Delivery and Newborn Care

Having a baby can be one of life’s most exciting experiences. However, childbirth can come with risks for both parent and child. National organizations have identified proven processes to reduce complications and improve patient outcomes. It is important for those having a baby to understand if their hospital is following these processes.

What is this measure?

These measures reflect national standards of care and treatment processes for delivery and newborn care. The measures include:

  • Elective delivery of the baby before the 39th completed week of gestation (induced births or those done by elective cesarean section)
  • Cesarean sections for low-risk, first-time births
  • Newborns exclusively fed breastmilk during the hospital stay

U.S. hospitals must report their compliance with these measures to The Joint Commission, a healthcare accreditation organization, the Centers for Medicare and Medicaid Services and other agencies.

Why is it important?

physician checking the pulse of an adult patient

The maternity and newborn measures are proven standards of care. They help reduce complications and improve patient outcomes.

For example, exclusive breastfeeding to newborn benefits both parent and child. Newborns who are breastfed have reduced risks of breathing problems and maintain a healthy weight. Breastfeeding can help lower the parent’s risk of high blood pressure and some cancers.

Patients and families can use these measure performances to objectively compare hospitals locally and nationally.

What is Johns Hopkins Medicine doing to continue to improve?

In 2011 Johns Hopkins Medicine developed a plan to become a national leader in core measures with a goal of reaching 96 percent compliance.

Collaborating Across Hospitals

Ensuring that patients always receive the core measure recommended treatments requires a well-coordinated effort throughout hospital departments.

Peers from across Johns Hopkins Medicine hospitals developed 40 core measure work groups, each focused on improving a specific set of core measures. These teams involved partnerships between quality improvement staff, nurse and physician leads, faculty members, IT staff and others to identify barriers to improvement and develop solutions.

The core measure work groups allowed hospitals to share best practices and lessons learned and improve internal processes to increase core measure compliance. Johns Hopkins Medicine also established a reporting system to track core measure compliance on each unit.


Frontline Perspective

Meta Phillips

As a stroke compliance specialist, Meta Phillips, R.N., advocates for a personal touch when reviewing patient charts to help improve processes and patient care.

Meta Phillips, R.N.
Stroke Compliance Specialist, Sibley Memorial Hospital

“The core measures reflect how well our hospital follows the best practices of care for stroke patients. By closely reviewing these care processes, we have the opportunity to concentrate on areas that need improvement.

In my experience, good communication is critical to meeting the core measures. Our Stroke Program team is small and communicates well. Our team shares information every day and talks about ways to address problems — both large and small.

Several years ago, our hospital was not meeting a best practice recommended by the American Heart Association. The best practice included using high levels of cholesterol-lowering medications to treat stroke patients. Our team presented these findings to our medications committee, whose support was helpful in educating our doctors on how to change their practice.

Reviewing these best practices requires a team effort. By reviewing our patients’ charts, we can immediately identify what is working and where we can improve. Our team is always trying to make our hospital’s processes better to provide the safest care for our patients.”


How can patients and families support safety?

Patients and families should become familiar with the core measures and talk to their health care team if they have any questions or concerns. You can also ask your health care provider how you can prepare for surgery or other procedures to reduce your risk of complications.

Be sure you clearly understand how to manage your health as you prepare to leave the hospital, such as any new prescription medications you may need.

For more information

Patient Resources


Quality and Safety Performance During COVID-19

The organization’s quality and safety performance may have been impacted by the COVID-19 pandemic. We would urge patients to consider more recent performance in combination with historical performance. Patients may benefit from discussing with their healthcare provider the disruptions COVID-19 may have caused on quality and safety of care.

See how Johns Hopkins Medicine prioritizes safety during the COVID-19 pandemic.