The KyPQC Data & Analytics Workgroup is dedicated to establishing a data reporting infrastructure that supports the initiatives of the KyPQC Obstetrical and Neonatal Workgroups. The Data & Analytics Workgroup will administer ongoing support for the creation and evaluation of workgroup initiatives by assisting in the development of clear goals, identifying performance measures, and determining the impact of program outcomes relevant to goals.
Includes dates that hospitals implemented specific aspects of an initiative; collected at the start.
Includes denominator and numerator data for initiative specific measures that tracks the hospitals process in improving the quality of care; collected monthly.
Includes denominator and numerator data for initiative-specific measures that track the hospitals overall outcome in improving the quality of care; collected quarterly.
Includes denominator and numerator data for initiative-specific measures that track long-term improvements statewide; collected yearly.
Maureen Marra, MD, FACOG, currently works as Physician Advisor for Medical Staff Quality within the Baptist Health Louisville Quality and Outcomes Management Department. Her primary role is reviewing Women and Children’s Health cases to assure quality of care. Her interests include analyzing trends in outcomes data and utilizing evidence-based medicine for policy and procedure development. Dr. Marra previously worked in private practice in Louisville, Kentucky. She is a graduate of the University of Kentucky, College of Medicine, and completed her residency in OB/GYN at the University of Louisville.
Melanie Landrum, CPC oversees the Kentucky Hospital Association (KHA) data program and assists with all the data for all quality improvement initiatives at KHA and the Kentucky Hospital Research and Education Foundation (KHREF). She has be in healthcare for over 20 years in both the inpatient and outpatient settings. Landrum graduated from Western Kentucky University with a Bachelor’s of Science Degree. Moch is also a Certified Professional Coder through American Academy of Professional Coders (AAPC). Quality Improvement Areas – Data – Kentucky Quality Counts, KY Statewide Opioid Stewardship (KY SOS), Hospital Quality Improvement Contractor with CMS (HQIC), Readmissions, Community Coalition, Kentucky Perinatal Quality Collaborative and COVID‐19 data reporting.
The total number of women admitted to L&D each month
The total number of women screened for SUD/OUD in L&D each month
The number of women that screened positive on the 5Ps tool (or initial validated screening tool) each month
The total number of women who screened positive on a secondary follow-up screening tool each month
The total number of women who screened negative on the initial screening tool (5P's) but the parturient or infant has one of the following: positive tox. test, infant is symptomatic, or known maternal substance use during this pregnancy each month
The total number of women with a positive screen who received a brief intervention each month
The total number of births discharged each month
The number of infants determined to have an exposure to/be affected by SUD/OUD each month
The number of infants determined to exhibit clinical signs/symptoms of withdrawal from SUD/OUD each month
The number of symptomatic infants that required medication for treatment each month
The number of symptomatic NAS infants that required transferring for treatment each month
The number of NAS infants that required transfer to higher levels of care for other health issues unrelated to NAS each month