QUALITY IMPROVEMENT David Conway, MD, FACOG

DISCLOSURE I have no conflicts of interest to disclose

INTRODUCTION Dr. Jerome Schlachter - Confidential Peer Review Board - CPRB Dr. Timothy Fisher – Patient Safety Organization - PSO

Why are we here? To improve the quality and safety of health care delivery Reduce harm to patients

Who are we? Diverse organization committed to quality Tertiary centers Community hospitals Birth centers

Who are we? Diverse group of providers OB/GYNs Faculty Private practice Family physicians Midwives Certified Nurse Midwives Lay midwives

How do we maximize quality as PSO? Propose that each member have a QA process in place Establish regional guidelines Review outcomes as consultant

Developing a Q I Program Background Increase the likelihood of desired health outcomes Hospitals continually evaluate care Continuous improvement vs. punitive Educational vs. punitive

Getting organized Requires effective leadership Requires cooperation by members

Developing tools Clinical pathways Must document rationale for deviation Quality indicators a measurable dimension Outcomes – eg, previa Processes – eg, VBAC provider profiles benchmarked to local, regional, national identify trends thresholds

Developing tools Standards, guidelines, and criteria Eg, ACOG Practice Bulletins Eg, departmental screening tools

Developing tools Provider buy-in essential Clinically important Guideline credibility Target audience Enlist physician champions make guidelines easy to follow quality vs. compliance measure improvement, share data update guidelines as needed

Implementation Leadership Define future Align people with vision Inspire members to make change Confidentiality

Medical record review Identify outliers Provider raised issues Clinical indicators Case referrals No deficiency Opportunity for improvement Documentation Incomplete prenatal care Inappropriate care System deficiencies

CORRECTIVE ACTION Formulate plan Re: hospital/staff bylaws ?Legal counsel re: due process Education Surveillance Counseling External peer review Supervision of care Probation Restriction of privileges Dismissal from department

ACOG Screening Tools Maternal mortality Unplanned readmission within 14 days Maternal cardiopulmonary arrest, resuscitated In-hospital antibiotics >24 hrs after NSVD Unplanned removal, injury, repair of organ during surgery Excess maternal blood loss requiring intervention

ACOG Screening Tools Eclampsia Delivery unattended by the responsible provider Death of infant >500 gm Delivery at <32 weeks without NICU Transfer of neonate to NICU Cesarean delivery for failure to progress

ACOG Screening Tools Cesarean delivery for non-reassuring fetal status Post-term pregnancy Repeat cesarean section

Concord Hospital Indicators Unexpected mortality Peri-operative mortality Miscellaneous Occurrences Req. Peer Rev. Deep incisional infection Organ space infection Superficial infection Iatrogenic injury

Concord Hospital Indicators Post-procedure hemorrhage Post-partum hemorrhage Apgar < 5 minutes Eclampsia Birth trauma 4th Degree Perineal Laceration

What is the future? Encourage Institutions to establish indicators Encourage institutions to establish OB QA Committees Encourage individuals and institutions to seek outside peer review as needed NNEPQIN as PSO