Frequently Asked Questions: OB/GYN Quality, Equity and Safety

Jeffrey Ecker, MD, chief of the Department of Obstetrics & Gynecology at Massachusetts General Hospital, discusses how the department's quality and safety program benefits patients.

Q: What is the quality assurance program in the Department of Obstetrics & Gynecology?

A: The quality assurance program helps us look back and see that the care we provided was best, and to look forward to create systems and projects that will assure it continues to be best. Our work also helps doctors adapt to changing evidence so that our care maintains the standard that we and our patients expect.

We use what is called a just-culture approach. The idea—and it is really very true at this hospital—is that we have conscientious, well-trained providers that are here to take the best care of patients. No one comes in saying, "I really want to mess up today." So when things do not turn out ideally, we are not looking for someone to blame. Instead, we are looking to understand how, if you have a group of well-trained and well-intentioned providers, occasionally things do not turn out as planned. We ask, "What about the system of care needs to be changed?" Because when errors or less-than-ideal outcomes happen, it is generally not because of one simple thing, but because the system is very complicated. In most cases, many things need to line up for an error to occur.

Q: What are the components of the program?

A: There are three main elements of our quality, equity and safety program: administration, case review and simulation.

• First, we make sure that physicians and staff are properly credentialed and that we fulfill the reporting requirements from the state and other health care organizations. Doing that allows us to compare our performance to others and learn from them.
• Second, our team of specialists from across the Department of Obstetrics & Gynecology reviews cases with certain outcomes to see if the appropriate elements of care were provided. If they were not, we work to identify why they were not and how we can improve so that they will be provided in the future.
• Finally, we identify potential emergencies or challenges in delivering health care to our patients and we conduct simulation drills to be certain we are ready to handle them. This is very important because rare emergencies in obstetrics may occur once in a hundred or a thousand deliveries. Rather than waiting for one of those rare events to happen and seeing how we handle it, we use simulation and other tools to rehearse so if it does happen, our performance will be ideal.

Q: How do you apply what you learn through case study and simulation to providing patient care?

A: The approach that we take really depends on the incident we are looking at and the sort of care involved. For one, we want to create environments where anyone—from a nurse or a unit secretary to a top surgeon—feels empowered to speak up if he or she sees something that is important to a patient’s care, and that others are prepared to hear what he or she has to say. Our work requires a team approach, relying on everyone on the team to contribute their perspective, knowledge and training to be sure the outcome of each patient is as good as possible.

Second, we institute structures and systems. That may mean ensuring that recommendations for best care—whether it is antibiotics that should be given to prevent infection before a certain kind of surgery or the timing for certain kinds of deliveries in obstetrics—are carried out. It could also mean that if there was an adverse outcome or problem with a piece of equipment, we might establish a very specific system so that we would not have that problem the next time.

Finally, we look at rates and compare the rate of a certain outcome at Mass General to rates at other hospitals to see if we over-perform or underperform. Then we will try to figure out what is it that makes us better than others, or what is it that has made us underperform, and how can we improve. This often involves sharing rates with colleagues across Mass General Brigham and across the country, and asking the question, Is there something you do that you ascribe your rate to? And they may say, "We are doing this or that, and it may be something we should try."

Q: How are patients involved in the quality, equity and safety program?

A: Our quality, equity and safety program involves patients in a lot of ways because the patient is a really important part of her care team. So we involve her in the process—not to make it her responsibility; ultimately it is our responsibility—but to leverage everything she knows about her health. For example, we ask patients again and again who they are and what their birthday is so we do not confuse one Jane Smith born on January 5 with another Jane Smith born on June 25. But we will also ask a patient about her allergies, even what procedure she is here for. Sometimes patients are surprised, but I also think they understand how important it is.

The second aspect of quality and safety that patients should know about is that we try to be transparent—both about what we do best and what could be done better. Patients are generally glad to hear that we are honest and that we are paying attention. We also encourage patients to share their experiences and thoughts on how we can improve the care we deliver.

Q: How does the quality and safety program relate to broader trends in health care today?

A: One of the broad themes that you hear about a lot these days are checklists and standardizing care. Some of that is built into the Affordable Care Act, but health care providers are talking about this in many forums. We want to identify what is best practice and to standardize it so that first, no one forgets, and second, best practices are not left up to each individual provider. Of course, there cannot be checklists for everything in medicine. There are plenty of opportunities for providers to come up with innovative solutions to address specific circumstances. However, having guidelines helps to ensure that we get the best results each time.

Another trend is a focus on outcomes, and that is an area where there are a lot of opportunities for us and others to expand. Asking questions like, "How did we do? How does this hospital perform with a certain type of patient? What are our outcomes from a procedure compared to other places? How does one doctor perform compared to another? How do we improve care so that we are operating close to the best, either within our department or elsewhere?" It can be tricky, because all patients are not the same, but having a sense of how we perform compared to others will help us continue to improve every day.