Collaborative VON NICHD Neonatal Research Network Canadian Neonatal Network Participants 114 member NICUs 17 NICUs _ QI Focus Promote surfactant treatment in preterm infants 23 to 29 weeks Reduce risk of CLD in VLBW infants Reduction in CLD or nosocomial infections Findings Infants in intervention hospitals more likely to receive surfactant in the delivery room Clinical practice can be changed with Quality Improvement Improvement in both CLD and infection rates (VLBW: very low birth weight; CLD: chronic lung disease ; NICHD: National Institute of Child Health & Human Development) Table 2: Cluster Randomized Trials18-20 16 marchofdimes.com Toward Improving the Outcome of Pregnancy III Evolution of Quality Improvement in Perinatal Care The Ohio Perinatal Quality Collaborative (OPQC) is another example of a successful state initiative with diverse strategies for quality improvement. OPQC was founded in 2007 as a collaboration of providers, payers and state agencies that uses quality improvement methods to improve perinatal health statewide.22 OPQC publishes a monthly graph on its website, communicating across the spectrum of providers as well as consumers, clearly hoping to engage a new audience in the reporting of quality perinatal outcomes.23 The material in Figure 3, including the caption, is an actual Ohio Perinatal Quality Collaborative aggregate outcome chart that is available to the public electronically. They are released periodically. Aims for Improvement The Institute of Medicine’s landmark publication, Crossing the Quality Chasm: A New Health System for the 21st Century, references the six aims for improvement in care: care that is family centered, safe, effective, equitable, timely and efficient.24 Figure 4 adds a seventh key domain, social and environmental responsibility, with patients and families at the center of improvement efforts.25 Figure 3: Ohio Perinatal Quality Collaborative23 This is the Ohio Perinatal Quality Collaborative’s (OPQC, www.OPQC.net) aggregate control chart for inductions of labor at 36 to 38 weeks gestational age without apparent medical or obstetric indication for 20 Ohio maternity hospitals accounting for 47 percent of Ohio births (Am J Ob Gyn 243.e1-8). The data for this analysis is derived from Ohio birth certificates, which do not permit exclusion of all indicated inductions. For example, abruption as an indication is not reported on birth certificates. The intervention began September 2008. The centerline (mean) was recalculated, as shown, on two occasions because of statistically significant change. Toward Improving the Outcome of Pregnancy III marchofdimes.com 17 Evolution of Quality Improvement in Perinatal Care Conclusion and Recommendations This chapter has provided a history of perinatal quality improvement. There has been great progress, as well as many developments that provide encouragement for the future. The continuing expansion of multihospital collaboratives will greatly improve the rapid dissemination of evidence-based protocols and processes. There are, of course, challenges to be addressed, as well as the following recommendations: 1. State regulatory agencies should try to adopt a standard definition of levels of perinatal care, to enhance quality improvement by allowing comparisons of outcomes across units within and across states and to enable providers to assess and be held accountable for population-based perinatal outcomes (total cohort accountability).26 2. Use of The Joint Commission Perinatal Care Core Measure Set should be encouraged and incentivized. Use and measurements of other National Quality Forum-endorsed perinatal measures also should be encouraged. 3. Patients and families should be offered the opportunity to participate in all quality improvement initiatives. The legacy of improving perinatal outcomes stated so clearly in TIOP I is a dynamic process that has matured in sophistication and productivity. Evolution of commitment and methodology will continue across all current collaborators, and the growing inclusion of patients and their families in the process shows great promise.