Improving Physician Behavior with an Obstetric Dashboard

OVERVIEW: A major complication of vaginal births is severe perineal laceration, and it is now an obstetric quality measure (AHRQ and The Joint Commission). One major risk factor of anal sphincter lacerations is episiotomy. National quality benchmarks recommend restricted use of episiotomy (in the absence of an indication like shoulder dystocia), with a recommended benchmark rate of less than 5.0% (Leapfrog) to reduce the occurrence of severe anal sphincter injuries. AIM STATEMENT: The aim of the primary phase was to reduce the episiotomy utilization by individual providers outside of the national benchmark by 10% and reduce the institutional rate by at least 25.0% in 6 months. The aim of the second phase was to reduce the frequency of severe perineal lacerations by 25% at CUH in 6 months. MEASURES OF SUCCESS: Incidence rate of episiotomy utilization by specific providers in spontaneous vaginal deliveries without shoulder dystocia and the incidence rate of severe perineal laceration in spontaneous vaginal deliveries without shoulder dystocia. INTERVENTIONS: In the primary phase, we instituted scheduled notifications of providers' episiotomy utilization rates using a physician dashboard. For our second project, heat pack application in the late first stage of labor was instituted. RESULTS: Following dashboard implementation, there was significant reduction in the institutional rate of episiotomy (9.0% pre-intervention vs. 2.7% post-intervention, p<0.001). However, no significant reduction in the frequency of severe perineal lacerations was observed (2.42% pre-intervention vs. 1.14% post-intervention, p=0.08). In the second study, we found the baseline incidence rate of severe perineal laceration to be 3.06% with no significant change in the incidence rate following initiation of our heat pack intervention (3.47% in the last quarter, p= 0.20). CONCLUSIONS AND NEXT STEPS: When variation in physician performance exists, utilization of a physician dashboard comparing individual provider behavior to peers can result in a significant improvement in provider and institutional performance on specific metrics.