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A State-Wide Obstetric Hemorrhage Quality Improvement Initiative

Bingham, Debra DrPH, RN; Lyndon, Audrey PhD, RN, CNS-BC; Lagrew, David MD; Main, Elliott K. MD

MCN: The American Journal of Maternal/Child Nursing: September-October 2011 - Volume 36 - Issue 5 - p 297–304
doi: 10.1097/NMC.0b013e318227c75f
Feature Article

Purpose The mission of the California Maternal Quality Care Collaborative is to eliminate preventable maternal death and injury and to promote equitable maternity care in California. This article describes California Maternal Quality Care Collaborative's (CMQCC's) statewide multistakeholder quality improvement initiative to improve readiness, recognition, response, and reporting of maternal hemorrhage at birth and details the essential role of nurses in its success.

Project Design and Approach In partnership with the State Department of Maternal, Child, and Adolescent Health, CMQCC identified maternal hemorrhage as a significant quality improvement opportunity. CMQCC organized a multidisciplinary, multistakeholder task force to develop a strategy for addressing obstetric (OB) hemorrhage.

Project Description The OB Hemorrhage Task Force, co-chaired by nurse and physician team leaders, identified four priorities for action and developed a comprehensive hemorrhage guideline. CMQCC is using a multilevel strategy to disseminate the guideline, including an open access toolkit, a minimal support-mentoring model, a county partnership model, and a 30-hospital learning collaborative.

Clinical Implications In participating hospitals, nurses have been the primary drivers in developing both general and massive hemorrhage policies and procedures, ensuring the availability of critical supplies, organizing team debriefing after a stage 2 (or greater) hemorrhage, hosting skills stations for measuring blood loss, and running obstetric (OB) hemorrhage drills. Each of these activities requires effort and leadership skill, even in hospitals where clinicians are convinced that these changes are needed. In some hospitals, the burden to convince physicians of the value of these new practices has rested primarily upon nurses. Thus, the statewide initiative in which nurse and physician leaders work together models the value of teamwork and provides a real-time demonstration of the potential for effective interdisciplinary collaboration to make a difference in the quality of care that can be achieved. Nurses provide significant leadership in multidisciplinary, multistakeholder quality projects in California. Ensuring that nurses have the opportunity to participate in formal leadership of these teams and are represented at all workgroup levels is critical to the overall initiative. Nurses brought key understanding of operational issues within and across departments, mobilized engagement across the state through the regional perinatal programs, and developed innovative approaches to solving clinical problems during implementation. Nursing leadership and integrated participation was especially critical in considering the needs of lower-resource settings, and was essential to the toolkit's enthusiastic adoption at the unit/service level in facilities across the state.

This fascinating account of how one state attempted to better understand one essential health marker can serve as the blueprint for similar projects attempting to improve perinatal statistics.

Debra Bingham is the Vice President of Research, Education, and Publications for the Association of Women's Health, Obstetrics, and Neonatal Nursing (AWHONN) and Formerly the Executive Director of the California Maternal Quality Care Collaborative, Stanford University. She can be reached via e-mail at

Audrey Lyndon is an Assistant Professor in the Department of Family Health Care Nursing from University of California, San Francisco.

David Lagrew is the Chief Integration and Accountability Officer at Saddleback Hospital and Professor of Clinical Obstetric and Gynecology Medicine at the University of California Irvine.

Elliott K. Main is from California Pacific Medical Center and Chair, California Maternal Quality Care Collaborative, Stanford University.

None of the authors have any financial interest or affiliation with any organization or company related to the material in this manuscript. They have no conflicts of interest with the content of this article.

© 2011 Lippincott Williams & Wilkins, Inc.