Teamwork training and an emphasis on standardized processes can reduce perinatal harm. A study found the improvements also reduce malpractice costs.

  • Perinatal malpractice cases are among the costliest for hospitals.
  • Interdisciplinary teamwork can be improved without reducing autonomy.
  • Standardized processes can be effective in reducing perinatal harm.

Team training of obstetrical unit physicians, along with improved use of standardized best practices, can significantly reduce the risk of perinatal harm, a researcher suggests. Those interventions also can reduce malpractice losses in a big way.

Research led by William Riley, PhD, professor at the School for the Science of Health Care Delivery at Arizona State University in Phoenix, found that those two strategies were most effective in improving perinatal safety, though other approaches also helped.

Riley notes that obstetrical claims are among the most common malpractice claims and typically result in far higher settlements or jury awards than other claims. Perinatal injuries are involved in 43% of the total malpractice cases exceeding $5 million in loss payout, he says, and it is not uncommon for more than half of a hospital’s risk management budget to be spent in the labor and delivery area.

Maternal admissions with complications typically are twice as costly as stays without complications, and admissions with pregnancy and delivery-related complications account for $17.4 billion in annual U.S. hospital costs, Riley and colleagues note in their report.

Three Interventions Introduced

The study consisted of implementing three different interventions at 14 hospitals for five years and comparing incidents of perinatal harm to a baseline two-year period. The interventions were standardization of evidence-based, interdisciplinary teamwork training, and routine clinical education regarding best practices with performance feedback.

“Because of the methodology and the complexity of the project, it couldn’t be a randomized trial in which you hold everything constant and just change one thing,” Riley explains. “This was more of a quasi-experimental approach with the goal of seeing if these interventions reduced perinatal harm first and foremost, but secondly to ascertain if that had an impact on malpractice claims. The study revealed the answer to both is yes.”

The researchers found that a reduction in perinatal harm was associated with improved performance with standardized best practices and team training of obstetrical unit physicians and staff. The median dollar amount of perinatal claims paid decreased significantly in the intervention period compared to the baseline period and total indemnity losses paid significantly decreased. There was no significant decrease in non-perinatal malpractice claims activity in the participating hospitals. (An abstract of the study is available at: http://bit.ly/2fdwgNr.)

More Costly Than Other Claims

The study results are derived from only a four-year period of the study in order to create a five-year time lag from date of injury that would allow for the later filing of malpractice lawsuits. There was a total of 125 claims made resulting from birth injuries during this time period with 25 claims resulting in payments at a total cost of $27.3 million, the researchers found, with legal defense costs accounting for 15% of total claims cost. Approximately 6.7 claims were filed for every 10,000 deliveries, and approximately 1.3 claims were paid for every 10,000 deliveries.

Obstetrical claims were costly in comparison to other malpractice claims at the hospitals. They represented 9% of all malpractice claims paid at the hospitals, but they accounted for 24% of the total malpractice costs and 27% of legal defense costs. The intervention period saw significant reductions in the median financial losses, a $385,980 median decrease in total losses per 10,000 deliveries. That was driven by a total median reduction of indemnity loss of $363,440 per 10,000 deliveries, the study report explains.

The effect of the interventions also was assessed by comparing the level of obstetrical malpractice claims activity with all malpractice claims activity in the participating hospitals, and there was a significant reduction in the total number of obstetrical claims paid (a 44% reduction), losses paid (78%), and indemnity payments (85%), the researchers found. At the same time, there were no significant reductions in the total non-obstetrical claims in the same hospitals.

Standardization Highly Effective

Determining which intervention makes the most difference is difficult, Riley says, but he and his colleagues lean toward the importance of standardized peer processes. They often felt the emphasis on interdisciplinary functioning and team coordination had a significant effect.

Standardized care bundles have been shown to be effective in reducing ventilator-acquired pneumonia, central line infections, and other issues, but there was not much research showing that they worked well with reducing perinatal harm, Riley says. Bundles were introduced over time during the project, and they proved as effective as has been reported in other research, Riley says.

Improve Teamwork, Be Encouraged by Results

Improving teamwork also proved effective.

“Once we introduced the simulation team training, that’s when the rates of harm went below the median,” Riley says. “The interventions had a cumulative effect. It was a combination of interventions that helped, which led to a change in the safety environment of those units. They were sensitized to the issue, and the culture of safety improved. We can say that definitively.”

Riley suggests that risk managers should be encouraged by the results because in addition to proving the value of those particular strategies, the experience with the 14 hospitals demonstrated that objections to interdisciplinary training and standardization are unfounded.

“The big lesson is that it is possible for medical staff and nurses to agree on standardized care processes in order to improve patient outcome,” Riley says. “It does not interfere with their medical autonomy or result in cookbook medicine, which is a fear you often hear. It’s just the opposite: It results in better care and safer care.”


  • William Riley, PhD, Professor, School for the Science of Health Care Delivery, Arizona State University, Phoenix. Email: william.j.riley@asu.edu.