Patient Safety and Quality Improvement Committee

Dr. Holly S. Puritz

Dear colleagues,

The District IV Patient Safety and Quality Improvement Committee is happy to share its second newsletter with you. The goal of the District IV Patient Safety and Quality Improvement Committee is to promote patient safety in hospital and office settings and to provide a forum in which members can share safety projects in the district.

We hope you find the following information helpful and applicable in your own practices. We welcome contributions from any District IV member. Please feel free to contact any one of us on the Patient Safety and Quality Improvement Committee. A list of committee members can be found at the end of the following reports. Thank you for your interest in promoting patient safety in District IV.

On behalf of my fellow committee members,

Holly S. Puritz, MD, Virginia Section chair


Dr. Raymond L. CoxMessage from the committee chair: Redefining ‘term’
Raymond L. Cox Jr, MD, MBA

Ob-gyns’ current definition of “term” is remarkably similar to definitions used by many cultures as early as the fifth century. Old English law codified a broad timespan for estimated date of confinement to prevent women from being persecuted for adultery while their husbands were off fighting in the Crusades and other wars. While there have been no challenges to the notion that human gestation lasts around 280 days, we now have tools that allow us to more accurately calculate gestational age. Recent research has made a strong case for a narrow window for optimum gestation, lasting approximately two weeks.

In August 2012, ACOG sponsored the reVITALize Obstetric Data Definitions Conference. The conference brought together more than 80 leaders in women’s health, public health, and vital statistics. The purpose of the meeting was to review and update many of the metrics and definitions that inform our specialty. Consensus was reached on 70% of the topics reviewed, including a more accurate definition of “term” that more clearly reflects our current knowledge base.

Physicians, hospitals, and states that have aggressively pursued reduction in elective induction prior to 39 weeks’ gestation have seen remarkable improvements in many perinatal outcomes. The Joint Commission has made this metric its first required perinatal core measure.

Over the next few months, the District IV Patient Safety and Quality Improvement Committee will survey all hospitals in District IV to determine the level of implementation of standards to prevent elective induction prior to 39 weeks. We hope to share the results of our findings at the 2013 Annual District Meeting in October. We believe our district membership has an important leadership role to play in ensuring the widespread prudent use of elective delivery to promote improved perinatal outcomes and patient safety.


Dr. Victoria L. GreenInformed consent and shared decision-making
Victoria L. Green, MD, JD, MBA, Georgia Section vice chair

The quest to provide the highest standards of quality care in clinical practice is the goal of all medical providers. Thus, the zeal to consistently and continuously improve the quality of care persists unabated. The issue of quality was propelled to the forefront of the consciousness of mainstream America with the release of the Institute of Medicine report To Err is Human: Building a Safer Health System in 1999 and its companion piece, Crossing the Quality Chasm: A New Health System for the 21st Century, in 2001.

In addition to a focus on the system failures that may result in errors, these writings elaborate on the importance of patient-centered care that is respectful and responsive to individual patient preferences, needs, and values. The importance of communication and informed consent is evident as a critical component in providing safe, quality care.

Informed consent is an ethical concept that is integral to contemporary medical practice. Effective communication increases patient satisfaction, physician satisfaction, adherence to treatment plans, and appropriate medical decisions, which may result in better health outcomes. It is a process of communication whereby a patient is enabled to make an informed and voluntary choice about accepting or declining medical care.

The emerging science of patient-centered decision-making promotes an awareness of the importance of the patient’s role in managing her own care. As health and health care are becoming increasingly complex, the need for the concept of shared decision-making in health choices that affect the quality, and often the length of an individual’s life, is growing exponentially.

Despite detailed forms, graphics, and our best efforts to relate the reasons for a particular course of treatment, the risks and benefits of treatment, and the alternatives, the patient often lacks the required information to make an informed choice. Important reasons why we may be unsuccessful in providing truly informed consent include:

  • Lack of unbiased information on the true risks and benefits of a procedure
  • Inattention to the goals and concerns of the individual patient
  • Failure to encourage and empower the patient to participate in her health care decisions by asking the needed questions to ensure adequate assessment of health care concerns

Consequently, shared decision-making is the process of providing personalized information about the options, outcomes, probabilities, and scientific uncertainties of treatment options, while allowing the patient to communicate her values and the relative importance she places on the risks and benefits discussed. Through shared decision-making, the patient should be able to easily understand the information evaluated, the alternatives considered, and the reasoning and rationale for arriving at the suspected diagnosis and to choose the recommended course of action.

During this process of sharing information about options, outcomes, and preferences, steps are taken to work toward a consensus, and ultimately an agreement is reached that reflects the values and ideology of both the patient and the health care provider. This shared decision-making safeguards the patient against unwanted medical treatment and makes possible the patient’s active involvement in her medical planning and care. 

Logically, shared decision-making meets the goals of all stakeholders in the decision-making process. However, its efficacy is also supported by randomized controlled trials that demonstrate increased patient knowledge, enhanced patient satisfaction, improved adherence to recommendations, better alignment between values and choices, and more satisfaction with decisions. In addition, providers gain increased insight into patient preferences and efficiency of care is improved.

Despite its obvious benefits, shared decision-making may be hampered by:

  • Lack of time
  • Inadequate objective data on treatment risks and complications
  • Unexplored patient values, interests, and assumptions that may influence health care choices
  • Unclear alternatives as technology advances rapidly
  • Patient access to incorrect information
  • Lack of insurance coverage for the options the patient desires
  • Detrimental influence of friends and family (although family influence may have a positive effect on information exchange)
  • Unclear roles and relationships with uncertainty as to how much information should be provided

There is significant support for widespread adoption of shared decision-making policies. The Affordable Care Act supports programs to facilitate shared decision-making and development of patient decision aids. The Washington State Legislature had bipartisan support for a coordinated demonstration project on use and evaluation of shared decision-making and decision aids, aligning shared decision-making goals and strategies with state leadership.

Health providers should ascribe to the principles of shared decision-making by engaging patients in discussion and eliciting patient preferences in health care choices. This behavior reflects respect for the dignity and autonomy of individual patients and a commitment to help them participate fully and meaningfully in the decisions that affect their bodies and their lives.

More information on informed consent and shared decision-making:


Dr. Tamika C. AugusteHospital safety measures across DC
Tamika C. Auguste, MD, District of Columbia Section vice chair

The District of Columbia is a city of 68 square miles with a diverse population of 601,723 and a metro population of approximately 5.3 million. DC has a total of 16 hospitals, and seven provide ob-gyn services.

Constance J. Bohon, MD, DC Section chair, and I have been investigating what safety measures these hospitals have invested in to make the city a safer place for women to have babies. Safety contacts for the DC Section have been established at these hospitals and were asked to share measures that have been implemented at their institutions to improve the care of women in the perinatal area. The responses were interesting and surprisingly similar.

The majority of hospitals are practicing simulation drills and/or activities that are both individual and multi-disciplinary. The simulation drills focus on individual tasks and teamwork. Some are quite extensive, involving high-fidelity simulators and in-situ drills with teams of people on labor and delivery. Other simulations involve low-fidelity modalities and focus on specific tasks like laceration repair. Most hospitals are focusing on simulation activities designed for improved patient care and safety.

Another major effort across the hospitals involves communication. All hospitals have implemented modalities to improve communication. They have recognized that miscommunication accounts for the majority of perinatal sentinel events and are making efforts to improve communication overall. Many of the hospitals are focusing on communication surrounding electronic fetal monitoring (EFM). They now require staff to have annual certification in EFM and education in using SBAR (Situation, Background, Assessment, Recommendation).

In efforts to improve communication across the labor and delivery team, many hospitals have also implemented team huddles. Huddles are when the labor and delivery team gathers to discuss each woman on the labor unit. Topics discussed include specific medical issues, known issues with the fetus, EFM categories, pain management, and treatment course. These huddles ensure that everyone taking care of the patient is on the same page. Any potential issues or concerns are brought up and discussed. The huddles are happening anywhere from twice a day to every three hours at some hospitals.

Other safety measures occurring across DC include infant abduction drills, increased maternal-fetal medicine involvement on the labor and delivery unit, and compliance with no elective inductions prior to 39 weeks’ gestation.

These safety measures can be implemented by any institution. Some are more extensive than others, but their use is definitely feasible. It’s important to think about new and innovative safety measures that your institution can implement to improve the care of your patients. When it comes to safety, we want to share what we are doing. We all have the same common goal of improved safety.

DC Section leadership wanted to find out what its hospitals are doing to encourage collaboration. We wanted to share some of the more successful initiatives across DC. We hope to make DC a safer and desired place for women to have their babies.


Dr. William E. BrownPolicy standardization in North Carolina
William E. Brown, MD, North Carolina Section vice chair

Vidant Medical Center (VMC) is a private, not-for-profit academic medical center located in eastern North Carolina. VMC is part of Vidant Health, a private, not-for-profit health system organized in 1997 through mergers and the acquisition of 10 not-for-profit entities in eastern North Carolina. VMC is the flagship hospital for Vidant Health and serves as the teaching hospital for the Brody School of Medicine at East Carolina University. VMC has 861 licensed beds and employs more than 6,500 employees.

Leaders at VMC actively engage staff in performance improvement and building highly reliable processes to ensure safe and quality care reaches patients every time. Standardization is an essential process to reduce variability and improve patient care. Three examples of policies that guide staff when caring for patients at VMC are at:

Discharge of newborns
Prevention of kidnapping
Universal protocol for preventing wrong site, wrong procedure, and/or wrong person surgery, or other invasive procedure


District IV Patient Safety and Quality Improvement Committee members

Raymond L. Cox Jr, MD, MBA, District IV Patient Safety and Quality Improvement Committee chair

Michael D. Moxley, MD, District IV Patient Safety and Quality Improvement Committee chair elect

Thomas W. Hepfer, MD, District IV vice chair

Rachel K. Casey, MD, District IV Junior Fellow vice chair

Jennifer M. Keller, MD, District IV young physician

Tamika C. Auguste, MD, District of Columbia Section vice chair

Victoria L. Green, MD, JD, MBA, Georgia Section vice chair

Jessica L. Bienstock, MD, Maryland Section vice chair

William E. Brown, MD, North Carolina Section vice chair

Nabal J. Bracero, MD, Puerto Rico Section vice chair

Scott A. Sullivan, MD, South Carolina Section vice chair

Holly S. Puritz, MD, Virginia Section chair

Christian A. Chisholm, MD, Virginia Section vice chair

Orville P.C.M. Morgan, MD, West Indies Section vice chair

Stephen H. Bush, MD, West Virginia Section vice chair