Improving Perinatal Care: A Focus on Patient-Centered Care and Evidenced-Based Measures

Middlesex Hospital
Middletown, Connecticut, USA


The team at Middlesex Hospital is a participant in IHI’s Collaborative on Improving Perinatal Care.

Arthur McDowell, MD, Vice President Clinical Affairs, Team Sponsor
Kenneth Eckhart, MD, Pregnancy and Birth Center Department Chair
Terisa Brainard, RN, Nurse Manager
Mary Lynne Riley, MA, CHCQM, Quality Improvement (QI) Coordinator
Anne Bingham, MD
Beverly Byrd, MD
Julie Flagg, MD
Aysegul Ozbek, MD
Karren Collins, RN
Sue Beebe, RN
Jamie Hull, RN
Katherine Focacci, RN
Sharon Finn, MSN, Director Quality Improvement



The Middlesex Pregnancy and Birth Center is a level two Labor, Delivery, Recovery, and Postpartum (LDRP) facility with approximately 1,100 births per year. Middlesex is committed to ongoing improvement of the quality and safety of perinatal and post partum care. We will demonstrate this by implementing interventions for patient-centered care, and through evidence-based measures designed to reduce variation in care, reduce harm, and improve team communication and staff satisfaction. While our hospital strives to improve several aspects of perinatal care, this report focuses specifically on four areas of improvement.

Perinatal Bundles (Elective Induction and Augmentation Bundles)
  • By February 2007, improve patient safety and reduce the incidence of birth trauma by implementing the IHI Perinatal Bundles (Elective Induction and Augmentation)  
  • Achieve 95 percent compliance rate by June 2008
  • Beginning January 2009, maintain 98 percent compliance rates
Instrumented Delivery Bundle (Vacuum and Forceps Deliveries)
  • By June 2008, begin processes required to implement the Instrumented Delivery Bundle, including a policy and procedure, documentation checklist, and audit tool
  • Implement the Instrumented Delivery Bundle by May 2009
  • Achieve a 95 percent compliance rate by June 2009
Perinatal Harm: Trigger Tool Audits
  • Implement Trigger Tool audits starting November 2006
  • Achieve a goal of 5 percent or less of  adverse events  per 100 live births
Patient Centeredness
  • Include patient centeredness as part of the post partum priority group that oversees patient satisfaction by including two to four patients in the group by September 2008
  • Design and implement a post partum support group (“Parents and Babies Connect”) by July 2009
  • Trial hourly rounds  for four “Ps” (potty, position, pain, oral nutrition) by February 2009
  • Trial “Ticket to Discharge” by November 2008
  • Continue breast feeding support group, ongoing approximately 10 years



Perinatal Bundles (Elective Induction and Augmentation Bundles)

  • Compliance rate for Elective Induction Bundle
  • Compliance rate for Augmentation Bundle
Instrumented Delivery Bundle (Vacuum and Forceps Deliveries)
  • Compliance rate for Instrumented Delivery Bundle
Perinatal Harm: Trigger Tool Audits
  • Percentage of harm per 100 live births using a sample of 20 records per month
Patient Centeredness
  • Press Ganey satisfaction scores



  • Utilized situational DVDs through IHI: Conducted movie nights for staff and physicians and individuals could watch on their own; staff and physicians needed to sign off that they watched the videos. The Advanced Fetal Monitoring and Assessment program developed by Advanced Practice Strategies was utilized to test competencies of staff and physicians to ensure improved communication related to electronic fetal monitoring (EFM) and accurate reporting of Situation, Background, Assessment, and Recommendations (SBAR) communication technique.
  • Utilized IHI Perinatal Bundle criteria in our order sets initially on paper, then in the computerized physician order entry (CPOE) system. Implemented initially with two obstetrics (OB) groups prior to spreading to all groups.
  • Established nurses as gatekeepers for enforcing compliance with 39 weeks for elective inductions.
  • Utilized audit tool to conduct weekly audits to initially complete five per week and then all inductions (since we have a low rate of inductions) for composite and compliance rates.
  • Developed hyperstimulation (tachysystole) algorithm to ensure common language.
  • Standardized no scheduled Cesarean section prior to 39 weeks (twins 38 weeks).
  • Deep dive: Using IHI criteria and one month of data for patients who had pitocin, we conducted chart audits twice yearly. Instrumented deliveries and post partum hemorrhage were noted in the deep dive and subsequently, policies and procedures were implemented for these (instrumented delivery policy and procedure, code red and hemorrhage kit with all appropriate supplies). 
Instrumented Delivery Bundle (Vacuum and Forceps Deliveries)
  • Utilized IHI’s recommended criteria for Vacuum Bundle.
  • Utilized other teams’ policies and procedures as a guide, manufacturer’s guidelines, and American College of Obstetrics and Gynecology (ACOG) guidelines to develop a policy for instrumented deliveries (both vacuum and forceps).
  • Developed a checklist that is included as part of the chart to ensure all appropriate criteria are documented.
  • Developed an audit tool and conduct monthly audits of all instrumented deliveries.
  • Utilized IHI recommended criteria and Trigger Tool and made modifications to the tool that were appropriate for our organization.
  • Conducted audits on 20 random charts per month. Nurse Manager, QI Coordinator, Department Chair, and staff nurse conduct the audits. This may vary depending on availability of staff. Due to staffing changes and constraints, we were several months behind in conducting audits; as a result we have reconvened the audits starting April 2009 and are now tracking adverse events and specific triggers to determine if further inquiry into process improvements are needed.
  • Standardized our epidural drip order sets to bupivicaine or robivicaine with or without  Fentanyl.
  • Standardized ephedrine administration in our epidural order sets — premixed syringes in five milliliters.
Patient Centeredness
  • Added patients to our post partum priority task force to review Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results and provide feedback for improvement. Presented this idea to the task force, task force formulated specific criteria and interview questions for the potential members. We contacted physician groups to obtain names of possible candidates for objective views by patients who had a good or bad experience. We then interviewed individuals via telephone. We chose two patients initially and when they were unable to attend due to scheduling conflicts, they were replaced and we continue to replace patients as needed.
  • Received a letter from a patient who had benefited from attending our breast feeding support group requesting a post partum support group for patients not breastfeeding. We subsequently developed a post partum support group with post partum depression as the central topic and also include journaling, infant massage, infant growth and development, and dance. We continue to refine and add other topics based on patient feedback.
  • Huddles: To promote team communication we conduct a brief overview of patients and unit status, including census done at the beginning of every shift and ad hoc as needed due to patient status or census changes.
  • Hourly Rounds: Rounds are conducted hourly from 7 AM to 10 PM; must be seen between 10 and 2, 4 and 7. Includes the four “Ps” (potty, position, pain, oral nutrition). Can be seen by nurse, secretary, or patient care technician. We have noticed an increase in patient satisfaction with pain control per Press Ganey results.
  • Ticket to Discharge: Developed to assist with patient partnering in the discharge process. Green ticket attached to the baby’s crib includes all processes needed to discharge mom and baby from the hospital.
  • Whiteboards in all patient rooms with patient name, medications and administration times, and plan of care.
  • Pain management posters with alternate pain management techniques placed in all patient bathrooms; patients have since requested sitz bath and abdominal binders.
  • Breastfeeding Group: Continues to be extremely popular and is run by our lactation consultant.







Summary of Results / Lessons Learned / Next Steps
Summary of Results
From January 2007 to October 2009 we increased our augmentation composite rate from 72 percent to 97 percent. This is attributed in large part to physician awareness of the importance of assessing estimated fetal weight and documentation prior to the start of Oxytocin. We had recent changes in CPOE that affected documentation of the Bishop score, which contributed to our one month dip in results. With virtually consistent results at 95 percent or above, we have started to track compliance rates. For elective inductions, we improved from 89 percent to 98 percent for the same time period and currently have no elective inductions prior to 39 weeks.  We have significantly reduced bottlenecking due to the decrease in overall elective inductions that lasted two to three days.
We have seen a decrease in infants (37 to 39 weeks) transitioning in our special care nursery. We implemented the Instrumented Delivery Bundle in March 2009 following extensive work to develop a policy and procedure for both forceps and vacuum deliveries. We also developed an audit tool and a checklist; our team determined that the checklist should be part of the record and helps to assist with our documentation efforts. This has proven to be very beneficial and we continue to educate physicians on the importance of utilizing the sheet to ensure appropriate documentation.
From March 2009 to October 2009 we increased our compliance with the Instrumented Delivery Bundle from 64 percent to 100 percent, with variation occurring month to month. Consistent utilization of the check list will stabilize our results. We have noticed reduced variation in the usage of the vacuum related to pulls and pop-offs. In our patient-centeredness efforts we now think of our patients and community members as active team members to reduce harm and improve patient care and satisfaction. Each member of our team and the Pregnancy and Birth Center staff have commented that participation in the IHI initiatives has measurably improved collaboration and teamwork between all levels of staff.
Next Steps
As we continue our improvement journey we are interested in management of second stage labor to decrease primary C-sections. We are developing checklists and/or algorithms for management of specific conditions and emergent situations, and plan to develop protocols to address the safety aspects for managing obese patients. We currently have an evaluation form for our post partum support group and are making changes to the program based on this valuable feedback. We have faced challenges with staffing constraints to consistently complete audits for defensibility (i.e., can be explained by complete documentation of patient records); however, we have revised the IHI defensibility tool to meet our needs and plan to move forward with this initiative by having nurses complete the audits in addition to physicians completing some of their own record audits, with the goal of improving our medical record documentation. We continue our training programs for ongoing staff education and will be administering a new culture of safety survey by year end, when we look forward to making further strides in our goals toward improving perinatal care.


Contact Information

Terisa Brainard, Manager, Pregnancy and Birth Center


Mary Lynne Riley, Quality Improvement Coordinator
Average Content Rating
(1 user)
Please login to rate or comment on this content.
User Comments