The scope of quality improvement (QI) work is broad, and narrowing this down involves thoughtful consideration to selecting key quality metrics. This can be based on evaluating the importance to different stakeholders, financial implications, and prioritization to areas of opportunity identified through benchmarking of data against like size facilities/units. Let’s use, for example, a quality initiative of supporting intended vaginal birth and reducing primary cesarean delivery. This is an area presenting both quality and cost opportunities, with a significant impact on both the mother and newborn. The following article/chapter will discuss quality and financial aspects, stakeholder involvement, subsequent development of goal statements, and metric examples as related to reducing primary cesarean delivery.
Quality Opportunities and Maternity Care
Although cesarean delivery can be medically necessary and lifesaving in certain circumstances, the significant increase over the years without an associated decrease in maternal/newborn complications speaks to opportunities and further work in this area. In the low risk nulliparous, term, singleton, vertex (NTSV) patient population, research has shown a significant increase in maternal complications including hemorrhage associated with transfusion or hysterectomy, shock, acute renal failure, anesthesia complications, infection, venous thromboembolism, assisted ventilation, wound disruptions, hematoma, and cardiac events when comparing cesarean to vaginal delivery (ACOG, 2014).
The first cesarean often leads to subsequent cesareans, which creates an increased risk of uterine rupture, uterine atony, abnormal placentation including placenta previa and accreta, and surgical adhesions. The increased rate of cesarean delivery is believed to be a significant contributing factor to a sharp increase in the incidence of abnormal placentation. This has led to the development of hospital programs that include specialized multidisciplinary teams, training, facilities, equipment, and planning around these high-risk patients (Silver et.al., 2015).
Newborns are also impacted by cesarean birth, experiencing complications including increased neonatal intensive care unit admissions and respiratory complications, a higher likelihood of childhood asthma, and adverse effects on early breastfeeding (Smith et.al, 2016). These complications have a significant impact on patients as well as increased costs to the hospital and ultimately the greater community.
Cost Opportunities
The financial implications of cesarean delivery without complications are significant for the patient and hospital and extend beyond to taxpayers, insurance companies, and the government. Studies have shown that cesarean delivery is $5,000 to $10,000 more than a vaginal delivery. These numbers double or triple when considering that most women go on to have more children and often have repeat cesarean delivery (Smith et.al, 2016).
Stakeholder Involvement
Stakeholders include the patient, family, provider, facility, healthcare system, and insurance companies/payors. Various stakeholders have become engaged with reducing the primary cesarean rate in the low-risk population: World Health Organization, the American College of Obstetricians and Gynecologists (ACOG), the Joint Commission, Healthy People 2030, and watchdog organizations such as Leapfrog, to name a few (Smith et.al, 2016). As part of a QI initiative to support vaginal birth and reduce primary cesareans, the California Maternal Quality Care Collaborative (CMQCC) has done a tremendous amount of work in engaging stakeholders within the state including care providers, educators, policymakers and healthcare purchasers. The end result is the development of a safer model of care with a simultaneous reduction in overall healthcare costs.
Developing SMART objectives
Once key metrics are decided upon, stakeholders are engaged and on the same page, another step in the process involves use of a structured approach towards developing goal statements. SMART objectives can be used as a guide, referring to specific, measurable, achievable, relevant, and timebound. Continuing along with reducing primary cesarean delivery, an example of a goal statement could be-within one year, our NTSV primary cesarean rate will be reduced by 15%.
- Specific? What specific measure has been chosen? Is it all women undergoing primary cesarean delivery or only NTSV women?
- Measurable? Can it be calculated? In our example, the numerator is # NTSV cesarean deliveries over the denominator # ALL NTSV deliveries (vaginal & cesarean)
- Achievable? Is this realistic?
- Relevant– Is this pertinent to our patient population?
- Timebound– Is there a date we are setting to achieve this goal?
Metrics
The next step is deciding upon all metrics to be monitored- outcome, process, structure, and balancing. See the table below for metric definitions and examples using our primary cesarean delivery initiative. Let’s say we are focusing work on reducing cesarean delivery as related to cephalopelvic disproportion/failure to progress, with actions aimed to reduce fetal malposition.
| Metric | Definition | Examples |
| Outcome measures | What happened to the patient | Nulliparous, term, singleton, vertex (NTSV) primary cesarean rate |
| Process measures | Reflect steps in the process to get to the desired outcome | – Chart review on the frequency of maternal repositioning in labor – Percentage of nurse and provider completion of labor workshops |
| Structure measures | Evaluate available resources, systems, and processes that impact how care is delivered- environment, equipment, staff, and guidelines
| – Policy/guidelines for labor support – Percentage of nurse and resident completion of labor workshops (review: labor support, cervical assessment/fetal station/position; techniques on manual rotation; techniques on maternal repositioning to facilitate fetal rotation and descent) |
| Balancing measures | Used to evaluate if changes made related to the initiative cause unintended consequences in other areas | – unexpected neonatal complication rate (healthy term newborns)
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The process should flow such that once staff are properly trained, guidelines are established, and chart review demonstrates interventions are being put into practice, changes in outcome data should follow. Balancing measures tell us if unexpected changes are occurring in other areas. For example, if waiting for longer periods of time before delivery (ex. pushing longer in the second stage) are more complications in the healthy term newborn resulting, such as subgaleal bleeds or other birth injuries?
In summary, selecting key quality metrics involves evaluating quality, cost, and data opportunities along with the importance to various stakeholders. Using the SMART approach in developing goal statements establishes a baseline for performance and helps in monitoring progress towards goals. Clearly defined metrics will help to evaluate if the interventions implemented translate to work being done at the bedside, create any untoward effects, and lastly result in improved patient outcomes.
References
American College of Obstetricians and Gynecologists (2014). Obstetric Care Consensus No. 1. Obstetrics & Gynecology, 123(3), 693-711. doi:10.1097/01.aog.0000444441.04111.1d
Smith H, Peterson N, Lagrew D, Main E. 2016. Toolkit to Support Vaginal Birth and Reduce
Primary Cesareans: A Quality Improvement Toolkit. Stanford, CA: California Maternal
Quality Care Collaborative)
Silver R., Fox K., Barton J., Abuhamad A., Simhan H., Huls C., Belfort M., & Wright J (2015).
Center of Excellence for Placenta Accreta. American Journal of Obstetrics &
Gynecology, 561-568.
Copyright by Jeanette Zocco MSN, RNC-OB, C-EFM, C-ONQS