Development of a large-scale obstetric quality-improvement program that focused on the nulliparous patient at term

Abstract

Objective: The purpose of this study was to identify an appropriate population and a balanced set of maternal and neonatal measures to drive a hospital network obstetric quality improvement program. Study design: Sutter Health, a large Northern California health care system withO40,000 births annually, served as the site for this project. We chose to focus on the standardized nulliparous patients: term, singleton, and vertex. A multidisciplinary task force evaluated and selected perinatal outcome and process measures. Data from every hospital were collected prospectively electronically and analyzed centrally. Results: Outcome measures that were selected included term, singleton, and vertex rates of 3rd/ 4th-degree laceration, cesarean birth, 5-minute Apgar score of !7, and patient satisfaction. The process measures included episiotomy, induction (37-41 weeks), and admittance with cervical dilation of R3 cm. Data collection completeness improved each quarter; by the end of 2002, the data collection completeness rate had reached 99.7%. Every measure demonstrated a large variation among our hospitals, which indicates opportunities for improvement. Conclusion: This balanced set of measures for term, singleton, and vertex patients has been straightforward to collect over a large and diverse hospital system and has engaged all participants successfully. Ó 2004 Elsevier Inc. All rights reserved. KEY WORDS Quality improvement Cesarean delivery Perineal laceration Induction Nulliparity -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Over the last 5 years, we have seen a reappraisal of traditional quality indicators in obstetrics. The value of the measures (total cesarean birth rate and the rate of vaginal birth after cesarean [VBAC]) to accurately reflect a birthing unit's quality of care has been challenged by both clinical leaders and new data. 1,2 We describe here an alternative approach to obstetric quality assessment and improvement that focuses on treatment of a standardized population of women who are having their first delivery and the implementation of this method in a large hospital network