Details on the expose: Hospitals know how to curb maternal death and injury—so why aren't they doing it?

1. 'How could a blind spot like this happen?'

Quality problems fly under the radar for a wide variety of reasons. In this case, part of the issue is a serious gap in metrics specifically related to maternal safety. 

Think of the way quality metrics become mainstream as a funnel. There are thousands of quality and safety protocols out there, and, of all of these, only a few are considered general measures of hospital quality. Those few are chosen based on factors like how well supported they are by evidence, how much they impact outcomes, and how feasible they are to both measure and report. 

The integrated care advantage

As an industry, we tend to rely on Medicare to produce the curated list. When Medicare crowns certain metrics as required to report and/or makes reimbursement dependent on them, those metrics become mainstream indicators. Other payers will generally follow Medicare's lead when they pick quality metrics for their own commercial and Medicaid contracts, because they will be relatively uncontroversial among hospitals, who have to report on them anyway for Medicare. Internally at hospitals, boards and executives will typically focus on those same metrics to assess their organization's own quality. 

But Medicare isn't in the business of regulating obstetrics—and the likeliest alternative sources— Medicaid or the Joint Commission—have not yet stepped in to push their own curated list, or at least not one specifically focused on maternal safety.

2. 'Core measures or not, we must have been measuring quality in labor and delivery.  What have we been paying attention to, if not this?'

Yes, quality metrics relating to perinatal safety and quality exist, including some from Medicaid and the Joint Commission.  But, as the USA Today investigation flags, they are incomplete—specifically when it comes to critical elements of maternal safety. Early elective deliveries, overall C-section rate, rate of pre-natal and post-natal visits—those are the usual suspects that are measured, and they're all important. However, they don't fully address risk of death or injury due to hemorrhage, pre-eclampsia, etc. 

Meanwhile, maternal safety risks are becoming increasingly dire due to population factors including an increasing maternal age and a greater prevalence of chronic conditions.

3. 'As an executive or board member, what questions should I be asking?'

12 things CEOs need to know in 2018

The USA Today investigation has handed leaders a set of questions to start asking. For instance, 'Where are we on maternal safety?' is a perfect starting point for jump-starting a conversation.  Maternal safety protocols do exist and seem accepted pretty strongly—such as the hemorrhage prevention bundle from the ACOG-linked Alliance for Innovation in Maternal Health. Ideally Medicaid and the Joint Commission can look to these protocols to build national metrics for maternal safety; in the meantime, every individual hospital and system can take action.

• If, as an executive or board member, you need a follow-up question to push on to ensure you're squarely in the terrain of maternal safety (versus other types of perinatal quality indicators), you can ask more specific questions like, "Where are we on compliance with protocols around quantifying blood loss?"
  
  
• If you oversee a multi-hospital system, remember that quality performance tends to be variable within the system. Push for information about potential pockets of low performance and ask for answers to help close those gaps.
  
  
• If staff need resources and help, encourage them to take a look at the Alliance for Innovation on Maternal Health's resources, which include a number of free bundles and tools. AIM is still adding participants in their collaborative, which either states or multi-hospital health systems can join. You can find more information here.
  
  
• If your system has an owned or ‘captive’ malpractice insurer, ask whether that organization can help with resourcing and momentum. Anyone who focuses on reducing malpractice risk will be the natural ally of efforts to reduce avoidable maternal mortality and injuries.

4. 'Beyond asking pointed questions about maternal safety, what contributions are appropriate for executives/board?'

Starting the conversation is only the first step.  Keep in mind that the difference between strong and weak overall hospital safety performance is never whether protocols exist, because all hospitals have protocols (or even whether one specific protocol has perfect compliance). 

Instead, the big picture here is about how much institutional weight is put behind protocol expansion, refinement, and uptake across all services the hospital or health system provides. Every budget cycle, each hospital or system makes a call about how much to invest in the analytics, staff, and leader bandwidth, all of which are required to build a strong foundation for quality and safety. Decisions about these investments have ripple effects across specialties and services—and often end up making or breaking whether the protocols specific to any given clinical area are in place or actually used.     

Maternal fetal medicine by the numbers

Maternal safety is a case in point.  Our data shows that maternal care quality is not compartmentalized to processes within labor and delivery (L&D); it's linked to how well a hospital does on reported quality metrics overall—across all reported metrics and all hospital services.  High overall quality performers will have an overall labor and delivery complication rate of roughly 10% for vaginal deliveries, 5% for C-sections. (Keep in mind that includes any complication, big or small, not just the life-threatening ones). Conversely, a hospital with overall low quality performance will have complication rates of over 20% in both delivery types. The difference tends to be overall resourcing and bandwidth to focus on quality across all services (clearly with some extra attention applied to gaps like maternal safety).

5. 'Should I be worried about data on our maternal safety shortfalls getting out?'

Don't let negative publicity have a chilling effect on your organization's participation in quality improvement efforts. Despite the impression the general public might get from the way that audio captured from a private webconference is featured in the story, no one at the AHA did anything wrong by hosting a session on maternal safety, making it private, or reading participants the riot act about how sad the current state really was. In fact, those running the session likely had the same goals as the USA Today reporters—to shed a light on shortfalls and get hospitals to take action.  

As for the hospitals who reported their own process shortfalls as part of voluntary quality improvement efforts—and then had their safety compliance gaps called out in the press– being candid about problems in order to find solutions is the way that quality improves.  Thank you for your efforts and keep going.