In the UAB Department of Obstetrics and Gynecology, quality and safety are at the core of everything we do.

Our mission is to provide the highest standard of care to women through continuous quality improvement, evidence-based practice, and a culture of patient-centered safety. In partnership with UAB Medicine, we actively measure, monitor, and improve outcomes in both inpatient and outpatient settings. The following metrics represent our department’s ongoing commitment to delivering safe, effective, and compassionate care.

Patient Safety and Performance Measures

In the Women and Infants Center, patient safety is critically important. We strive to deliver effective, efficient care while protecting our patients from preventable harm. Healthcare-associated infections and hospital-acquired conditions are continuously monitored through standardized national measures.

Our efforts focus on six major patient safety domains:

• Central Line-Associated Bloodstream Infections (CLABSI)
• Catheter-Associated Urinary Tract Infections (CAUTI)
• Surgical Site Infections (SSI)
• Hand Hygiene Compliance
• Patient Falls and Injuries
• Hospital-Acquired Pressure Injuries (HAPI)

Central Line-Associated Bloodstream Infections (CLABSI)

A CLABSI occurs when bacteria enter the bloodstream through a central venous catheter. These infections can be prevented through strict adherence to best practices and sterile technique.

Prevention Practices:

• Confirm central line placement is medically necessary
• Use full sterile precautions during insertion
• Perform hand hygiene before and after line manipulation
• Clean catheter hubs prior to access
• Assess daily for catheter necessity and remove as soon as possible
• Regularly monitor infection data to identify opportunities for improvement

Catheter-Associated Urinary Tract Infections (CAUTI)

CAUTIs occur when bacteria enter the urinary tract via an indwelling catheter. Prevention focuses on minimizing use and maintaining sterile technique.

Prevention Practices:

• Use catheters only when medically indicated
• Perform hand hygiene before insertion and manipulation
• Keep drainage bags below bladder level
• Empty catheters regularly and maintain a closed system
• Reassess daily for catheter necessity and remove promptly

Surgical Site Infections (SSI)

SSIs can occur at or near surgical incisions after procedures. The Women and Infants Center monitors SSI rates, ensuring consistent application of perioperative best practices.

Prevention Practices:

• Surgical hand and arm scrub prior to procedures
• Use of sterile gowns, gloves, masks, and hair coverings
• Appropriate antibiotic prophylaxis
• Skin antisepsis using germicidal agents
• Environmental cleanliness in the operating room
• Continuous review of SSI trends and root cause analysis

Hand Hygiene Compliance

Hand hygiene is the most effective method to prevent infection. Compliance is measured as the percentage of adherence to UAB’s hand hygiene protocol.

Core Practices:

• Clean hands upon room entry and exit
• Use alcohol-based sanitizer or soap and water
• Perform hand hygiene before and after glove use
• Conduct regular audits and provide feedback for improvement

Patient Falls and Injuries

Falls are a major cause of hospital-related harm. Our goal is to achieve zero preventable falls through proactive risk assessment and environmental safety.

Fall Prevention Practices:

• Assess fall risk on admission and daily
• Apply fall risk armbands where appropriate
• Keep call lights and mobility aids within reach
• Maintain clutter-free rooms and hallways
• Educate patients and families about fall prevention
• Track and analyze fall data to identify trends

Hospital-Acquired Pressure Injuries (HAPI)

Pressure injuries, or bed sores, occur when prolonged pressure limits blood flow to skin and tissue. These injuries are measured per 1,000 patient days, with lower incidence indicating improved outcomes.

Prevention Practices:

• Perform daily skin assessments
• Reposition patients every 2–4 hours
• Use pressure-relieving mattresses and cushions
• Keep skin clean and dry
• Engage wound care specialists for early intervention

Ambulatory Clinic Quality Improvement (QI) Metrics

Quality extends beyond the hospital setting into every clinic encounter. The Women and Infants Center Ambulatory Clinics are committed to ensuring patients receive safe, coordinated, and respectful care in every visit.

We track and improve performance in four key ambulatory domains:

• Hand Hygiene Compliance
• Patient Identification
• Endorsed Test Results (ETR)
• Patient Satisfaction

Hand Hygiene Compliance

Hand hygiene remains a cornerstone of infection prevention in ambulatory settings.
Compliance is assessed through anonymous patient surveys and staff observations.

Ambulatory Practices:

• Clean hands upon entering and leaving exam rooms
• Perform hand hygiene after glove use or contact with body fluids
• Reinforce education for all staff and providers
• Monitor results monthly and implement action plans as needed

Patient Identification

Accurate patient identification prevents diagnostic and treatment errors. UAB ambulatory staff follow the two-identifier rule (e.g., name and date of birth) before any procedure or test.

Safety Practices:

• Verify identifiers at check-in and before all procedures
• Reconfirm identity for lab collection and imaging
• Audit compliance to maintain 100% adherence

Endorsed Test Results (ETR)

Timely test result review ensures accurate follow-up and continuity of care. Providers are expected to endorse (review and sign) all lab and imaging results within seven days.

Performance Strategies:

• Provider education on timely result endorsement
• Continuous ETR compliance tracking
• Workflow optimization to reduce delays

Patient Satisfaction

Patient feedback is one of the most important indicators of quality. UAB OB/GYN ambulatory clinics routinely collect and review satisfaction surveys to enhance care experience and communication.

Our Commitments:

• Deliver clear explanations and instructions
• Involve patients in decision-making
• Provide compassionate, respectful care
• Act on feedback to continually improve care delivery

Our Commitment to Excellence

At UAB, our Quality and Patient Safety program reflects a shared commitment—among physicians, nurses, residents, fellows, and staff—to continuous learning and improvement.

By integrating patient feedback, data-driven metrics, and multidisciplinary teamwork, we ensure that every patient receives safe, high-quality, and equitable care—from the delivery room to the clinic exam room.