California Perinatal Quality Care Collaborative Research Articles

Implementation of a multi-site neonatal simulation improvement program: a cost analysis

BackgroundTo improve patient outcomes and provider team practice, the California Perinatal Quality Care Collaborative (CPQCC) created the Simulating Success quality improvement program to assist hospitals in implementing a neonatal resuscitation training curriculum. This study aimed to examine the costs associated with the design and implementation of the Simulating Success program.MethodsFrom 2017–2020, a total of 14 sites participated in the Simulating Success program and 4 of them systematically collected resource utilization data. Using a micro-costing approach, we examined costs for the design and implementation of the program occurring at CPQCC and the 4 study sites. Data collection forms were used to track personnel time, equipment/supplies, space use, and travel (including transportation, food, and lodging). Cost analysis was conducted from the healthcare sector perspective. Costs incurred by CPQCC were allocated to participant sites and then combined with site-specific costs to estimate the mean cost per site, along with its 95% confidence interval (CI). Cost estimates were inflation-adjusted to 2022 U.S. dollars.ResultsDesigning and implementing the Simulating Success program cost $228,148.36 at CPQCC, with personnel cost accounting for the largest share (92.2%), followed by program-related travel (6.1%), equipment/supplies (1.5%), and space use (0.2%). Allocating these costs across participant sites and accounting for site-specific resource utilizations resulted in a mean cost of $39,210.69 per participant site (95% CI: $34,094.52-$44,326.86). In sensitivity analysis varying several study assumptions (e.g., number of participant sites, exclusion of design costs, and useful life span of manikins), the mean cost per site changed from $35,645.22 to $39,935.73. At all four sites, monthly cost of other neonatal resuscitation training was lower during the program implementation period (mean = $1,112.52 per site) than pre-implementation period (mean = $2,504.01 per site). In the 3 months after the Simulating Success program ended, monthly cost of neonatal resuscitation training was also lower than the pre-implementation period at two of the four sites.ConclusionsEstablishing a multi-site neonatal in situ simulation program requires investment of sufficient resources. However, such programs may have financial and non-financial benefits in the long run by offsetting the need for other neonatal resuscitation training and improving practice.

Readmission After Neonatal Intensive Care Unit Discharge: The Importance of Social Drivers of Health

ObjectiveTo determine associations between sociodemographic and medical factors and odds of readmission after discharge from the neonatal intensive care unit (NICU) for infants with very low birth weight (VLBW, <1500g). Study DesignCohort study using linked data from the California Perinatal Quality Care Collaborative, California Vital Statistics, and the Child Opportunity Index 2.0 (COI). Infants with VLBW born from 2009 through 2018 in California were considered. Odds ratios of readmission within 30 days of discharge adjusting for infant medical factors, maternal sociodemographic factors, and birth hospital were calculated via multivariable logistic regression and fixed effect logistic regression models. Results42,411 infants met inclusion criteria. 8.5% of all infants were readmitted within 30 days of discharge. In addition to traditional medical risk factors, two sociodemographic factors were significantly associated with increased odds of readmission in adjusted models: payor other than private insurance for delivery [aOR =1.25 (95% CI 1.14-1.36)] and maternal education of less than high school degree [aOR = 1.19 (95% CI 1.06-1.33)]. Neighborhood COI was not associated with odds of readmission. ConclusionsSociodemographic factors, including lack of private insurance and lower maternal educational attainment, are significantly and independently associated with increased odds of readmission after NICU discharge, in addition to traditional medical risk factors. Socioeconomic deprivation and health literacy may contribute to risk of readmission. Targeted discharge interventions focused on addressing social drivers of health warrant exploration.

Early childhood outcomes of NICU graduates with cytomegalovirus infection in California.

To assess demographics and outcomes up to 3 years of age among children with cytomegalovirus (CMV) infection in California neonatal intensive care units (NICUs) during 2010-2021. The California Perinatal Quality Care Collaborative (CPQCC) collects data on all very low birth weight (VLBW, birth weight ≤ 1500 g) and acutely ill infants with birth weight > 1500 g across 92% of NICUs in California. VLBW infants and those with neurological conditions are referred to a statewide high-risk infant follow-up (HRIF) program. CMV infection was defined as a positive culture or PCR identified during the NICU hospitalization. During 2010-2021, CMV reporting rates averaged 3.5/1000 VLBW infants (n = 205) and 1.1/1000 infants >1500 g (n = 128). Among all 333 infants with CMV, 314 (94%) were discharged home alive, 271 (86%) were referred for HRIF and 205 (65%) had ≥1 visit. Whereas infants born to mothers <20 years of age had highest CMV reporting rates and those born to Hispanic mothers comprised 49% of all infected infants, they had the highest loss of follow-up. At the 12-month visit (n = 152), 19 (13%) infants with CMV had bilateral blindness and 18 (12%) had hearing loss. At the 24-month visit, 5 (5%) of 103 had severe cerebral palsy. Among infants admitted to the NICU, those with CMV diagnoses may over represent infants with more severe CMV disease and outcomes. The CPQCC and HRIF program findings may help inform implementation of surveillance for congenital CMV infection in other U.S. states and guide strategies to reduce disparities in access to services.

Achieving Normothermia in Low-Birth-Weight Neonates

Achieving normothermia, defined as an axillary temperature of 36.5°C–37.5°C, in very-low-birth-weight (LBW) neonates (<1,500 g and/or <32 weeks gestational age), has been shown to improve patient outcomes and decrease morbidities and mortality. Reduce by 10% hypothermia (temperatures <36.5oC) on NICU admission for all neonates weighing less than 1,500 g at birth and/or births that are less than 32 weeks gestation. Research has shown an association between hypothermic admission temperatures and increased mortality and morbidity in preterm newborns. Evidence shows that for every decrease of 1°C in admission temperature below 36.5°C, there is an 11% increase in the odds of developing late-onset sepsis and 28% increase in the odds of death. In October 2017, a multidisciplinary team reviewed existing internal data reports and data from the California Perinatal Quality Care Collaborative (CPQCC) regarding neonatal hypothermia admission rates. The plan, do, act, study methodology was used for this quality improvement project. All practice changes were reviewed and discussed at monthly interdisciplinary meetings. The goal was set for ambient temperatures in the delivery rooms and operating rooms to be set at 72°F or higher. Using the Textbook of Neonatal Resuscitation (7th ed.) thermoregulation guidelines, a “small baby” kit was created with warming items to be used in the delivery rooms. Before leaving the delivery room, a minimum goal for the neonate’s axillary temperature was set at 36.8°C. If the neonate’s temperature was less than 36.8°C, thermoregulation interventions were performed by the neonatal team until the target temperature was reached. Information was disseminated to all staff on the labor and delivery (L&D) and NICU units regarding the performance-improvement goals. Quarterly data reports were posted on both units reflecting the data. From 2016 to 2018, newborn normothermia rates at our facilities increased from 70% to 85%, and hypothermia rates decreased from 26.5% to 2.8%. A multidisciplinary team approach between L&D and NICU units was crucial in achieving our goal and improving the care for our smallest patients.

A Neonatal Intensive Care Unit's Experience with Implementing an In-Situ Simulation and Debriefing Patient Safety Program in the Setting of a Quality Improvement Collaborative.

Extensive neonatal resuscitation is a high acuity, low-frequency event accounting for approximately 1% of births. Neonatal resuscitation requires an interprofessional healthcare team to communicate and carry out tasks efficiently and effectively in a high adrenaline state. Implementing a neonatal patient safety simulation and debriefing program can help teams improve the behavioral, cognitive, and technical skills necessary to reduce morbidity and mortality. In Simulating Success, a 15-month quality improvement (QI) project, the Center for Advanced Pediatric and Perinatal Education (CAPE) and California Perinatal Quality Care Collaborative (CPQCC) provided outreach and training on neonatal simulation and debriefing fundamentals to individual teams, including community hospital settings, and assisted in implementing a sustainable program at each site. The primary Aim was to conduct two simulations a month, with a goal of 80% neonatal intensive care unit (NICU) staff participation in two simulations during the implementation phase. While the primary Aim was not achieved, in-situ simulations led to the identification of latent safety threats and improvement in system processes. This paper describes one unit’s QI collaborative experience implementing an in-situ neonatal simulation and debriefing program.

Learning from Wildfire Disaster Experience in California NICUs.

Wildfires have been affecting California greatly, and vulnerable patients in neonatal intensive care units (NICUs) are not exempt. Our aim was to learn how personnel working in NICUs of California hospitals handled issues of neonatal transfer during wildfire disasters in recent years, with an ultimate goal to share lessons learned with healthcare teams on disaster preparedness. We identified California fires through newspaper articles and the CalFire.gov list. We determined which hospitals were affected and contacted members of the healthcare team through connections via the California Perinatal Quality Care Collaborative (CPQCC) database. We audio recorded interviews over phone or remote conferencing software or by written survey. We coded and analyzed transcripts and survey responses. While describing disaster preparedness, equipment (such as bassinets and backpacks), ambulance access/transport and documentation/charting were noted as important and essential. Teamwork, willingness to do other tasks that are not part of typical job descriptions, and unconventional strategies contribute to the success of keeping NICU babies safe when California wildfire strikes. Healthcare teams developed ingenious and surprising ways to evacuate NICU babies.

Continually Improving Outcomes for Very Low Birth Weight Infants.

* Abbreviation: CPQCC — : California Perinatal Quality Care Collaborative In this edition of Pediatrics , Lee et al1 present trends in survival without major morbidity as well as trends in individual morbidities in very low birth weight infants with birth weights of 401 to 1500 g or gestational ages between 22 and 29 weeks born between 2008 and 2017. In this cohort of almost 50 000 infants across 143 hospitals belonging to the California Perinatal Quality Care Collaborative (CPQCC), survival without major morbidity consistently increased from 62.0% to 67.2%. The largest improvements in morbidity were seen in infants with necrotizing enterocolitis and nosocomial infection. Bronchopulmonary dysplasia rates did not change significantly. There has been a steady stream of reports of decreased neonatal morbidity and mortality since the 1990s. Most, but not all, networks have reported these widespread improvements.2–5 The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network’s report of outcomes in a nearly identical population studied between 1993 and 2012 demonstrated increased use of evidence-based practices such as antenatal corticosteroids and adoption of less invasive ventilation as well as improvements … Address correspondence to Roger F. Soll, MD, Division of Neonatal-Perinatal Medicine, University of Vermont Medical Center, Smith 551, 111 Colchester Ave, Burlington, VT 05401. E-mail: roger.soll{at}uvmhealth.org

Improving outcomes for preterm infants in the California Perinatal Quality Care Collaborative

Through the collaboration of hospitals, partners in the state government, communities, foundations, and academic institutions, the California Perinatal Quality Care Collaborative (CPQCC) has contributed to improving outcomes for preterm infants. Specific strategies have included real-time data reports, toolkits of evidence-based practice, dissemination through educational meetings, and collaborative quality improvement projects.

Delayed Cord Clamping and Umbilical Cord Milking among Infants in California Neonatal Intensive Care Units.

To assess the current practice of delayed cord clamping (DCC) and to determine patient and hospital factors that predict DCC. The California Perinatal Quality Care Collaborative (CPQCC) collects data on preterm and acutely ill infants. In 2016, 52 CPQCC neonatal intensive care units (NICUs) collected data on DCC. Hospital and patient characteristics were analyzed using multivariable logistic regression. Of 5,332 deliveries, 1,555 (29%) newborns received DCC. Hospital rates ranged from 0 to 74.5% and increased from 21 to 37% throughout 2016. Infants delivered at <32 weeks or with birth weight <1,500 g were more likely to receive DCC (odds ratio: 2.80; 95% confidence interval: 2.33, 3.36). Cesarean delivery was associated with less likelihood of DCC (odds ratio: 0.68; 95% confidence interval: 0.59, 0.79). After risk adjustment, 17 (33%) hospitals had higher than expected DCC rate. Hospitals with less than 50 NICU beds are more likely to practice DCC, whereas Level 3 American Academy of Pediatrics NICUs, nonprofit owned hospitals, and teaching institutions were less likely to practice DCC (p < 0.001). There are opportunities to implement quality improvement activities to increase DCC rates.

Perinatal Risk Factors and Outcome Coding in Clinical and Administrative Databases.

Administrative databases may allow true population-based studies and quality improvement endeavors, but the accuracy of billing codes for capturing key risk factors and outcomes needs to be assessed. We sought to describe the performance of a statewide administrative database and the clinical database from the California Perinatal Quality Care Collaborative (CPQCC). This population-based retrospective cohort study linked key perinatal risk factors and outcomes from the 133-unit CPQCC database to relevant billing codes from administrative maternal and newborn inpatient discharge records, for 50 631 infants born from 2006 to 2012. Using the CPQCC record as the gold standard, we calculated the positive predictive value, negative predictive value, and Matthews correlation coefficient for each item, then evaluated comparative performance across units. The Matthews correlation coefficient was highest (>0.7; strong positive correlation) for multiple delivery, Cesarean delivery, very low birth weight, maternal hypertension, maternal diabetes, patent ductus arteriosus, in-hospital death, patent ductus arteriosus and retinopathy of prematurity surgeries, extracorporeal life support, and intraventricular hemorrhage. Maternal chorioamnionitis, fetal distress, retinopathy of prematurity staging, chronic lung disease, and pneumothorax were the least reliably coded. Maternal factors and delivery details were more reliably coded in the maternal inpatient record than the newborn inpatient record. Several important perinatal risk factors and outcomes are highly congruent between these administrative and clinical databases. Several subjective risk factors and outcomes are appropriate targets for data improvement initiatives. The ability for timely extraction of administrative inpatient data will be key to their usefulness in quality metrics.

Vignettes identify early onset sepsis management variation in a multi-center antibiotic stewardship collaborative

Background Vignette-based research methodology offers a unique method of simulating “real world” scenarios to understand decision making in behavioral, social, and health sciences. Clinical vignettes have been validated in adult outpatient studies to more accurately reflect physician management relative to chart review. Objective The objective of this study was to test the feasibility of vignette cases to identify specific areas of individual provider variation in early onset sepsis management within a multi-center antibiotic stewardship collaborative. Methods This study was implemented during a multicenter neonatal antibiotic stewardship collaborative undertaken by the California Perinatal Quality Care Collaborative (CPQCC). A web-based survey with six case vignettes and nine questions related to …

Maternal Body Mass Index and Risk of Intraventricular Hemorrhage in Preterm Neonates

PURPOSE To evaluate the association between body mass index (BMI) and the development of intraventricular hemorrhage (IVH) in preterm infants. METHODS This is a retrospective cohort study of a population-based cohort of infants who were born between 22 and 32 weeks gestation from 2007 to 2011. Maternal and infant data were extracted from the California Office of Statewide Health Planning and Development (OSHPD) and the California Perinatal Quality Care Collaborative (CPQCC) datasets, from 136 neonatal intensive care units. Infants with major congenital anomalies, and those without neuroimaging performed were excluded. …

Extreme hyperbilirubinemia and rescue exchange transfusion in California from 2007 to 2012

To evaluate the impact of statewide learning collaboratives that used national guidelines to manage jaundice on the serial prevalence of extreme hyperbilirubinemia (EHB, total bilirubin ⩾25 mg dl(-1)) and exchange transfusions introduced in California Perinatal Quality Care Collaborative (CPQCC) hospitals in 2007. Adverse outcomes were retrieved from statewide databases on re-admissions for live births ⩾35 weeks' gestation (2007 to 2012) in diverse CPQCC hospitals. Individual and cumulative select perinatal risk factors and frequencies were the outcomes measures. For 3 172 762 babies (2007 to 2012), 92.5% were ⩾35 weeks' gestation. Statewide EHB and exchange rates decreased from 28.2 to 15.3 and 3.6 to 1.9 per 100 000 live births, respectively. From 2007 to 2012, the trends for TB>25 mg dl(-1) rates were -0.92 per 100 000 live births per year (95% CI: -3.71 to 1.87, P=0.41 and R(2)=0.17). National guidelines complemented by statewide learning collaboratives can decrease or modify outcomes among all birth facilities and impact clinical practice behavior.

Determinants of chronic lung disease severity in the first year of life; A population based study.

First, create a clinical severity score for patients with chronic lung disease of infancy (CLDi) following neonatal intensive care unit (NICU) stay. Second, using California wide population-based data, identify factors associated with clinical severity of CLDi at 4-9 months corrected gestational age (CGA). Pediatric pulmonologists ranked and weighted eight factors reflecting clinical severity of CLDi. Utilizing these data we scored and assigned these to 4-9 month old CGA moderate/severe bronchopulmonary dysplasia (BPD) infants, born<30 weeks gestational age (GA), within the California High Risk Infant Follow up (HRIF) program. Infants were studied relative to factors from the California Perinatal Quality Care Collaborative (CPQCC). We received survey responses from 43/88 pediatric pulmonologists from 28/53 North American training centers who are experts in CLDi. Strong agreement between ranking (72-100%) of respiratory system parameters and weighting (out of 100 points weighting was within 20 points) was observed with severity of CLDi. Data from 940 CLDi premature infants <30 weeks GA were obtained. Infants with severe CLDi scores at 4-9 months CGA (relative to a zero score) showed positive associations with being male, odds ratio[OR] = 2.45[confidence interval (CI) 1.26-4.77]), >30 ventilator days, OR = 3.82 (1.30-11.2), postnatal steroids OR = 3.94 (1.94-7.84), and a surprising inverse association with retinopathy of prematurity stage 3-4, OR = 0.24 (0.09-0.67) CONCLUSIONS: The CLDi clinical severity score allowed for standardized assessment of pulmonary morbidity, and evaluation of risk factors in the NICU for CLDi following NICU discharge. These observations point to risk factors associated with CLDi outcomes at 4-9 months CGA.

Therapeutic hypothermia during neonatal transport: data from the California Perinatal Quality Care Collaborative (CPQCC) and California Perinatal Transport System (CPeTS) for 2010

To evaluate cooling practices and neonatal outcomes in the state of California during 2010 using the California Perinatal Quality Care Collaborative and California Perinatal Transport System databases. Database analysis to determine the perinatal and neonatal demographics and outcomes of neonates cooled in transport or after admission to a cooling center. Of the 223 infants receiving therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE) in California during 2010, 69% were cooled during transport. Despite the frequent use of cooling in transport, cooling center admission temperature was in the target range (33-34 °C) in only 62 (44%). Among cooled infants, gestational age was <35 weeks in 10 (4.5%). For outborn and transported infants, chronologic age at the time of cooling initiation was >6 h in 20 (11%). When initiated at the birth hospital, cooling was initiated at <6 h of age in 131 (92.9%). More than half of the infants cooled in transport do not achieve target temperature by the time of arrival at the cooling center. The use of cooling devices may improve temperature regulation on transport.

480: Perinatal core measure: antenatal steroid performance improvement following a preterm birth risk assessment decision model and perinatal QI toolkit

Antenatal steroid (ANS) exposure is an emerging national perinatal care core safety measure. We report ANS performance at a large tertiary level perinatal center after a collaborative quality improvement (QI) effort that included an antenatal management decision model and process improvement using a California-wide perinatal QI toolkit. The California Perinatal Quality Care Collaborative (CPQCC) network defines this measure as the percent of delivered premature infants (401-1500 grams and 24+0 to 33+6 weeks) whose mothers had received ANS. A QI initiative was implemented at our institution in 2006 after benchmarking ANS performance in 2005. OB triage care was standardized with an evidence based decision model and order set to identify ANS candidates between 24 and 34 weeks gestation using published ACOG criteria. For women with symptomatic contractions, the decision model used clinical findings and fetal fibronectin (fFN) to determine management. Women meeting preterm birth (PTB) risk criteria including fFN positive testing received an initial course of ANS. Women who did not meet PTB risk criteria (eg stable cervix with negative fFN) did not receive ANS and were not admitted, even if persistent uterine activity. QI activities also included a state-wide perinatal ANS toolkit to improve processes of documentation and data collection. During the five year study period (2005-2009), there were 27,737 births and 60,015 total OB triage evaluations for all indications including PTB risk assessment decision model to determine ANS administration. Performance of state quality measure for ANS administration at our center increased significantly between 2005 baseline and the 2009 assessment of decision model and QI toolkit (77.1% vs 100%, p<0.01). Our center performance was significantly higher than mean state system-wide performance (p<0.01). Quality Improvement initiatives including evidence based decision models to standardize management and the use of perinatal tool kits can improve performance of Perinatal Core measure ANS administration.

Prevention of Group B Streptococcus early-onset disease: a toolkit by the California Perinatal Quality Care Collaborative

The California Perinatal Quality Care Collaborative (CPQCC) was organized in 1996 in an effort to improve perinatal outcomes in California. CPQCC has a robust infrastructure of quality improvement resources and expertise and uses a database of demographic and outcome data from neonatal intensive care units in California. In 2004, CPQCC developed a toolkit to provide an evidence-based framework and supporting documents for hospitals to use in systematically addressing persistent early-onset disease (EOD) because of Group B Streptococcus (GBS) in their centers. The CPQCC toolkit was based on the 2002 Centers for Disease Control guideline, 'Prevention of Perinatal Group B Streptococcal Disease.' This article presents an updated version of the CPQCC toolkit reflecting several population studies published since the 2002 guideline. Current epidemiological trends in incidence of EOD with GBS, changes in antibiotic sensitivity and the potential value of newer strategies are discussed.

Promoting antenatal steroid use for fetal maturation: Results from the California Perinatal Quality Care Collaborative

The California Perinatal Quality Care Collaborative (CPQCC) was formed to seek perinatal care improvements by creating a confidential multi-institutional database to identify topics for quality improvement (QI). We aimed to evaluate this approach by assessing antenatal steroid administration before preterm (24 to 33 weeks of gestation) delivery. We hypothesized that mean performance would improve and the number of centers performing below the lowest quartile of the baseline year would decrease. In 1998, a statewide QI cycle targeting antenatal steroid use was announced, calling for the evaluation of the 1998 baseline data, dissemination of recommended interventions using member-developed educational materials, and presentations to California neonatologists in 1999-2000. Postintervention data were assessed for the year 2001 and publicly released in 2003. A total of 25 centers voluntarily participated in the intervention. Antenatal steroid administration rate increased from 76% of 1524 infants in 1998 to 86% of 1475 infants in 2001 (P < .001). In 2001, 23 of 25 hospitals exceeded the 1998 lower-quartile cutoff point of 69.3%. Regional collaborations represent an effective strategy for improving the quality of perinatal care.

Prospective Evaluation of Postnatal Steroid Administration: A 1-Year Experience From the California Perinatal Quality Care Collaborative

Postnatal steroids (PNSs) are used frequently to prevent or treat chronic lung disease (CLD) in the very low birth weight (VLBW) infant, and their use continues despite concerns regarding an increased incidence of longer-term neurodevelopmental abnormalities in such infants. More recently, there has been a suggestion that corticosteroids may be a useful alternative therapy for hypotension in VLBW infants, but there have been no prospective reports of such use for a current cohort of VLBW infants. The California Perinatal Quality Care Collaborative (CPQCC) requested members to supplement their routine Vermont Oxford Network data collection with additional information on any VLBW infant treated during their hospital course with PNS, for any indication. The indication, actual agent used, total initial daily dose, age at treatment, type of respiratory support, mean airway pressure, fraction of inspired oxygen, and duration of first dosing were recorded. From April 2002 to March 2003 in California, 22 of the 62 CPQCC hospitals reported supplemental data, if applicable, from a cohort of 1401 VLBW infants (expanded data group [EDG]), representing 33.2% of the VLBW infants registered with the CPQCC during the 12-month period. PNSs for CLD were administered to 8.2% of all VLBW infants in 2003, 8.6% of infants in the 42 hospitals that did not submit supplemental data (routine data-set group, compared with 7.6% in EDG hospitals). Of the 1401 VLBW infants in the EDG, 19.3% received PNSs; 3.6% received PNSs for only CLD, 11.8% for only non-CLD indications, and 4.0% for both indications. At all birth weight categories, non-CLD use was significantly greater than CLD use. The most common non-CLD indication was hypotension, followed by extubation stridor, for which 36 (16.3%) infants were treated. For hypotension, medications used were hydrocortisone followed by dexamethasone. Infants treated with PNSs exclusively for hypotension had a significantly higher incidence of intraventricular hemorrhage, periventricular leukomalacia, and death when compared with infants treated only for CLD or those who did not receive PNSs. The common early use of hydrocortisone for hypotension and the high morbidity and mortality in children receiving such treatment has not been recognized previously and prospective trials evaluating the short- and long-term risk/benefit of such treatment are urgently required.

Organizing Regional Perinatal Quality Improvement

After completing this article, readers should be able to: 1. List the primary steps in organizational development of a regional perinatal quality improvement program. 2. Describe opinion-making, practice-enabling, and audit and feedback strategies. This case study provides information on key decisions and critical steps for those implementing regional perinatal quality improvement (QI) programs. Designers and developers should be cognizant of the considerable evidence base and theoretical work that can guide program development. Such evidence and theory are contained in sidebar reviews and commentary that accompany this description of the development of the California Perinatal Quality Care Collaborative (CPQCC). The authors recognize that others might and should act on the evidence differently according to local circumstances. Perinatal-neonatal leaders in California have been addressing perceived concerns relating to the quality of care for decades. From the pioneering work of Williams (1) to more recent Perinatal Profiles of risk-adjusted hospital level perinatal-neonatal mortality, (2) significant hospital-specific variations in mortality have persisted. Such differences persist even after adjusting for level of care and case mix across institutions. (3) In addition, both Wirtschafter and associates (4) and Wilson and colleagues (5) have described variation within hospital networks operated by large California health maintenance organizations. Increasingly, California’s leaders became aware that both private and public payers were concerned about how and who should address the issue. (See Sidebar #1) | Contemporary writers echo previous generations’ concern for attending to the quality of care. Galvin and McGlynn (1) cite public surveys that indicate increasing appreciation of and interest in quality, paralleling the public’s embracing of automobile safety and environmental issues. Steffen (2) suggests that “(high) quality care is the capacity of the elements of that care to achieve legitimate medical and non-medical goals.” Blumenthal (3) reviews the evolution of definitions of quality and notes the preeminence of the one formulated by the Institute of Medicine in 1990: Quality consists of the “degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” (4) Public and payer attention to the value of the care rendered follows from the concerns over ever-rising health care costs. Blumenthal (3) argues that physician understanding and expertise about the nature of quality is both expected and required. The inclusion of “competence in perinatal quality assessment/improvement” is under consideration by the Sub Board for Neonatal/Perinatal Medicine. | || *