KEY ACTIVITY #2:
Review Perinatal Care Clinical Guidelines Including Specialty Referral
This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines.
Overview
Clinical care guidelines for pregnant people are evidence-based recommendations that help healthcare providers and pregnant people make informed decisions about the optimal care during pregnancy and childbirth. For example, both PHMI Clinical Practice Advisory Group Guidelines and the American College of Obstetricians and Gynecologists (ACOG) recommend as a clinical care guideline that a first prenatal care visit occur during the first trimester of pregnancy. Clinical care guidelines should be incorporated into systems to aid practitioners in providing the most effective evidence-based recommendations and treatments to patients. Clinical care guidelines have been shown to reduce patient harm by enhancing communication and standardization. In medical institutions, the application of protocols and guidelines is frequently delayed due to a lack of healthcare provider awareness or overly complex clinical algorithms. However, it has been demonstrated conclusively that using clinical care guidelines such as protocols and checklists improves outcomes, and their use is strongly encouraged. At the patient level, clinical guidelines can be applied to create a flag or alert in the EHR to notify the care team of gaps in obstetric and preventive services. These alerts enable the care team to efficiently identify necessary services related to patient visits.
Every year, over four million people give birth in the United States, with one million experiencing one or more complications during pregnancy, labor and delivery or the postpartum period.[1] According to studies, up to 60% of all pregnancy-related deaths may be prevented if people had better access to healthcare, received better quality care, and modified their health and lifestyle behaviors.[2] Timely and appropriate prenatal and postpartum care can provide the groundwork for new parents’ and infants' long-term health and well-being.[3] Clinical guidelines are one component of improving the quality of perinatal care.
Clinical guidelines can help address equity in perinatal outcomes by providing guidance on how to identify and address disparities in care. For example, guidelines may recommend that healthcare providers screen patients for social needs, such as transportation, food access, economic insecurity, education and housing, which can impact maternal health outcomes. Guidelines may also recommend that healthcare providers use evidence-based practices that have been shown to improve outcomes for all patients, regardless of race or ethnicity. By following clinical guidelines, healthcare providers can ensure that they are providing evidence-based, equitable care to all patients.
Leveraging the adoption of perinatal clinical guidelines can help patients and families by providing systems to assess potential social needs and thus provide patients with more comprehensive, respectful, and culturally appropriate care. For example, the National Institute for Health and Care Excellence (NICE) guideline on pregnancy and complex social factors recommends providing training on how to communicate effectively and sensitively with pregnant people who face multiple disadvantages.[4]
Prenatal care visits are highly structured and can therefore be supported through the use of highly structured visit templates in the EHR. Engagement of the care team can be supported through specialized applications such as care coordination and population health management applications, and/or through the creation of freestanding databases. Relevant HIT capabilities to support this activity include: electronic access to prenatal care guidelines, registries, clinical decision support, care dashboards and reports, quality reports, outreach and engagement, and care management and care coordination.
See Appendix D: Guidance on Technological Interventions.
Reports should have the capacity to filter by provider, location and care team, where applicable.
Access to outside data may be a consideration or requirement (e.g., California Immunization Registry (CAIR) or immunization registry data, referral consultation reports, hospitalization data, and data from other practices) as services received outside the health center may be part of compliance. While claims data may be helpful in this regard, lag time may impact its usefulness. Patient-facing applications should be strongly considered to assure patients are informed and appreciative of the nature and importance of recommended care.
Action steps and roles
Please see the Clinical Guidelines for Prenatal Care in the introduction for the PHMI Clinical Practice Guidelines for Key Medi-Cal Populations of Focus.
In addition, the American College of Obstetricians and Gynecologists (ACOG) recommends early postpartum follow-up care, including screening for depression and anxiety, for all postpartum patients.
1. Assess the needs and priorities of the organization and its stakeholders, such as patients, providers, managers, and policymakers.
Suggested team member(s) responsible: Medical director or their designee.
Identify organizational capacity to review and implement or update current clinical care guidelines. Assess organizational priorities as well as patient and provider priorities, and determine points of alignment or potential conflict.
2. Identify the gaps and barriers in the current practice and where clinical care guidelines could help improve outcomes.
Suggested team member(s) responsible: Medical director or their designee.
Review perinatal clinical care guidelines currently used in clinical care. Evaluate if these guidelines cover the range of best practices or if new care guidelines need to be implemented.
3. Review relevant and reliable clinical care guidelines that are based on the best available evidence and aligned with the organization’s goals and values.
Suggested team member(s) responsible: Medical director or their designee.
Review Clinical Guidelines Advisory Group (CGAG) recommendations on timeliness of prenatal and postpartum care. Determine additional sources to review for additional perinatal care guidelines. See the resources at the end of this activity for further information on evidence-based clinical care guidelines.
4. Consider the local context, resources and preferences of the organization and its stakeholders. Integrate the guidelines to suit the specific needs and circumstances of the organization.
Suggested team member(s) responsible: Medical director or their designee, patients, clinical team.
Care guidelines reflect recommendations for best practices. To best implement these guidelines into clinical practice, careful consideration should be taken around how they intersect with the organization's unique needs.
5. Monitor and evaluate the process and outcomes of guideline implementation using appropriate indicators and methods.
Suggested team member(s) responsible: Medical director or their designee, QI team, clinic managers.
Utilize care gap reports (Key Activity 3: Use Care Gap Reports or Registries to Identify All Patients Eligible and Due for Care) and other metrics to evaluate whether implementation of the guidelines are improving desired metrics, such as access to prenatal care in the first trimester or screening for perinatal depression.
6. Collect data on the adherence to the guidelines, the quality and safety of care, the patient satisfaction and outcomes, and the costs and benefits of implementation.
Suggested team member(s) responsible: Medical director or their designee; QI team, clinical team.
Construct mechanisms to evaluate guideline implementation from multiple perspectives: clinician, patient, QI team.
7. Analyze data to identify problems, challenges, successes and lessons learned. Make modifications to care guideline implementation as needed.
Suggested team member(s) responsible: Medical director or their designee; QI team, clinical team.
Based on collected data, assess for patterns of workarounds, inadequate implementation, workflow challenges, and patient concerns. Identify successes to inform future implementation strategies.
8. Provide feedback and support to the stakeholders involved in guideline implementation.
Suggested team member(s) responsible: Medical director or their designee, clinic manager, clinical staff.
Convey information from action item #6 to relevant team members. Encourage ongoing communication regarding implementation of care guidelines.
9. Sustain and scale up guideline implementation by ensuring ongoing commitment, engagement and support from the organization’s leadership and stakeholders.
Suggested team member(s) responsible: Medical director or their designee.
10. Share best practices and experiences with other healthcare organizations that are interested in adopting or implementing clinical care guidelines.
Suggested team member(s) responsible: Medical director or their designee.
Resources
Endnotes
- CDC Review to Action. (2018). Building U.S. Capacity to Review and Prevent Maternal Deaths. Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs
- CDC Review to Action. (2018). Building U.S. Capacity to Review and Prevent Maternal Deaths. Report from nine maternal mortality review committees. Retrieved from http://reviewtoaction.org/Report_from_Nine_MMRCs
- American College of Obstetricians and Gynecologists (ACOG). (2018). Optimizing Postpartum Care. ACOG Committee Opinion No. 736. Obstet Gynecol, 131:140-150.
- Introduction | Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors | Guidance | NICE