Rural Maternal Health Series: Engaging with Perinatal Quality Collaboratives for Rural Hospitals

Featured Speakers

	Kristen Dillon, MD, FAAFP, Chief Medical Officer, Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services
	Jacqueline Wallace MD, MPH, Perinatal & Infant Health Team, Maternal and Infant Health Branch, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), Centers for Disease Control and Prevention (CDC)
	Caroline Sedano, MPH, Perinatal Unit Manager at the Washington State Department of Health
	Annie Glover, PhD, MPH, MPA, Senior Research Scientist at the University of Montana Rural Institute for Inclusive Communities and a Research Associate Professor at the University of Montana School for Public and Community Health Sciences

Perinatal Quality Collaboratives (PQCs) are state or multi-state networks of multidisciplinary teams working to improve maternal and infant healthcare and outcomes statewide using quality improvement methods. PQCs work with hospitals, healthcare providers, and community members to improve the safety and quality of maternity care, often leveraging information from their state's Maternal Mortality Review Commission to inform the work. Speakers will address PQC work in more detail, as well as addressing examples and strategies for rural hospitals and their state's PQC to work together effectively.

Additional Resources

• National Network of Perinatal Quality Collaboratives
• ReviewtoAction.org

From This Webinar

• PowerPoint Handout
• Listen to or download an audio version [MP3]

Transcript

Kristine Sande: I'm Kristine Sande and I'm the program director of the Rural Health Information Hub. And I'd like to welcome you to today's webinar. This is the second in a four-part series that we're hosting in collaboration with the Federal Office of Rural Health Policy focusing on rural maternal health. Today's webinar, we'll highlight rural hospitals engaging with the perinatal quality collaboratives. We have provided a PDF copy of the presentation on the RHIhub website, and that's accessible through the URL on your screen.

At this point, I'd like to introduce my co-host, Dr. Kristen Dillon, who is the chief medical officer with the Federal Office of Rural Health Policy. Dr. Dillon.

Kristen Dillon: Hi, everyone. It is just great to have so many of you, hundreds of you joining us today and for this series. So as she mentioned, my name is Kristen Dillon. I am a rural family physician and the chief medical officer for the Federal Office of Rural Health Policy. Our office sits in the Health Resources and Services Administration or HRSA, which is part of the Federal Government's Department of Health and Human Services. Among our mission is the charge to work on improving access for rural communities to healthcare and fostering care that's effective, equitable, safe, and of high quality.

So in that realm, the highest priority work that I and many of my colleagues across HHS are doing is addressing the crisis in maternity care in our country. We can see how it's disproportionately impacting people of color and rural residents and many of us are focusing everything we can on what we as the federal government, what state governments, what health systems, what community members can do to improve this very concerning situation.

So one of the things we decided we could do was this four-part series of presentations that is really looking to improve knowledge, to improve your motivation and to improve skills among the staff working in rural hospitals around maternity care. For hospitals that have birth units, we're promoting and facilitating forward motion around the birthing-friendly hospital measure. It's a good measure. It looks at implementation of standardized care sets, which is what we'll be talking about in the April 9th webinar in two weeks.

And what we'll be doing today, which is engaging with your state's perinatal quality collaborative to learn from others and implement best practices. And then the fourth in the series on April 23rd is aimed at hospitals without birth units. We certainly encourage hospitals that are still offering birthing services and especially hospitals that are referral centers to also attend. We know that people who are pregnant, birthing, postpartum are going to present for care everywhere.

Just because your facility closed its birth unit does not mean the need to have capabilities in that area has ended. And we're working really hard on sharing information and listening so that we can develop a shareable, scalable solution that helps hospitals identify what's the scope of services you can safely offer, what's the equipment you need, how do you train your staff to do that, and how do you set up the right coordination to get patients where they need to go when the transfer is necessary.

So we look forward to having you here with us today and please join us in the future. We certainly are in conversations about everything we can do to pull together what we learned from this series and how we'll share that back. With that, it's my pleasure to introduce our speakers for today's webinar. Jacqueline Wallace, Jackie is a medical officer for the statewide Perinatal Quality Collaborative Program at the Centers for Disease Control and Prevention. Dr. Wallace is an obstetrician gynecologist physician with a deep commitment to woman centered care that respects ethnic and cultural diversity delivered through the lens of reproductive health as a human right.

Next, Caroline Sedano is a perinatal unit manager at the Washington State Department of Health. She uses she/her pronouns. In her current role, she supervises the State's Maternal Mortality Review Program, the Washington State Perinatal Collaborative, the Title V Perinatal and Women's Health Domains, the Birth Equity Project, and is the principal investigator for Washington's ERASE Maternal Mortality, PQC and MHI Grants. Prior to her time at the Department of Health, Caroline served as a CDC Public Health Associate for the Shoalwater Bay Tribe and a desk officer for the CDC's Global HIV/AIDS program. Welcome.

And finally presenting today will be Annie Glover. She/her. She's a senior research scientist at the University of Montana Rural Institute for Inclusive Communities and a research associate professor at the University of Montana School for Public and Community Health Sciences. She's the director of the Montana Perinatal Quality Collaborative, facilitates the Montana Maternal Mortality Review Committee and is the principal investigator of Montana CDC Perinatal Quality Collaborative grant, the HRSA/AIM capacity grant and Montana's Title V Maternal Child Health Block Grant needs assessment.

A tribal descendant of the Bitterroot Salish and Pend d'Oreilles, Dr. Glover's rural policy work has included serving as a state lobbyist for the Confederated Salish and Kootenai Tribes. So we'll start with Dr. Wallace giving us a high level look at perinatal quality collaboratives. And then we just are so grateful to have colleagues from Washington State and Montana joining us to talk about their state-based experience in a way that hopefully you the audience can connect with and learn from. So with that, I'll turn it over to Jackie.

Jacqueline Wallace: Thank you so much, Kristen, and good afternoon, everyone. Again, my name is Jackie Wallace and I'm the medical officer for the Perinatal Quality Collaborative Program at the CDC, which is also a bureau within HHS. Many of you may have participated in the first webinar of this series just a few weeks ago. And during that webinar I reviewed some basic information about PQCs. So I'm going to do my very best not to repeat too much of that information, but I'm hoping rather to build upon it and spend a little bit more time discussing the details of how hospitals collaborate together with PQCs.

We'll start today by reviewing the state of maternal health in the United States more broadly talk a little bit about the history of quality improvement in maternal child health. And then it's my pleasure to pass the microphone to the two state PQCs, which is really the highlight of this afternoon's talk. The next several slides review the state of maternal mortality in the U.S. and they are a courtesy of the Dr. Lisa Hollier of the Maternal Mortality Prevention team here at CDC. So many thanks to Dr. Hollier for her slides.

These data presented come from the Pregnancy Mortality Surveillance System or PMSS, which is within CDC. And you can see that the pregnancy related mortality has not improved over the last almost two and a half decades. And just of note, PMSS is using the specific definition of mortality being a death while pregnant or within one year of the end of pregnancy from any cause that's related to or aggravated by the pregnancy.

Equally, or maybe even more concerning is that there are persistent and significant disparities that exist in maternal outcomes in the United States. And you can see from this slide that's broken out by racial and ethnic groupings that the Native Hawaiian and other Pacific Islander, the non-Hispanic Black pregnancy related mortality is significantly higher than non-Hispanic White, non-Hispanic American Indian and Alaska Native also far exceeds that of non-Hispanic White, non-Hispanic, Asian and Hispanic.

These disparities, which I think is probably of most interest to this group is that these disparities, there are disparities that also exist based on geography. So the columns on the right, the two farthest columns on the right are mortality for rural areas which are almost twice as high as those of the large central and fringe metro areas. And this is really the real reason that we're here today.

Maternal mortality review committees have determined that about 84% of pregnancy-related deaths were determined to be preventable. So that's why we're working so hard. We can do something about this. And preventable is defined as there's some chance of the death being prevented by one or more reasonable changes to patient, family, provider, facility, system or community factors.

That's really the foundational reason I think why we do this work. And this slide shows perhaps a more practical reason why we're here today, and that's because CMS birthing-friendly designation. So in 2022, CMS established this birthing-friendly designation to describe high quality maternity care. And to earn the designation, a hospital or hospital system needs to respond to the question that's there on the slide.

Do you participate in a statewide or national Perinatal Quality Collaborative? And also do you implement patient safety practices or bundles? And the hospitals have the choice to answer yes no or not applicable. So that's what we're here for today is to delve into the Perinatal Quality Collaborative portion of that question and talk a little bit more about what that means.

So to start that conversation, I'm going to just give a really, really quick overview of the history of perinatal quality improvement. This maternal child health QI... Well, really QI in general in the United States really took off in the late '90s with a couple of really important reports published by the Institute of Medicine. And in 1997, the first Perinatal Quality Collaborative was formed in California. Throughout the 2000s, there was growth of perinatal QI largely spearheaded by professional organizations and states.

Throughout the 2010s, there came additional requirements from the Joint Commission and also CMS that propelled perinatal QI. And then by the 2020s, bringing us up to the present, there is now a Perinatal Quality Collaborative in every state. CDC does support PQCs and also the National Network of PQCs. So a brief review of what exactly is a PQC. So PQC is a state or multi-state network of multidisciplinary teams. The teams are generally made up of perinatal care providers, public health professionals, and community members and community-based organizations that are working together to improve population level maternal and infant outcomes.

So PQCs address gaps and reduce variation in care. And it's really critical because variation in care is a big driver of health disparities. There's variation in care at the hospital level, at the patient level, and PQCs really help hospitals address care processes that may contribute to the variations in outcomes.

And they do this through the use of quality improvement methods. So where are PQCs? Well, as I mentioned everywhere. Based on reporting from September of 2023, 76% of all birthing hospitals in the U.S. participate with their state PQC. However, there is quite a lot of variety in what the shape and structure and activities of a PQC. There's a big range in experience. As I mentioned, the first PQC was formed in 1997. The youngest PQC was formed in 2024.

PQCs are sometimes housed within the Department of Health of a state or often within an academic institution. There are some PQCs that are standalone non-profits. Some are housed within the State Hospital Association. And oftentimes the PQCs are actually a formed from a partnership of these different actors. So I do understand it can make it a little difficult to actually find a PQC.

So I really wanted to highlight this map. This map is from the National Network of PQCs, and you can see the link is right there and we're going to try to demonstrate this interactive map to you. So Mackenzie, if we can try to go to the NNPQC map.

So when you go to the NNPQC page, you have to scroll all the way down to the bottom. It's not exactly intuitive, but just you get to this nice map. If you hover over a state, like if you go over Texas, it will show you the Texas Collaborative for Healthy Mothers and Babies. And you're able to click on that and you can see the contact information to the left. So hopefully this would make it easier for you to find your state PQC if you're looking to connect with them.

PQCs implement or support quality improvement initiatives and they're supporting the hospitals as the hospital teams implement quality improvement activities. So a PQC initiative includes these three pillars. There's the collaborative learning, the rapid response data, and the quality improvement science support. So for collaborative learning, PQCs use this collaborative learning model where the teams are doing a lot of sharing and learning from each other.

And when I say teams, I mean the hospital teams. So PQCs are great at bringing hospital teams together and providing information. So lots of webinar series. Some PQCs will provide simulation training. There are often kickoff meetings or large annual meetings that bring folks together. And PQCs will also push out newsletters and podcasts, all in an effort to get out information about best practices.

Often hospital teams often talk about how it's the collaborative learning. That's a huge one of the best parts about all of this learning because the teams share their challenges, they share their successes, they share what works and what doesn't work, and it's a tremendous learning space for hospital teams.

The second pillar for PQCs, a PQC QI initiative would be rapid response data. So PQCs receive data from hospitals and it does vary a bit from state to state. So in some states the hospitals will submit data directly to the PQC through secure portals. Sometimes hospitals will report data to the hospital association or to the State Department of Health, or there are a couple of different ways that it's done. But basically the PQCs get information, the data from hospitals and package it into an understandable summary report and then feed it back rapidly to hospitals. And it's really a huge benefit.

It's meant to be of benefit to hospitals so that you can track your own progress as you're making changes and improving outcomes. It also gives hospitals the ability to look at how your hospital may compare to those in your region or those in your state, or even nationally. So it's meant to be really beneficial. And then the last pillar of a QI initiative would be the QI science support.

I think we're all acutely aware of being the fact that rural hospitals and Critical Access Hospitals don't have a lot of resources and PQCs are there to provide support. So they will often hold coaching calls to review what it means to do quality improvement activities. They'll often offer training so that the hospital teams can boost their skills in quality improvement. And some PQCs will do site visits as well to come to your facility, get to know you to better understand the barriers and the facilitators that you have in your facility.

Those are the general activities of a QI initiative. We talked at the last webinar that the initiatives really vary from PQC to PQC, but are often based on the AIM, A-I-M patient safety bundles, which you can find at SaferBirth.org. But some PQCs will work on initiatives that are not an AIM bundle. Just FYI. So what can we expect moving forward? Just to let you know what you might see in the future, there's a growing emphasis on health equity.

We're really hoping that PQCs start to view all of their activities through this lens of health equity. Also, the PQCs are expanding, starting to expand beyond hospital work. So engaging antenatal care facilities, postpartum, also infant care. Also, there's increasing patient and community engagement going on. So all of those things are somewhat new for PQCs, but they're really reaching out into these different areas and hopefully a huge skill of the PQCs as conveners and collaborators and that will hopefully keep moving forward as they work with hospitals and these outpatient and community-based organizations to really move the needle on our maternal and infant health outcomes.

So there are a lot of ways that you can connect into this Maternal Child Health QI. You can start to reach out into your network or into your health system to the folks that you know to see who is working on perinatal QI, get an understanding of what they're working on. One important step would be to identify a QI team. One of the most important steps that a hospital can take to be successful in QI is to have a dedicated team.

So just starting to think about who could work on this dedicated QI team will put you forward quite a bit and multidisciplinary teams are ideal. I obviously would encourage you to contact your state PQC. We showed you the map. I'm happy to help if you want to email me if you're having some difficulty in contacting your PQC. We really want everyone who wants to be involved to get involved. And then last, I'll just finish up. I'd recommend that everybody read their state MMRC, their Maternal Mortality Review Committee.

Read your MMRC report. And that you can find the link is in these slides. That's at ReviewtoAction.org. They really give a great, would give you a great understanding of what's happening in your state and the priorities that are best for you and your hospital. I think that's it for me. Yes. So now it's really my pleasure to pass the microphone over to Caroline Sedano.

Caroline Sedano: Hi, everyone. My name is Caroline Sedano. I am the perinatal unit manager at the Washington State Department of Health. I'll be sharing our recent response to OB closures in our state and how our PQC has been involved and where we're hoping to take this work in the future. So first a little bit about Washington. We average about 85,000 births per year. And a little less than half of those are covered by Medicaid. 75% of pregnant people receive prenatal care in the first trimester and nationally, Washington does have a low infant and maternal mortality rate. However, we do see persistent disparities. American Indian and Alaskan Native communities along with Black and Pacific Islander communities are disproportionately impacted by infant fetal and maternal deaths.

Our maternal mortality panel has recently published findings that I included here on the slide. So similar to the national data that was shared, about 80% of pregnancy-related deaths in Washington were determined to be preventable and a significant amount occurred. A majority occurred after the end of pregnancy. A leading cause of pregnancy-related deaths in Washington are behavioral health conditions and a significant number of those are associated with substance use.

American Indian and Alaskan Native people face higher maternal mortality rates. And overall there is about 40% of perinatal maternal mortality is among rural residents. Like many states, we have been tracking the status of rural health services closely. We have seen that in the last five years there's been an 11% decrease in birthing hospitals or hospitals that provide birthing services. And that of as of 2024, about 41% of rural hospitals offer OB services.

So now I'll share a little bit about our PQC in Washington. In Washington, our PQC is called the Washington State Perinatal Collaborative or WSPC. This serves as a statewide hub for Perinatal Quality Collaborative initiatives and programs that serve pregnant and parenting people. The group takes many of the recommendations that come from our Maternal Mortality Review Program and either tracks their status in the state or is a lead implementer in the state.

Currently, our initiatives include the AIM bundles that Jackie mentioned earlier. So we're currently wrapping up the SUD bundle and moving into mental health. We also are focused on smooth transitions, which improves transfers between birthing centers, and hospitals levels of care, and developing new clinical guidelines.

So our PQC sits in the Washington State Title V program and within the perinatal unit. So our organizational structure has the MMRP, the PQC, Maternal Innovations Grant, and the Birth Equity Project in one unit to ensure alignment and collaboration between these programs.

So now I'll share a little bit about our response to rural health work in Washington. This kicked off for us in the fall of 2022 when there was a OB closure in a hospital that served a large tribal community. The closure resulted in community meetings and a fair amount of media coverage and requests coming to Department of Health around our response to this.

So after the initial response, we formed a committee that was called the Rural Access to Safe Deliveries Work Group. And that started meeting regularly. That group included representatives from the Title V program and the PQC as well as the State Office of Rural Health at the Department of Health.

The hospital association in Washington participates in this calls as well as the Rural Collaborative, which is a non-profit organization supporting access to care and our state Medicaid office. That group came together to meet and form some response and collect some data and information about rural access in Washington. We convened a virtual forum a few months later on rural access to safe deliveries to better understand the challenges in maintaining care and we also did a landscape assessment where we interviewed hospital staff for their feedback on those challenges.

In December of last year, we were able to offer small $5,000 grants to rural hospitals that wanted to specifically work on their hemorrhage policies. And then earlier this year we continued to learn about OB closures in our state. This month, actually yesterday, we co-hosted a session on rural OB care during a statewide rural health conference.

So I wanted to share a little bit about the discussions that we had with hospitals through the PQC outreach. So this was some of the feedback that we received from that virtual forum and the landscape assessment. So as to why some of the OB services were being shut down at hospitals. So not enough deliveries to maintain nursing staff skill, workforce shortages, so inability to recruit staff to work at rural facilities, and the expense. So low Medicaid reimbursement and inability to cover the services.

And this is the session that happened yesterday. It was co-facilitation and planning by that planning committee that I mentioned. And so the State Department of Health, our PQC and the State Office of Rural Health worked with the Rural Collaborative, the Hospital Association, and our state Medicaid office to plan this event as an additional way to get information from hospital staff on the challenges as well as start talking about solutions.

So where are we going with this work? We have spent the last year really gathering information about the challenges of maintaining OB care in Washington as well as building relationships with both hospitals and leaders that are already working in this space. So now we really are shifting into providing some solutions and building out a program of what supporting rural maternity care might look like in Washington.

So around maintaining provider skill, we are getting ready to launch simulation trainings for about 44 hospitals over the next 18 months. We are developing a contract with the hospital association to do this. Our PQC was able to provide small grants to the rural hospitals around hemorrhage work. They had to provide a hemorrhage policy to be eligible for these funds and can use the funds to purchase equipment that they need to address hemorrhage, including the Jada System and updating their hemorrhage carts.

Those that didn't have policies or needed to update them, our PQC was able to provide some support. And those that are working on this hemorrhage project will be prioritized in the simulation training that will start later. So those two projects will hopefully go hand in hand. And we're also exploring if we want to offer those grants to birthing centers as well.

The next few projects are in early stages of implementation and still kind of exploratory. So we're in early conversations with a hospital to be a regional training center for rural providers to work for short periods of time on a rotating basis to maintain volume and skill needed at critical access hospitals.

And then to address workforce shortages, we are also exploring a provider advisory group to help develop recruitment and placement for rural providers in facilities that are looking for providers.

The financial burden on hospitals is significant and so of course it's one of the more challenging obstacles to work with hospitals on. The session yesterday that I mentioned at the State Rural Health Conference really did focus on getting more information from hospital staff as to what support would help address some of the financial barriers. So we have had conversations with technical assistance providers that can offer financial modeling support for how to build out and maintain OB care.

So we really are learning what role our PQC can play in this work and who needs to be involved. We know from our maternal mortality data that OB care is vital for safe births and reducing the maternal death rate in our state. So we look forward to building out our support to rural communities. And with that, I will hand it off to the next speaker.

Annie Glover: Thank you so much for having me. I really enjoyed this last presentation. One of the best parts about Perinatal Quality Collaboratives is that we do cross-learning across our facilities, but also between states. And we translate the learning that we get from a state like Washington to a state like Montana. So I just want to thank Caroline for that presentation because I know I wrote some notes down myself.

So my name is Annie Glover. I'm at the University of Montana. Like Jacqueline said, I'm the director of the Montana Perinatal Quality Collaborative in the Montana Alliance for Innovation of Maternal Health. And I'll be talking today a bit about the work that we've been doing in Montana facilities. I'm going to start off with just a little bit of information about how we got here.

So we initiated our Perinatal quality collaborative work through our MHI grant or the Maternal Health Innovation Grant that Montana has from HRSA. And we initiated this in 2021. We conducted a CDC LOCATe assessment. We also did this LOCATe assessment or started the LOCATe assessment with our critical access hospitals that don't have obstetric units. And they said it wasn't going to fit for their circumstances. And in fact, a lot of our birthing centers felt that the LOCATe assessment was not quite there for what they were providing.

So we created an additional assessment using World Health Organization emergency obstetric care indicators. We vetted this with providers in Montana and assessed our critical access hospitals to see where they are in terms of being ready to respond to obstetric emergencies. What we can see from this assessment from 2021 are a few things. The first takeaway that I had was that we launched this at the height of COVID-19 and our health facilities across Montana were overworked, burdened, and focusing on an entirely different emergency. And they were so engaged with this work.

I love doing rural health because we do so much with so little in our rural communities and this is such good evidence that despite this other emergency that was going on, our facilities were ready and really, really excited and engaged to be focusing on obstetric care. We also found that facilities were assessing at lower levels than they thought that they would be. And then they had self-assessed prior to going through this in-depth assessment. We found really concerning resource shortages, both in terms of commodities as well as in terms of staffing at these critical access hospitals that it was an alarm for us that we needed to do some work directly with our hospitals.

So currently the Perinatal Quality Collaborative is in its third year of implementation. We're doing obstetric sepsis in 19 of our hospitals. And in fact, it's 19 of 25 birthing facilities. One has closed since our current grant year began. We have really good coverage across the state. Since our PQC started in 2021, our facilities that are enrolled in the PQC have delivered 75% of Montana's babies.

We are really happy to report that 16 of Montana's critical access hospitals are birthing facilities, 14 of them have participated at least in one of the patient safety bundles that we've implemented. And we've also had one IHS service unit participate. It is the only service unit in Montana that has OB facilities.

Notably, our key disparities in Montana are American Indian people as well as rural populations. And I just wanted to note some highlights here. I have this on the slide. When we talk about rural in Montana, we are talking about few people as well as extreme remoteness. The Fort Peck Reservation up in the northeast corner of Montana, as you can see, is larger than the state of Delaware. There is one hospital there that delivers, but it's a small hospital.

Most people are needing to transfer or go and have a plan delivery in a larger city. And this poses extreme risk. These individuals who are living in rural areas are more likely to have severe maternal morbidity and other obstetric complications. American Indian people in Montana are three times as likely to have severe maternal morbidity and are much more likely to present and deliver in a hospital without OB services. So we find it's very, very important to listen to our facilities, hear what they need from us to be engaged in this work, and hear from them about what's important and what they're seeing as we proceed and identify initiatives that the PQC will be implementing in partnership with them.

So just some examples of where we have been. Our MPQC, Montana Perinatal Quality Collaborative, we co-brand it with AIM because we have focused primarily on implementing AIM patient safety bundles through the Perinatal Quality Collaborative. This has been what our birthing facilities have asked for and what has really kept them engaged.

I've presented here some process measures. These are the process measures that the AIM program provides in their patient safety bundle. The top one is related to hemorrhage. Notably, that when we started our Perinatal Quality Collaborative in 2021, just a quarter of our facilities were reporting that they were doing quantified blood loss. And by the end of that year of implementation, we were up to nearly 70%. In the fall, we'll be going back to do sustainment initiatives to look back on these to see where we are, but that was a really significant improvement. In terms of making sure that we are providing that standard of care that follows the evidence-based best practices.

Severe hypertension in pregnancy was our last initiative. Again, we found improvements. I've provided some structure measures here. Something that we try to do with our initiatives in Montana is make sure that we have repetition year after year, so these are institutionalized. So something that we've repeated are making sure that clinical debriefs are happening around these severe events, making sure that there's multidisciplinary case review.

We're always using the same IHI best practices in terms of plan-do-study-act QI initiatives. So these facilities are getting more and more practiced in the science of quality improvement because we just keep coming back with the same model and they engage in that model with just a different flavor across these different bundles.

So I want to talk a little bit about emergency obstetric care in Montana. So similarly to what we're seeing nationally, critical access hospitals are closing their obstetric units. Nearly half of Montana's critical access hospitals close their obstetric units in the last 20 years. So people might be delivering in a hospital without a unit just because that's what happens. The baby comes when the baby comes.

A recent study found that American Indian people in Montana are 20 times more likely to give birth at a facility without an obstetrics unit. This is due to what I demonstrated on the map and that is that two of our Indian Health service units haven't been able to open obstetric units. Critical access hospitals located on and near reservations are less likely to have obstetric units and reservations are located in the most remote parts of the state. And so this is the consequence.

I wanted to include this story. This is from the Roundup Record Tribune. This is back when we first started doing this work. We had been out in the field doing simulations and this hospital actually participated in one of our simulations shortly before this happened. But I just love this story. It turned out well. But note the caption from the newspaper notes that this was the first delivery that Roundup Hospital had in eight years. Roundup Hospital doesn't have and didn't have an OB unit. They were transported by ambulance to Billings and hit a deer on the way. But everyone is doing well. So this is a more Montana story I would be hard-pressed to find for you, but this is what our hospitals are facing.

So when we engage our rural facilities, we do so across several really important partnerships. The first one is that our HRSA Maternal Health Innovation Program, also called Moms has been funding simulation since the start of that program in 2019. And we have coordinated our simulation program with the PQC really closely. So these two charts show the number of participants who have gone through these simulations during this period of time, as well as the number of facilities that have gone through these simulations.

The hospital association in Montana has been an enormous partner with the MPQC-AIM from the start. They share data with us. They promote the QI activities and they endorse the MPQC. They serve on our steering committee. And so that's been a really, really important partnership. And then the Montana Perinatal Association or the Association of Perinatal Nurses, they have been extremely engaged.

They started PQC work with Neonatal Safe Sleep Initiative several years ago, but didn't have infrastructure and funding and supported moving this over to the maternal health work that we do now. Some other strategies that we use are that we provide a lot of data support to our hospitals. We collect data through a really user-friendly REDCap system that we provide a lot of technical assistance on.

We provide a simple QI platform for PDSA cycle tracking that we can do our QI coaching in directly with those hospitals and see it as it's happening. We do the outcomes and surveillance data analysis and reporting. We report that to the AIM data center, to the CDC, and then we report those all back to the hospitals themselves so they can see and they can check those data.

We really are doing a lot of work to make our learning sessions accessible. The simulation, as I said, is synchronized with the MHI program. Our learning sessions are conducted on Zoom and they're recorded chunk by chunk so people can step in and step out. We have these small facilities. As you all I'm sure know well, it's not like there are a lot of people on the floor at one time that everyone can go and sit in a learning session. Somebody has to staff the hospital. And so we listen to what the hospitals tell us in terms of what they need from us to be engaged. We do tabletop simulations on the Zoom. We do a lot of case-based learning. We'll do things like a fish and bone diagram activity.

We are just now starting an initiative where we'll be doing data sharing between the MMRC and the PQC to use MMRC cases in that case-based learning. And then we do individualized QI coaching. We do all calls. We do regional calls. We try to pair up smaller facilities with their referral hospitals, and we're just now launching a partnership with Montana State University College of Nursing. Their DNP students will be doing their QI doctoral projects as QI coaches with our PQC sites. And so I'm very excited about that. That benefits the students. It grows that workforce and provides more live support.

Finally, my last slide, one initiative that I didn't plan to have was we had a little secret shopper. My nephew made a very early entrance this month and he decided to make that entrance at one of our PQC critical access hospitals that has OB. He was a bit dramatic about it, and so we had transport involved. He spent over a week in the NICU. He's doing great, but both hospitals have been heavily engaged in the PQC and provided amazing care and both are at home doing well.

And so I just wanted to share that he endorses rural obstetric care. It matters. We need strong transport networks. We need to facilitate high quality, risk appropriate care. We need to be inclusive of our remote communities and hear what they have to say and what they need. We need to understand that critical access hospitals, whether or not they have OB units, are part of the maternal health system in rural states like Montana. And we need to adapt our patient safety bundles for rural OB, rural emergency departments and the realities that we have for transport. So thank you so much and I will turn it over to the host.

Kristine Sande: Great. Thanks so much. Those were really great presentations. How is implemented patient safety bundles defined for the CMS birthing friendly designation? Is there a minimum standard for what that means?

Jacqueline Wallace: That's a great question. I don't have a great answer for that. I'm not part of CMS and so I just want to be clear about that, I'm just speaking from what I've read and learned. There is not a strong definition of that at this time. CMS is considering this measure to be sort of a work in progress. They're definitely working on providing better definitions for participation and better definitions for implementing patient safety bundles. But it's not specifically defined at this time to my knowledge.

Kristine Sande: All right. And another question for you. Are the data you used publicly available?

Jacqueline Wallace: I'm speaking very generally because I don't know the specific details of every single PQC, but typically no.

Kristine Sande: Okay. Clarification. She was asking about the rapid response rate.

Jacqueline Wallace: So typically, the information is shared back specifically to a hospital and you don't see... You may see de-identified hospital data. It's all aggregated. So you're not seeing patient level data. Typically, it would be anonymous. You may be able to compare yourself to other hospitals, but it's typically the hospitals aren't named. But depending on the states, and please Annie and Caroline jump in because if it's a state with only a few hospitals, then the PQC may not even share that information because people can figure out which hospital is which hospital.

So I think broadly speaking, most PQCs are not sharing information with other hospitals. They're not sharing your hospital information with other hospitals. And most of the time they're not sharing certainly identifiable data with the public.

Annie Glover: I can clarify that too.

Jacqueline Wallace: Thank you.

Annie Glover: We have a data use agreement with the hospital association that very strictly governs who can see the data. We can send the hospital's data back to that hospital, but we do not release hospital identifiable data to the broader collaborative or to the public. We also have data use agreements with each of our member hospitals in the Perinatal Quality Collaborative that govern that as well. So we report a hospital's data back to them, but not... We only use aggregate data for other reporting.

Kristine Sande: Question for anybody, what advice do you have for health systems which span multiple states? For example, this person is in South Dakota and one of the major health systems has a footprint in both North Dakota and Minnesota in addition to South Dakota. All of the PQCs are operating differently. But what would be the best way for the PQCs to come together to support the health systems even though it spans multiple states.

Annie Glover: We usually think of our hospital systems at the facility or the site level. And so we have large hospital systems in Montana that have multiple sites in different cities. So we'll include those as an individual hospital. And we generally just invite those sites that are in Montana to be part of the Montana Perinatal Quality Collaborative. Though if we had one, for instance from Northern Wyoming who wanted to join us, we certainly wouldn't turn them down. And so I think probably from a system perspective, it might be good to engage with whatever Perinatal Quality Collaborative opportunity is available for that site itself.

Caroline Sedano: I just wanted to add really quickly, really similar to what Annie shared, we do have some other state hospitals that are participating in some of our quality improvement initiatives by participating in the monthly coaching calls or getting some technical assistance from our staff. It's not solidified or an official process, but we do invite hospitals from other states to participate in a Blue Bands Project if they're interested in participating.

Kristine Sande: Another question for you, Caroline. How hard was it to get the group together for your rural closure advisory group such as the hospital association, healthcare system, state office, Medicaid, etc?

Caroline Sedano: Yeah. I would say surprisingly, it was not hard. I mentioned this really kicked off in Washington because of one hospital OB service that closed and there were a couple providers who were really active in spreading the word, getting community involvement. So really I think that activation of that community outreach, there's a provider that contacted multiple state agencies and was really like, "This is an issue. This is an equity issue because it's affecting tribal communities."

I think she was able to contact the right people and the right people were really interested in this topic and realized that it was a gap in the work that we're doing as part of our PQC, realized it was a gap in the rural health office, that it was a gap doing maternity care. So I think it really just... She got in touch with the right people and the right people had the time and capacity and saw this as an important issue.

We were meeting every other week for quite some time and engagement was high and now we're meeting monthly, I think as we think about more specifically actually implementing projects and just having more of a work group structure. But no, I don't have any guidance for you. Other than that, I think people were really passionate about this and saw it as an important issue to connect about.

Kristine Sande: Thank you. Question for Annie. Since we are considering the AIM hypertension or hemorrhage bundle, but hospitals tell us they've already done a lot of work on these topics, however, we're not sure if evidence-based best practices are being used. In some cases. we know that estimated blood loss is being used. How did you engage hospitals that felt they'd already been working on these topics?

Annie Glover: That's a really great question. I would say a couple of different ways. First of all, working on the topic of hemorrhage or hypertension is definitely not the same as having implemented an AIM patient safety bundle. And so we are very clear and explicit about that. And so we opened up that conversation. Please tell us what do you think working in the hypertension topic means? What did that mean for your hospital? And then have that conversation with them and then encourage them to take our baseline assessment, which is an in-depth assessment on their progress towards each element of the bundle.

The second thing that we did was let them know that we think of high quality perinatal care as being regionalized. And if they're a big hospital who did in fact implement the hemorrhage or hypertension bundle or whatever we're trying to do, then we still need them engaged in the PQC because the PQC is about cross-learning. And we need that hospital to make sure that their regional smaller hospital referring network are sending patients in having done everything that they needed to do in that patient safety bundle relevant to their scope and their level of care.

So we encourage them to join the PQC as a leader and we really aim for a hundred percent coverage every single time. So if they feel like they've done the bundle already, then we pitch a different type of involvement to them with the bundle because we let them know that their patients are going to be so much better off if they're smaller hospitals that are sending them patients are in communication with them.

Kristine Sande: So another question for you, Caroline. Your PQC was able to provide funding to hospitals for QI. How is the PQC funded?

Caroline Sedano: So up until a few years ago, our PQC was funded with general funds for just staff time. We did apply for and receive the PQC grant that is now supporting some of the grants that we're able to provide as well as additional staff time and just general capacity building. So that grant has really been a game changer for building out structure and sort of formalizing a lot of the processes that we do. We were in a lucky situation where we had some general funds that we needed to spend by a certain time and we were able to identify this project and move really quickly to get the money out to hospitals.

That was a unique situation where we just had had some unspent funds due to some staff vacancies and delayed projects starting that we were able to mobilize our contracts to move really quickly to get those out.

Kristine Sande: Great, thank you. And maybe last question, given the time, do any of the speakers have any non-emergency medical transportation programs that they really like or have worked well with the maternal health?

Kristen Dillon: I can harken back to my experience working in Oregon's Medicaid program. So I'm assuming the questioner is asking about that non-emergency medical transportation benefit that's part of Medicaid and can be a crucial element for getting folks to appointments, especially when the travel distances get longer. There are multiple vendors and clearing houses and other entities out there and I'm not in a position to be able to specifically name or recommend anything. I do know there's been a lot of shifting and each state and region wants to be just real careful in terms of what they select and what the standards are because we know transportation can just be so crucial for getting folks to care.

Kristine Sande: Great. And one last one real quick. Are any of you aware of grants to assist with PPH for equipment purchase? Does it look like it? The person who asked might want to check with the Rural Health Information Hub resource and Referral service. We can do a search for you to see if we can find a grant that would work for that sort of thing.

Kristen Dillon: I think I would encourage them, Kristine also to check with their State Office of Rural Health. The SHIP grant program might also be an option. I don't know the exact parameters, but the State Office of Rural Health may also know about some kind of more block grant money that might be available.

Kristine Sande: Right. Great. So at this point, we will wrap up and I'll let Dr. Dillon have the last word.

Kristen Dillon: Sure. So thank you all so much for attending. We really appreciate the opportunity to connect with you. And please go to our website to learn more about HRSA and the Federal Office of Rural Health Policy. We'd also love for you to click the link and sign up for the HRSA or especially the FORHP announcements, weekly announcements that will keep you up to date on grant opportunities, technical assistance, webinars like this one, and all things rural health, including from our partners and others outside of our agency. So thank you all so much for attending and we really look forward to seeing you again in two weeks as we continue on this journey towards better, safer maternal healthcare.

Kristine Sande: And the slides that were used today are available on our website. Thanks so much for joining us and have a great day.