Developing Relevant Indicators to Measure Progress in Patient Safety

Developing Relevant Indicators to Measure Perinatal Patient Safety

Background.  Washington Hospital Center (WHC), a 926-bed teaching hospital, is the largest obstetric service in Washington, DC with 4500 births per year.  The perinatal units struggled with sentinel events, inconsistent practices, and increased risk exposure.  In 2005, WHC signed an agreement with Kaiser Permanente to implement a comprehensive perinatal patient safety program.  The program includes team training for emergencies, human factors techniques to improve interpersonal communication, and changing the work environment from one of “blame and shame” to one that focuses on system, not individual, problems.  This program is nationally recognized, but the current measures of success could be strengthened as the focus is on rates of harm and malpractice claims. 

Appropriate measures must be identified in order to assess progress in improving patient safety.  Pronovost, Miller, and Wachter (2006)¹ suggested a comprehensive measurement model for assessment of progress in patient safety initiatives.  This model has four domains including measures of rates of patient harm, frequency of providing correct interventions, provider knowledge and learning, and the culture of safety. 

Statement of the Problem.  Using the proposed model, this project identified perinatal indicators and tested them for relevancy to measure improvements in patient safety.

Indicators Selected.  Indicators from the four domains were selected.  Data were collected from administrative databases, aggregate reports, and medical records.  Each indicator was evaluated for relevance and accuracy based on the nature of the indicator.  Indicators included rates of postpartum hemorrhage, unanticipated admissions to the NICU for term babies, and cesarean section for variant fetal heart rate patterns.  The primary limitations for this project included inaccuracy in the medical records and administrative databases and potential bias related to implicit review of medical records. 

Results.  Commonly used outcomes indicators such as cesarean rates, APGARs, and NICU admissions were not found to be useful as outcome indicators because of the lack of variation and documentation errors.  However, using the specific cases with poor outcomes to trace process was found to be very useful.  For example, examination of term NICU admissions led to observation of poor processes related to scheduling inductions and/or cesarean births at less than 39 weeks gestation.  Record review of cesarean births for variant fetal heart rate patterns found poor compliance with new assessment parameters despite recent organizational efforts at standardizing electronic fetal monitoring nomenclature.

Conclusions.  The purpose of this project was to identify perinatal indicators to measure progress with patient safety initiatives.  The most relevant indicators were process ones very specific to the program initiative, while commonly used outcome indicators were the least useful.  It is important to note that process indicators are labor intensive to collect and analyze, and appropriate resources must be allocated when planning measurement of patient safety progress.

¹Provonost PJ, Miller MR, Wachter RM. Tracking Progress in Patient Safety: An Elusive Target. JAMA 2006; 296:696-699.