OB/GYN Executive Quality Committee (EQC)

The OB/GYN Executive Quality Committee (EQC) was created in 2017 and includes the three MQOs, key faculty, nursing leadership, and the Quality and Clinical Data Manager. The major EQC focus areas include: patient safety review, mortality review, Residents on Quality (ROQ) oversight/review, Surgical Site Infection (SSI), QI projects, communication issues, quality scorecard, perinatal core measures, and collaboration with Pediatrics MQOs. The EQC reviews clinical cases each month. These cases are collected from several sources including: ROQ database, trend trackers, patient safety committee, faculty request, nursing leadership, anonymous reporting, and risk management. If the EQC concludes that more information is needed or there are opportunities for improved care, they will request faculty or fellows to provide a careful review of the case.

The EQC not only reviews reported patient safety cases but also seeks to proactively identify other performance improvement (PI) opportunities and subsequently perform the necessary PDA cycle that may result in a change of practice or operations (i.e. OASIS, Opioid stewardship, Baby Friendly, etc.). Additionally, the EQC serves as a resource to department faculty and staff members seeking to implement a PI initiative. The EQC serves as the ‘warehouse’ for maintaining a department portfolio on PI and Quality/Safety projects which subsequently are published in our Department of OB/GYN Quality, Patient Safety, and Performance Improvement Annual Report.

Residents on Quality (ROQ)

One of the major focuses of the EQC is to review cases that are submitted by residents and fellows to the M&M database. Upper level residents are required to submit cases that meet certain criteria for the Obstetric and Gynecologic rotations (Appendix 4). These cases are entered into the ROQ REDCap database by the two lead ROQ members. Each case is assigned for further review via email to a ROQ team member who reviews the case for additional detail. ROQ cases are reviewed with faculty leads (Dr. Straughn, Dr. Richter, and Dr. Brumfield) to determine which cases will be presented at the M&M/QI conference. The OB/GYN Quality and Clinical Data Manager also reviews ROQ cases and identifies cases to be reviewed by the EQC.

Departmental Quality Committee

The Departmental Quality Committee is comprised of residents, fellows, and faculty representing all divisions in the department. This committee is responsible for QI projects and other quality initiatives. This committee has initiated numerous quality projects that have improved clinical care in the department. This committee meets quarterly. The EQC and Departmental Quality Committee have ongoing and completed numerous QI projects over the last five years.