OB/GYN gearing up for QI push?

Federal efforts increase focus on quality

When the American College of Obstetrics and Gynecology released an opinion on preparing for clinical emergencies last April1, it was part of what one physician thinks is a ramp-up of emphasis on improved patient safety and quality improvement initiatives in the specialty.

"There are a couple of moving pieces that are driving this," says Eduardo Lara Torre, MD, residency program director and an associate professor in the department of obstetrics and gynecology at Virginia Tech's Carilion School of Medicine in Roanoake, VA. "The first is that the federal government is moving to pay for performance, which means we need to focus on being much more outcomes-based," he says. That means that specialties that had not yet focused on pathways and protocols are starting to do so as a way to keep patients out of the hospital.

The second issue is related to educational endeavors. The Accreditation Council for Graduate Medical Education (ACGME) is shifting its focus to quality improvement and training physicians to think in terms of QI. Lara Torre says that residents now have to create quality projects during their residency and learn to look at system-based practices to assess how they operate and look for ways to improve both cost-effectiveness and outcomes.

More simulations?

Lastly, Lara Torre believes that liability issues have led to some positive changes as a way to mitigate insurance costs. As one example, in Virginia, they created a simulation program for shoulder dystocia. Every single physician and nurse went through training. It led to a break in insurance rates and also ensured that when it occurs, it is more easily managed. Lara Torre says that he can point to the two cases he had of shoulder dystocia in the last 12 months and know they went more smoothly because he had practice in a simulated event.

Another project using simulations on postpartum hemorrhaging started recently, too. "Everyone goes through these. We all have to be checked out on how we manage it from the first interventions through any surgical intervention, from phone calls to action." While the data have not shown that such efforts work yet, Lara Torre is convinced. In the next six months, a protocol on neonatal emergencies that will involve rescue drills is planned.

The push for more QI and patient safety initiatives may result in more and more simulations, something traditionally done in emergency departments and surgery, as well as obstetrics because it is just not possible to practice emergencies on real patients. Most of the things that can go wrong in an obstetrics unit are blessedly rare. But that makes knowing what to do when they happen even more important.

In an article introducing a special patient safety and quality issue of the American Journal of Perinatology2, William Grobman, MD, MBA, says that many obstetric emergencies are preventable. In an interview, he adds that while there is good QI work being done already, there is certainly more that can be done. "Do we ever know absolutely the best way to do things? No. But simulations provide an organized and systematic approach to safety" that can benefit patients and providers alike.

"How else can we practice," Lara Torre concludes. "Knowing all the steps, and knowing everyone knows them dramatically increased your comfort level in managing the patient."

For more information on this topic, contact:

  • Eduardo Lara-Torre, MD, Residency Program Director, Associate Professor, Department of Obstetrics and Gynecology, Virginia Tech-Carilion School of Medicine, Roanoke, VA. Email: eltorre@carilionclinic.org.
  • William Grobman, MD, MBA, Associate Professor, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL. Phone: (312)472-4685.


  1. ACOG Committee on Patient Safety and Quality Improvement. ACOG Committee Opinion No. 487: Preparing for clinical emergencies in obstetrics and gynecology. Obstet Gynecol. 2011 Apr;117(4):1032-4.
  2. Grobman WA. Obstetric patient safety: an overview. Am J Perinatol. 2011 Aug 4.