Outcome and process measures
| Measure | Numerator | Denominator | Method of collection | Data source | Frequency of collection | Frequency of analysis |
| Outcome measures | ||||||
| Maternal mortality ratio | No of cases of maternal death that occurred for a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from unintentional or incidental causes. | Total no of live births in the same measurement period. | Retrospective Document Review | Mortality registry | Quarterly | Annual |
| Severe maternal morbidity (SMM) rate | No of hospital discharges for females with any listed diagnosis code of SMM as in the numerator inclusions. | Total no of delivery hospitalisations in the same period. | Retrospective Document Review | Obstetrics Admission registry/log, Medical Records Review, blood bank registry/log, ICU/HDU registry/log. | Monthly | Monthly |
| Maternity units composite measures for the 3 Domains of; Openness of Communication, Non-Punitive Response to Errors, and staffing. | Composite level average % positive responses by respondent work area/unit (Maternity wards) | Retrospective Document Review. | Baseline Corporate level repository of safety culture survey results. Postintervention national online platform for safety culture survey results | Annual | Annual | |
| Process measures | ||||||
| Percentage of compliance with unit based safety Huddles | No of maternity unit-based safety huddles conducted and documented as per policy and documented in the measurement period | No of maternity shift changes that occurred in the same measurement period. | Retrospective Document Review. | Patient safety huddle forms. | Monthly | Monthly |
| Percentage of Compliance with Chart Review of Cases Flagged by ACOG criteria | No of cases reviewed by the chart review team in the measurement period. | No of cases that were flagged by ACOG criteria, Pregnant, peripartal or postpartum woman: (1) receiving four or more units of blood products and (2) who had unplanned admission to an ICU/HDU in the measurement period. | Retrospective Document Review. | Blood outgoing logs in blood bank, unplanned admission log in ICU/HDU and SMM findings done by the chart review teams. | Monthly | Monthly |
| Percentage of Compliance with Haemorrhage Risk Assessment at Admission | No of admitted cases for labour that had completed haemorrhage risk assessment in the measurement period. | No of admitted cases for labour that were reviewed (sample size) regardless of the stage of labour in the measurement period. | Retrospective Medical Records Review. | Maternity admission log & patients’ medical records (haemorrhage risk assessment forms). | Monthly | Monthly |
ACOG, American College of Obstetricians and Gynecologists; HDU, high-dependency unit; ICU, intensive care unit.