The Maternal Quality Landscape – A primer in Three Parts

Quality measures, transparency, quality improvement –these “buzz words” are proliferating in the blogosphere, reflecting increased activity and interest around improving the quality of health care in the United States.  How does maternity care fit into this picture?  This blog post series will contain three parts: Part 1 will provide an introduction to the history of the general quality measure landscape.  Part 2 will deconstruct and demystify the alphabet soup of indicators, measures and organizations involved and explain their relationship to one another. Part 3 will review the current National Quality Forum (NQF) perinatal measures and discuss The Joint Commission (TJC) Perinatal Core Measure Set, describe how these measures are being used by various organizations and/or states, and discuss their limitations as well as their potential.  We will conclude with suggestions on how maternity care advocates can engage with maternal quality improvement efforts on national and local levels.

Maternal Quality Care – A brief historical overview

Childbirth Connection, with their Transforming Maternity Care project, has been a strong voice in the emerging maternal quality landscape, as have other key stakeholders.   Maternal quality measures have been highlighted as one way to track maternal outcomes of interest and have these outcomes become transparent for health care decision-making.   But to understand how these can work for advocates of evidence-based maternity care, we have to understand how maternal quality fits into the larger landscape of quality improvement.

Quality improvement is not a new phenomenon.  Efforts to improve healthcare quality started a century ago, largely due to the general disorganization of American medicine in the early 19th century.  Care and conditions varied widely from one hospital to the next.  Medical schools were largely for-profit and there was little consistency in curriculum between one school and the next.  In the early 1900s, two professional organizations, the American Medical Association (AMA) and the American College of Surgeons (ACS) began developing and enforcing minimum standards for medical schools (AMA) and for hospitals (ACS).  While this consolidated and increased the professional authority of these organizations and helped establish necessary qualifications of hospital staff, specifications for the collection and maintenance of patient-centered medical records, and particular kinds of diagnostic and treatment units such as laboratory services, these efforts focused on the training and education of medical professionals but not the performance of professionals themselves.

This set the stage for activities and organizations related to hospital accreditation, leading to the creation of the Joint Commission on Accreditation of Hospitals (JCAHO) in 1951 (JCAHO shortened its name to The Joint Commission (TJC) in January 2007).  In the mid 1960s, two developments shifted TJC’s focus away from certifying minimum standards and toward determining quality.  Most hospitals were meeting the minimum standards and new theoretical conceptions of quality were garnering attention.  One such model, proposed by Donabedian (JAMA 1988;260(12):1743-1748), emphasized a three-pronged approach to quality measurement.  In order to measure quality, he argued, you must assess the process of caring for patients and the outcomes this care achieves in addition to the structure of the organization itself (staffing and physical characteristics).  The final important factor pushing quality improvement along was creation of the federally-funded Medicare program in 1965. This created a need for the US federal government to determine hospital eligibility for Medicare reimbursement. The legislation introducing Medicare specified that any hospital accredited by the Joint Commission was automatically “deemed” eligible for Medicare reimbursement.  Thus, the federal government became a primary user of accreditation, and later, of quality assessment of the care provided under Medicare.

This process evolved from the mid 1960s to the mid 1980s when TJC adopted a new model of quality improvement.  Based largely on the research of W. Edward Deming and adapted from industry to the health care arena, this model emphasized that most errors were propagated by systems, not people.  Inspecting records to identify errors was likened to “scraping the toast after it’s burnt” – it was more important to address the systems that contributed to errors before the errors occurred.  TJC adopted this approach and called it “continuous quality improvement” (CQI).  The focus moved from auditing individual records to promoting quality in the organizational structure of the hospital.  Proponents contrasted CQI to the “theory of bad apples,” the name given to earlier quality improvement efforts that attempted to make things better by unearthing and ousting outlier practitioners and hospitals who were poisoning the well.

To summarize, underlying modern quality improvement efforts is the application of business principles to healthcare—hospitals take inputs and transform them into products.  To assess “quality,” it is necessary to define the products and find ways to measure them (Wiener, 2000).   An essential part of CQI is the identification of preferred ways of doing things.  Rather than setting minimum acceptable standards for performance, CQI calls for “specifications of process,” described as “clear, scientifically grounded, continuously reviewed statements of how one intends to behave” (Berwick, 1989 p. 56).

Once quality measures have been developed, and reported, several stakeholder groups can then use this information:

  • Consumers can use performance data to make decisions when choosing providers, hospitals, and health care plans.
  • Purchasers (employers, health plans and Medicare/Medicaid) can leverage performance data to increase value. In the near future, performance measures may be used to determine reimbursement rates for care, and there is a lot of discussion in policy circles about this strategy.
  • Hospitals and Healthcare providers can use the data to target areas in need of improvement, assess the effectiveness of quality improvement programs on an ongoing basis, and advertise the high-quality care they give
  • Policy makers can use data to determine the overall performance of the health-care system and identify under-performing areas in need of policy interventions

Quality advocates believe that measurement, while essential, must be carefully applied.  Donald Berwick (formerly of the Institute for Healthcare Improvement and Administrator for the federal Centers for Medicare & Medicaid Services (CMS) since July 2010) warns that measurement and publication of performance data is not a sufficient strategy for improvement: “The danger lies in a naive and atheoretical belief, rampant today in the orgy of measurement involved in health care regulation, that the assessment and publication of performance data will somehow induce otherwise indolent care givers to improve the level of their care and efficiency” (Berwick, 1989 p. 55).  In a later paper Berwick and colleagues (2003) take a more balanced view.  Measurement is a necessary component of quality improvement but not sufficient to bring about change by itself.

What does all this have to do with Maternal Quality Improvement?

Why has maternity care been left out of the larger movement toward quality improvement in medicine?  One reason is that as we have seen, Medicare, as a federally administered health insurance program, has dominated much of the development and utilization of quality measures.  Although public insurance pays for nearly half (41% in 2003) of all births in the U.S., the program responsible is Medicaid, which is administered at the state level.  Until recently, states have not invested much in measuring quality or coordinating their efforts, but this is changing rapidly for two reasons.  First, in an economic climate with declining state revenues, administrators of Medicaid programs are increasingly seeking reliable ways to assess quality of care to justify expenditures.  Second, the 2010 Patient Protection and Affordable Care Act (PPACA) included several provisions relevant to childbearing women.  The one most applicable to this issue is Section 2701, which provides a directive to develop a health care quality measurement program for adult beneficiaries of Medicaid.  <Section 2701 of PPACA notes that “not later than January 1, 2011, the Secretary shall identify and publish for comment a recommended core set of adult health quality measures for Medicaid eligible adults.”> While not explicitly identifying maternal quality measures, it is reasonable to think that since Medicaid covers a significant proportion of US births, and childbearing women comprise a significant adult population within Medicaid, this is an opportunity for the newly adopted quality measures in maternity care to be used for evaluation of Medicaid programs covering maternity benefits.

So now you have a sense of the historical backdrop, in Part 2 we will review the many ways to look at quality and the organizations involved, and in Part 3 we will review the maternity quality measures in greater detail.   A great resource for this is the Childbirth Connection webinar by Dr. Elliott Main of the California Maternal Quality Care Collaborative (Christine’s colleague).  If you listen to this presentation before the next posts, you’ll have done your homework!

Posted by:  Christine Morton, PhD (CMQCC) and Kathleen Pine, (University of California, Irvine)



Berwick, D. M. (1989). Continuous improvement as an ideal in health care. New England Journal of Medicine, 320(1), 53-56.

Berwick, D. M., James, B., & Coye, M. J. (2003). Connections between quality measurement and improvement. Medical Care, 41(1), I30-I38.

Wiener, C. L. (2000). The Elusive Quest: Accountability in Hospitals. New York: Walter de Gruyter.

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