title: The implementation of unit-based perinatal mortality audit in perinatal cooperation units in the northern region of the Netherlands.
abstract: BACKGROUND
  Perinatal (mortality) audit can be considered to be a way to improve the careprocess for all pregnant women and their newborns by creating an opportunity to learn from unwanted events in the care process. In unit-based perinatal audit, the caregivers involved in cases that result in mortality are usually part of the audit group. This makes such an audit a delicate matter.
  
  
  METHODS
  The purpose of this study was to implement unit-based perinatal mortality audit in all 15 perinatal cooperation units in the northern region of the Netherlands between September 2007 and March 2010. These units consist of hospital-based and independent community-based perinatal caregivers. The implementation strategy encompassed an information plan, an organization plan, and a training plan. The main outcomes are the number of participating perinatal cooperation units at the end of the project, the identified substandard factors (SSF), the actions to improve care, and the opinions of the participants.
  
  
  RESULTS
  The perinatal mortality audit was implemented in all 15 perinatal cooperation units. 677 different caregivers analyzed 112 cases of perinatal mortality and identified 163 substandard factors. In 31% of cases the guidelines were not followed and in 23% care was not according to normal practice. In 28% of cases, the documentation was not in order, while in 13% of cases the communication between caregivers was insufficient. 442 actions to improve care were reported for 'external cooperation' (15%), 'internal cooperation' (17%), 'practice organization' (26%), 'training and education' (10%), and 'medical performance' (27%). Valued aspects of the audit meetings were: the multidisciplinary character (13%), the collective and non-judgmental search for substandard factors (21%), the perception of safety (13%), the motivation to reflect on one's own professional performance (5%), and the inherent postgraduate education (10%).
  
  
  CONCLUSIONS
  Following our implementation strategy, the perinatal mortality audit has been successfully implemented in all 15 perinatal cooperation units. An important feature was our emphasis on the delicate character of the caregivers evaluating the care they provided. However, the actual implementation of the proposed actions for improving care is still a point of concern.
authors: Department of Obstetrics and Gynaecology, CB22, University Medical Centre Groningen, P,O, Box 30001, 9700 RB, Groningen, The Netherlands. m.t.van.diem@umcg.nl
authors: Mariet Th
authors: MT
authors: van Diem
authors: Albertus
authors: A
authors: Timmer
authors: Klasien A
authors: KA
authors: Bergman
authors: Katelijne
authors: K
authors: Bouman
authors: Nico
authors: N
authors: van Egmond
authors: Dennis A
authors: DA
authors: Stant
authors: Lida H M
authors: LH
authors: Ulkeman
authors: Wenda B
authors: WB
authors: Veen
authors: Jan Jaap H M
authors: JJ
authors: Erwich
mesh_terms: D000328:Adult; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008485:Medical Audit / Q000458:organization & administration*; D009426:Netherlands / Q000453:epidemiology; D010043:Outcome and Process Assessment, Health Care; D018743:Perinatal Care / Q000592:standards*; D054238:Perinatal Mortality; D011247:Pregnancy; D011787:Quality of Health Care