State Health Department Evaluates Quality of Maternity/Newborn Services at HHC Hospitals and Their Affiliate Academic Medical Centers

New York, February 13, 1996 --- A State Health Department review of maternity and newborn services in New York City hospitals has found little difference in the quality of care provided by public and private institutions. The State's findings were released today by State Health Commissioner Barbara A. DeBuono, M.D., M.P.H.

The Health Department investigation was prompted by a New York Times series in March, 1995, critical of obstetric and neonatal care in New York City public hospitals and citing a higher death rate for babies born at public hospitals. The neonatal mortality data contained in the Times series were not sufficiently adjusted to account for such risk factors as lack of prenatal care or maternal substance abuse.

The Health Department first reviewed the birthweight specific infant mortality rates at all New York City hospitals; these data were released last Spring. The Department then undertook a comprehensive evaluation of maternity and newborn care at each of the eleven Health and Hospitals Corporation (HHC) facilities, and at the seven academic medical centers that serve as affiliates to the HHC hospitals. Teams of medical consultants -- including obstetricians, neonatologists, nurse midwives and obstetric and neonatal nurses -- spent several days at each hospital reviewing medical records for high-risk cases, interviewing staff, observing obstetrical/neonatal units and evaluating hospital quality assurance policies and practices.

The good news is that we found generally good quality of maternal/infant care in both the public and private hospitals, Commissioner DeBuono said. Our consultants reviewed some of the most difficult cases treated by the hospitals and found relatively few instances of inadequate care.

I am concerned, however, that the most common problems identified in the case reviews involved inadequacies in such fundamental patient care aspects as performing complete diagnostic assessments, responding to changes in the patient's clinical condition, ordering and securing timely and accurate test results and documenting patient status and the care provided, Dr. DeBuono said.

The medical consultants reviewed medical records of nearly 1,700 maternal and newborn high-risk cases, including those in which the death of a mother or infant occurred, or some other serious medical problem existed or complications arose. These high-risk cases, while not representative of the hospital population as a whole, were selected as sensitive indicators of quality of care concerns. The reviewer's task was to determine if inadequate medical care was a factor contributing to such adverse events as infant deaths, unnecessary cesarean sections, infections, long hospital stays or other preventable injury or harm.

The review of records identified quality of care problems in 3.0 percent of high-risk cases evaluated at HHC hospitals, and 2.8 percent of high-risk cases evaluated at affiliate hospitals. The survey did reveal a significantly higher percent of quality of care problems at one HHC facility. At Woodhull Hospital 14.3 percent of medical records reviewed suggested that standards of care were not met during the maternity or newborn hospitalization which contributed to adverse events for mothers or babies.

I am very concerned about the quality of care issues identified at Woodhull Hospital, Dr. DeBuono said. While I understand that the hospital has made recent changes to its maternity and neonatal services leadership, I have sent an investigative team to Woodhull to conduct an in depth evaluation of the hospital's current performance. We are prepared to provide direction to the hospital to help them take immediate steps to upgrade their obstetric and neonatal care services.

In contrast to Woodhull's poor performance record, two HHC hospitals -- Jacobi Medical Center and Metropolitan Hospital Center -- had no adverse events resulting from poor obstetric/neonatal care. Among affiliate hospitals, Westchester County Medical Center had no evidence of poor care contributing to adverse events in obstetric/neonatal records reviewed.

Woodhull Hospital had significantly higher than average quality of care problems associated with adverse events in all maternity records evaluated by the consultants. Reviewers found inadequate care contributed to medical problems in 12.5 percent of Woodhull Hospital's high-risk prenatal care records and 22 percent of records covering labor, delivery and postpartum care. Review of neonatal birth records and nursery charts did not reveal significant problems at Woodhull or other hospitals.

The most frequently identified problems at both HHC and affiliate hospitals involved lack of adequately trained staff in the delivery room to resuscitate newborns with breathing problems, and incomplete assessment or inadequate management of medical problems involving the mother, fetus or infant, including diabetes, high-blood pressure, infections, fetal distress. Other quality issues involved insufficient discharge plans for high risk mothers and babies, and failure to obtain timely consultations with specialists such as neurologists and cardiologists.

The Health Department evaluation failed to document systemic quality of care problems related to supervision or clinical competence of medical residents or nurse midwives. With few exceptions it was found that nurse midwives and residents were providing care that met accepted standards, and supervising physicians were appropriately involved in high-risk cases.

The consultants also evaluated each hospital's internal quality assurance procedures and follow-up activities for cases in which medical care problems or complications were documented. In general hospitals with the greater number of quality of care problems tended to have weaker quality assurance systems. For example, Woodhull Hospital which had the highest number of quality of care problems was judged by the consultants to have the weakest internal quality assurance program. Conversely, Jacobi and Metropolitan hospitals which had no deficiencies contributing to adverse events, were judged to have more than adequate quality assurance programs.

Recommendations

Based on this comprehensive review the Department of Health has made a series of recommendations to improve obstetrical/neonatal care at all hospitals in New York State.

  • All hospitals should reinforce with medical, nursing and support staff the need to provide careful attention to fundamental aspects of patient care. This includes monitoring of high-risk patients, communication among the members of the medical team, attention to laboratory test results in patient management, appropriate use of consultants, patient education and meaningful discharge planning.
  • All hospitals should reaffirm their commitment to quality assurance, including development of multi-disciplinary approaches for monitoring patient care, and enhanced training and continuing education opportunities for hospital staff.
  • All hospitals should enhance the quality and completeness of medical records through staff training and improved documentation.
  • The Health and Hospital's Corporation central administration should assure consistency in the quality of care provided by its hospitals by identifying positive performance and sharing information on successful quality improvement and oversight methods.
  • The Department of Health should develop a more reliable and comparable perinatal database in order to conduct future monitoring of birth outcomes in New York hospitals. The Department of Health will appoint a task force to help design a more sophisticated data system that is sensitive to personal risk factors that may contribute to poor birth outcomes.

The Department of Health is committed to ensuring that all pregnant women receive the highest standard of care so their infants will get the best start in life, Dr. DeBuono said.

2/13/96-16

OPA Contact: Claudia Hutton, Director, Public Affairs (518) 474-7354
New York State Department of Health Posted 4/8/96 Revised: January 2002