Birth Certificate Accuracy Key Driver Diagram

Interventions
AIM • Identify improvement team
• Identify all sources of 10 key birth certificate variables
Key Drivers • Identify steps for birth certificate data collection and entry into
birth registry system using a process flow diagram
• Identify area for process improvement using process flow
Strong communication diagram
between clinical team • Ensure staff entering birth certificate data has access to
and birth data staff necessary clinical data
In 9 months,
• Utilize PQCNC and NC Department of Vital Statistics for
improve the Trained clinical and birth
education and training of clinical staff and staff entering birth
data collection teams
accuracy of 10 certificate data
key birth • Disseminate birth certificate variable definitions to birth
certificate and clinical staff
certificate Audit process for data
• Ensure clear understanding of birth registry variables
verification
variables to • Ensure clear understanding by birth data team of medical
80% to terminology related to birth registry variables
Appreciation of the
support public importance of the Birth • Coaching and outreach by PQCNC and NC Department of Vital
health and Registry information Statistics
quality
improvement Birth Registry fields • Partner with NC Dept. of Vital Stats to complete 10 monthly
efforts include essential and chart audits by comparing medical record data with birth
specific certificate data to identify gaps and measure accuracy
information/definitions • Review quarterly PQCNC data reports with executive lead to
track improvement
Identification and
spread of best practices • Clarify birth registry definitions and instructions on monthly
for data entry and hospital team webinars
verification.
• Participate in monthly hospital team webinars and in-person
site visit with PQCNC QI Manager
• Attend face to face meeting to collaborate with other Birth
Certificate Accuracy PQIT’s