Elements of a successful quality improvement and patient safety program in obstetrics and gynecology.

Abstract

In this article we present the elements of one approach to quality improvement and patient safety that we believe can be successful and sustainable in the field of obstetrics and gynecology, along with several strategies (and caveats) that have worked and are working in academic and nonacademic institutions in the United States. Also included are several noteworthy definitions of quality to provide some additional perspectives on what is meant by quality in health care.

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Elements of a Successful Quality
Improvement and Patient Safety
Program in Obstetrics and Gynecology
Joseph C. Gambone, DO, MPHa,b,*,
Robert C. Reiter, MDc,d
aDepartment of Obstetrics and Gynecology, David Geffen School of Medicine at UCLA,
Los Angeles, CA 90095, USA
bCollege of Osteopathic Medicine of the Pacific, 309 E. Second Street,
Pomona, CA 91766, USA
cQuality and Clinical Performance Improvement ProMedica Health System,
2142 North Cove Boulevard, Toledo, OH 43606, USA
dConrad Jobst Tower, Suite 200, Toledo, OH 43606, USA
No goals in health care delivery are more critical than keeping patients
safe from harm during treatment and improving the processes and outcomes
of their care. In 1914, Ernest Codman, a well-respected Boston physician,
recognized this and stated that ‘‘Every hospital should follow every patient
it treats long enough to determine whether the treatment has been success-
ful, and then to inquire ‘If notdWhy not?’ with a view to preventing similar
failures in the future.’’ When he tried to establish a registry to track the
outcomes of clinical care at Massachusetts General Hospital he was expelled
from the medical staff and removed from the Harvard faculty. Fortunately
he carried on his work elsewhere and inspired others over the years to add to
an impressive body of knowledge that now exists about quality improve-
ment and patient safety. Although Codman never used the term ‘‘patient
safety’’ it is clear from his writings that he considered the safety of the
patient as an important outcome of success, and any preventable medical
or surgical error as failure [1].
Today, both managers and clinicians in health care are well aware of the
importance of patient safety and the need to continuously improve the care
that they deliver, and are almost always supported by top leadership to
establish processes that address these issues. The establishment of the Joint
* Corresponding author. 436 Hogan Circle, Durango, CO 81301.
E-mail address: jgambone@ucla.edu (J.C. Gambone).
0889-8545/08/$ - see front matter ? 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.ogc.2007.12.004obgyn.theclinics.com
Obstet Gynecol Clin N Am
35 (2008) 129–145

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Commission on Accreditation of Health Care Organizations (TJC), inspired
by the work of Codman and others, has provided the expectation that
hospitals and other health care facilities promote and perform quality
improvement and patient safety activities.
Obstetrics and Gynecology as a specialty has an impressive record with
respect to Patient Safety and Quality Improvement programs including
those sponsored by the American College of Obstetricians and Gynecolo-
gists (ACOG). ACOG as well as other women’s health specialty organiza-
tions around the world are providing educational materials and tools to
guide these processes.
In North America, the specialty of anesthesia is credited by many as the
discipline in health care that initially focused and published on safety using
the term ‘‘patient safety.’’ The now well-known monograph by the Institute
of Medicine (IOM) of the US Academy of Sciences, ‘‘To Err is Human,’’ and
its follow-up publication ‘‘Crossing the Quality Chasm,’’ called attention to
how common medical and surgical errors are [2,3]. These publications and
others [4,5] have put patient safety and the reduction of error at the top
of the list of quality improvement efforts.
It is easy to become confused by the lexicon and jargon that exist in the
field of quality improvement in health care and forget that all activities,
whatever they are called, are ways to improve performance periodically or
on an ongoing basis. Berwick’s seminal article on health care improvement
correctly emphasizes the need to prospectively and continuously improve
the processes of care [6]. The best and most effective overall approach to
improving quality, however, is to incorporate other important and useful
improvement activities, some of which are retrospective and periodic.
Risk management is traditionally performed retrospectively and is one of
the activities and terms that may now cause some confusion. Risk manage-
ment in North America was mainly undertaken to protect institutions from
any medico-legal liability as a result of medical and surgical errors. Around
the world and even now in North America a more prospective process of
clinical risk management is being developed to study ways to identify and
‘‘manage risk’’ and prevent errors from happening [7].
Thus quality assurance or QA, continuous quality improvement or CQI,
risk management or RM, and patient safety are all part of the lexicon of ‘‘im-
provement’’ and represent distinct activities in health care delivery. Each has
its unique characteristics, strengths, and weaknesses; and each has an impor-
tant function in the movement to improve health care delivery (Fig. 1).
In this article we present the elements of one approach to quality
improvement and patient safety that we believe can be successful and sus-
tainable in the field of obstetrics and gynecology, along with several strate-
gies (and caveats) that have worked and are working in academic and
nonacademic institutions in the UnitedStates. Box 1 contains several note-
worthy definitions of quality, and is included to provide some additional
perspectives on what is meant by quality in health care. All of us as
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consumers can state legitimately that we know what quality is when we see
or experience it. The last anonymous definition in Box 1 further implies that
consideration of cost or value is a necessary component of quality.
Three approaches to quality assessment and improvement
Fig. 2 illustrates the continuum of clinical practice presented in the form
of a ‘‘normal curve’’ from worst performance on the left to best performance
on the right. The three approaches to Quality Assessment and Improvement
Fig. 1. Comparative characteristics of performance improvement activities, risk management
(RM), quality assurance (QA), continuous quality improvement (CQI), and patient safety.
(Adapted from Berek JS. Berek & Novak’s Gynecology, 14th edition. Baltimore: Lippincott,
Williams and Wilkins, 2007; with permission.)
Box 1. Definitions of quality
? Doing the right thing the first timedThe Joint Commission
? Exceeding the customer’s expectationsdW. Edwards Deming
? The degree to which health services.increase the likelihood of
desired health outcomes and are consistent with current
professional knowledgedInstitute of Medicine (IOM)
? Doing the right thing; Doing the right thing right; Doing the
right thing right the first time; Doing the right thing right the
first time and at the right costdAnonymous
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opportunities are represented as Quality Assurance (A) on the left of the
curve, which is designed to prevent or eliminate substandard practice. These
activities tend to focus on individual practitioners who are ‘‘outliers’’ and
may involve sanctions. Such activities include credentialing and privileging,
peer review, traditional risk management, and other primarily retrospective
tools. Continuous Quality Improvement (B) is prospective and is designed
to improve performance in ‘‘real time.’’ Activities include evidence-based
practice and practice guidelines and efforts to reduce unnecessary variation
in health care delivery. The focus of these activities is on ‘‘systems of care’’
and teamwork rather than on individuals and punitive measures and sanc-
tions are not appropriate or effective. Usually, a continuous improvement
tool such as the FOCUS-PDCA method (Fig. 3) is adopted. The goal of
Continuous Improvement activities is to move the curve in Fig. 2 to the
right using best-performance standards as benchmarks. Finally, Clinical
Innovation (C) on the right side of the curve in Fig. 2, represents best
clinical performance and leading edge practice. These activities typically
include new ways of practicing, sometimes using research protocols with
informed consent, as well as new ways to improve care at the organizational
level such as the use of electronic medical records. Note that all of three of
these activities, and therefore most opportunities for improvement in health
Fig. 2. Clinical improvement activities. Quality assurance (A), continuous improvement (B),
and clinical innovation (C). (Adapted from Hacker NF, Moore JG, Gambone JC. Essentials
of Obstetrics and Gynecology, 4th edition. Philadelphia: WB Saunders, 2004; with permission.)
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care, move the overall standard of care toward the right side of the curve,
toward better performance.
Elements of a successful and sustainable improvement program
There are seven elements or steps that can be applied to initiate a success-
ful and sustainable quality improvement and patient safety program in
obstetrics and gynecology. These steps are based in part on the Quality
Improvement in Women’s Health Care manual published by ACOG [8]
and modified by us for the ACOG postgraduate course on Quality Improve-
ment and Patient Safety. The seven steps are listed in Box 2.
The goals of a quality improvement and patient safety program should
also include overall organizational improvement at your institution. Impor-
tant administrative and nonclinical processes such as appointment schedul-
ing and even food service should be studied and improved because they
impact not only patient satisfaction but also the quality of care and affect
health outcomes.
Institutions must reduce medico-legal risk by both retrospective review
and also by prospective clinical risk management to prevent errors that
can lead to harm to patients and to financial liability. However, they need
to do this while maintaining appropriate due process for medical and pro-
fessional staff. Finally, it is becoming increasingly important that health
Fig. 3. FOCUS-PDCA. A continuous improvement model to guide the process of making im-
provements now widely used in health care. (From Langley DJ, Nolan KM, Nolan TW. The
foundation of improvement. Silver Spring, MD: API Publishing; 1992; with permission.)
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SUCCESSFUL QI AND PATIENT SAFETY PROGRAM