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Quality Improvement Initiative Participation Agreement

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Problem Statement

Maternal and infant health in the United States remains a critical public health concern. Despite advances in medical care and technology, the U.S. continues to experience higher maternal and infant mortality rates compared to other high-income nations. Disparities in outcomes are striking, with Black, Indigenous, and rural communities bearing a disproportionate burden of adverse events.

In Colorado, the state fares better than national averages in some areas, but significant challenges remain. Rural regions and communities of color face barriers to accessing high-quality, timely perinatal care. Geographic disparities and socioeconomic inequities contribute to preventable deaths and severe maternal morbidity. The state also faces challenges with rising rates of preterm births, low birth weight, and postpartum mental health concerns, all of which exacerbate health inequities and strain healthcare systems.

Quality Improvement Initiatives

Quality improvement (QI) initiatives are essential to addressing areas of needed focus in improving maternal and infant health. These initiatives can drive evidence-based practices, promote system-wide accountability, and ensure equitable access to care for all families. The urgency of these challenges requires coordinated and innovative responses.
The Colorado Perinatal Care Quality Collaborative’s (CPCQC) goal is to ensure that birthing individuals and their families receive culturally relevant, safe, equitable, high-quality care no matter who they are or where they live. CPCQC employs the Institute for Healthcare Improvement’s Model for Improvement Framework to implement the Alliance for Innovation on Maternal Health’s (AIM) Patient Safety Bundles. These evidence-based initiatives target the leading causes of preventable maternal deaths in Colorado.

Colorado Prioritizes Quality Improvement Implementation

Colorado has prioritized hospital-based AIM Patient Safety Bundle implementation through Senate Bill 24-175. By December 2025, all Colorado hospitals with labor and delivery and/or neonatal intensive care units must be enrolled in at least one QI initiative through CPCQC.

The CPCQC QI Initiatives support hospital alignment with additional quality programs such as CMS’s Birthing Friendly Hospital Designation, Colorado HQIP, and Anthem BCBS Blue Distinction.

Learn more about the active QI initiatives by visiting our website.

CPCQC approaches our QI initiatives as collaborative partnerships with hospitals, built on shared goals of advancing maternal and infant health. The sections below outline the mutual commitments and responsibilities that enable us to work together effectively to achieve meaningful and lasting improvements.

Expectations of the CPCQC Team

The Colorado Perinatal Care Quality Collaborative will:

  • Provide access to a designated Program Manager, QI Advisor, and Data Analyst with expertise in the subject matter and improvement methods.
  • Provide information on the subject matter, application of that subject matter, and methods for process improvement, both during and between monthly initiative meetings.
  • Offer guidance and feedback to teams during 1:1 coaching sessions and as needed.
  • Provide rapid-cycle data analysis and feedback through the creation of data dashboards.
  • Provide opportunities for peer-to-peer learning among Colorado hospitals.
  • Provide education and resources to support hospital success.
  • Share best practices and tools from states across the country through the national network of PQCs.

The information, coaching, and material resources provided by CPCQC staff, including program managers, QI advisors, and data analysts, are intended for educational purposes only and do not constitute legal advice. Every institution should consult with its own legal advisor to revise, tailor, and/or abridge general advice and resource materials to reflect the needs of the individual institution.

Expectations of Participating Hospitals

While participation in the CPCQC QI Initiative is free of cost, successful QI collaborative participation requires time and resources to support infrastructure, tools, and active participation. Participating birthing hospitals agree to:

  • Connect the initiative goals to the strategic initiatives in the organization in partnership with your quality and risk leaders.
  • Designate a senior champion to serve as a sponsor on behalf of the hospital leadership. Communicate with CPCQC should this champion change over time.
  • Provide resources to support their team, including time to devote to this project.
  • Meet minimum active engagement requirements per CO SB24-175 including:
    • Enrollment: The hospital has signed a Data Use Agreement (DUA) with CPCQC and selected an open CPCQC QI initiative to implement.
    • Coaching: The hospital attends one virtual QI Coaching session with CPCQC per quarter (4x/year).
    • Survey Completion: The hospital submits a survey about its practices related to the selected QI initiative at least twice yearly.
    • Meeting Participation: At least one hospital-level representative attends at least 75% (9 out of 12) of the monthly QI initiative meetings and one annual forum during the 12-month QI initiative.
    • Data Submission: The hospital submits QI initiative data disaggregated by race, ethnicity, and payor, at least 75% of the time (Data submission may be monthly or quarterly depending on the selected QI initiative).
    • OR, for hospitals that qualify, meet the minimum sustaining engagement requirements per CO SB24-175 including:
    • Enrollment: The hospital has signed a Data Use Agreement (DUA) with CPCQC and selected an open CPCQC QI initiative to implement.
    • Coaching: The hospital attends one virtual QI Coaching session with CPCQC once every 6 months (2x/year).
    • Survey Completion: The hospital submits a survey about its practices related to the selected QI initiative at least twice yearly.
    • Meeting Participation: At least one hospital-level representative attends at least one QI initiative meeting (virtual, in-person, or regional) every three months 75% (4 per year), and one annual forum during the 12-month QI initiative.
    • Data Submission: The hospital submits at least two-quarters worth of an initiative-specific reduced data set disaggregated by race, ethnicity, and payor during 12 months to demonstrate sustained quality improvement and equity outcomes.

In agreement with the participation requirements outlined above, please provide the contact information and signature of at least one hospital C-suite representative.

CPCQC Quality Improvement Team: qi@cpcqc.org

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