Quality Assurance and Improvement Tools: How to Choose Wisely

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As a result of increases in maternal morbidity and mortality, as well as payer focus on outcome measurement, quality assurance and improvement activities have gained popularity over the past decade. The majority of these quality assurance and improvement projects in obstetrics have focused on high-risk, high-liability emergency situations such as postpartum hemorrhage, shoulder dystocia, and eclampsia. However, increasing awareness and resources are being focused on lower-risk, lower-liability, but more common clinical scenarios that account for the bulk of maternal morbidity and mortality, such as cesarean deliveries, hypertension, and depression. Thus, individual physicians, practices, and hospitals must choose among a plethora of quality assurance and improvement practices and tools that each address a compelling issue.
Stewardship, an extension of the ethical principles of distributive justice and beneficence, requires that physicians and hospitals manage limited and finite health care resources to provide effective medical care.1 Balancing ethical stewardship and attention to patient safety suggests that some quality assurance and improvement interventions should receive priority over others. However, it is unclear how to prioritize correctly to meet these ethical obligations.
In this issue of Obstetrics & Gynecology, Lundsberg and colleagues (see page 214) evaluate quality assurance and improvement practices in California’s maternity hospitals using a statewide survey.2 The authors identify substantial variation in both the quality assurance and improvement activities that hospitals choose to enact and how they implement these activities. For example, 9.7% of hospitals surveyed did not regularly review cases with significant morbidity, mortality, or both, and another 14.6% of hospitals reviewed these cases but did not implement remedies. Data collection and infrastructure is an imperative that allows for all other types of quality assurance and improvement. Understanding the prevalence and nature of adverse outcomes is foundational to effecting change, and data collection should be a must-do for all obstetric hospitals. However, because even the simple collection of data requires resources, actually using collected data to enact positive change is imperative in terms of both patient safety and ethical resource utilization.
As with any type of treatment in medicine, substantial variation in treatment suggests that there is mixed evidence of etiology, effectiveness, or both. There is never a question as to which drug is best for syphilis because the evidence is well-established. On the other hand, treatment of pelvic pain has many approaches because both the etiology and treatment evidence are complex. The multiple checklists, protocols, and bundles available to obstetricians is not surprising given the multifactorial etiology and nuanced evidence surrounding perinatal morbidity and mortality. To prioritize among these tools, we suggest that physicians and hospitals should evaluate the quality of the underlying evidence as well as consider potential for both outcomes improvement and resource utilization.
First, the quality of evidence surrounding quality assurance and improvement initiatives should guide the process of choosing a tool to implement. As with the clinical medicine literature, studies that are prospective, conducted across multiple sites, and demonstrate improvements in outcomes that are clinically meaningful should be relied on more highly than others. Protocols that are developed at single institutions are lower on the evidence ladder but deserve further investigation on a larger scale before adoption. This groundwork in high-quality science also helps to improve end-user buy-in. Second, the relationship between potential for improvement in clinical outcomes and resources used to achieve those results should be considered. Those interventions that are low–resource-intensive but high-yield in terms of quality assurance and improvement represent “quick wins” and should be considered first. Those that are more resource-intensive but also high-yield are “major projects” and should receive attention second.3
Simple creation of protocols is not enough. Not all protocols improve patient outcomes.
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