Requirements for California Hospitals to Participate in a CMQCC-sponsored Quality Improvement Initiative

CMQCC is the designated Perinatal Quality Collaborative (PQC) for the state of California. Perinatal Quality Collaboratives are a statewide network of teams that are established to improve perinatal health outcomes. CMQCC was established in 2006 with a mission to end preventable morbidity, mortality and racial disparities in California maternity care. One of the methodologies utilized by CMQCC to accomplish this mission is the Learning Initiative/Collaborative directed at mitigating one of the drivers of perinatal morbidity/mortality with a goal of improving birthing outcomes. Centers for Medicare and Medicaid Services (CMS) implemented a new hospital reporting requirement beginning in 2022 to assess hospital participation in a structured statewide PQC. One of the ways to indicate participation with CMQCC is the active enrollment in a CMQCC-sponsored quality initiative as outlined here.

Enrollment

  1. Submit a signed Participation Agreement.
  2. Convene a Quality Improvement (QI) team.
    • Identify a Nursing Champion.
    • Identify a Provider Champion.
    • Identify a Quality Champion as indicated.
    • Identify other front-line and multidisciplinary leaders.
  3. Submit a team roster including contact information and role designation.
  4. Attend a QI initiative Kick-off Event.
  5. Complete baseline assessments as indicated.
    • Recommendation: Identify patient and/or community partners.

Meeting Participation

  1. At least one member of the QI team must be active participants for:
    • Kick-off and closing celebrations.
    • A minimum of 80% of scheduled CMQCC-sponsored QI initiative meetings/webinars.
    • QI coaching/outreach calls.
    • Presenting hospital-specific progress reports at scheduled QI initiative meetings.
    • Develop and present QI initiative journey report at closing celebration.
  2. Participate in shared learning with other organizations in the QI initiative.
    • Recommendation:
      • Engage in transparent data and resource sharing with QI initiative participants.
      • Serve as an initiative coach/mentor for other QI initiative participants or future QI initiatives.

Data Submission

  1. Submit a signed data use agreement as part of the QI initiative Participation Agreement prior to the Initiative kick-off.
  2. Submit timely data as outlined by the QI initiative.
    • Data will be contained within the Maternal Data Center as appropriate.
    • Data will be sufficient in content and quality to determine meaningful use.
    • Data will be stratified by measures as outlined in the QI initiative to ensure health equity in the outcomes (e.g., race, ethnicity, language, payor, etc.).
    • Data will be reviewed on a timely basis as outlined by the QI initiative (i.e., monthly, quarterly, etc.).
    • Data outcomes will be shared with staff and providers as indicated by the QI initiative.
    • Recommendation:
      • Transparency in data sharing during QI initiative meetings.
      • Identify and monitor QI initiative balancing measures.
      • Identify opportunities to share data outcomes with patients/community partners.

Quality Initiative Time Period

  1. Complete and submit structure and process measures as outlined by the QI initiative.
    • Develop/implement annual review process for structure/process measures.
  2. Review/implement resources provided by QI initiative.
  3. Complete charter, driver diagram, as outlined by the QI initiative.
  4. Implement/evaluate PDSA QI cycles as indicated by the driver diagram.
  5. Develop and implement a QI initiative communication plan for staff/providers.
  6. Develop and implement a QI initiative education plan for staff/providers.
    • Implement onboarding QI initiative education plan for new hires.
    • Implement annual review process as indicated for quality initiative (i.e. skills day, privileging process, etc.).
  7. Implement/evaluate at least one new policy/practice change.
  8. Develop and implement evaluation plan.
    • Identified improvement in an established process/outcome measure.
    • Include intervention plan for identified opportunities for improvement.
  9. Hospitals who complete the QI initiative in its entirety will be considered as “participating in a QI initiative.”
    • Develop and implement feedback processes for patient and community input as appropriate.

Sustainability

  1. Complete and submit sustainability plan as outlined by the QI initiative.
  2. Complete and evaluate 30, 60, 90-day audits as outlined by the QI initiative.
  3. At a minimum complete evaluation review/reaffirmation of structure/outcome measures annually and develop remediation measures as indicated.
    • Outcome data will be reviewed with an equity lens through appropriate stratification options as indicated by the initiative.
    • Results shared with staff/providers at least annually.

 

Learn more

If your institution is interested in joining a CMQCC collaborative, please email info@cmqcc.org.