At Childbirth Connection, we know that performance measurement is an essential element for moving toward the maternity care system that women and families deserve — one that meets the Triple Aim of better care, better outcomes, and better value. Performance measurement is central to our 2020 Vision for a High-Quality, High-Value Maternity Care System and companion Blueprint for Action consensus reports. So, we are thrilled that the National Quality Forum (NQF) has approved for endorsement 12 continuing and 2 new maternity care performance measures.
Pending a 30-day appeal period, these will continue to be available or be newly available as nationally endorsed performance measures for both quality improvement and public reporting. I am pleased to offer this update as co-chair of the multi-stakeholder Steering Committee that evaluated measures submitted by developers within the formal NQF consensus development process with explicit criteria for endorsement.
What is the National Quality Forum?
NQF works to improve the quality of the nation’s health care system by
- building consensus about national priorities and performance improvement goals and working in partnership to achieve them,
- endorsing national performance measures and other consensus standards for use in quality improvement and public reporting, and
- using education and outreach to help reach national goals.
NQF does not develop measures or report measured performance.
NQF-endorsed measures available for quality improvement and public reporting
Although the scope of the recent NQF project was reproductive health and the full episode of maternity care, nearly all submitted and approved measures apply to the period around the time of birth.
Approved measures with relevance to a large segment of the maternal and newborn population include measures of:
- the cesarean rate in low-risk first-birth women (#0471)
- the extent of exclusive breastfeeding at hospital discharge (#0480)
- elective delivery carried out before 39 weeks gestation (#0469)
- incidence of episiotomy (#0470).
Other measures endorsed through the present project can improve care in important ways for a smaller portion of this population — for example, a measure of babies under 1500 grams who were not born in facilities equipped to meet their needs (#0477).
Other important maternity care measures are currently endorsed through child health, ambulatory care, or other NQF consensus development projects — for example, Healthy Term Newborn (#0716), a composite measure of low-risk newborns who do not experience significant complications at birth or during the hospital stay.
The Steering Committee’s report, which is expected to be publicly available in May after the appeal period, summarizes specifications and Committee support for measures recommended for endorsement and provides a table of nearly 30 NQF-endorsed reproductive and perinatal health care measures.
Increased, standardized public reporting of maternity care performance is needed
Public reporting of measured performance can help women choose their maternity care provider and place of birth, purchasers make wise investments, and health plans and policy makers monitor service providers and care quality. At this time, however, maternity care performance reporting is limited and inconsistent across the country. For example, some programs report on a hospital’s total cesarean rate, some use the endorsed measure of cesarean rate in low-risk first-birth women, while no cesarean rate is reported for many other hospitals; and with rare exception cesarean rates are not currently available for clinicians, health plans, and other levels. Childbearing women and their advocates and other stakeholders should work for widespread public reporting of standardized measures of maternity care performance to foster transparency, accountability, informed decision making, value-based purchasing, and improvement.
The Joint Commission’s Perinatal Care measure set
The NQF Steering Committee and Board of Directors continue to support all five measures included in The Joint Commission’s Perinatal Care core measure set. These include the early elective delivery, low-risk cesarean, and exclusive breastfeeding measures noted above, as well as measures of giving steroids to women at risk of preterm birth (#0476) and health-care-associated infections in high-risk newborns (#1731). Although nearly one-quarter of those discharged from U.S. hospitals are childbearing women and newborns, just a fraction of hospitals with maternity units report on the Perinatal Care measure set as a component of The Joint Commission reaccreditation process, due to current incentives to report on measure sets of special relevance to Medicare beneficiaries. Discussions are under way with The Joint Commission to identify ways to increase reporting of the Perinatal Care measure set across the country.
Measures that were not endorsed or were withdrawn
Applying the submitted measures to the increasingly rigorous NQF endorsement criteria relating to importance, scientific acceptability, usability, and feasibility, the steering committee did not recommend for endorsement seven measures that had been endorsed through the previous 2008 NQF perinatal consensus project and one newly submitted measure. Developers withdrew nine previously endorsed measures from consideration, primarily because they are superseded by related measures under development. The Steering Committee’s report identifies measures that were withdrawn and those that were not found to meet the criteria for endorsement.
Need for maternity care measures for all “levels” of care and in eMeasure format
Most measures in the current set apply exclusively to facilities. To encourage all segments of the health care system to work in concert for improvement, measures of other “levels” of care are needed, including measures that apply to individual clinicians, clinician groups, accountable care organizations, and health plans. Fortunately, the AMA Physician Consortium for Performance Improvement Maternity Care Work Group is developing and testing a series of measures of clinician-provided maternity care for future submission to NQF. Also expected in the future is a requirement that the submitted measures be available as eMeasures that can be captured and reported through electronic data sources.
Need to fill maternity care measure gaps
Currently endorsed measures provide important opportunities for quality improvement and public reporting. Unfortunately, many additional measures are needed to address other potential areas for maternity care quality improvement. The Steering Committee’s report includes a lengthy list of topics recommended for measure development. Recommended topics include measures:
- reproductive health (e.g., primary care of reproductive age women and pregnancy planning and prevention),
- prenatal care (e.g., weight gain, ultrasound use, prenatal testing, smoking cessation, diabetes),
- intrapartum care (e.g., vaginal birth after cesarean, spontaneous labor and birth, labor induction, composite labor and birth quality),
- postpartum care (e.g., breastfeeding, composite care processes, depression), newborn care (e.g., care of preterm and low birthweight babies), and
- cross-cutting maternity measures (e.g., shared decision making, care coordination, experience of care surveys, composite woman-reported outcomes, and harmonized measures relevant to multiple care levels).
It appears that measures that are currently under development address a small proportion of the recommended topics. This is another area that would benefit from engagement of consumers, consumer advocates, purchasers, and others: finding and supporting potential developers for priority measures can lead to more timely access to needed tools for improvement and reporting.