Perinatal safety improved with focus on high-risk factors and education

HCA sees dramatic drops in complications, liability after special effort

A large hospital system has seen a 45% reduction in new obstetrical claims after implementing a series of steps that focus on the high-risk factors most likely to contribute to birth injuries, and similar drops were seen in categories such as mechanical injuries and birth trauma. The dramatic results were produced by providing more education to staff and enacting some safety standards that are stricter than those considered acceptable in most hospitals.

The leaders of the program at Hospital Corp. of America (HCA) say the same steps could be used in any hospital to the same effect, and they suggest that risk managers take advantage of the experience of their health care system. HCA is the largest health care provider in the country, with 190 hospitals and 44,000 beds. Obstetrical services are provided at 123 of those hospitals, and HCA delivers about 225,000 births annually — about 5% of births nationwide.

Those big numbers also meant HCA dealt with a substantial number of obstetrical claims, says James D. Hinton, vice president of risk insurance at HCA in Nashville, TN. And more importantly, these obstetrical claims cost far more than other types of claims. From 1995 to 1999, obstetric claims represented only 8% of total claims but 30% of total claim payments, he explains.

"We also found that 50% of all dollars paid on claims above $1 million were obstetric," Hinton says. "Our rate of obstetrical claims was not unusually high, but the cost of those claims made obstetrics one of the most serious risk management issues for HCA, maybe our biggest concern."

Every hospital that delivers babies has the same issues that HCA addressed, he notes. HCA had the advantage of a massive database of information from its many hospitals, which helped it zero in on the factors that could have the most impact on reducing injuries and claims. The HCA success story offers a way for other hospitals to benefit from that data analysis, Hinton adds.

"We had to do something, and what we did really worked," he says. "We've reduced the frequency of claims by over a third, and our total costs are down by almost 50%. For HCA, that's an annual savings of somewhere around $40 million. It's been hugely successful."

HCA spent about $2.5 million on the effort, mostly for additional education for staff, but Hinton says that was a good investment when the system's annual cost for obstetrics claims was averaging $120 million. He emphasizes that the same results, and the same ratio of expenditure to savings, could be achieved by any smaller health system or an individual hospital.

Fetal monitoring, VBAC were hot issues

HCA first identified some of the hospitals in its systems that had the highest rates of obstetrical claims and started gathering data on exactly how the claims came about: what type of claims result, what issues led to the birth injuries, and how the injuries might have been prevented. Using that data, HCA started developing a master strategy for the whole system.

The HCA initiative involved several strategies, including the development of a hospital and divisional perinatal task force and perinatal guidelines, data collection and analysis, on-site education for high-risk obstetrics, on-site consultation by HCA's experts as needed, and post-claim follow-up to learn from every less-than-optimal birth experience. HCA began the effort in 1996 with 40 hospitals and then expanded the effort until all HCA hospitals were included in 2002. Between 2002 and 2005, the health system added new initiatives as the program expanded and built on its successes, explains Janey Myers, BSN, assistant vice president of the perinatal safety initiative.

Hospitals were required to track obstetrics claims and report data on a quarterly basis, Myers notes. The accumulation of data helped Myers and her colleagues drill down to the real risk factors for those claims. HCA provided a discount on its malpractice insurance to member hospitals as an incentive to participate fully. The data gathered by HCA revealed that these four "hot-topic" issues resulted in a high proportion of obstetrics claims:

  • fetal heart monitoring;
  • vaginal birth after cesarean (VBAC);
  • delays in performing emergency cesareans;
  • injuries associated with operative vaginal deliveries.

The data steered HCA to several risk reduction initiatives, including more extensive use of fetal heart monitoring, medication safety protocols, a zero-tolerance policy for kernicterus, and universal screening for jaundice. (See box below with some of the initiatives.)

Injuries and claims drop sharply at HCA

These are some of the results from the perinatal safety initiative at Hospital Corp. of America (HCA):

  • Incidents of trauma during birth were reduced from 9.8 per 1,000 births in 2002 to 4.6 per 1,000 in 2004. Mechanical injury claims fell from 74 in 2001 to 38 in 2004. This was achieved by focusing on inappropriate use of vacuum extractions and forceps. HCA developed a standard approach to identifying patients appropriate for vacuum and forceps delivery, along with protocols for safe use of those techniques and a web-based vacuum extraction course.
  • The number of new obstetrics claims was 253 in 1996 and held steady until 2001 when it dropped to 222, and then it dropped sharply in 2004 to 127. The number of claims in 2005 was 140.
  • Actuarial projections for reported claims per 10,000 births were approximately 14 for 1996 through 2000 and then fell to 12 in 2001 and 2002. The number dropped sharply to 8.3 in 2003.
  • The actuarial projection for settled claims per 10,000 births was between 4.8 and 5.8 for 1996 to 1999. Then it dropped to 3.7 in 2000, 3 in 2001, 3.2 in 2002, and 3.5 in 2003.

Fetal monitoring a major issue

Much of the effort involved education aimed at labor and delivery nurses, Myers says. For instance, the perinatal safety group identified fetal monitoring — specifically, the failure of nurses and physicians to communicate adequately when they recognize changes in fetal well-being — as a high-risk factor for obstetrical claims.

"We saw that over 50% of the claims were related to monitoring-related events," she reports. "It was a failure to recognize what they were looking at, failure to intervene, intervening improperly, or failure to document."

To address that issue, HCA implemented a system in which all 4,800 labor and delivery nurses throughout the HCA system underwent additional training on fetal monitoring with a two-day session from the Association of Women's Health, Obstetric, and Neonatal Nurses (AWHONN). HCA also collaborated with the American College of Obstetrics and Gynecology (ACOG) to develop web-based fetal monitoring training for physicians and nurses.

The training was not for the novice nurse but rather was intended to improve the skills of nurses already considered competent in fetal monitoring. Nurses were required to have six months' experience on the job before they could go through the two-day course.

The emphasis on fetal monitoring began to pay off immediately, Myers says. From 2001 to 2003, there were an average of 58 monitoring-related obstetrics claims per year, but after the additional training was provided in 2003, the number of claims dropped to only 20 in 2004.

"Fetal monitoring was improved by an emphasis on training and competency, but also teamwork and communication," she reports. And it wasn't only the nurses, Myers says. "Physicians needed this training as much, if not more, than the nurses," Myers says. "They had to learn to communicate, to use the same terminology, to get across a sense of urgency when necessary and to intervene."

Another dramatic improvement involved the prevention of kernicterus, a form of brain damage caused by excessive jaundice. Kernicterus results when the substance that causes jaundice, bilirubin, is so high that it moves out of the blood into brain tissue.

The condition has tragic effects on the child (and results in very expensive lawsuits) but is completely preventable with proper monitoring of bilirubin levels, so HCA declared kernicterus a "never event." That meant a zero-tolerance policy for kernicterus; not even one case could be accepted as just an unfortunate outcome.

To eliminate kernicterus, HCA implemented a new policy that requires testing bilirubin levels on all newborns. That policy goes above and beyond what is considered the standard of care in obstetrics, Myers explains, but it is the only way to ensure that no baby will ever suffer kernicterus at an HCA facility.

The results were undeniable. From June 2004 to February 2005, there were 1.2 cases of kernicterus in the HCA system per month, a rate that Myers says was typical over the past several years. But after the mandatory bilirubin testing was implemented, there were zero cases from February 2005 to June 2005.

"We implemented universal screening so that we can predict the risk of jaundice and kernicterus with every single baby we deliver," she says. "In addition to practically eliminating kernicterus, we have been able to reduce the number of babies coming back to our emergency room with hyperbilirubinemia, high levels of jaundice, by 84%."


For more information on perinatal safety programs, contact:

  • James D. Hinton, Vice President, Risk Insurance; and Janey Myers, Assistant Vice President, Perinatal Safety Initiative, HCA, One Park Plaza, Nashville, TN 37203. Telephone: (615) 344-9551.
  • Karen Thomas, Executive Director, Association of Women's Health, Obstetric, and Neonatal Nurses, 2000 L St. N.W., Suite 740, Washington, DC 20036. Telephone: (202) 261-2400. Web:
  • Sterling B. Williams, Vice President for Education, American College of Obstetricians and Gynecologists, 409 12th St. S.W., P.O. Box 96920, Washington, DC 20090-6920. Telephone: (202) 638-5577. Web: