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0003525850
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Committee on Quality of Healthcare in America, Institute of Medicine, Washington, DC: National Academies Press;
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Committee on Quality of Healthcare in America, Institute of Medicine. Crossing the quality chasm: a new health system for the 21 st century. Washington, DC: National Academies Press; 2001.
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(2001)
Crossing the quality chasm: A new health system for the 21 st century
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2
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56849097883
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Sakala C, Corey M. Evidence-based maternity care. Milbank Report (in press). Good comprehensive review of which of our current obstetric practices are truly evidence based and where there are improvement opportunities. Also, this review is a good source of economic information that is otherwise hard to track down.
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Sakala C, Corey M. Evidence-based maternity care. Milbank Report (in press). Good comprehensive review of which of our current obstetric practices are truly evidence based and where there are improvement opportunities. Also, this review is a good source of economic information that is otherwise hard to track down.
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3
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33644760687
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Variations in the incidence of postpartum hemorrhage across hospitals in California
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Lu MC, Fridman M, Korst LM, et al. Variations in the incidence of postpartum hemorrhage across hospitals in California. Matern Child Health J 2005; 9:297-306.
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(2005)
Matern Child Health J
, vol.9
, pp. 297-306
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Lu, M.C.1
Fridman, M.2
Korst, L.M.3
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4
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36248941150
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Letter from North America: Understanding and minimizing nocebo effects in childbearing women
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A short essay that directly addresses the principle of 'first do no harm' in the context of maternity care
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Sakala C. Letter from North America: understanding and minimizing nocebo effects in childbearing women. Birth 2007; 34:348-350. A short essay that directly addresses the principle of 'first do no harm' in the context of maternity care.
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(2007)
Birth
, vol.34
, pp. 348-350
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Sakala, C.1
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5
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39749188773
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Quality assessment tools: ACOG Voluntary Review of Quality of Care Program, Peer Review Reporting System
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A nice review of where the peer-review process was and the new ACOG-sponsored approach, especially relevant for smaller hospitals or hospitals with intractable issues
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Lichtmacher A. Quality assessment tools: ACOG Voluntary Review of Quality of Care Program, Peer Review Reporting System. Obstet Gynecol Clin North Am 2008; 35:147-162. A nice review of where the peer-review process was and the new ACOG-sponsored approach, especially relevant for smaller hospitals or hospitals with intractable issues.
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(2008)
Obstet Gynecol Clin North Am
, vol.35
, pp. 147-162
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Lichtmacher, A.1
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6
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18644383685
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Five years after to err is human: What have we learned?
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Leape LL, Berwick DM. Five years after to err is human: what have we learned? JAMA 2005; 293:2384-2390.
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(2005)
JAMA
, vol.293
, pp. 2384-2390
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Leape, L.L.1
Berwick, D.M.2
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7
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33748747494
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The checklist: A tool for error management and performance improvement
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After reviewing the advances made in other high-risk areas using checklists, this review is a guide to the evolution of medical and critical care checklists, and a discussion of the barriers and risks to their implementation
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Hales BM, Pronovost PJ. The checklist: a tool for error management and performance improvement. J Crit Care 2008; 21:231-235. After reviewing the advances made in other high-risk areas using checklists, this review is a guide to the evolution of medical and critical care checklists, and a discussion of the barriers and risks to their implementation.
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(2008)
J Crit Care
, vol.21
, pp. 231-235
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Hales, B.M.1
Pronovost, P.J.2
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8
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47549113426
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Annals of medicine: The checklist
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10 December 2007. Available, Accessed 19 July 2008. This wonderfully written essay is useful to give to department members when introducing the concept of checklists
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Gawande A. Annals of medicine: the checklist. The New Yorker, 10 December 2007. Available http://www.newyorker.com/reporting/2007/12/10/ 071210fa_fact_gawande. Accessed 19 July 2008. This wonderfully written essay is useful to give to department members when introducing the concept of checklists.
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The New Yorker
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Gawande, A.1
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9
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33845880922
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An intervention to decrease catheter-related bloodstream infections in the ICU
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Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006; 355:2725-2732.
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(2006)
N Engl J Med
, vol.355
, pp. 2725-2732
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Pronovost, P.1
Needham, D.2
Berenholtz, S.3
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11
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35548986180
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Clark S, Belfort M, Saade G, et al. Implementation of a conservative checklist-based protocol for oxytocin administration: maternal and newborn outcomes. Am J Obstet Gynecol 2007; 197:480e1-480e5. A landmark quality-improvement project that is being emulated around the country. This will serve as the paradigm for safe use of oxytocin going forward.
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Clark S, Belfort M, Saade G, et al. Implementation of a conservative checklist-based protocol for oxytocin administration: maternal and newborn outcomes. Am J Obstet Gynecol 2007; 197:480e1-480e5. A landmark quality-improvement project that is being emulated around the country. This will serve as the paradigm for safe use of oxytocin going forward.
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12
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0033981872
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ABC Surveillance Team. Effects of hospital policies based on 1996 group B streptococcal disease consensus guidelines
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Factor SH, Whitney CG, Zywicki S, Schuchat A, ABC Surveillance Team. Effects of hospital policies based on 1996 group B streptococcal disease consensus guidelines. Obstet Gynecol 2000; 95:377-382.
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(2000)
Obstet Gynecol
, vol.95
, pp. 377-382
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Factor, S.H.1
Whitney, C.G.2
Zywicki, S.3
Schuchat, A.4
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13
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47949119430
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Clark SL, Belfort MA, Byrum SL, et al. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol 2008; 199:105e1-105e7. A thought-provoking opinion essay on establishing a quality program that improves outcomes and reduces litigation claims using protocols, practice guidelines, and teamwork rules.
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Clark SL, Belfort MA, Byrum SL, et al. Improved outcomes, fewer cesarean deliveries, and reduced litigation: results of a new paradigm in patient safety. Am J Obstet Gynecol 2008; 199:105e1-105e7. A thought-provoking opinion essay on establishing a quality program that improves outcomes and reduces litigation claims using protocols, practice guidelines, and teamwork rules.
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14
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39849084823
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Simulation in obstetrics and gynecology
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An excellent review of all kinds of simulation and simulators used for obstetrics and gynecology training
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Gardner R, Raemer DB. Simulation in obstetrics and gynecology. Obstet Gynecol Clin North Am 2008; 35:97-127. An excellent review of all kinds of simulation and simulators used for obstetrics and gynecology training.
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(2008)
Obstet Gynecol Clin North Am
, vol.35
, pp. 97-127
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Gardner, R.1
Raemer, D.B.2
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15
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34249912004
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Recurrent obstetric management mistakes identified by simulation
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This study used simulation to identify common errors in key obstetric emergency situations that can then be taught proactively
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Maelovitz S, Barkai G, Leasing JB, et al. Recurrent obstetric management mistakes identified by simulation. Obstet Gynecol 2007; 109:1295-1300. This study used simulation to identify common errors in key obstetric emergency situations that can then be taught proactively.
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(2007)
Obstet Gynecol
, vol.109
, pp. 1295-1300
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Maelovitz, S.1
Barkai, G.2
Leasing, J.B.3
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16
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33845401223
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Training for shoulder dystocia: A trial of simulation using low-fidelity and high-fidelity mannequins
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Crofts JF, Bartlett C, Ellis D, et al. Training for shoulder dystocia: a trial of simulation using low-fidelity and high-fidelity mannequins. Obstet Gynecol 2006; 108:1477-1485.
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(2006)
Obstet Gynecol
, vol.108
, pp. 1477-1485
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Crofts, J.F.1
Bartlett, C.2
Ellis, D.3
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17
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48549107585
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Improving neonatal outcome through practical shoulder dystocia training
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A well done study that can demonstrate the beneficial effects of simulator training on actual patient outcomes. One of the very few studies that has been able to do so
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Draycott TJ, Crofts JF, Ash JP, et al. Improving neonatal outcome through practical shoulder dystocia training. Obstet Gynecol 2008; 112:14-20. A well done study that can demonstrate the beneficial effects of simulator training on actual patient outcomes. One of the very few studies that has been able to do so.
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(2008)
Obstet Gynecol
, vol.112
, pp. 14-20
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Draycott, T.J.1
Crofts, J.F.2
Ash, J.P.3
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18
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35948968714
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Change in knowledge of midwives and obstetricians following obstetric emergency training: A randomized controlled trial of local hospital, simulation centre and teamwork training
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An important article that found that specific training showed benefit, but it mattered not whether it was done at the local hospital versus a simulation center nor whether team training was added
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Crofts JF, Ellis D, Draycott TJ, et al. Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomized controlled trial of local hospital, simulation centre and teamwork training. BJOG 2007; 114:1534-1541. An important article that found that specific training showed benefit, but it mattered not whether it was done at the local hospital versus a simulation center nor whether team training was added.
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(2007)
BJOG
, vol.114
, pp. 1534-1541
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Crofts, J.F.1
Ellis, D.2
Draycott, T.J.3
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19
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42449142759
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Hospital, simulation center, and teamwork training for eclampsia management: A randomized controlled trial
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Another well done study that found the same results as the trial reported above, though this trial added observations on the actual performance afterwards
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Ellis D, Crofts JF, Hunt LP, et al. Hospital, simulation center, and teamwork training for eclampsia management: a randomized controlled trial. Obstet Gynecol 2008; 111:723-731. Another well done study that found the same results as the trial reported above, though this trial added observations on the actual performance afterwards.
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(2008)
Obstet Gynecol
, vol.111
, pp. 723-731
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Ellis, D.1
Crofts, J.F.2
Hunt, L.P.3
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20
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39849103168
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Team function in obstetrics to reduce errors and improve outcomes
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An excellent recent review of the principles behind teamwork training and 'crew resource management
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Nielsen P, Mann S. Team function in obstetrics to reduce errors and improve outcomes. Obstet Gynecol Clin North Am 2008; 35:81-95. An excellent recent review of the principles behind teamwork training and 'crew resource management'.
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(2008)
Obstet Gynecol Clin North Am
, vol.35
, pp. 81-95
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Nielsen, P.1
Mann, S.2
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21
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33845936212
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Effects of teamwork training on adverse outcomes and process of care in labor and delivery: A randomized controlled trial
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This impressive multicentered RCT by the original authors of team training did not find any clinical outcome improvements. This should give pause to expensive team training programs but should not obscure the value of many of the principles of teamwork
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Nielsen PE, Goldman MB, Mann S, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol 2007; 109:48-55. This impressive multicentered RCT by the original authors of team training did not find any clinical outcome improvements. This should give pause to expensive team training programs but should not obscure the value of many of the principles of teamwork.
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(2007)
Obstet Gynecol
, vol.109
, pp. 48-55
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Nielsen, P.E.1
Goldman, M.B.2
Mann, S.3
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22
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51449120725
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Behaviors that undermine a culture of safety
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Provider behavior can have significant deleterious consequences for safety and quality. This recent sentinel event alert describes the behaviors and potential actions that leaders and administrators should take. This should be an area of zero tolerance. Joint Commission, 9 July, Available at
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Joint Commission. Behaviors that undermine a culture of safety. Sentinel Event Alert 40, 9 July 2008. Available at http://www.jointcommission.org/ SentinelEvents/SentinelEventAlert/sea_40.htm. Provider behavior can have significant deleterious consequences for safety and quality. This recent sentinel event alert describes the behaviors and potential actions that leaders and administrators should take. This should be an area of zero tolerance.
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(2008)
Sentinel Event Alert
, vol.40
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23
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34247400784
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Rapid response systems: A systematic review
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A good review of the literature that identifies the weaknesses in the evidence base that exists today. Essentially, the support is less than desired but there is considerable heterogeneity in the studies, making it difficult to be definitive
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Winters BD, Pham JC, Hunt EA, et al. Rapid response systems: a systematic review. Crit Care Med 2007; 35:1238-1243. A good review of the literature that identifies the weaknesses in the evidence base that exists today. Essentially, the support is less than desired but there is considerable heterogeneity in the studies, making it difficult to be definitive.
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(2007)
Crit Care Med
, vol.35
, pp. 1238-1243
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Winters, B.D.1
Pham, J.C.2
Hunt, E.A.3
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24
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56849106230
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Grand Rounds: Ob Team Stat: Developing a better L&D rapid response team
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A nice description of the process of improving response times to emergencies on labor and delivery. Describes well how the barriers were overcome
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Catanzarite V, Almryde K, Bombard A. Grand Rounds: Ob Team Stat: Developing a better L&D rapid response team. Contemporary OB/GYN; 2007. pp. 1-7. A nice description of the process of improving response times to emergencies on labor and delivery. Describes well how the barriers were overcome.
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(2007)
Contemporary OB/GYN
, pp. 1-7
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Catanzarite, V.1
Almryde, K.2
Bombard, A.3
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25
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0033198985
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Davis D, Thomson O'Brien MA, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or healthcare outcomes? JAMA 1999; 282:867-874.
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Davis D, Thomson O'Brien MA, Freemantle N, et al. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or healthcare outcomes? JAMA 1999; 282:867-874.
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26
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39849105105
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Elements of a successful quality improvement and patient safety program in obstetrics and gynecology
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Gambone J, Reiter RC. Elements of a successful quality improvement and patient safety program in obstetrics and gynecology. Obstet Gynecol Clin North Am 2008; 35:129-145.
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(2008)
Obstet Gynecol Clin North Am
, vol.35
, pp. 129-145
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Gambone, J.1
Reiter, R.C.2
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27
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33750559337
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Evidence-based strategies for implementing guidelines in obstetrics: A systematic review
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Chaillet N, Dubé E, Dugas M, et al. Evidence-based strategies for implementing guidelines in obstetrics: a systematic review. Obstet Gynecol 2006; 108:1234-1245.
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(2006)
Obstet Gynecol
, vol.108
, pp. 1234-1245
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Chaillet, N.1
Dubé, E.2
Dugas, M.3
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28
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3442901380
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Sutter Health, First Pregnancy and Delivery Clinical Initiative Committee. Development of a large-scale obstetric quality-improvement program that focused on the nulliparous patient at term
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Main EK, Bloomfield L, Hunt G, Sutter Health, First Pregnancy and Delivery Clinical Initiative Committee. Development of a large-scale obstetric quality-improvement program that focused on the nulliparous patient at term. Am J Obstet Gynecol 2004; 190:1747-1766.
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(2004)
Am J Obstet Gynecol
, vol.190
, pp. 1747-1766
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Main, E.K.1
Bloomfield, L.2
Hunt, G.3
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29
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84921702909
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Audit and feedback: Effects on professional practice and healthcare outcomes
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CD000259. doi: 10.1002/14651858.CD000259.pub2
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Jamtvedt G, Young JM, Kristoffersen DT, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2006:CD000259. doi: 10.1002/14651858.CD000259.pub2.
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(2006)
Cochrane Database Syst Rev
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Jamtvedt, G.1
Young, J.M.2
Kristoffersen, D.T.3
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30
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85120112076
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Althabe F, Buekens P, Bergel E, et al. A behavioral intervention to improve obstetrical care. N Engl J Med 2008; 358:1929-1940. This is one of the best done studies looking at introduction of new guidelines into obstetric practice. Unfortunately, they used the 'kitchen sink' approach (multiple different techniques at the same time) so that we do not know if lesser interventions might also work.
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Althabe F, Buekens P, Bergel E, et al. A behavioral intervention to improve obstetrical care. N Engl J Med 2008; 358:1929-1940. This is one of the best done studies looking at introduction of new guidelines into obstetric practice. Unfortunately, they used the 'kitchen sink' approach (multiple different techniques at the same time) so that we do not know if lesser interventions might also work.
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31
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56849091037
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Every change needs a champion
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Makes the important point that the publication of evidence-based care practices alone does not change clinical practice
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Bingham D. Every change needs a champion. J Perinat Educ 2007; 16:8-10. Makes the important point that the publication of evidence-based care practices alone does not change clinical practice.
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(2007)
J Perinat Educ
, vol.16
, pp. 8-10
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Bingham, D.1
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Developing and implementing new safe practices: Voluntary adoption through statewide collaboratives
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Leape LL, Rogers G, Hanna D, et al. Developing and implementing new safe practices: voluntary adoption through statewide collaboratives. Qual Saf Healthcare 2006; 15:289-295.
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(2006)
Qual Saf Healthcare
, vol.15
, pp. 289-295
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Leape, L.L.1
Rogers, G.2
Hanna, D.3
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35
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A framework for the development of maternal quality of care indicators
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Korst LM, Gregory KD, Lu MC, et al. A framework for the development of maternal quality of care indicators. Matern Child Health 2005; 9:317-341.
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(2005)
Matern Child Health
, vol.9
, pp. 317-341
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Korst, L.M.1
Gregory, K.D.2
Lu, M.C.3
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Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement
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Main EK, Moore D, Farrell B, et al. Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. Am J Obstet Gynecol 2006; 194:1644-1651.
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(2006)
Am J Obstet Gynecol
, vol.194
, pp. 1644-1651
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Main, E.K.1
Moore, D.2
Farrell, B.3
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Assessing quality obstetrical care: Development of standardized measures
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Mann S, Pratt S, Gluck P, et al. Assessing quality obstetrical care: development of standardized measures. Jt Comm J Qual Patient Saf 2006; 32:497-505.
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(2006)
Jt Comm J Qual Patient Saf
, vol.32
, pp. 497-505
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Mann, S.1
Pratt, S.2
Gluck, P.3
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33847116199
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Measuring the quality of inpatient obstetrical care
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A balanced review of current measures used for inpatient quality measures
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Bailit JL. Measuring the quality of inpatient obstetrical care. Obstet Gynecol Surv 2007; 62:207-213. A balanced review of current measures used for inpatient quality measures.
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(2007)
Obstet Gynecol Surv
, vol.62
, pp. 207-213
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Bailit, J.L.1
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The tension between needing to improve care and knowing how to do it
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This is an important note of caution as we move rapidly into large-scale quality-improvement projects. It does not advocate slowing down but rather approaching quality improvement as a scientific endeavor
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Auerbach AD, Landefeld S, Shojania KG. The tension between needing to improve care and knowing how to do it. N Engl J Med 2007; 357:608-613. This is an important note of caution as we move rapidly into large-scale quality-improvement projects. It does not advocate slowing down but rather approaching quality improvement as a scientific endeavor.
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(2007)
N Engl J Med
, vol.357
, pp. 608-613
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Auerbach, A.D.1
Landefeld, S.2
Shojania, K.G.3
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