Recommendations From a National Panel on Quality Improvement in Obstetrics

Although it was not singled out as an isolated theme at the national panel, intrapartum fetal surveillance was noted to be an essential component of obstetrical patient safety, validated by current national initiatives. As a result, it featured prominently in many of the discussions and was felt by the panel to be relevant to many of the drafted recommendations. Although several educational and team training interventions have been successful, the panel recognized that there were gaps in consistent and reliable training for physicians, nurses, and midwives in intrapartum fetal surveillance across the country. The SOGC has recognized theimportance of this issue and has issued a statement urging further work in this area. In particular, standardized interprofessional training has been provided as a key opportunity for strengthening collaboration in maternity care.

During the panel discussion, it became evident that several themes were represented across all five high-risk areas. They related to the design of training programs, engagement of health care professionals, and the role of existing training and maintenance of competence programs aimed at improving the quality of obstetrical care. The panel indicated there was variability across regions in how health care professionals are trained to address some of the high-risk areas; in particular, not all continuing professional development programs are evidence-based in design. The panel articulated an awareness of how challenging it can be to engage busy clinicians with high-volume workloads; this applies both to continuing professional development programs and to quality improvement efforts. The panel suggested that there is currently a lack of appropriate incentives for participation in continuing professional development. Panel members provided examples of incentives such as Doctors BC, which has provided funding for physicians in each health authority to engage in quality improvement activities. Québec similarly has offered provincial funding for physicians to participate in continuous professional development activities, such as the programs offered by l'Approche multidisciplinaire en prévention des risques obstétricaux (AMPRO).

Panel members also debated the obstetrical community's readiness to adopt standardized processes such as the consistent use of checklists. The panel noted that checklists have been successfully implemented at some sites but that cultural resistance has prevented their adoption in other regions.

Finally, the panel commended the SOGC for supporting the Managing Obstetrical Risk Efficiently and Advances in Labour and Risk Management training programs, but it was noted that uptake was variable across the country. Nonetheless, these programs are examples of system-wide initiatives with the potential to broadly improve quality of care in some or all high-risk areas.

By focusing and coordinating quality improvement efforts across the country, this national panel believes that obstetrical care can move beyond incremental local changes to system-wide enhancements that will benefit Canadian mothers, babies, and families, as well as health care providers. Members of the panel recognized some commonality between their discussions and the recent U.K. report, “Each Baby Counts,” including effective interprofessional communication, timing of clinical decisions, and technical skills-based issues. These three high-level concepts influenced the recommendations of the U.K. report and are also reflected in a second joint report on obstetrical care published by the CMPA and HIROC. Communication issues within and across health care teams were a leading contributing factor to obstetric medicolegal cases in this latter report and are reflected across the recommendations by the national panel. Practising the acquisition, retention, and recovery of situational awareness is a fundamental concept linked to this theme and was also a focus of the U.K. report. One of the main challenges to maintaining situational awareness in intrapartum care is the sensitivity to time for clinical decisions and resulting actions. Thus, attention to improving individual and team situational awareness is warranted. Finally, several medicolegal cases featured gaps in technical skills, particularly in the interpretation of intrapartum fetal health surveillance data. The panel endeavoured to capture this latter concept in its recommendations.

Given that these common safety issues have been broadly and consistently identified, the panel supported the fact that quality improvement efforts are essential tools to help address the current implementation gap. These efforts can facilitate rapid evaluation and adoption of evidence-based solutions customized to local needs. Panel members also noted that quality improvement is one approach in the implementation tool box and recommended that health care providers leverage local and national expertise in implementation science to facilitate their efforts. In discussing the implications of implementation, the panel noted that it is important to consider in each setting whether the problem being solved is a knowledge gap, a skills gap, or another determinant of clinician behaviour. Health care providers seeking solutions to these gaps should tailor their approaches accordingly. Similarly, panel members generated several examples of local best practices, and currently evolving regional networks could facilitate the sharing of these potential solutions.

As the panel reflected on the recommendations generated for the five high-risk areas, challenges were recognized. Some of the high-risk areas had a body of evidence supporting promising interventions (see Figure) that are ready for dissemination. Others lacked clarity in fundamental definitions or measures, and although they had a dearth of evidence, they may still offer opportunities to standardize aspects of care according to available best practices. Furthermore, for some of the high-risk areas, there exist clear standards of care; in others, none are available. Panel members also highlighted that even in cases where standards exist, these require operational adaptation at a unit level that is based on the level of care available and the accessibility of specialized staff. The panel also recognized that checklists featured prominently among the promising interventions. It is important to emphasize that checklists are solutions that need to be applied to the appropriate prioritized problem. The panel recommends that close attention be paid to training, implementation planning, and evaluation of checklists. Finally, because audit and feedback tools feature prominently among the recommendations, it is important to acknowledge that standards for optimization of tools are available in the literature.

The panel wished to convey in this paper a call to action to the Canadian maternity care community. Engaged stakeholders need to work collectively to bring these recommendations to fruition: front-line clinicians, hospital administrators, provincial and territorial medical associations, regional networks, and national bodies (e.g., SOGC, CMPA, CFPC, HIROC, Health Standards Organization, Canadian Anesthesiologists Society, Royal College of Physicians and Surgeons of Canada, Canadian Association of Midwives), as well as provincial governments, provincial perinatal programs, and regional health authorities. Provincial quality councils could also be tremendously helpful in facilitating some of the panel's recommendations. The panel also recognized that accreditation standards and clinical practice guidelines could be powerful levers for change.

This was a novel experience in Canada to bring together multiple partners in obstetrical care to create action-oriented recommendations focused on quality improvement. We believe that future focused, coordinated efforts will not only reduce medicolegal risk but, more importantly, will also improve the safety of care for Canadian mothers and babies.

The panel wishes to thank Monique Lafrance for meeting coordination.