reviews on a state level, and the UIC APC also lacks standardization, and therefore each process varies across the network hospitals.

The goal of a project was to establish, organize, streamline, and standardized data collection process for the APC in anticipation of preparing for and executing M&M reviews.

The approach to reach our goal was to first map the steps in the current process. We then conducted focus groups with representation from each hospital for feedback and developed a transition action plan to prioritize potential solutions, assigned owners to tasks and established a timeline for implementation.

There are five key findings in analyzing the current M&M process, including not all cases are reviewed during the M&M review meeting, lack of clarity around APC and hospital roles and responsibilities. ePeriNet database inputs are not regularly audited, excessive number of templates, lack of established processes and timelines.

We selected a series of metrics to compare the current and targeted states. We looked at the number of templates for all eight hospitals, number of steps in the process, total average cycle time, we also looked at our data that was entered into ePeriNet, whether that was done within 30 days, and we did this for our PMRs, our SMM forms and our VPT, and Anna will talk further about the definitions of these terms.

After analysis of our current processes, we arrived at the five top recommendations for improvements were define APC team roles and communicate them with hospitals. Standardize and minimize documentation required hospitals in advance of reviews and define deadlines. APCs were to create and maintain a standard case and holdover list. Establish a dedicated subject matter expert to complete required forms and action plans to be input into ePeriNet within 30 days of the M&M review, and the APC was to audit ePeriNet data entries on a timely basis.

The last step of our process improvement project was developing an action plan for transitioning into the new M&M review process. We listed specific action items that needed to be completed, which staff member was responsible for those items, and a timeline for completion.

In Illinois, every hospital belongs to an administrative perinatal center. This is a program that was developed by the Department of Public Health, and it requires that APCs conduct reviews at their hospitals based on volume of deliveries. Again, as previously mentioned, there is no standardized format for executing M&M reviews on a state level and the UIC APC also lacks standardization, and therefore each process varies across the network hospitals.

For instance, each hospital used their own set of case review templates, roles weren’t defined as to who was supposed to be doing what. There was a lot of duplication of effort. Information was often lacking and significant time was lost searching for the essential case information, and a lot of times this was even done while the M&M was being conducted, which led us to not complete the cases that we needed to review. Often these cases were put on hold, but they were lost and it was very difficult for us to track which cases were on hold, which cases we had done and which ones we still needed to do.

The goal was to establish and organize, streamline, and standardized data collection process for the APC in anticipation of preparing for and executing M&M reviews. Perinatal regionalization is a strategy to improve maternal and perinatal outcomes. Regionalization ensures that there are hospitals that can provide a full range of services for pregnant women and their babies in a geographic region. With perinatal regionalization, each hospital receives a designation indicating the level of care they can provide. State health agencies often manage regionalized systems, but sometimes a hospital network or a nonprofit organization oversees the system in its region. Variability in the application of established criteria makes it a challenge for many states to monitor where the high-risk deliveries are occurring at appropriate facilities.

Currently, Illinois has a robust perinatal regionalization system that includes 10 administrative perinatal centers that supervise 122 obstetric hospitals in Illinois. This has helped to provide quality care to perinatal patients in Illinois since the perinatal regionalization system inception in 1976. Illinois Code 640 requires every hospital to be designated at one of four levels of care based upon its functional capabilities and its capacity to serve pregnant women and newborns at risk for poor birth outcomes. Hospitals with no prenatal services are designated as a level zero, level 3 is the highest level of care serving the most high-risk complex and critically ill population of pregnant women and babies. Examples of other states with regionalized perinatal systems include California, New York, Ohio, and South Carolina.

The UIC APC is made up of eight hospitals. Four are level 3s, which provide the highest level of care. Three are level 2s, which provide care for moms and babies with selected complications. We also have a level zero which provides no obstetrical or neonatal services. The frequency of M&M reviews is based on the delivery volumes. IDPH code requires one review per 500 births.

The objective of a well-run M&M conference is to identify adverse outcomes associated with medical error, to modify behavior and judgment based on previous experiences, and to prevent repetition of errors leading to complications. Despite over a century of shared experience with M&M conferences among medical centers, many of the limitations of the M&M conference still exist today.

These include haphazard retrospective collection of data, focus on isolated and anecdotal events without consideration of previous similar events, recall bias, lack of meaningful audit, narrow focus on individual performance, lack of system-based thinking and lack of multi-disciplinary involvement. It is widely recognized that these issues continue across all healthcare sectors, and we recognize that these issues are seriously pervasive in our M&M review, which led us to embark on the process improvement project to improve the quality of our M&Ms, which ultimately will improve outcomes for our mothers and our babies.

Anna Calix: Hi, everyone. Thanks for being here. Just a review of what process improvement is as a concept, it’s founded on the principles of lean, and the lean philosophy refers to the idea that streamlining and eliminating ways from administrative and business processes should be implemented wherever possible. There are several different types of waste that can be observed in business processes. These include waiting, overproduction, rework, motion, over processing, intellect, inventory, and transport.

In our analysis, we found that all types of waste were found within our operations. We recognized that there was a need for improvement of the process, but we didn’t even know where to begin. We collaborated with the university’s business process improvement shared service to develop a strategy in improving our M&M process.

There are four phases to the process. The prep phase is to define the problem and the scope of the project. The planning phase is essentially mapping out the project. During the analysis phase, which is the most substantial portion of your project, you collect data and analyze your current process, followed by designing what your desired future state process will look like. In the close phase, you’re putting all the pieces together and projecting what your improvement outcomes will look like.

Phase zero, the prep phase. In this first phase of the process improvement project, you have to ensure that the problem is well defined and understood by all parties involved, that entails defining the problem, what you hope to achieve, the high-level process overview. Where the particular process you’re looking at improving begins, and also then what triggers the end. You define who the stakeholders are, the financial impact of your process, and any potential barriers to the successful implementation of your process improvement.

It was also important to identify what the process performance measures were. Some typical performance measures would be survey responses or cycle time as well as timelines. You do that so you are able to compare and see if your improvement worked. We concluded in our analysis that there really was no established performance measure of our process nor was there a timeline in place. Those factors in and of themselves were red flags that we needed to really improve our process.

It’s easy to want to jump right into the process and start with your analysis, but this part of the process is really important because you need to identify whether or not a given problem that you know exists is a problem that actually needs to be solved if it even can be solved and whether or not it’s worthwhile to solve.

The next phase, phase one, which is the planning phase, the main goal is to develop what’s called your project charter. That captures the reasoning for initiating a project otherwise called the business case. It clearly outlines the problem statement, objective or goal statement. You are going to be defining your timeline for your project, and also what falls within the scope of the project. Then we also started working out our focus group planning.

Our problem statement was that for the eight network hospitals, the APC currently uses 27 different case list templates and abstract templates to capture data for approximately 40 M&M reviews that are scheduled during the fiscal year. There is no established timeline for data collection. These duplications and delays pose a risk to the APC to maintain its grant funding.

The objective statement that we came up with for our project was to establish an organized, streamlined, and standardized data collection process for the APC in anticipation of preparing for and executing M&M reviews including the follow up data entry after the review.

Moving on to the next phase, which is the analysis phase, after we completed all of our preliminary work, getting things set up through the prep phase and the planning phase, we began this portion which is divided into two parts. To assess the current state of our M&M review process, we conducted the following steps. We identified process issues and then prioritized them. We established what our baseline metrics were going to be. We conducted our first focus group with the network hospitals, and then we mapped out what our current state process looks like.

In order to identify what the issues were in the current process, the APC team, individually brainstormed, everything that we could think of that was an issue along the process. We then came together and compiled a list of all the issues, and it turned out to be 46 issues that we found. We then divided these up into 10 different categories. A lot of the issues were things that were outside of our control, or weren’t specifically a part of this process. What we did was prioritize which issues were most important to address and ended up with a list of 15 issues divided over 5 categories.

These issue categories were the duplication of effort which were issues related to duplication of requests for charts and cases and abstracts and form receipt and form completion. For example, two different APC team members would be sending the same requests to the same hospital for the same case list. We saw that kind of duplication of work over and over again throughout this process.

Another category was unclear roles. There was a lack of clarity around APC team and hospital responsibilities in ownership of data inputs. Sometimes both APC member and a hospital member would be completing the same form or even two APC members. There was, even amongst the APC members, a lot of lack of clarity around roles and responsibilities.

The next category was lack of process and timeline. There was no established process for case list accuracy, IDPH reporting, hold over cases, ePeriNet data audits or hospital connections for transport disposition, and no established timeline for deliverables, including case lists, abstracts, charts, transport updates, and forms.

Just to elaborate a bit further on one phone regarding the transport dispositions, what would happen is that a baby would be born, for example, at hospital A, transported to hospital B. The baby would then die at hospital B, and then it was unclear whether that death was attributed to hospital A or B, who was supposed to enter that? Who was supposed to fill out the forms? Who was supposed to report that? Things like this, again, we just saw over and over.

Equipment and tech issues were another broad category, which generally referred to a lack of understanding on how to use the technical resources or equipment, or just wouldn’t work properly. Sometimes these things, these issues were as simple as the iPad wasn’t charged or someone forgot the passcode to get into the iPad, or we would encounter issues with internet connection.

Then the last category is administrative issues, and these were issues related to forms missing information or the forms not being available at all. Then inconsistent data input into the ePeriNet database for transport outcomes and dispositions. Again, that category of transport outcomes and dispositions coming up, and we see that overlap because transports would be reviewed at M&M. Oftentimes, one of these various forms would need to be filled out in association with that transport. Either the case wouldn’t be reviewed, so we wouldn’t have the form at all. The form would literally get lost, because we were often still using paper forms. Or you would have, for example, a gestational age of 37 on the transport record, a gestation of 36 on the PMR and then entered into the ePeriNet database, you would have 35. Just a lot of inconsistency there as well.

As mentioned before, we didn’t have any metrics in place to measure our process to evaluate whether or not we were successful in our process. We had to come up with a list of metrics. The number of templates for all eight hospitals, again, this has been touched on. There were 27 different templates because there was one maternal, one neonatal and one case list template for each hospital. Our target was to have only three total templates for use across all hospitals.

The number of steps in the process. Once we outlined every single step in our process, we had 67 activity steps and the goal was to reduce that to 54. The total average cycle time refers to how long it took to complete one full M&M cycle was on average 6.2 days per M&M review for one review. For all 40 M&Ms throughout the year, that equaled 247.4 days. Our goal was to reduce that to 4.9 days per M&M or 197.9 days a year.

The next metric was to increase the percent of data entered into ePeriNet within 30 days after the M&M review for PMR and SMM forms because those two forms were not fully complete until after the review where a disposition of the case would be assigned. The current completion rate for PMR forms was 2.6%, and for SMM forms was 10%, which is very low, and that’s because a lot of the fields were missing completion on these forms or they’d be complete, but they wouldn’t make it into the ePeriNet database within that 30-day timeframe. The goal was to increase both of these to 90%.

Then the last metric was increasing the percent of data entered into ePeriNet within 30 days after the event for the VPT form, which is a very preterm birth. That is a separate metric because the VPT form, the very preterm birth did not require a disposition from the M&M review.

Another part of this phase was conducting our focus group and that was interviewing additional stakeholders in the M&M review process made up of several members across our various network hospitals. It was administered by an independent third party, and this is just some of the top feedback items that they provided, which were similar in nature to those identified by the APC team.

The duplication of effort of the administrative staff and hospitals, confusion around the APC administrative staff role regarding the transport issue, again. Hospitals sending chart cases, abstracts to different APC members, that role, again, being confusing. One of the issues was that there was no clarity on staff availability outside of business hours. Oftentimes, these M&M reviews were occurring very early in the morning. The hospital members sometimes needed to get in touch with the APC staff late at night, the day before, or very early the morning of. They didn’t know how to go about reaching the staff or when they would receive a response to their inquiries.

Then, again, the final item being tech issues, and they specifically identified that the APC teams don’t know how to effectively use the resources such as Zoom, Box, iPads, bookmarks, Owl, and sound.

Lastly, which was really a very impactful point of our process for the team was seeing our current process map, which is what you’re looking at now. While you can’t read it, you can clearly see how overwhelming, cumbersome, and complex the process appears. There are actually 67 unique activity steps, which are identified by the individual boxes. The blue lines that you can see represent the flow of the process, and you may be able to see if you look closely where there are several loops, which are identifying rework in that cycle.

The rows are each a different stakeholder in the process. We have the APC team in green, and the team as a whole had its own row, because those were steps in the process that didn’t have a particular owner. Then we have the APC medical team. Then we have the APC coordinator, administrator, educator, and finally in blue is the hospital. The columns are different stages in the process defined by reaching a milestone event. For example, the first stage ends when the final case list has been decided on. Now from this, hopefully, you can tell why we really needed to streamline our process.

The second part of the analysis phase. The tasks we completed during this part of the process were to brainstorm solutions to the issues we identified, prioritize those solutions, conduct a follow focus group for hospitals to provide input on solutions, just like they did on the issues, and to develop our desired state map. Finally, outlining an action plan and timeline in preparation for the implementation of our desired future state.

We brainstormed 17 solutions to the issues that we had come up with, and then we ended up using the matrix you can see at the bottom of the slide in order to prioritize those solutions. All of the solutions were different tactics that we wanted to apply eventually along our process with the perinatal center, but we had to prioritize them based on ease of implementation, permanence of the solution, impact of the solution cost of the solution, to know which that we’re going to have the greatest impact and be more realistically implemented.

We did subdivide those 15 of the solutions into 2 categories, then the remaining two solutions were long term solutions that we would focus on after we had completed our implementation phase. The two categories of the suggested improvements that we ended up narrowing our list down to where to clarify APC and hospital roles and responsibilities for case lists, charts and abstracts, transport outcomes, PMR, SMM, and VPT forms and ePeriNet audits. The second category were under creating, updating and streamlining processes, documents, templates, and checklists to improve data gathering and M&M review meeting effectiveness.

The follow up focus group that we conducted with the network hospital members, like I said, were for them to brainstorm their suggestions on solutions to the issues. Again, they were largely similar to a lot of the input that the APC team had as well. They did specifically request that the APC work with hospitals to identify a dedicated subject matter expert at the hospital to complete the required forms to be input into ePeriNet within 30 days with the perinatal center checking after completion for accuracy.

Other feedback was again related to providing standardized templates, guides, checklists, procedure manuals, and then another common theme was the suggestion to approve upon communication and expectations by having detailed out office messages with information on how to be reached after hours and when a response could be expected.

What I know you’ve been anxiously awaiting to see is our future process map. The steps we reduced to 54 from 67. We did identify clear roles and establish timelines and all of this resulted in less duplication of effort, less time wasted, less rework and less wait times.

Based on all the work we did, the team developed an action plan that listed the specific activities that must be done to ensure the successful implementation of that new process, including who was responsible for each task with due dates for completion. A couple examples include creating the case list, maternal and neonatal abstract templates and identifying which hospitals do have tech challenges and finding workarounds for those hospitals, as well as providing a technical guidance document for each M&M review.

In the closing phase, we essentially wrapped up our project. We generated a summary report recapping our entire process, and then a more extensive final report detailing specific activities and metrics where we looked at what our projected outcomes were going to be.

This table shows what those projected outcomes were. The time savings included 27 and a half hours or 3.4 days equaling approximately $1,151 per M&M review saved. For 40 M&M reviews held every year, that time savings added up to 1098.7 hours or 137.3 days totaling over $46,000. We had an overall anticipated improvement of 20%. The 56% improvement that we projected definitely well exceeded that target. That concludes our process, and now we will go on to the implementation of the process and then some suggestions for future improvements.

Joanne: Our primary goal in conducting the process improvement was to establish and organize, streamline and standardized data collection process for the APC in anticipation of preparing for and executing M&M reviews, including follow up after the reviews due to two of three staff members who were part of the process leaving. Then on top of that, COVID. The transition was very difficult.

However, having said that, there were some positives. We did actually implement three templates. We streamlined that to have only one case study, one maternal abstract and one neonatal abstract. Also the PMR and SMM completion was more effective. Data was actually entered into ePeriNet within that 30-day guideline that we talked about. What was interesting to see was that the forms were completely filled out and that when we did have something that did not match from what the hospital had inputted, that didn’t match what they were sending us or what we actually wrote during the M and M&M process, we were able to capture that right away and fix that issue instead of waiting three years prior to their perinatal site visit. Anna.

Anna: Come back.

Joanne: It’s okay.

Anna: We decided to do this part together, and now Joanne is leaving me. Joanne didn’t say this, but she should be very proud of herself because Joanne was left all alone to implement this process, and she actually did a fantastic job given the circumstances. Since I’m on the screen with him, that’s my son, Liam. He was stillborn on his due date, and that happened while I was working at the perinatal center.

This project was very personally important to me because even before Liam was born, I was very passionate about improving perinatal outcomes, but then when I had Liam, even given the circumstances around his birth and death and knowing everything that I knew and being in the position that I was in, he still died. It’s definitely become a personal passion of mine to improve outcomes for moms and babies.

As far as future improvements go, or future opportunities for improvement, this project’s goal in particular was about eliminating waste, since we had to identify one goal. There is a lot more that can be done to improve this specific process as a whole, such as improving the quality of the meetings, reducing lead time or cost, improving customer service are just a few examples of other improvements.

Then there are some other less measurable, more intangible areas that need improvement. For example, M&M review culture. The goal in theory is to provide an open, confidential learning environment with the idea that it’s providing an opportunity to reduce and prevent morbid and mortality cases. The culture and tone of that review is supposed to be nonjudgmental. However, that is often not the case. Participants frequently express explicit or implicit blame for events that have occurred, and the reviews themselves are viewed as cumbersome, a hassle, an administrative test to complete a requirement to fulfill, and the actual purpose of the review is forgotten, which is to improve outcomes for moms and babies.

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