Quality Improvement and Risk Reduction: Two Peas in a Midwife’s Pod

Midwives have a unique skill set … to develop processes that improve the ability to deliver care that is high quality and safe.

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Like peas in a pod, quality improvement comes hand in hand with risk management.
Like peas in a pod, quality improvement comes hand in hand with risk management.

Quality improvement and risk management are often treated as unrelated aspects of the health care system. They are housed in different departments and operate independently rather than in unison. It is unfortunate that the work of improving patient safety and reducing risk of liability is usually sliced this way because the departments are really two sides of the same coin. Both aspire to promote patient safety and enhance the patient experience.

So we must ask why quality improvement and risk management are often conceived separately. In some cases, conceptualization and design have excluded those who directly provide care, thereby limiting effective implementation. In others, the work has been relegated to post hoc analysis and committee discussions without a sincere effort to create sustained change. For health systems to fully embrace the Triple Aim – to improve health, control costs, and improve the experience of the people – symbiosis in quality and risk must be achieved.

Midwives have a unique skillset for this work. Our training and experience allow us to understand the work patterns and needs of our physician and nurse colleagues and the values and preferences of the community. These connections can be foundational to develop processes that improve the ability to deliver care that is high quality and safe.

ACNM Healthy Birth Initiative: Reducing Primary Cesarean Collaborative

There are several quality-focused projects that directly include risk-management strategies or opportunities. The ACNM Healthy Birth Initiative: Reducing Primary Cesarean Collaborative aims to train midwife leaders in quality improvement around physiologic birth and cesarean reduction. Risk-reduction strategies include incorporation of shared decision making into policies and practice; inclusion of objective, evidence-based definitions of active labor and arrest of labor; and regular review of all operative births that occur due to a diagnosis of dystocia. More information, including how to join the Collaborative, is available online at www.birthTOOLS.org.

ACNM Benchmarking Project

The ACNM Benchmarking Project also provides an opportunity for practices to retrospectively examine their outcomes and identify opportunities for change. Ideally, practice administrators, or staff midwives with a proclivity for data, can apply various tools to understand factors contributing to an outcome. The practices that achieve “best practice” designation are available to serve as a resource. The Institute for Healthcare Improvement has information available on their website and through their online training on using quality improvement tools to understand drivers, develop measures, and conduct and track tests of change. Many of the resources are available for free.

Effective Communication

Effective communication among members of the health care team is essential to both risk and quality.  This includes communication with patients and families in the event of adverse outcome. Administrators, clinicians, and patients and family can build an organizational culture of communication and safety by proactively approaching common sources of miscommunication and conflict1. A blueprint for organizations is published in the Journal of Midwifery and Women’s Health1. The Professional Liability Section of ACNM has information on disclosure and communication in adverse events in the current Professional Liability Resource Kit, available for download at http://www.midwife.org/Professional-Liability-Information.

Quality and risk must become integrated concepts whenever providers, administrators, and policy makers think about patient safety and experience. Midwives have a unique position in the US health system as providers who link physician and nursing organizations and consumers. Midwives must engage in these activities and be change agents.


  1. Lyndon A, Johnson C, Bingham D, et al. Transforming communication and safety culture in intrapartum care: A multi-organizational blueprint. J Midwifery Womens Health; 2015(60)3:238-243.

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