00003081-201009000-00010

Role of ClinicianInvolvement in PatientSafety in Obstetricsand Gynecology

SUSAN MANN, MD,* and STEPHEN PRATT, MDwDepartments of *Obstetrics and Gynecology and wAnesthesia,Critical Care & Pain Medicine, Beth Israel Deaconess MedicalCenter, Harvard Medical School, Boston, Massachusetts

Abstract: Patient safety is a significant concern forhealthcare providers. Involving physicians in clinicalquality activities in obstetrics and gynecology can bedifficult for many reasons including time demands,lack of knowledge of process improvement activities,or change fatigue due to failure of adequate imple-mentation of previous activities. This overview forimproving the culture of safety identifies roles physi-cians can play fromparticipating in quality assessmentand improvement activities, improving teamwork be-tween disciplines, communicating effectively, creatingdepartmental guidelines, and deciding on outcomemeasures for benchmarking. An improved culture ofsafety is better for our patients and may reduce mal-practice exposure.Key words: patient safety, quality improvementobstetrics, teamwork

IntroductionIt has now been more than a decade sincethe Institute of Medicine (IOM) pub-lished its report highlighting the impact

that medical errors have on patient safety.Sadly, little has changed in the pastdecade to lessen the impact of error orto improve the culture of safety inwhich healthcare providers work. Al-though some individual successes havebeen made, we have not changed thenature of medical care to improve patientsafety. Obstetrics presents unique chal-lenges to patient safety. Multiple provi-ders are often caring for multiple patientson units with limited resources (operatingrooms, anesthesia providers, etc). Tradi-tionally, these providers do not worktogether to determine the best utilizationof these resources. The very nature ofobstetric medicine makes it private, andless amenable to open communication.In fact, generally mothers are literallybehind closed doors while they labor,limiting the ability of team membersto observe the care their colleagues pro-vide and to look for errors. Finally, ob-stetric care providers are frequently not

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Correspondence: Susan Mann, MD, Department ofObstetrics and Gynecology, Beth Israel DeaconessMedical Center, Harvard Medical School, Boston,MA. E-mail: [email protected]

CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 53 / NUMBER 3 / SEPTEMBER 2010

CLINICAL OBSTETRICS AND GYNECOLOGYVolume 53, Number 3, 559–575r 2010, Lippincott Williams & Wilkins

physically present in the labor and deli-very unit. They may be performing sur-gery, rounding, or seeing patients in theiroffices.

Despite these challenges, developing aculture of safety in obstetric medicine isincreasingly urgent. This is the only med-ical arena in which it is possible to have a200%mortality rate. Recent data demon-strate that adverse events are commonin obstetrics, and a large percentage ofmajor adverse events are preventable.1

Substandard care contributes to approxi-mately 50%ofmaternal deaths, with poorcommunication and teamwork being theprimary factors in the substandard care.2

Poor communication and coordinationin providing care has been identified in43% of the closed malpractice claims inobstetrics.3

Leadership, at both the executive andclinical levels, is essential to a vibrantculture of patient safety.4 Obstetric nurseswho feel supported by their administra-tion are more likely to feel empoweredto pursue resolution of clinical conflict.5

Examples of executive leadership includeexecutive walk rounds, and financial andadministrative support for patient safetybehaviors. Obstetric care providers canprovide clinical leadership. Examplesof clinical leadership behaviors includeensuring appropriate task completion(delegation, role clarity, and task prior-itization), developing protocols andguidelines, working to increase team trustand commitment, monitoring the envir-onment, and encouraging a cooperativeclimate.

Several barriers have prevented obste-tricians from taking active clinical leader-ship roles in patient safety. Fear ofliability and lack of knowledge of clinicalguidelines have been cited as reasonsobstetricians shy away from leadershiproles.6 Low scores with regard to patientsafety attitudes may reflect a lack of will-ingness to become clinical leader. In asurvey by Stumpf et al,6 nearly 40% of

obstetricians did not believe that com-munication improved patient safety.One must believe in the concept ofpatient safety if one has to lead othersinto them.

Physician Involvement inQuality ActivitiesThe discipline of Obstetrics and Gynecol-ogy has a long history of studying mater-nal and neonatal outcomes and pursu-ing improvements in care. Obstetriciansstarted Maternal Mortality Review com-mittees in the 1920s. The initiation of statematernal mortality study committees inthe 1930s coincided with the beginning ofsignificant declines in maternal deaths inthe United States.7 The American Collegeof Obstetricians and Gynecologists(ACOG) has supported clinicians withpublications regarding peer review, qual-ity assurance, standards for Obstetric-Gynecologic Services, and guidelines forprenatal care. In 2000, ACOG releasedQuality Improvement inWomen’sHealthCare, which helped to lay the foundationfor hospital obstetrics and gynecologydepartments to track and understandtheir own outcomes. The focus of thismonograph was on moving from punitiveapproach to an educational approach. In1989, Berwick8 published a sentinel articleon continuous quality improvement asthe ideal in healthcare which helped tomove the focus of healthcare to continu-ously improving care and reducing waste,rework, and complexity. The Quality Im-provement model also known as QualityAssessment (QA), Quality Management,or Process or Performance Improvementhasmoved from focusing on ‘‘bad apples’’to improving the systems of care.Recently, Watcher and Provonost9 haveraised the concern that patient safetymovement needs to strike the correctbalance between no blame and individualaccountability. In comparing medicine

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with the airline industry, using the exam-ples of hand washing and time-outs forsurgical procedures individuals shouldhold one another accountable for definedevents. A copilot would not fly with apilot who refused to use the preflightchecklist.

A Model of QA andImprovement and thePhysician’s RoleIt has often been difficult to describe amodel for peer review and quality im-provement that fits obstetric and gyneco-logical departments of varying sizes andresources. Smaller departments withfewer staff may have difficulty reviewingpeer’s charts objectively as they may bepractice partners or competitors. Underthese circumstances, charts may be pre-sented for review to a hospital-widecommittee, but other disciplines may beunfamiliar with the standards of care forthe practicing obstetrician/gynecologist.ACOG introduced the Voluntary Reviewof Quality of Care program, which pro-vides a comprehensive review of obste-trics and gynecology service performedby community-based physicians andnurses.10

The Joint Commission (TJC) requiresthat hospitals have an executive commit-tee of the medical staff charged with peerreview, credentialing, and QA. Table 1describes the steps involved in creating astrong quality improvement process. Thedepartment chairman designates a qualitychairperson and committee to performthe necessary activities; the chairman thenreports back to the hospital executivecommittee. Departmental leaders are alsooften required to post and update a qual-ity dashboard, which allows the public,board of trustees, and department mem-bers to view a measure that reflects asnapshot of that department’s ‘‘quality’’of care.

Developing a structure for QA andwork improvement for a department isessential. It is important to get broadrepresentation from different constituen-cies such as call-group representatives,physicians in private practice, hospital-employed physicians, midwives, and resi-dent designees appropriately. Hospitalswith larger departments often get supportfrom hospital-level quality committeesor employ their own nurses and supportstaff to support the quality activities.Early work in the quality arena focusedon retrospective analysis of events.

Case identification can be variableamong institutions. The identification ofthese events has been aided by TJC, whichhas provided a list of sentinel events thatrequire retrospective reviews and rootcause analysis. ACOG has also publisheda list of quality indicators for case reviewby departmental quality leaders.11 Othersources of indicators for chart review arecases that are mandated for reporting toindividual state board of registration of

TABLE 1. Quality Activities

1. Create a committee-broad representation,rotate membership

2. Decide on quality indicators-encourageanonymous event reporting

3. Identify sources to provide charts based onindicators

4. Review charts5. Present charts at monthly Quality Assessment

meetings – gain consensus on review6. Identify specific education need for individual

providers if necessary7. Identify cases to present for staff education at

Morbidity/Mortality conferences8. Identify care processes that need attention and

process improvement9. Educate staff on processes requiring change

based on case based learning10. Provide annual Quality Update to

department – educate all staff on dashboardmeasures, case review process, review ofchanges in departmental guidelines

11. Track outcomes of chart reviews to identifytrends for procedures or individuals

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medicine or the local public health de-partment. Failure to follow guidelinesprovided by malpractice carriers forexample, dictation of a note for a shoulderdystocia complication, or a fourth degreerepair can also be reviewed. Anonymousevent reporting in which providers reportthe concerns of quality of care, failure ofinstrumentation, or inadequate staffingshould be encouraged in all the depart-ments. Selection of indicators that areto be reviewed is the work of the QAcommittee, with the approval of the de-partment chairperson and buy-in fromthe staff. The identification and distribu-tion of charts for review by individualcommittee members is the work of thestaff supporting the committee. Thesecharts can be flagged by discharge diag-nosis code or length of stay data, labora-tory services, admission to neonatalor maternal intensive care units and re-ports can be created by informationtechnology services department within ahosptial.

The process of peer review of theflagged charts can be difficult and at timesuncomfortable for members serving onthe committee. Landon et al12 describethat often there are no standards forclinical competency or thresholds foracceptable care. Chart review should beperformed before a meeting so that thecases can be presented and discussedby the committee members. An effort torespect any conflicts of interest during thereview process is necessary, for example,one should not review their own partner’scases and one should refrain from thediscussion of a case if one was a providerof care. Interviews can be performed byquality nursing staff beforemeetings if thecharting of the case is unclear; however,an educational role for physician is toprovide feedback when charting doesnot support clinical decision-making.The chart review and discussions shouldbe based on the standards of care for thatcommunity and relevant guidelines.

It is important for a structured processof discussion to occur after the presenta-tion of the case. Goldman and Ciesco13

looked at the poor interrater reliability ofsingle reviewers and recommended the useof multiple reviewers, and structuredassessment instruments, particularly forreviews that have major consequences forpatients and practitioners. Levine et al14

recommended to use structured peer re-view without discussion and consensus,when therewere single reviewers and therewas an enormous variation between theindividual reviewers. Therefore, it is re-commended that a QA committee pre-sents a case using a structured review,including pathology reports, fetal heartratemonitor strips, and local and nationalguidelines.

After discussion, the committee mem-bers should arrive at a consensus regard-ing the chart review of: no deficiency incare, opportunity for improvement, defi-ciency in care, and/or system issues iden-tified. In our department of Obstetricsand Gynecology, at Beth Israel Deacon-ess Medical Center we have used such asystem of structured peer review and con-sensus; for several years we have reviewedbetween approximately 420 and 460 casesyearly. The average rate of a case with nodeficiency is 86% to 89%, opportunity forimprovement 7% to 10%, and deficiencyin care 1% to 4%. Forster et al15 reviewedthe adverse events of an obstetrical serviceand found that adverse events and poten-tial adverse events were most commonlythe result of ‘‘system’’ problems and notindividuals. Many charts are reviewedthat have no deficiency in care but com-plications can arise that can cause a pro-longed length of stay or scar tissue cancause an unintentional entrance into thebladder. In our experience, an opportu-nity for improvement is identified whenthere is an error in dictation of an opera-tive report, or a delay in implementationof plan of care which did not cause harmto a patient, or failure to use a correct

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consent form. In cases of opportunity forimprovement, the committee chairper-sons write a letter to a provider for educa-tional but not punitive reasons. In casethere is deficiency of care, the case isreferred to the departmental executivecommittee composed of senior membersand division directors who decidewhetherthe provider needs an educational coun-seling session or not. If there is a signifi-cant departure from the standard of careor outcome, it is reported to the hospital-wide patient care assessment committee,a subcommittee of the medical executivecommittee.

All of this work is dependent uponphysician involvement and it is often anexcellent educational activity for physi-cians who participate. Thus, it is impor-tant to rotate membership or have sharedappointments so thatmore physicians canparticipate in the review and discussion,and if they are unable to attend a meetingthe charts are reviewed in a timely fashion.Each case is also reviewed for potentialsystem issues, which may need furtherattention. The case is then referred to anestablished obstetric or gynecologicalworking group to develop a change inprocesses of care or a checklist to aidproviders. The chairperson of the qualityassurance also gives input to cases forpresentation at the Morbidity and Mor-tality conferences; the staff could learnfrom the experience especially when safe-guards are put into place. It is also usefulto track the outcomes of the chart reviewsand indicators for review and providerinvolved in the case in a database. Thistrend is important to identify certain typesof complications for example, prolongedtime in operating room for individuals,who may need additional training forcertain types of surgical procedures.Creating a baseline comparison of allphysicians in the departmentmay identifya physician who has a spike in the numberof cases requiring review, a situation,which may require further attention.

Finally, the work performed and the sta-tistics obtained are reviewed in a yearlyquality improvement grand round forall staff.

Physician Involvement inCreating a Culture of SafetyThrough Improved TeamworkImproving teamwork between the mem-bers and disciplines of labor and deliveryunit provides a safety net for patients.Communicating plans of care for all pa-tients allows the staff to raise safety con-cerns about the plan itself or to monitorfor deviations from the plan. Raisingconcerns may cause conflict between pro-viders; learning how to resolve the conflictamong members in a respectful way isessential for sending a unified messageto patients and maintaining staff morale.These concepts are the essence of a team-work program in labor and delivery.Creating a team structure in labor anddelivery leads to improved outcomesand staff satisfaction.16,17 Nielsen andMann18 discuss 3 types of teams in laborand delivery. The core team is involvedwith direct patient care. A coordinatingteam takes the 30,000-foot view, managesthe workflow of the entire unit, helpsto triage activities, and resolves conflicts.Members of the coordinating teaminclude the charge nurse, a designatedobstetrician, anesthesiologist, and chiefresident. The third is a contingency teamor a rapid response team composed ofpredetermined members of the core teamwho respond to issues such as an emer-gence of cesarean delivery. The behaviorsor communication events that are taughtin a teamwork course often includehuddles, team meetings, briefings, hand-offs of care, debriefings, etc.19 A huddleis a quick communication between 2providers, for example, an obstetricianand a nurse, or a nurse and an anesthesiaprovider to update one another regarding



the status of a patient. A teammeeting is amultidisciplinary meeting among all pro-viders where important patient and pro-vider information are discussed. Table 2provides an outline for the discussion ofa team meeting. It is important that alldisciplines participate in the meetings asthey raise their specific concerns regard-ing care of the patient. Balancing work-load at the meeting can provide assistanceto an overworked colleague who mayperhaps be reluctant to ask for assistance.Identifying work that could be postponedduring times of high acuity, could im-prove patient satisfaction if patients arekept at home instead of waiting for pro-longed periods in the waiting area until itis safe to proceedwith elective procedures.The third type of communication event isthe briefing, which should occur before anoperative delivery. The specific concernsabout this patient, including possible needfor blood products, previous difficult sur-geries or issues with anesthesia, and co-morbidities are shared with the team toprovide a shared vision among all care-givers. A debriefing occurs at the conclu-sion of a procedure allowing providers toshare teamwork or procedure-related con-cerns with the team. The World HealthOrganization recently recommended a si-milar sign in and sign out of the operatingroomapproach thatwhen performedwitha TJC mandated timeout was shown toimprove morbidity and mortality by 38%in 8 hospitals on different continents.20

Role ClarityThe understanding of one’s own roles andresponsibilities on the team, and those of

one’s team members is crucial to success-ful teamwork. In order to perform one’stasks, or to monitor the task performanceof one’s team members one must be clearabout what those roles should be. Datasuggest that clinicians, especially nurses,are frequently unsure about team mem-bers’ roles, and often make inaccurateassumptions about the role of others.

The importance of role clarity has beendemonstrated in both simulated and clin-ical arenas in obstetrics. Robertson et al21

found that task completion increasednearly 4 folds during a simulated obstetricemergency when roles and the responsi-bilities of each role were clearly defined.Staff confidence and feelings of compe-tence also improved with the improve-ment in role structure. In the clinicalenvironment, Skupski et al22 developed arapid response team for obstetric hemor-rhage with clear expectations for the tasksto be completed and the role of each teammember. They educated staff about theseprocesses and better defined the role of in-house obstetricians with regard to patientmonitoring. These changes were asso-ciated with improvements in maternalmortality and acid-base status after majorhemorrhage. Staff obstetricians can helpmaintain role clarity by clearly definingpatient care plans, giving directions tospecific individuals when tasks are as-signed, maintaining crowd and noisecontrol during emergent events, and sup-porting a team-oriented and trustingenvironment.

Physician’s Role inthe Development andImplementation of GuidelinesGuidelines can be adopted from exist-ing organizations, and can become thestandard of care for the department.Examples include Guidelines for Perina-tal Care a joint publication from ACOGand the American Academy of Pediatrics,

TABLE 2. Team Meeting Agenda

1. Each patient’s care plans2. Any safety concerns regarding each patient3. Physician availability and coverage

arrangements4. Individual staff workload and availability5. Elective work scheduled on the unit

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a set of broad guidelines ranging fromroutine labor to maternal transports andmanagement of multiple gestations.Morespecific guidelines are usually created bydepartmental members on representativecommittees in response to an adverseevent or prospectively thinking abouthow to improve care in an area, whichmay be of a potential challenge. It isimportant that physicians are familiarwith both national guidelines and alsospecific departmental guidelines. An ex-ample of a guideline that a departmentcan create may refer to the requirementsfor a physician’s presence on labor anddelivery. This guideline may be created asa result of an outcome specific to thedepartment for example, an unattendeddelivery. Another type of guideline can becreated using a prospective Failure ModeEffect Analysis, which is a method forpredicting possible errors and when com-bined with an estimate of the severity ofthe error allows one to prioritize qualityimprovement projects.

Guidelines are usually developed thro-ugh the work of a multidisciplinary com-mittee including physician representation.After the development and acceptance ofthe guideline by senior leadership, intro-duction and implementation to the entirestaff can be a challenging process. Tools togain staff buy-in or acceptance includeusing case-based learning and sharingthe frequency or severity of events whiledescribing the efforts to improve theprocesses of care.

Effective CommunicationImproving communication may be themost important factor in the effort toimprove patient safety. Ineffective com-munication has been cited as a leadingcause of preventable errors across manydisciplines of medicine. A growing bodyof literature now indicates some of thereasons that healthcare providers com-municate poorly. Lingard et al23 found

that up to 30% of intraoperative commu-nication events failed to produce theirintended effect due to poor timing ofthe communication, the wrong audience,or inappropriate content. Other causes ofcommunication failure include interrup-tions, hierarchy, workload stress, ambientnoise, and lack of structure for commu-nication, especially during handoffs.

Less data exist on the impact thatpoor communication has on obstetricoutcomes. TJC identified poor communi-cation as a root cause in 72% of perinataldeaths.24 Data do exist demonstratingthat obstetric care providers frequentlycommunicate ineffectively in both simu-lated and clinical environments. Using insitu simulated eclampsia drills, Thomp-son et al25 found that timely communicat-ing with senior obstetric staff was arecurrent problem. Similarly, Danielset al26 demonstrated that obstetric resi-dents communicated poorly with theirpediatric team members during a simu-lated emergent delivery. Although 63%called for pediatric help during the simu-lated maternal cardio-pulmonary arrest,only 10% gave helpful information to thepediatricians when they arrived.

More concerning, interdisciplinarycommunication may be lacking in theclinical care of the parturient. Simpsonet al27 used focus groups to describe thecommunication patterns between the ob-stetricians and obstetric nurse in 4 laborand delivery units. The authors foundthat the communication processes werefrequently not consistent with effectiveteamwork. The nurses at 1 site oftencommunicated with obstetricians onlyfor admission orders and at delivery,amounting to only 2 to 4 minutes ofinteraction. Across the sites, nursesdescribed having to use catch phrases orcodewords to get the obstetricians to listento their recommendations. They evenpurposely withheld information fromphy-sicians to influence their interactions.This need to play the ‘‘physician-nurse



game,’’ clearly has the potential to under-mine trust between team members and tolead to patient harm.

It is clear that poor communication isa common factor in patient harm. Exactlywhat clinicians can do to help improvecommunication is less well described. Re-commendations are often broad, withoutspecific goals that can be implemented,for example, TJC recommendation for‘‘timely communication of critical tests.’’Even the ACOG Committee Opinion onPatient Safety is relatively silent on inter-disciplinary communication. Although‘‘Improve Communication’’ is 1 of the 7recommendations of the opinion, this sec-tion focuses entirely on the disclosure ofadverse events to patients. TJC’s ‘‘Writeit down and read it back,’’ recommenda-tion, and prohibited abbreviations list are2 examples of specific recommendationsto improve communication.

Obstetric providers can ensure thatthey meet the communication standard.TeamSTEPPS, a team-training curricu-lum developed by the US Department ofDefense based on the concepts of CrewResource Management (CRM), definesthe standards of effective communicationas being complete, clear, brief, andtimely.28 It also outlines several tools tohelp achieve these goals. The most signif-icant of these is the ‘‘check back,’’ atechnique in which the receiver of infor-mation repeats the information back tothe speaker to ensure that it has beenheard correctly and understood. Obstetri-cians should use this tool with all commu-nication events and expect others use itback to them. This is difficult as it oftenfeels forced and unnatural and as clinicalleaders on labor and delivery units, phy-siciansmust take an active role in ensuringit occurs.

Second, obstetricians can ensure thatthey communicate all appropriate infor-mation with their team members. Com-municating the plan may seem trivial andobvious in obstetrics, ‘‘Have a healthy

baby and mother.’’ However, nurses andresident physicians frequently cannotarticulate the specific goals for theirpatients, largely because the goals havenever been communicated. An example ofa specific goal in a laboring patient mightbe: augment labor, place an intrauterinepressure catheter to assure adequate con-tractions, and delivery by cesarean sectionif no progress is made within 2 hours. Theplansmade for 1 patientmay dramaticallyimpact the safety of the rest of the unit andvice versa. For instance, the obstetriciancaring for a patient with a protractiondisorder and Level 2 (indeterminate) fetalheart rate tracing may wish to ‘‘push thepit’’ to either help labor progress or ‘‘havethe baby declare itself.’’ This is a reason-able plan assuming personnel to performan emergency cesarean delivery are read-ily available and informed of the possibi-lity. However, if staff is not available, or ifmultiple providers have the same plan atthe same time, both mother and babycould be at risk.

Clinicians must communicate their lo-cation, how they can be reached, and whowill cover their patients during an emer-gency if they are off the unit. This cover-age should be explicitly arranged, and aclear handoff of the patients should occur.With the growing popularity of ‘‘labor-ists,’’ many units have built-in coveragearrangements.Medical concerns should becommunicated with the appropriate teammembers. Pediatric providers should bewarned about potential fetal anomalies.Anesthesia staff should be proactively con-tacted about patients who might pose ahigh anesthetic risk (obesity, coagulo-pathy, significant cardiac or pulmonarycomorbidities). Finally, physicians shoulddevelop structured processes for handingoff or transferring the responsibility ofcare. One of the specific recommendationsof the IOM report was decreased relianceon individual vigilance and an increasedattention to handoffs. However, there isstill no large-scale structured process for

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handoffs. Obstetricians should developformalized systems for handing off re-sponsibility of their patients, ideallyface-to-face. Structured communicationtechniques such as SBAR (Situation,Background, Assessment, Recommenda-tions) should be used whenever possible.This transfer should be communicatedwith all team members.

Perhaps the most important communi-cation behavior that obstetric care provi-ders can perform is to actively work tofoster an atmosphere conducive to patientsafety. Patient safety is predicted on trust,open communication, and effective inter-disciplinary teamwork.27 Some physi-cians undermine the atmosphere of trustwith disruptive or abusive behavior. AJoint Commission Sentinel Event Alertindicated that ‘‘intimidating and disrup-tive behaviors can foster medical errors,contribute to poor patient satisfaction,and to preventable adverse outcomes, in-crease the cost of care, and cause qualifiedclinicians, administrators, and managersto seek newpositions inmore professionalenvironments.’’29 It has been estimatedthat 3% to 5% of physicians present aproblemwith disruptive behavior. Rosen-stein and O’Daniel30 have demonstratedthe negative effects that aggressive anddisruptive behaviors have on patientsafety and staff retention in the periopera-tive setting. Similar behaviors have beendescribed in obstetrics. Veltman31 foundthat 60.7% of labor and delivery unitsnoted disruptive behavior, generally oc-curring at least monthly. In all, 41.9% ofthe units indicated that adverse patientoutcomes had occurred as a direct resultof these behaviors, and 39.3% stated thatnurses had left the unit due to the intimi-dation. In another survey, 34% of nursesstated that they hadbeen concerned abouta physician’s performance, but only 1%actually shared these concerns.32 Obste-tric nurses have described explicit epi-sodes of aggressive behavior: ‘‘I wouldbe petrified if at 7 AM they (the physicians)

walked in and I didn’t have the pit going.They’d yell at me.’’27

Physicians can help create an open andtrusting communication atmosphere byasking other teammembers to raise safetyconcerns, by expressly giving them per-mission to question unclear orders or tochallenge apparently dangerous actions.Openly communicating in this way duringa briefing before surgery (eg, cesareandelivery) can set the tone for better com-munication throughout the procedure.33

Physicians should thank the staff whoquestion their behavior, even if the ques-tioner is wrong, because the act of ques-tioning is done for patient safety andshould be encouraged.

Measurement of Qualityof CareThere are many organizations and agen-cies that have proposed measures of qual-ity to help patients, providers, insurersto differentiate healthcare providers. Insome cases healthcare organizationshave modified care to score well on themeasures which may actually improveoutcomes for example, Leapfrog—hospi-talists in Intensive Care Units 24 hoursper day. The organizations make sugges-tions for of the entire healthcare andrarely focus just on women’s healthcare.Table 3 identifies some of these organiza-tions, their funding source or who thegroup represents, mission statements orareas of interest and Uniform ResourceLocator address. All of the organizationslisted here have measures that affectthe practicing obstetrician/gynecologist.Although ACOG is the only organizationto focus exclusively on women’s health-care, some organizations, for example,TJC and National Committee for QualityAssurance have significant influence onwhat measures hospitals or health plansneed to collect for accreditation. Otherorganizations can directly affect physician



TABLE 3. Organizations Involved With Quality Measurement

Name ofOrganization Funding Source

Mission /Focus ofMeasures URL

Leapfrog Large employergroups whopurchaseinsurance

Support those who useand pay for healthcarePromoting high-valuehealthcare throughincentives and rewards

http://www.leapfroggroup.org/

JointCommission(JC)

Independent,nonprofitorganization

Sets standards by whichhealthcare quality ismeasured in Americaand around the world.Healthcareorganizations obtainaccreditation throughmeetingJC standards

http://jointcommission.org

NationalQualityForum

Nonprofitorganizationconsumerorganizations,public and privatepurchasers,physicians, nurses,hospitals,accrediting andcertifying bodies,supportingindustries, andhealth-careresearch andqualityimprovementorganizations

Setting national prioritiesand goals forperformanceimprovement;Endorsing nationalconsensus standards formeasuring and publiclyreporting onperformance; andPromoting theattainment of nationalgoals through educationand outreach programs

http://www.qualityforum.org

Institute forHealthcareImprovement

Independent not-for-profitorganization

Works to accelerateimprovement bybuilding the will forchange, cultivatingpromising concepts forimproving patient care,and helping healthcaresystems put those ideasinto action.

http://www.ihi.org/ihi

United HealthCare (UHC)Parentcompany:UnitedHealthgroup

For profit managedhealthcare andhealth insurancecompany

Empower people withinformation, guidanceand tools to makepersonal health choicesand decisions Physiciansare placed in tiers basedon reviews of 30 UHCpatients and compliancewith guidelines

https://www.geoaccess.com/uhc/po/Default.asphttp://www.unitedhealth-group.com

AmericanCollege ofObstetriciansand

NonprofitorganizationLargestorganizationproviding

Keeps its membersinformed about currentmedical care standardsand ACOG’sprofessional

http://www.acog.org

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choice through higher copay, such as thetiering system used by United Healthcareand others. Press-Ganey is a reflection ofpatient experience with a healthcare orga-nization both inpatient and outpatient interms of patient satisfaction, which isimportant for organizations competingin a marketplace.

The authors previously described aspecific set of measures that can be usedfor internal and possibly external bench-marking in obstetrics: the Adverse Out-come Index (AOI).34 The AOI wasdeveloped as part of a trio of measuresto assess obstetric outcomes. The AOI is acomposite measure of 10 adverse mater-nal or neonatal outcomes designated inTable 4. The AOI is defined as percentageof deliveries complicated by one or moreof the identified outcomes. A scoringsystem to assess the severity of the out-comes was developed with assistance

from the ACOG Quality Improvementand Patient Safety Committee. Two othermeasures were developed along with theAOI to further assess severity and acuity

TABLE 3. (continued)

Name of

Organization Funding Source

Mission /Focus of

Measures URL

Gynecologists(ACOG)

healthcare forwomen

recommendationsthrough the publicationof Committee Opinions,Practice Bulletins, andTechnologyAssessments

NationalCommittee forQualityAssurance(NCQA)

Private, 501(c)(3)not-for-profitorganization

Builds consensus aroundimportant healthcarequality issues byworking with largeemployers,policymakers, doctors,patients and health plansto decide what’simportant, how tomeasure it, and how topromote improvement.

http://www.ncqa.org

Press-Ganey Partners with morethan 7,000healthcareorganizations tomeasure andimprove theirquality of care.

Acts upon the needs of allcustomers to improvethe delivery of care andachieve organizationalresults

http://www.pressyganey.com

URL indicates uniform resource locator.

TABLE 4. Adverse Outcome Index

Indicator Score

Maternal death 750Neonatal death >2500 g 400Uterine rupture 100Maternal admission to ICU 65Birth trauma 60Return to OR/labor and delivery 40Admission to NICU >2500 g andfor >24h

35

Apgar <7 at 5min 25Blood transfusion 203 or 4-degree perineal tear 5

Adapted from Jt Comm J Qual Patient Saf. 2006;32:497–505.34

ICU indicates intensive care unit; NICU, neonatal intensivecare unit; OR, operating room.



of the care on a labor and delivery unit.The Weighted Adverse Outcome Scoredescribes the acuity of the care and is thetotal score of all adverse events identifiedin the Table divided by the number ofdeliveries in a year. The Severity Indexdescribes the severity of the outcomes. It isthe sum of the adverse outcome scoresdivided by the number of deliveries withan identified adverse outcome in a year.The AOI outcome measure has recentlybeen used in studies evaluating interven-tions such as induction of labor and thedescription of a comprehensive patientsafety initiative in labor and delivery in-volving team training.17,35

Two tools used to measure staff satis-faction regarding the safety of theirworking environment are the Agencyfor Healthcare Research and Quality(AHRQ) Hospital Survey of PatientSafety Culture and the Sexton SafetyAttitude Questionnaire (SAQ).36,37 Staffattitudes toward safety measured by theSAQ have been shown to correlate withpatient outcomes in the intensive care unitand are an important initial measure ofthe effect of team training. Teamworktraining in obstetrics, whether throughsimulation or classroom-based courses,has consistently been associated withimprovements in staff attitudes towardpatient safety and teamwork.2,16,38

The Press-Ganey survey tool can beused in the inpatient or outpatient settingto measure patient satisfaction. The Press-Ganey survey allows an organization to dointernal and external benchmarking for theperspective of the patient experience andallows institutions to focus on processes,which may need improvement.

Formal Training to Promotea Culture of SafetyA growing body of literature now de-scribes formal training in techniques toimprove patient safety. These educational

systems are frequently based on CRMconcepts. Other safety training includestask training in high-risk procedures, spe-cific policy and procedure development,and formal conflict resolution techniques.The best way to teach teamwork has notbeen established and is controversial.

The development of clinical protocoland guidelines is perhaps the simplestway to promote teamwork. These guide-lines help to define clinical roles, ensurethat all tasks are completed, promotemonitoring of team members’ action,and develop cohesion within the team.This has been described as an integral partof a multifaceted approach to improve-ment in patient safety.16,17 Guidelines canbe published by professional societies’risk management organizations, or indi-vidual institutions. Protocols for suchhigh-risk areas as the management of ob-stetric hemorrhage and the managementof the administration of magnesium inpreeclampsia may improve patient safety.

Classroom-based team training allowslarge numbers of clinical staff to be taughtthe concepts of teamwork and patientsafety. Didactic lectures can be supple-mented with clinical scenarios, vignettes,videos, and other media to teach boththe intellectual concepts and specific be-haviors of team-based care. The advan-tages of classroom-based training are thatit is relatively inexpensive, large numbersof staff can be trained quickly, feedbackto and questions from the participants canbe included, and multiple specialties canbe trained simultaneously. This type oftraining can highlight patient safetyprocesses that help maintain ‘‘normalcy’’on the unit to prevent adverse events(eg, multidisciplinary meetings, preproce-dure briefings, effective handoffs). Thishelps teach staff techniques to preventadverse events instead of concentratingon ways to respond to them. Disadvan-tages include low fidelity training in theteamwork skills, and little or no practicein actual crisis management.

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Classroom-based team training hasbeen effectively used to train large num-bers of labor and delivery staff.16,17,38,39

Several curricula are available. The Med-Teams program was developed to im-prove teamwork behaviors and reducederrors in the emergency roomand hasbeen successfully translated to obstetrics.1

TeamSTEPPS, developed by the AHRQ,is a highly adaptable program based onbest available research in teamwork. Ithas been used extensively by the US mili-tary to standardize teamwork training inobstetrics.28

Simulation has received considerableattention in both the lay and academicpress. To be effective, a simulator mustprovide a high degree on physical,emotional, and conceptual realism (orfidelity). Full-immersion, high-fidelity si-mulation performed in a dedicated simu-lation center is generally considered thegold standard. This method allows theparticipants to practice both clinical andteamwork skills. Scenarios can be devel-oped that embed the need for teamworkbehaviors into the evolution of the clinicalevent. Clinical staff can be trained indi-vidually, or in preformed clinical teams.The disadvantages on this type of traininginclude its cost, the need to remove clin-icians from clinical care, a lack of realismcompared with the clinicians’ own workenvironment, and an overemphasis oncrisis management.

High-fidelity simulation can be effec-tively used in obstetrics to teach bothclinical and teamwork behaviors. Poorleadership and workload managementskills have been identified in obstetrictrainees.26Common clinical and team-work errors during obstetric emergencieshave been identified among attending ob-stetricians, identifying potential areas foreducation. Crofts et al40 found that high-fidelity training in the management ofshoulder dystocia was associated with ahigher degree of successful vaginal deliv-ery than training in lower fidelity models.

The same authors demonstrated thattraining in a high-fidelity simulator wasassociated with improved attitudes andteam behaviors, and that the addition ofdidactic, teamwork-specific training didnot confer additional benefit.2

Crisis simulation within the clinicalsetting, in situ simulation or ‘‘fire drills,’’has been increasingly described. Within situ simulation, a mannequin or actorportrays a patient on the actual unit whereclinicians practice. Common drill scenar-ios in obstetric include maternal hemor-rhage, eclampsia, failed intubation, andshoulder dystocia. Advantages of in situsimulation include the ability to train theentire staff on the unit at once, the abilityto identify weaknesses within the systemof care that are potential barriers to safecare (latent errors), inclusion of otherareas within the hospital (eg, laboratories,blood bank, code teams), and the abilityto train without leaving one’s clinicalenvironment. Disadvantages includedistracting caregivers from their clinicalresponsibilities, and potential significantcost.

Thompson et al25 used eclampsia drillson their unit, and found recurrent com-munication and coordination failures,inefficiencies, and deficiencies in clinicalskill. Similarly, Riley studied teamworkbehaviors during simulated, in situ crisesin 6 hospitals ranging from 700 to 3300deliveries per year. They found generallyfair scores in teamwork behaviors. Thesescores tended to decrease as the acuity ofthe simulated scenario increased.41 Cur-rently, more than 50% of obstetric unitsin the United Kingdom regularly conduct‘‘fire drills’’.42

Finally, simulation has been used toimprove technical skills in obstetrics.Crofts et al43 used a simulated shoulderdystociamodel to identify common errorsmade by obstetricians and midwives.They were able to demonstrate significantimprovements over a 1-year period withcontinued education and exposure to the



simulated environment. These improve-ments in knowledge and technique canlast up to 1 year after training.44 The samegroup found that task performance andneonatal outcomes also improved in theclinical arena during delivery of an actualinfant with shoulder dystocia after train-ing in the simulator.45 Improvements inthe estimation of maternal blood lossduring massive hemorrhage have alsobeen demonstrated with various simu-lated techniques, including web-basedtraining modules.

Irrespective of the method of training,teamwork, and the development of a pa-tient safety culture can only be effective ifthe concepts and behaviors learned can betranslated to the clinical environment. Todate, no research has directly studied theimpact of any teamwork training methodon changes in teamwork behaviors in theclinical setting in obstetrics. This transla-tion is likely to require continual coach-ing, feedback, behaviors reinforcement,and a long implementation period.

The methods of patient safety trainingdescribed above have all been shown toimprove the culture of safety. Teamworktraining in obstetrics has consistentlybeen associated with improvements instaff attitudes toward patient safetyand teamwork. Pratt and Mann16 usedthe Safety Attitudes Questionnaire, andfound that clinician attitudes towardpatient safety were significantly higheramong labor and delivery staff after class-room-based team training, than thoseworking on other units who had not beentrained.37 Gardner et al3 developeda 6-hour simulation course involvingobstetricians, anesthesiologist, obstetricnurses, and midwives. Self-assessment ofteamwork and communication demon-strated improvements in both areas morethan 1 year after the course. In addition,most clinicians felt that their clinical prac-tice had changed. Finally, Haller et al38

trained 239 obstetric nurses, physicians,midwives and other labor and delivery

staff in a 2-day, classroom-based, CRM-style course. Initial reactions to the courseand evidence that participants learned theCRM concepts were both very positive.Surveys of the staff over the next yeardemonstrated improvements in attitudestoward patient safety, stress recognition,work conditions, and job satisfaction.Participants reported improved availabil-ity of clinical information and the ‘‘feelingpart of a bigger family.’’ Staff attitudestoward the culture of safety have beenshown to correlate with patient outcomes.

Ultimately, an improved culture ofsafety should improve patient outcomes.A large, prospective, randomized trialevaluating the impact a classroom-basedCRM course based on the MedTeamscurriculum previously developed for theemergency room failed to demonstrateimprovements patient outcomes. Theauthors did find a 10 minutes (B33%)improvement in the time from decision toincision in emergent cesarean deliveries.Inadequate power, high staff turnover,and a short implementation time for theteamwork behaviors may have contribu-ted to the negative results.1 Others havedemonstrated improvements in patientoutcomes associated with both classroomand simulation-based team training. Prattand Mann16 trained more than 220 in aclassroom-based CRM teamwork course.In addition, the authors described a struc-tured implementation process involvingthe use of templates, structured language,coaches, and 3 types of formal teams thathelped to translate the behaviors to theclinical environment. They found thatobstetric complication rates decreasedby 23%after the implementation of team-work. Pettker et al17 described amultistepprocess designed to improve safety ontheir labor and delivery unit, includingclinical protocols, fetal monitor certifica-tion, a safety committee, and classroom-based team training. The entire processrequired nearly 2 years. The adverse eventrate was decreased by nearly 28%. Similar

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data have been demonstrated in the pri-vate practice obstetric setting. Shea-Lewisdescribed a 43% reduction in the rate ofadverse obstetric events after the imple-mentation of a CRM-based team train-ing curriculum in an intermediate-sizedcommunity hospital.39 Finally, Draycottet al46 developed a 1-day course thatcombined didactic and simulation train-ing in both teamwork behaviors and ob-stetric crisis management. All obstetriccare providers at a large, urban centerwere required to attend the course inmulti-disciplinary sessions. Evaluationof more than 19,000 deliveries demon-strated a 50% reduction in the rate ofneonatal hypoxic ischemic encephalo-pathy after the training.

Finally, improved teamwork may helpdecrease malpractice risk. This would beespecially important in obstetrics wheremalpractice premiums are creating crisesin many states.47 Decreased complicationrates, better patient satisfaction when anadverse event does occur, and a betterability to defend cases that have beencared for by a well-coordinated team areall potential ways to decrease malpracticerisk.19

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