Abstract
Background
Persistent disparities in maternal health outcomes in the United States highlight the need for effective quality improvement (QI) strategies. State-based quality care collaboratives (QCCs) disseminate standardized QI toolkits for labor and delivery (L&D) units, yet adoption and sustainability vary. This study examined contextual and organizational factors influencing toolkit implementation by prioritizing and systematically analyzing nurse leader perspectives to identify system-level solutions.Methods
We conducted 11 discussion sessions with 21 nurse leaders from L&D units across 10 states. Using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, we explored experiences with QCC-supported toolkits, barriers and facilitators to implementation, and opportunities for improvement. Thematic analysis identified cross-cutting themes.Findings
Toolkit adoption depended on alignment with patient needs, resources, and workflows at each site. Organizational culture, leadership support, and maternal health expertise shaped uptake, whereas rigid metrics and competing priorities undermined engagement. Technological infrastructure-particularly electronic health record capabilities-and adequate staffing were critical enablers. QCCs provided essential support for underresourced hospitals, but hospitals that locally developed solutions were unable to systematically share with other similar hospitals. Sustainability was challenged by initiative fatigue, resource instability, and staff turnover.Conclusions
Nurse leaders emphasized that system-level approaches are needed to strengthen toolkit adoption and impact. Centralized resource sharing, targeted support for underresourced hospitals, and collaborative learning networks can enhance effectiveness and sustainability in maternal health QI.