has also included research and program efforts, with collaborative and population-based statewide quality improvement efforts. As a major purchaser of health care services, the government also has significant influence over providers. Medicare took the lead in tying improvements in utilization of inpatient care to payments by introducing Diagnosis Related Group (DRG) reimbursement in 1983. While perinatal patients clearly fall outside the realm of Medicare reimbursement changes, many payers adopted the DRG reimbursement model for perinatal care, driving some of the same utilization changes. As Medicare has evolved, tying reimbursement to the reporting of adult quality metrics, it is only a matter of time (and already occurring in some states) before the public reporting and pay-for-performance of perinatal quality measures reaches the state Medicaid system. The hope is that TIOP III can help drive the perinatal community to be active participants in that process. The Joint Commission, as the primary accrediting body for most health care facilities in the United States, plays a significant role in choosing quality measures that will be reported by hospitals. The Joint Commission’s focus has been largely on adult measures in concert with Medicare; however, it recently updated its Perinatal Care (PC) Core Measure Set. Among the 17 perinatal measures endorsed by the National Quality Forum (NQF), The Joint Commission selected five: elective delivery, cesarean section, antenatal steroids, health care-associated bloodstream infections in newborns and exclusive breastmilk feeding. Role of Foundations, Collaboratives and other Nonprofit Organizations Perinatally related goals have been a longterm primary focus of foundations and nonprofit organizations and a vital force in quality improvement. The March of Dimes has played a leadership role in this arena since before the publication of TIOP I in 1976.1 While the March of Dimes is the primary convener of TIOP I, II, and 3, it is but one of many organizations involved in perinatal improvement. The Institute for Healthcare Improvement (IHI), a nonprofit organization that works to increase the quality of patient care by introducing improvements throughout the health care system, developed the “Idealized Design of Perinatal Care Model” and took a lead role in defining the continuum of high-quality care, from an informed woman and family to providing risk-appropriate care in a setting adequately resourced to meet all needs.12 Toward Improving the Outcome of Pregnancy III marchofdimes.com 15 Perinatal medicine has been involved in the increasingly common multi-institutional collaborative methodology to improve the quality and safety of care. Two early models that have informed this approach are IHI’s Breakthrough Series13 and the Northern New England Perinatal Quality Improvement Network.14 Most collaboratives consist of multidisciplinary teams that work together with expert faculty to apply quality improvement methods adopted from other industries to test and implement change ideas designed to improve care.15 A number of examples, illustrating the breadth of active collaborative perinatal initiatives follow. The Vermont Oxford Network (VON) conducted the first formal improvement collaborative in neonatology in 1995. Analysis demonstrated measurable improvements in both chronic lung disease and nosocomial infections at participating neonatal intensive care units (NICUs), when compared to a control group of non-participating NICUs.16 In addition to the clinical improvements, costs of care of participating NICUs were reduced, demonstrating that quality improvement can result in cost reduction.17 Subsequently, VON and other groups have conducted neonatology collaboratives addressing a variety of improvements in quality and safety. Three examples of cluster randomized trials of collaborative quality improvement in neonatology are shown in Table 2. The Maryland Perinatal Collaborative is a statewide initiative to test, adopt and implement evidence-based improvement strategies in obstetric units at hospitals in Maryland and the District of Columbia. More than 250 perinatal professionals in hospital multidisciplinary teams conducted a selfassessment and chose the improvement activity that best met its needs. Process, outcome and satisfaction measures, along with development of case studies and “improvement stories,” were employed. Notable improvements in Level I, II and III units were documented, such as a decrease in uterine rupture rate and decrease in returns to the operating room/labor and delivery. Level III units had a 23 percent decrease in admissions to the NICU for babies > 2500g with a greater-than-24-hour stay.21 State collaboratives, such as the Maryland example, are a dynamic, growing, productive and influential force in perinatal quality improvement. Their lineage can be traced in many states to state/regional programs initiated immediately after the release of TIOP I. While the original state education programs put in place to improve care have tended to atrophy, they still exist in a few geographic areas and live on in collaboratives that focus on identifying evidence and data for statewide system change or improvement. Evolution of Quality Improvement in Perinatal Care