1. Freda, Margaret Comerford EdD, RN, CHES, FAAN

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Suddenly the word "quality" is everywhere in the literature about healthcare, and even in the lay press. Has quality of care suddenly become fashionable? For nurses, the concept of quality has always been in fashion. Quality has been consistently taught in basic nursing courses, and practiced in our daily work. One only has to look at our most indispensable model in nursing, the nursing process, to see that nurses have always positioned quality as the foundation of our work. We assess, diagnose, plan, implement, and then evaluate. The nursing process is, at its heart, quality improvement.


I'm not complaining about this new emphasis on quality improvement in healthcare. Doing a better job for our patients is a goal to be admired, and I'm thrilled at the attention being paid to it. I'm sure you've noticed that recently there have been conferences about quality of care all over the country. At the end of 2009 I attended a wonderful Symposium on Quality Improvement to Prevent Prematurity convened by the March of Dimes, and it was extremely exciting to see the large attendance and tremendous interest in this topic by healthcare providers and policy makers as well. There were numerous presentations about effective programs to improve the quality of perinatal health. One of the most talked-about topics at the conference was late preterm birth, a subject discussed in the pages of MCN often in the last few years. Important questions were raised about how to reduce late preterm births, especially those due to elective inductions or cesarean births. One featured speaker from the Intermountain Health System in Utah presented particularly surprising statistics about their successes in this effort (Oshiro, Henry, Wilson, Branch, & Varner, 2009).


Their baseline prevalence of elective births <39 weeks was 28%, and they therefore initiated a program to change this in 9 of their 21 hospitals in Utah and Idaho. They developed guidelines for what they considered a new quality improvement project, and then offered a series of presentations in all those hospitals. They obtained a clear buy-in from the department chairs to change the practice, and then mandated that elective deliveries <39 weeks would be prohibited unless a substantial medical risk was apparent. Of course there was initial opposition to the program by both physicians and nurses; some physicians disputed the health risks to infants <39 weeks, and some nurses resented being put in an adversarial position as enforcers of the new policy. Widespread educational programs ensued, and nurses were removed from the enforcer role by a policy requiring that elective births <39 weeks would require permission from the department chair. Performance measures were instituted for all nine hospitals, and for each practitioner. Ongoing education and monitoring ensured that the program was continuing at each site; those who opposed the program began to comply. Within 6 months of starting the program, elective births <39 weeks dropped to 10%. At the 6-year point their rate of elective birth <39 weeks was 3%. These startling and exciting results show all of us who work in perinatal health that quality of care can be improved.


Nurses have always believed that quality improvement was integral to our work. There is no doubt that we can play a major part in this new era of emphasis on quality. Let's use what we know from the literature to develop quality improvement programs and publish them in the literature so others can adopt what we've done. We can make it happen. Quality improvement is always in fashion for nursing.




Oshiro, B., Henry, E., Wilson, J., Branch, D. W, & Varner, M. W. (2009). Decreasing elective deliveries before 39 weeks of gestation in an integrated health care system. Obstetrics and Gynecology, 113(4), 804-11. [Context Link]