In the Literature: Geisinger’s ProvenCare safely reduces cesarean rate with implementation of evidence-based guidelines

This project was selected from among many reported in the peer reviewed literature. For a list of more articles on quality improvement, visit our resource bibliography.


Berry SA, Laam LA, Wary AA, et al. ProvenCare perinatal: A model for delivering evidence/ guideline-based care for perinatal populations. Jt Comm J Qual Patient Saf. 2011;37(5):229-239. [abstract]


22 clinical sites and 4 hospitals affiliated with Geisinger Health System in Pennsylvania


“To demonstrate that a large integrated health care delivery system, enabled by an electronic health record (EHR), could successfully reengineer a complicated clinical process, reduce unwarranted variation, and reliably deliver evidence-based care.” (p. 229) Geisinger has successfully demonstrated effectiveness in acute care specialties with their ProvenCare system and sought to adapt it to perinatal care, for the first time addressing a largely well population and integrating multiple outpatient clinics.


Geisinger created a 9-phase, year-long improvement plan, adapted from its ProvenCare model:

  • Engage champions – administrative and steering teams were created with emphasis on participation by individuals with in-depth knowledge of the local context in the various practice sites.
  • Understand context – an improvement specialist visited each site to map out work process flows and connect with staff in each site where the initiative would be implemented.
  • Compile evidence – a group of seven physicians reviewed evidence from the peer-reviewed literature, ACOG guidelines, and other expert guidelines.
  • Establish “best practice measures” (BPMs) – all clinicians provided feedback and came to consensus on 103 measures of best practice, which were grouped by trimester.
  • Identify barriers to compliance with BPMs – with an improvement specialist, each practice site reviewed their process flow map along with the list of BPMs to determine if the work process at that practice site would create a barrier for reliably achieving BPMs.
  • Process redesign – the barrier identification process was repeated in an iterative process until the proposed process flow enabled reliable achievement of BPMs.
  • Develop a phased implementation and just-in-time education plan – the team identified several sites for pilot phase implementation to identify problems with the information technology systems or other process break downs.
  • Go live beta – staff were trained just before implementation and the IT systems supporting the new work process were launched in the pilot sites. Feedback was incorporated to optimize implementation in the remaining sites and technological problems were fixed in real time or as quickly as feasible.
  • Go live production – the system was implemented in all sites.

In the intrapartum settings, Geisinger implemented the augmentation and induction bundles from the Institute for Healthcare Improvements Perinatal Improvement Community.


Significant improvement occurred for nearly all of the 103 best practice measures identified, indicating that care process improved to be aligned with best evidence. Notably, 100% of new mothers have been screened for postpartum depression since late 2009. In addition, at one of the two referral hospitals, the primary cesarean section rate decreased 32% (from 30.3% to 23.8%). At the other, the rate remained the same. There was no increase in birth trauma. Neonatal intensive care admissions decreased both overall and among the subgroup of babies born to women with insulin-dependent gestational diabetes.



Filed in Blueprint, Care coordination, Clinical controversies, Clinical practice guideline/policy change, Health information technology, Health information technology, In the Literature, New care delivery model, Performance measurement, Performance measurement/reporting, Strategies on Thu., Jun 16, 2011

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