Public Health Leadership for Hospital Quality Improvement: A Case Study of a Maternal Health Quality Improvement Project by the County of San Bernardino Department of Public Health

Background: Elective labor induction prior to 39 weeks gestation, increases neonatal morbidity and is not recommended by The Joint Commission nor the American Congress of Obstetricians and Gynecologists. In 2006, the County of San Bernardino experienced the highest rate of labor induction (18.35% of total births) in California, with labor induction rates among all gestational ages as high as 62.71% at one hospital. Previous studies to reduce elective induction rates relied upon a system- wide approach, therefore San Bernardino County Public Health Department (SBCDPH) wanted to lead county-wide implementation of a quality improvement project to reduce elective labor induction rates at 37 and 38 weeks gestation.

Methods: From July 1, 2009 through June 30, 2012, SBCDPH engaged 15 birthing hospitals, obstetric clinicians, and community stakeholders in the project. The collaborative maintained advisory bodies to share best practices for quality improvement by developing and disseminating a toolkit; developed an Induction Tracking Grid to collect hospital-level data from partner hospitals; and used those data to promote ongoing improvements in reducing elective inductions. Title V MCAH block grant funding was provided by California Maternal, Child and Adolescent Health and additional technical assistance was provided by California Maternal Quality Care Collaborative.

Results: Analyses of Induction Tracking Grid data collected from 13 hospitals from September 2009 through November 2011 showed a significant downward trend in the rate of elective inductions at 37 and 38 weeks gestation, despite monthly fluctuations (p<0.0001). Thirteen hospitals implemented policy changes that resulted in higher scrutiny of scheduled deliveries and empowered nurses to establish “hard stops” before non-medically indicated inductions could be scheduled.

Conclusion: Based upon the SBCDPH experience, public health departments can lead quality improvement initiatives and engage local hospitals to develop policies that improve maternity care by convening advisory groups, facilitating data collection, providing education and on-going technical assistance.