Building on Lessons from Optimal Organizations for Maternity Outcomes (the BLOOM study)

About This Grant

BLOOM Project Summary Birth is the leading reason for hospital admission in the United States. There are three possible birth outcomes: spontaneous vaginal birth (SVB), which is a birth without forceps or vacuum, operative vaginal birth which is a birth with forceps or vacuum, and cesarean. SVB is the best birth outcome for most women and babies' short- and long-term health, the least expensive birth outcome, and the birth outcome most women want. This makes it an excellent example of high-value healthcare. SVB rates vary significantly across hospitals and this variation is not explained by hospital structural characteristics. There are high-performing hospitals where women have appropriately excellent SVB rates and these hospitals exist across all structural characteristics (bed size, teaching status, technology status, rurality, and state). Nurses provide most direct patient care to women in labor and this care is critical for supporting SVB. Preliminary research suggests that a hospital's nursing organizational resources, including the work environment and staffing, differentiate high-performers from low-performers. In this research we look to optimize the health of our current and future generations by learning from our high- performing hospitals for birth outcomes to inform practice and policy. The purpose of this study is to examine high-performing hospitals with excellent SVB outcomes overall and for women from racial/ethnic minorities, who typically experience lower SVB rates, compared with low-performers regarding the organizational resources that differentiate them and to understand what the high- performers do, especially regarding those differentiating organizational resources, that sets them apart. Accordingly, we propose to conduct an explanatory sequential mixed methods study. In Aim 1, we will examine the relationship between hospital nursing organizational resources and SVB, for women overall and from racial and ethnic minority groups in high-performing hospitals (compared to low), by leveraging a novel benchmarking/ranking approach42 that uses propensity score weighting and machine learning methods. Sub-Aim 1: We will explore the relationship of varying state midwifery and staffing legislation with the presence of high- and low-performers. In Aim 2, we will explore the pathways by which high- and low-performing hospital's nursing organizational factors prevent or contribute to SVB outcomes and disparities, as well as high-performer's actions, interventions or culture to realize these organizational factors, their recommendations for improvement and implementation. We will do this via a semi- structured qualitative interview with hospital maternity leaders. In Aim 3, we will develop a joint display map, integrating the aspects of the hospital organizational resources identified in Aim 1 with the pathways and recommendations from Aim 2 to understand the relationship between the organizational resources and performance status to illumine actions for improvement.