The UAB Department of OB/GYN is dedicated to improving the clinical outcomes of the women we serve through excellence in clinical care, research, and our training programs that educate women’s health providers of the future. Quality and patient safety efforts are critical to achieve excellence in women’s healthcare.

UAB Medicine Quality Activities

The ACMQO meets weekly with Dr. Rue and the quality officers from the other departments. This group monitors performance on key metrics and develops action plans in consultation with nursing leadership to address any issues identified through quality monitoring activities. There is an OBGYN Quality and Patient Safety Meeting with Dr. Rue and his Chief Medical Officer (CMO) team that meets every other month. This meeting includes the Chairman, Vice Chairs, EQC, nursing leadership, Residency Program Director, and OBGYN resident representative.

The following items are reviewed and discussed:

1. Patient safety events

2. Sepsis data

3. Mortality events

4. Ambulatory quality metrics

5. Value based metrics

6. Communication items

7. Risk management issues

Ambulatory quality metrics are reviewed and necessary action plans are implemented. Ambulatory metrics include documentation for influenza and BMI, endorsed tests results, clinic appointments, hand hygiene, and informed consent for procedures, etc. Additional quality data that is periodically reviewed includes: HAC, CAUTI, CLABSI, infection rates, and perinatal data. This data is compiled from different reporting agencies. The ACMQO is required to review mortalities, PSIs, sepsis cases, and patient safety cases for the CMO office. The ambulatory and department quality metrics are defined each fiscal year by UAB Medicine.

UAB Medicine Quality Goals and Benchmarks

1. Defined structure with clearly identified and accountable leadership.

2. Comprehensive program that involves all providers involved with patient care (faculty, trainees, APPs, nursing) with regularly scheduled meetings.

3. A thorough and systematic review of all HAC/PSI. This should also have a link to institutional review process.

4. A mortality review process that examines all patient deaths that occur as the discharge service responsible for the patient. This should also demonstrate responsiveness to the institutional mortality review process.

5. Evidence of departmental QI projects that link to institutional goals/priorities.

6. Academic productivity as evidenced by presentations and/or publications.

UAB Department of OB/GYN Engagement

In order to be successful, the EQC will frequently promote the mission and goals of the Section of Quality and Patient Safety to all members of the Department. A part of the educational effort will be a biannual departmental conference, where important clinical data is shared on longitudinal performance, the occurrence and frequency of complications, and other key outcomes tracked by our Section of Quality and Patient Safety. Ongoing performance improvement projects will be outlined in a transparent fashion, encouraging the participation and engagement of all faculty members including residents.

One important element of our performance improvement effort is a bimonthly Departmental QI conference that all faculty are encouraged to attend. Although a case-based review of complications, similar to a standard Morbidity and Mortality conference format, is part of the process, a mini lecture/discussion is required for every case. This QI conference has been a well-attended forum for faculty, fellows and residents to review complications and to discuss quality, patient safety, and compliance issues. The residents presenting at the QI conference learn how to work with other health system leaders and stakeholders to implement change. In addition to attending and presenting at the QI conference, select residents serve on the UAB Medicine Patient Safety Committee. These resident experiences help to satisfy ACGME core competency requirements in practice-based learning and improvement.

Scholarly Activity

In addition to designing, implementing, and evaluating QI projects, the Section of Quality and Patient Safety encourages research and career development in the area of quality management. Several of the quality projects have been published and presented at national meetings). Faculty members with an interest in quality will be encouraged to participate in quality seminars and training sponsored by UAB Medicine. Interested faculty should participate in the UAB Medicine Mini-Quality Academy.