Obcs

1. Birth & Death Certificate
Indiana Perinatal Quality Improvement Collaborative –
Quality Improvement Committee
11/13/2014
Erica Park
Nancy Swigonski, MD, MPH, FAAP
Kathleen Frogge, Program Director 2

2. “YOU CAN DESIGN AND
CREATE, AND BUILD THE
MOST WONDERFUL
PLACE [SYSTEM] IN THE
WORLD. BUT IT TAKES
PEOPLE TO MAKE THE
DREAM A REALITY.”
WALT DISNEY

3.  Overall goal: Reduce Indiana’s infant mortality rate
 In order to reach overall goal, Indiana needs good data
 2 areas of data:
 Birth certificate
 Death certificate
OVERALL GOAL

4. Death Certificate
Indiana Perinatal Quality Improvement Collaborative –
Quality Improvement Committee
11/13/2014

5. DEATH CERTIFICATE PROCESS

6. DEATH CERTIFICATE PROCESS
1. Funeral home receives a call from the hospital or the parents

7. DEATH CERTIFICATE PROCESS
1. Funeral home receives a call from the hospital or the parents
2. If parents decide to use their funeral services, infant will be
transferred to the funeral home

8. DEATH CERTIFICATE PROCESS
3. Hospital initiates a burial transit permit
Fills out Sections A & B

9. DEATH CERTIFICATE PROCESS
4. Person who picks up the body fills out more of the permit
Fills out Sections C

10. DEATH CERTIFICATE PROCESS
5. Funeral home completes the permit - fills out Sections D & E
 3 copies of this permit
 1. Health department by the hospital
 2. Crematory or cemetery
 3. Health department

11. DEATH CERTIFICATE PROCESS
6. Funeral director logs onto IDRS to initiate the death
certificate – generally within 24-48 hours but may be longer if
waiting for the mother’s release from hospital

12. DEATH CERTIFICATE PROCESS
6. Funeral director logs onto IDRS to initiate the death
certificate – generally within 24-48 hours but may be longer if
waiting for the mother’s release from hospital
7. IDRS opens with an initial search
 If name is already in the system, it will match the name to
the search
 If name is not in the system, it will initiate a new death
certificate form

13. DEATH CERTIFICATE PROCESS
8. Funeral director fills out demographic information

14. DEATH CERTIFICATE PROCESS
8. Funeral director fills out demographic information
9. Funeral director sends death record to the physician
 Physician must be registered in the system
 Physician will receive an email notifying him/her that a
death certification is in queue
 Email includes decedent’s name, date and time of death, place
of death, etc.

15. DEATH CERTIFICATE PROCESS
10. Physician logs onto IDRS and fills out medical information
and certifies the death

16. DEATH CERTIFICATE PROCESS
10. Physician logs onto IDRS and fills out medical information
and certifies the death
11. Physician sends the death record back to the funeral
director
 Funeral director receives a similar email notification

17. DEATH CERTIFICATE PROCESS
10. Physician logs onto IDRS and fills out medical information
and certifies the death
11. Physician sends the death record back to the funeral
director
 Funeral director receives a similar email notification
12. Funeral director finishes certificate

18. DEATH CERTIFICATE PROCESS
 Fetal deaths are registered in a separate system
 Key differences:
 Fetal death report requires more parent demographic
information
 If the fetus is <20 weeks gestation, the funeral home does
not have to report and the hospital can dispose the body

19.  Met with funeral director
 Discussed the death certificate process and issues with
timeliness
 Physicians not registered into the system causes delays
 Time it takes to fill out the death certificate data into IDRS
 Live birth: ~10 minutes
 Fetal death: ~15-20 minutes
DEATH CERTIFICATE
INFORMATION GATHERING

20.  Neonatologist
 Physicians must be registered into the IDRS – if the
attending physician is not registered this could cause delays
 Recent switch to electronic birth records and lack of training
may be causes of delay
 Physicians do not know they are able to initiate the death
certificate
 Ultimately these delays cause delays in burial of the baby
DEATH CERTIFICATE
INFORMATION GATHERING

21.  https://vrqa.isdh.in.gov/inthin/indextest.html
DEATH CERTIFICATE
INFORMATION GATHERING

22.  Key issue is getting physicians registered into IDRS
 Physicians can start the death record, but this was
unknown
 Others can start the death record with the physician
later signing with their personal identification
number (PIN), but this was unknown
DEATH CERTIFICATE DATA - FINDINGS

23.  Online Training
Training manuals
Indiana = 78 pages
CDC = 65 pages
IDRS system not self-explanatory
Webinar link does not work
DEATH CERTIFICATE DATA - FINDINGS

24.  Where in your hospital/system are there problems
with the death certificate process?
 What ideas do you have to make the system better?
 What methods at your hospital work well?
DEATH CERTIFICATE PROCESS –
BRAINSTORMING

25.  Identify the hospitals with highest number of infant
deaths and focus efforts on those first
 Register and demonstrate IDRS to physicians during
hospital orientations
 Preload physicians into the system
 Pilot a program using staff to initiate the certificate
DEATH CERTIFICATE DATA -
RECOMMENDATIONS

26. Birth Certificate
Indiana Perinatal Quality Improvement Collaborative –
Quality Improvement Committee
11/13/2014

27. BIRTH CERTIFICATE PROCESS –
THEORETICAL

28. 1a. Mother fills out the Mother’s Worksheet section of the CDC-
issued 12 page birth certificate form
BIRTH CERTIFICATE PROCESS
THEORETICAL

29. 1a. Mother fills out the Mother’s Worksheet section (MWS) of
the CDC-issued 12 page birth certificate form
1b. Hospital staff fills out the Facility Worksheet section (FWS)
of the CDC-issued 12 page birth certificate form
BIRTH CERTIFICATE PROCESS
THEORETICAL

30. 1a. Mother fills out the Mother’s Worksheet section (MWS) of
the CDC-issued 12 page birth certificate form
1b. Hospital staff fills out the Facility Worksheet section (FWS)
of the CDC-issued 12 page birth certificate form
2. Hospital staff logs onto BDRS
BIRTH CERTIFICATE PROCESS
THEORETICAL

31. 1a. Mother fills out the Mother’s Worksheet section (MWS) of
the CDC-issued 12 page birth certificate form
1b. Hospital staff fills out the Facility Worksheet section (FWS)
of the CDC-issued 12 page birth certificate form
2. Hospital staff logs onto BDRS
3. Hospital staff uses the CDC-issued 12 page birth certificate
form to fill out the electronic birth registration form
BIRTH CERTIFICATE PROCESS
THEORETICAL

32. 4. County health department receives birth registration data
BIRTH CERTIFICATE PROCESS
THEORETICAL

33. 4. County health department receives birth registration data
5. State Department of Health receives birth registration data
BIRTH CERTIFICATE PROCESS
THEORETICAL

34. 4. County health department receives birth registration data
5. State Department of Health receives birth registration data
6. CDC receives birth registration data
BIRTH CERTIFICATE PROCESS
THEORETICAL

35. BIRTH CERTIFICATE
INFORMATION GATHERING
 Vital Records Training Modules
http://in.gov/isdh/25584.htm
 For birth clerks, hospital staff that works with IBRS
 3 modules on the ISDH website
 Each take ~30 minutes to complete
 Module 1: Improving the Quality of Birth Certificate Data
 Module 2A: All Birth Worksheet Data Matters Part A
 Module 2B: All Birth Worksheet Data Matters Part B
 Visited hospitals to outline the birth certificate process

36. BIRTH CERTIFICATE FINDINGS

37. Findings from the hospital visits
 CDC-issued 12 page worksheet was “split” into 5 separate
worksheets
 Hospital has 300 births/day
 If no interruptions can get through 20-25 births into the
BDRS/day
 Time it takes to fill out (ideal)
 Ranges from 15 min–1.5 hours
BIRTH CERTIFICATE DATA - FINDINGS

38. The actual process is much more complex than the theoretical
process
Obstacles faced by the hospital staff
 Missing data
 Takes time to find sources of missing data and contact the
mother for information
BIRTH CERTIFICATE DATA - FINDINGS

39. The actual process is much more complex than the theoretical
process
Obstacles faced by the hospital staff
 Missing data
 Takes time to find sources for missing data and contact the
mother for information
 Variation in data sources (online, paper)
 Which source has the correct information?
BIRTH CERTIFICATE DATA - FINDINGS

40. The actual process is much more complex than the theoretical
process
Obstacles faced by the hospital staff
 Missing data
 Takes time to find sources of missing data and contact the
mother for information
 Variation in data sources (online, paper)
 Which source has the correct information?
 Availability of external data
 Example: prenatal care if begun in a different hospital
BIRTH CERTIFICATE DATA - FINDINGS

41. The actual process is much more complex than the theoretical
process
Obstacles faced by the hospital staff
 Missing data
 Takes time to find sources of missing data and contact the
mother for information
 Variation in data sources (online, paper)
 Which source has the correct information?
 Availability of external data
 Example: prenatal care if begun in a different hospital
 Changes to the questions and answer choices on the CDC-
issued 12 page worksheet
 Example: choices for “Mother’s Race”
BIRTH CERTIFICATE DATA - FINDINGS

42.  Variations of the birth certificate registration process in
hospitals
 Accuracy of the data must be addressed
 Timeliness of the data must be addressed
BIRTH CERTIFICATE PROCESS
FINDINGS

43. WHAT HAVE
OTHER
STATES
DONE?
WHAT ARE
BEST
PRACTICES?

44. BIRTH QUALITY WORKGROUP
 Recently, the CDC formed a Birth Data Quality Workgroup to
survey data quality practices among the State Departments of
Health
 Online survey
 Focused on activities that evaluate and ensure data quality
 Asked about actions in response to data quality findings
 46/52 completed the survey (88.4% participation)
 Results of the study led to 2 specific recommendations

45. BIRTH QUALITY WORKGROUP
RECOMMENDATIONS
 1. Data must be evaluated
on an ongoing basis
 Importance of rapid
cycling
 Recommend quick
response to poor data
quality from birth
facilities – weekly or
monthly vs. quarterly or
yearly

46. BIRTH QUALITY WORKGROUP
RECOMMENDATIONS
 2. Effective communication of
data quality is necessary
 1. Concrete feedback
 2. Increase awareness about
the merit of data quality
 3. Provide regular trainings and
newsletters
 4. Publish reports about
performance to increase
transparency
 5. Connect with upper-level
clinicians and hospital
administrations

47. BIRTH CERTIFICATE
FINDINGS FROM OTHER STATES
State Recommendations/Actions
Washington “Why Quality Data is Important and Help to Improve Your Data”
guide; website comparing data quality of facilities
Ohio Real time auditing; development of a new standardized H&P to
contain all necessary points
California Increased regional trainings; development of a CMQCC Maternal
Data Center

48. STATE OF WASHINGTON
 The State of Washington has developed a Birth Data Quality
Query System (BDQQ) webpage on their State Department of
Health website
 “The BDQQ is a tool to help you improve your birth data quality”
 The BDQQ system provides hospital profiles of “percent
unknown” for selected items on the birth certificate

49. STATE OF WASHINGTON
 There are 4 possible ways to look at the data for each birth
facility using the BDQQ system:
 1. “Average % Unknown” compared to facilities of similar birth
volume
 There are 4 possible ways to look at the data for each birth
facility using the BDQQ system:
 1. “Average % Unknown” compared to facilities of similar birth
volume

50. STATE OF WASHINGTON
 2. “% Unknown” of
certain birth data
items compared
to state

51. STATE OF WASHINGTON
 3. “% Unknown”
of certain birth
data items over
time

52. STATE OF WASHINGTON
 4. “Average %
Unknown”
compared to WA
state over time
 State also has a
PDF link on this site
to their guide
 Guide explains the
reports and the
birth certificate in
layman’s terms

53. STATE OF OHIO
 Ohio Perinatal Quality Collaborative (OPQC) and the Ohio
Department of Health Vital Statistics performed a study
focusing on 4 phases of birth data registration
 Phase I: Completing the electronic health record
 Algorithms to flag incomplete charts
 Empowering nursing staff
 Increased teaching of hospital staff

54. STATE OF OHIO
 Phase II: Empowering staff
 Nurses encouraged to
contact OB providers if data
was missing
 Emphasized safety benefits
to hospital staff peer-to-
peer

55. STATE OF OHIO
 Phase III: Real Time
Auditing
 Nursing supervisors
began real time
auditing for incomplete
medical record
 Pregnancy card
created for each
pregnant women
 Phase IV: Real Time
Auditing Continued and
Expanded to High Risk
Groups

56. STATE OF CALIFORNIA
 California Maternal Quality Care Collaborative (CMQCC)
development of a California Maternal Data Center (CMDC)
 CMDC is a statewide data center that collects and reports
timely maternity metrics (including data quality) in a way that
is “low cost, low burden, and high value for hospitals”
 Similar to Washington, but with more detail
 CMDC is overseen by a multi-stakeholder Steering Committee
composed of clinicians, hospitals, payers, purchasers,
consumer organizations, and relevant state agencies

57. STATE OF CALIFORNIA
 Demonstration site link:
https://demo.datacenter.cmqcc.org/hospitals/1
 Demonstration site link:
https://demo.datacenter.cmqcc.org/hospitals/1

58.  What are the steps that are taken to fill out the birth certificate?
 Who provides information? What sources are used to fill out the birth
certificate (paper, electronic)?
 What if you are unable to find information? What steps do you then take?
 Are there any specific areas on the birth data registration form that are
particularly difficult, unclear or usually not able to be filled out? Why is it
difficult?
 How long does it take to complete a birth certificate registration form?
 How long does a fairly “straightforward” birth take versus a more complicated one?
 How many births are entered in 1 day?
 How many births per week are entered?
 How long from the time of birth to entry into the system (average and range)?
 How long have you or the person who usually fills out birth certificate
information been doing this job?
 Are you/they hired specifically as a birth clerk or do you/they have other duties also?
 What other duties?
 How many hours per day are dedicated specifically birth data entry?
 What training did you/they receive regarding birth certificate?
 Have you/they used the birth certificate data training modules on the Indiana State
Department of Health website?
 If so, did you/they find it helpful?
BIRTH CERTIFICATE PROCESS –
WHAT IS THE PROCESS IN YOUR HOSPITAL?

59.  Where in your hospital/system are there problems
with the birth certificate process?
 What works well in your hospital?
 What ideas do you have to make the system better?
BIRTH CERTIFICATE PROCESS –
BRAINSTORMING

60.  1. Provide feedback
 Distribute a list of variables that commonly have errors to
hospital administration
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

61.  1. Provide feedback
 Distribute a list of variables that commonly have errors to
hospital administration
 Notify hospital administrative and clinical leadership about
the deficiencies in vital records process
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

62.  1. Provide feedback
 Distribute a list of variables that commonly have errors to
hospital administration
 Notify hospital administrative and clinical leadership about
the deficiencies in vital records process
 Use a website to publish performance reports to increase
transparency
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

63.  1. Provide feedback
 Distribute a list of variables that commonly have errors to
hospital administration
 Notify hospital administrative and clinical leadership about
the deficiencies in vital records process
 Use a website to publish performance reports to increase
transparency
 Increase vital records staff to be able to give more
immediate feedback
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

64.  2. Provide training incentives
 Recommend hospitals to include completion of training
modules in performance review
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

65.  2. Provide training incentives
 Recommend hospitals to include completion of training
modules in performance review
 Provide regular trainings and newsletters for birth
registration staff
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

66.  2. Provide training incentives
 Recommend hospitals to include completion of training
modules in performance review
 Provide regular trainings and newsletters for birth
registration staff
 Develop a post test and/or a Certificate of Completion for
staff completing modules
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

67.  2. Provide training incentives
 Recommend hospitals to include completion of training
modules in performance review
 Provide regular trainings and newsletters for birth
registration staff
 Develop a post test and/or a Certificate of Completion for
staff completing modules
 Pursue CEUs for nurses and CMEs for physicians for
completing birth certificate training modules
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

68.  3. New systems improvements
 Add definitions of fetal death and live birth on the electronic
birth and death registration systems
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

69.  3. New systems improvements
 Add definitions of fetal death and live birth on the electronic
birth and death registration systems
 Add a drop down box with causes of death on the screen that
match the CDC codes
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

70.  3. New systems improvements
 Add definitions of fetal death and live birth on the electronic
birth and death registration systems
 Add a drop down box with causes of death on the screen that
match the CDC codes
 Allow staff to receive email re: death certificate at the same
time as the physician
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

71.  4. Extend roles and approaches
 Communicate to physicians that they should register in IDRS
and that they can initiate the death record
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

72.  4. Demonstrate and implement
 Communicate to physicians that they should register in IDRS
and that they can initiate the death record
 Encourage hospitals to have physicians register in the IDRS
during hospital orientation
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

73.  4. Demonstrate and implement
 Communicate to physicians that they should register in IDRS
and that they can initiate the death record
 Encourage hospitals to have physicians register in the IDRS
during hospital orientation
 Communicate that staff (nurses, clerical staff) can be
authorized and trained to complete initial data that is then
confirmed by the physician and submitted
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

74.  4. Demonstrate and implement
 Communicate to physicians that they should register in IDRS
and that they can initiate the death record
 Encourage hospitals to have physicians register in the IDRS
during hospital orientation
 Communicate that staff (nurses, clerical staff) can be
authorized and trained to complete initial data that is then
confirmed by the physician and submitted
 Communicate that the hospital can initiate the prenatal birth
record
BIRTH CERTIFICATE DATA
RECOMMENDATIONS: 4 CATEGORIES

75. “Not every change is an improvement, but
every improvement is a change; you can’t
do anything better unless you can manage
to do it differently. You’ve got to let
yourself do better than other people.”
Eliezer Yudkowsky
STEPS TOWARDS EFFECTIVE CHANGE

76.  Indiana does very well in the completion of birth and death
certificate data
 However, improvements can still be made to improve the
quality of the data
 In order for Indiana to successfully reduce the infant
mortality rate, the state must have good quality birth and
death certificate data
SUMMARY

77. REFERENCES
1. Ahuja S, Bakus K, Crawford G, Fontana C, Gambatese M, Jessen A,
Justice D, Madsen-Straight A, Martin J, Pagnano S, Reed P, Thoma
M, Tretter E, Wishart L. Efforts to improve birth data quality:
results from a survey of data quality practices among US vital
records jurisdictions. Hyattsville, MD: National Center for Health
Statistics. 2014.
2. Ford S, White B. Summary of birth certificate data collection
challenges: lessons learned from Ohio and other states.
Columbus, OH: BEACON Ohio Department of Health. 2012.
3. Birth data quality query system. 2014. Washington State
Department of Health. Retrieved July 20, 2014 from
https://fortress.wa.gov/doh/bdqq/bdqq.aspx.
4. Main E, Castles A, Murphy B. Partnering for maternal data quality
improvement. California Maternal Quality Care Collaborative.
2013.