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How One Ob/Gyn Dept. Significantly Improved Performance on Six Quality Measures, in the June 2013 Issue of The Joint Commission Journal on Quality and Patient Safety

Added on May 24, 2013 in General News

View the multi-media news release.

(Oak Brook Ill.) Joint Commission Resources announces the June 2013 issue of “The Joint Commission Journal on Quality and Patient Safety.” In one of the articles, “Improving Recording Accuracy, Transparency, and Performance for Obstetric Quality Measures in a Community Hospital–Based Obstetrics Department,” William M. Gilbert, M.D., and his co-authors detail how the obstetrics/gynecology (OB/GYN) department at Sutter Medical Center, Sacramento (SMCS), achieved significant performance improvement on all six of its obstetric quality measures in a three-year period, including decreasing its rate of elective deliveries with less than 39 weeks of gestation from 15.3 percent to 2.3 percent. 

As the authors explain, the OB/GYN department formed a multidisciplinary perinatal data committee, which examined how its nurses and physicians were documenting data in the hospital’s records, and then identified areas for improvement and simplification so that hospital coders could more accurately record diagnoses and procedures. In addition, SMCS created a dashboard of its obstetric quality measures results, which is shared with the OB/GYN department’s physicians and hospital administration on a monthly basis to help reinforce good results. SMCS’s six obstetric quality measures include four measures from The Joint Commission’s perinatal care measure set (which will become mandatory beginning January 1, 2014 for accredited hospitals with 1,100 or more births a year to report) and two National Quality Forum measures. 

This issue also contains articles associated with the 2012 John M. Eisenberg Patient Safety and Quality Awards. 

“The Joint Commission Journal on Quality and Patient Safety,” published monthly by Joint Commission Resources, is a peer-reviewed journal, available by subscription, which serves as a forum for practical approaches to improving quality and safety in health care.


The 2012 John M. Eisenberg Patient Safety and Quality Awards were presented on March 8, 2013, in Washington, DC. 

Individual Achievement

An Interview with Saul Weingart 
Interviewed by Edward J. Benz Jr., M.D.

Dr. Weingart is recognized for his longstanding commitment and national contributions to patient safety through publication, education, research, and leadership.

Innovation in Patient Safety and Quality at the National Level

Kaiser Permanente Implant Registries Benefit Patient Safety, Quality Improvement, Cost-Effectiveness
Elizabeth W. Paxton, M.A.; Mary-Lou Kiley, M.B.A.; Rebecca Love, M.P.H., RN; Thomas C. Barber, M.D.; Tadashi T. Funahashi, M.D.; Maria CS Inacio, M.S.

Kaiser Permanente’s implant registries have shown unsurpassed and proven benefits for patient safety, quality, outcomes, and cost-effectiveness in its integrated health care system.

Innovation in Patient Safety and Quality at the National Level

Memorial Hermann: High Reliability from Board to Bedside
M. Michael Shabot, M.D., FACS; Douglas Monroe, M.D., M.B.A.; Juan Inurria, M.B.A., FACHE, FABC, CPHQ; Debbi Garbade, RN, M.S.N, CPHRM, CPHQ, CPSO; Anne-Claire France, Ph.D., CPHQ, M.B.B., FACHE

Memorial Hermann Health System’s High Reliability Journey from Board to Bedside initiative focuses on providing compassionate and operationally and financially efficient care by concentrating leadership and employee attention on high-reliability behaviors, evidence-based care, and harm prevention.

Performance Improvement

Improving Recording Accuracy, Transparency, and Performance for Obstetric Quality Measures in a Community Hospital–Based Obstetrics Department
William M. Gilbert, M.D.; Mary Campbell Bliss, RN, M.S., CNS; Amy Johnson, RN; William Farrell, Ph.D.; Laurie Gregg, M.D.; Christopher Swanson, M.H.A., FACHE

Sutter Medical Center in Sacramento, Calif., improved and simplified data capture for six obstetric quality measures, which all showed significantly improved trends from 2010 through 2012.

Teamwork and Communication

Editorial: Bringing Latent Safety Threats Out Into the Open

Louis P. Halamek, M.D., FAAP

Identification of Latent Safety Threats Using High-Fidelity Simulation-Based Training with Multidisciplinary Neonatology Teams
Elizabeth A. Wetzel, M.D.; Tara R. Lang, M.D.; Tiffany L. Pendergrass, B.S.N., RN; Regina G. Taylor, M.A., CCRP; Gary L. Geis, M.D. 

In simulations, the 29 latent safety threats (LSTs) identified in 16 in situ sessions and the 70 LSTs identified in 22 laboratory sessions were reported to neonatal ICU leadership, leading to 19 clinical care improvements.


Case Study in Brief

A Quality Improvement Intervention to Reduce the Rate of Elective Deliveries < 39 Weeks
Samia El Haj Ibrahim, M.P.H.; Kimberly D. Gregory, M.D., M.P.H.; Sarah J. Kilpatrick, M.D., Ph.D.; Glenn D. Braunstein, M.D.

Cedars-Sinai Medical Center in Los Angeles, Calif., has conducted three Plan-Do-Study-Act cycles of continuous quality improvement since January 2010, which has enabled it to hold its monthly rate of non-medically indicated elective deliveries less than 39 weeks to less than 5% since June 2012.


Strategies for Improving Communication in the Emergency Department: Mediums and Messages in a Noisy Environment 
Shari J. Welch, M.D., FACEP; Dickson S. Cheung, M.D., M.B.A., M.P.H.; Julie Apker, Ph.D.; Emily S. Patterson, Ph.D.

Provision of medical care in settings with high levels of ambient noise, such as the emergency department, presents unique communication challenges. 


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