8 Steps to Successfully Implement New Perinatal Care Quality Measure ePC-06

The Joint Commission introduced a new perinatal eCQM this year: ePC-06 (Unexpected Complications in Term Newborns). It applies to accredited hospitals that deliver more than 300 babies a year.

The Joint Commission does not yet require hospitals to submit ePC-06 for accreditation purposes. We should note that, as a result, most hospitals we work with haven’t submitted ePC-06 this year and continue to submit PC-06 manually as a chart-abstracted measure

But given the rising concern over maternity care precipitated by the high maternal death rate in the U.S., more hospitals may be submitting ePC-06 to The Joint Commission in 2022 as they review the quality and safety of their own maternal and perinatal care. Given that possibility, we’re going to walk you through what you need to know to successfully implement ePC-06 in your own quality department.

Four Reasons ePC-06 is Complicated to Implement

ePC-06, which measures the percent of full-term newborns with unexpected complications, is unexpectedly complicated to implement. But when you look under the hood, you’ll understand why.

1. Constructing ePC-06 requires you to collect and map huge numbers of data elements before you send it electronically to The Joint Commission. For example, ePC-06 includes 34 of value sets, which are basically diagnoses, procedures and treatments for newborns. Each value set includes different codes that fall within a particular diagnosis, procedure or treatment. One value set, congenital malformations, has nearly 7,000 different codes alone. You must correctly map to each code and each data element in each value set to automatically pull that information into the numerator of your measure.
2. Virtually every data element you need to collect and map to requires a date and time stamp. In maternity care, when things happen is important to know for safe and effective medical care. When did the mother’s blood pressure rise? When did the fetus’ heart rate slow? When did contractions start?
3. Data could come from multiple IT systems. Complications could occur in lots of different places: the emergency room, during pre-admission, on the labor and delivery floor, in an operating room or in recovery. That means you must pull your data elements from different IT systems, not just the patient’s inpatient EMR, to capture what you need and reconcile any discrepancies in dates and times.
4. Calculating the numerator itself is complicated. Your quality department must stratify all your correctly dated and timed data elements in each of the value sets into two categories: newborns with severe complications, based on three different criteria; and newborns with moderate complications, based on six different criteria.

By comparison, calculating your ePC-06 denominator is a walk in the park. It’s basically all live births with a gestational age of 37 weeks or more, excluding newborns with congenital malformations, fetal conditions or demonstrated maternal drug use.

Know What You’re Getting into and Why

Now, before I share a few tips on how to implement ePC-06 despite its complications (or before you decide it’s too complicated to set up given your patient population), let’s mention why The Joint Commission is doing this and why your hospital or health system may want to consider it—beyond the imperative of providing high-quality care to this vulnerable population, of course.

The goal of the introduction of ePC-06 is clear: to identify and decrease the number of unexpected complications in term newborns at a time when the quality and safety of maternity care is in the national spotlight.

If you’re a hospital or health system that delivers a lot of babies, you already know how important that is and why this measure is critical. But by deciding to collect and report this measure electronically versus manually via chart abstraction, you’re going all in on improving maternal and child health.

Eight Tips to Successfully Implement ePC-06

With ePC-06, as with any quality measure, it’s critical to know what you’re getting into before you go all in. Here are a few ways to prepare.

1. Educate yourself and anyone who would be involved on the measure’s voluminous and exacting specification.
2. Know what data elements you need for your patient population, who documents those data elements and where they document those elements currently.
3. Compare what you have with what you need in terms of data elements, who’s doing the documentation and where those data elements are coming from.
4. Fill in the gaps between what you have and what you need. That may require educating clinicians. That may require adding new structured fields to patients’ EMRs. It may also require additional documentation from clinicians.
5. If you’re adding new fields and modules for clinical documentation purposes, you’ll likely need to revise your internal workflows to enable your clinicians to capture all the data you need without giving them extra out-of-workflow steps. Tell your clinicians they need to capture the missing data elements, but ask them the best way to do so—without requiring five extra clicks in a patient’s EMR.
6. Give yourself plenty of time for validation. You need to validate that the way you’ve mapped this measure is capturing the right data and giving you an accurate measure that you can send to The Joint Commission. Test and test again until you know that you have it right.
7. Compare your electronic results with your chart-abstracted results. What we’ve found in the past are discrepancies between the two. An eCQM like ePC-06 can spot documentation issues with the same chart-abstracted CQM that make the chart-abstracted CQM less accurate in terms of measuring performance. This is an opportunity to flag and correct any issues.
8. Like all eCQMs, you need to regularly monitor your ePC-06 results and provide that feedback to your clinicians to both improve documentation and care for moms and newborns.

Implementing ePC-06 is complicated, time-consuming and requires lengthy validation and testing. But making the effort will give you a more accurate calculation of your unexpected complication rate in full-term newborns. With that more accurate calculation, you can compare your performance with peer hospitals and drill down into your clinical protocols to improve outcomes for moms and their babies.