used in accountability programs such as accreditation, public reporting and pay for performance.25 These criteria are designed to maximize the likelihood that improved health outcomes will result when hospitals work to improve their performance, while minimizing unintended consequences and the unproductive work that often results when the design of measures makes it easier to create “paper compliance” than to truly improve clinical care. The Joint Commission perinatal care measures, which meet the new criteria for accountability measures, were adopted for voluntary use by hospitals in 2009 and are discussed in Chapter 11 of this monograph. If widely used by hospitals, they offer the opportunity to greatly improve perinatal care in America’s hospitals by employing this model of measurement-driven improvement, which has already delivered consistent excellence across many valid measures of hospital quality of care. Since the publication of the IOM reports, health care organizations and providers have been exploring ways to improve their practices. Many, like those featured in this monograph, are implementing plans designed to reduce errors and improve patient safety and health care quality. There will always be concerns about individual blame and the threat of litigation. But, as Toward Improving the Outcome of Pregnancy III illustrates, clinicians are committed to improving health care delivery. The following chapters will show that improving our system of perinatal care is not just possible; it is happening. Chapter 2: Evolution of Quality Improvement in Perinatal Care Childbearing and birth have been, and are, sentinel events for society, women and families. Even before many clinical treatments were available, health professionals recorded fertility rates, pregnancy complications and birth outcomes. As the ability to alter natural biologic processes through individual and population-based interventions increased, the range of outcomes being monitored expanded. • This chapter traces the history of perinatal quality improvement, focusing on advances in perinatal quality improvement (QI) from 1950 through to the present, primarily in the United States, recognizing this restriction is largely artificial, as perinatal science and health policy are global. At this point, one could posit that the domain of perinatal QI starts with preconception and proceeds through to maturity. George A. Little, Jeffrey D. Horbar, John S. Wachtel, Paul A. Gluck, Janet H. Muri Toward Improving the Outcome of Pregnancy III marchofdimes.com 11 Toward Improving the Outcome of Pregnancy, the 90s and Beyond (TIOP II), the 1993 publication produced by a reconstituted ad hoc Committee on Perinatal Health, also convened by the March of Dimes, broadly expanded the operational definition of perinatal care to include preconception through the post-neonatal period. Implicit in TIOP II was the realization that perinatal care has a direct impact on an individual’s health long after birth.2 As Table 1 shows, a major difference between TIOP I and II was a strong emphasis in the latter on data, documentation and evaluation. TIOP II, with its broader operational definition of the perinatal period, gave more attention to ambulatory care, while continuing to underscore the need for improvement of hospital care. TIOP II also emphasized concepts, such as accountability and availability. Quality improvement was a major message and recommendation in TIOP II, and, as seen in the discussion to follow, it has evolved to be increasingly dynamic in the perinatal care system environment. Evolution of Quality Improvement in Perinatal Care Table 1: Summary of TIOP I and TIOP II Publications Year Published Focus Primary Recommendations TIOP I 1976 A regional perinatal care system Levels of care Level I — Uncomplicated maternity and newborn Level II — Uncomplicated and majority of complicated Level III — Uncomplicated and all serious complications Preparatory and continuing education in regional system Coordination and communication in regional system Major task ahead — financing, education, initiating action TIOP II 1993 Care before and during pregnancy Care during birth and beyond Data documentation and evaluation Financing Health promotion and education Reproductive awareness Structure and accountability Preconception and interconception care Ambulatory prenatal care Inpatient patient care Infant care Improving the availability of perinatal providers Data, documentation and evaluation Financing perinatal care 12 marchofdimes.com Toward Improving the Outcome of Pregnancy III Quality Improvement and the Impetus for TIOP III Evolution of the perinatal health care system from the 1970s to the present is well documented. Diverse scientific, system, policy and reimbursement changes increasingly came into play during the 1970s, 1980s and 1990s, while the United States implemented a system based upon matching the perinatal patient with the most risk-appropriate care and resulting in major improvements in outcomes, such as neonatal survival rates. As the expansion of beds, manpower and resources continued beyond academic centers and into community hospitals, concerns about the “de-regionalization” of care and the possible impact on quality began to emerge and, in part, drove the publication of TIOP II. Figure 1 displays