The integration of a QA/RM program in a rural healthcare obstetrical service.

Obstetrical services in a rural healthcare setting have special problems because the number of deliveries per month is below 100, with some facilities averaging fewer than 10 to 15 births per month. Medical resources may include obstetricians, pediatricians, or family practitioners, but not necessarily all three. Because it is not cost-effective to staff an obstetrical unit 24 hours a day when a low census is the norm, staffing patterns may be atypical and creative. The development of an effective credentialing system for both nursing and medical staffs is the first component of a QA/RM plan. Nursing staff play a vital role in modifying potential risk. When nurses do not routinely provide care on a unit, an efficient quality assurance plan is vital. Components of the plan must include staffing patterns and ratios, policies and procedures, and documentation. QA indicators should address both volume and outcome-oriented clinical indicators. Medical follow-up when indicated should also be part of the plan. Ongoing communication among team members and utilization of outside resources can assist in promoting an effective program. Although obstetrics is an area where the potential for risk exposure remains great, it is possible to create an efficient, practical risk management system.