A Framework for Quality Improvement
What is High Quality
In 2008, a Vision Team of innovators in the delivery of maternity care and health systems design defined the fundamental values, principles, and goals for a high-quality, high-value maternity care system. In the resulting consensus document,1 the team defined high-quality maternity care as
Woman-centered: Care givers should respect the woman's values, culture, choices, and preferences. All childbearing women should be treated with kindness, respect, dignity, and cultural sensitivity.
Safe: Care should be aimed at producing the best outcomes for women and infants with the least risk of harm. This requires coordination, teamwork, and a commitment to safety.
Effective: Care should be guided by the best available research. Care givers should avoid practices that are ineffective or harmful and should incorporate practices that have been shown to improve the health of women and infants.
Timely: Care should be delivered when it is needed, and women should not have to wait unnecessarily for long periods of time. The timing and progress of labor and birth should be based on the safest and healthiest options for the woman and her infant, not on convenience or other pressures.
Efficient: The maternity care system should deliver the best possible health outcomes and benefits with the most appropriate, conservative use of resources and technology. An efficient system does not waste resources and expose women and infants to harm from unnecessary treatments and medical interventions.
Equitable: All women and families should have access to and receive the same high-quality, high-value care. An equitable maternity care system addresses disparities related to class, race, ethnicity, and language to ensure optimal maternity care outcomes and experiences for every woman, infant, and family.
A maternity unit that is committed to quality will identify these aims as “true north” when planning, implementing, and evaluating quality improvement programs. Care that promotes, supports, and protects physiologic labor and birth and the judicious use of technology when indicated can help achieve all 6 of these aims.
and Protecting Physiologic Birth
While there are some exceptions, overall maternity care settings in the United States do not prioritize promoting, supporting, and protecting physiologic birth. In a national survey of a representative sample of women who gave birth in U.S. hospitals between July 2011 and June 2012, only 13% gave birth without any major obstetric interventions, such as epidural analgesia, induction/augmentation, and operative delivery.2 These interventions override normal physiology, and while the judicious use of each is essential for providing safe, high-quality care, their overuse directly affects maternal and fetal outcomes and the high and growing costs for payers and women.
Those who provide care for birthing women can identify ways to improve quality and value and to better support physiologic birth, but hospitals are complex systems, and making changes can be challenging. The growing and evolving field of quality improvement has helped identify best practices that can lead to long-lasting improvements in safety, quality, and value. These practices include the following:
Culture and leadership matter. Everyone plays a role in quality improvement, but those who care directly for childbearing women (nurses, midwives, obstetricians, anesthesiologists) and those who lead maternity units are particularly well suited to lead change.
Engage a team with diverse perspectives and work on a specific problem together. Change is easiest when those leading the change work on something specific, when they gain a common understanding of the nature of the problem, and when they incorporate the perspectives of everyone involved.
You cannot improve what you don’t measure and track. Data collection and analysis are fundamental to any successful quality improvement effort. Data can help identify the problem and sources of variation in outcomes, measure effectiveness of improvement strategies, and assess whether improved care processes have unintended negative consequences. Some simple tools can support effective data collection and analysis. We have included some in this toolkit.
Stages in the Quality Improvement Process
The quality improvement process follows the scientific process in identifying a problem, collecting data to substantiate the seriousness of the problem, analyzing the data to determine the real causes of the problem, designing changes, testing the changes, and implementing the solution on a broad scale. There are a number of different published approaches that can be taken. Deming and Shewhart described the process of improvement with several basic stages, the FOCUS-PDCA cycle.3 The FOCUS-PDCA cycle includes the following elements:
Find a Process to Improve: Begin by asking what problems exists or what opportunity for improvement exists. Data may already show a high rate of cesarean births for slow labor progress, or patients may complain about lack of comfort options when they prefer to avoid an epidural. Identify an issue or process that needs to be improved and that ideally fits at least one of the following criteria:
Of strategic importance or has a high degree of being a critical success factor in changing care
Represents a competitive area of service
Represents a problem area for the group
Significant in terms of safety, quality, cost, time
Overall, gaps in family-centered care, quality, and value should be highlighted when identifying a priority area for process improvement. Another aspect of identifying priority areas is to align the change with the perinatal measures endorsed by the National Quality Forum related to normal physiologic birth, including reducing rate of primary cesarean birth, reducing rate of elective delivery, and increasing rate of exclusive breastfeeding.
Organize to Improve: A team is put together, including those persons who are most involved with the process they wish to improve. The quality improvement process places high value on multi-stakeholder involvement and leadership within the team. Giving the responsibility for solving problems to the group experiencing the problem empowers them to work more effectively, helps them sell the changes to the people they work with, and most importantly ensures that those actually working on a project understand the process they are studying. Multi-stakeholder involvement allows the process being evaluated to be analyzed and understood from many different perspectives. Team based quality improvement brings about change and improvement that is understood by all involved, which will make successful implementation easier. For example, a process related to comfort options may include a nurse, a midwife, an obstetrician, an anesthesiologist, and a patient or patient representative.
Map Current Process: A flow chart is developed to document the current steps in the process. In the case of a quality improvement project relating to access to evidence-based comfort measures in labor, how are the woman’s comfort preferences communicated to the care team? What prenatal education and preparation are available to women? What happens during each assessment of comfort/coping in labor? What non-pharmacologic pain management options are available, and how does a woman access these options? This will help to highlight problem areas or areas that need to be studied in more depth to understand the reasons for variation.
Understand Sources of Variation: Through analysis of variation in the care processes mapped above, a quality improvement team identifies systemic areas of weakness and vulnerability that lead to patient safety and quality breaches and reduce the ability to reliably provide client-centered care. The team decides on the key components of a process that are most important to the desired outcome. For example, a unit manager may want to address high rates of labor augmentation because she has read recent research clarifying potential adverse effects of synthetic oxytocin, and the unit experienced a number of unexpected admissions of term infants to the neonatal intensive care unit (NICU) after augmented labors. Factors that may contribute to a high rate of labor augmentation include the medical conditions and risk factors of the women the hospital serves, women’s preferences, or the way care is provided. Data are collected on these factors through review of the literature, benchmarking, surveys, performance audits, interviews, provider profiling, focus groups, site visits, and medical records.
With regard to normal physiologic birth, the preferences of the maternity care professional and patient play a role. Researchers have shown that in the current health care system, provider preferences (eg, elective induction of labor, anesthesia, routine augmentation, separation of mother and infant) influence outcomes more than patient preferences (eg, pain relief intention, non-pharmacologic pain relief, infant feeding preference). For this reason, quality improvement teams must analyze the effect of patient and provider preferences and system accountability to both as part of the data collection process.
Initial data collection may reveal variation in performance that is related to a special cause or to a common cause. A special cause variation is not part of the basic process of care. These problems can be solved by direct actions. For example, if a certain provider routinely augments all nulliparous women, the unit manager can address the high use of augmentation by direct communication with this provider. A common cause variation occurs when many small sources of change within a process add up to unacceptable results without presenting an obvious solution. Projects to improve quality care are typically developed when common cause variation exists.
By carefully studying the differences between identified best processes and the unit’s current processes, a new process can be developed that will improve care and produce reliable, family-centered, high quality, high value care and outcomes. By gaining a thorough understanding of the variations that reliably produce the desired outcomes (safe, family-centered care) systems can provide infrastructure to decrease unwarranted variations that may produce undesired or harmful outcomes. For example, the data may show that a high proportion of women in labor are diagnosed with labor progress disorders in early labor, and new processes may be implemented to require documentation of active labor before pharmacologic augmentation can begin.
The PDCA Cycle
Plan: Develop an action plan and goals for implementation of the new or revised process.
Do: Implement the plan.
Check: Collect data to analyze the effects of the change(s) to see if the process improvement plan improved the quality of care.
Act: Analyze results and act upon them to continue the improvement or make changes. If a positive change is achieved, the practice is “held,” and a new policy or procedure is implemented to assure follow through. Periodic monitoring can then be conducted. If the change did not affect the process, then different opportunities for improvement should be identified and the PDCA process resumed.
AWHONN Perinatal Quality Measures Process
The actions of nurses have a significant impact on patient outcomes; therefore, a vital component of improving health care is to measure the quality of nursing care. This resource links to Women's Health and Perinatal Nursing Care Quality (NCQ) measures by The Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN).
Clarity in Collaboration
2012, the American College of Nurse Midwives (ACNM) has participated in the ReVITALize initiative which is part of
the Women’s Health Registry
project. This consensus-building process was designed to develop a common
language among the many stakeholders involved in maternity data collection in
the US. The first set of data definitions pertaining to clinical
obstetrics was released by ACOG as a result of this process. These definitions
have been endorsed by key professional organizations including AWOHNN, SMFM and
ACNM. Since then ACNM embarked on a parallel consensus building process
called Clarity in Collaboration to
define concepts specific to midwifery and collaborative maternity care not addressed
in ReVITALize. The Clarity in Collaboration definitions were designed to
enable consistent documentation of when midwifery care occurred and to capture
critical aspects of care such as collaboration, coordination, and continuity.
Nursing Quality Measurement (AWHONN)
Link to PDF download of AWHONN's position statement on nurse-sensitive quality. These are currently the recommended perinatal quality indicators proposed for adoption by the National Quality Forum Perinatal Measures.
Transforming Maternity Care Vision Team, Carter MC, Cory M, et al. 2020 vision for a high quality, high value maternity care system. Womens Health Issues. 2010;20(suppl. 1):s7-s17.
Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to mothers III: report of the Second National Survey of Women’s Childbearing Experiences. http://transform.childbirthconnection.org/wp-content/uploads/2013/06/LTM-III_Pregnancy-and-Birth.pdf. Published May, 2013. Accessed March 2, 2014.
* Adapted from The American College of Nurse-Midwives Service Directors Network’s Administrative Manual for Midwifery Practices, 3rd ed. (2006) Chapter on Quality Management by Cathy Collins-Fulea.