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  1. Edmonds, Joyce K. PhD, MPH, RN
  2. Woodbury, Samuel R. BA
  3. Lipsitz, Stuart R. ScD
  4. Weiseth, Amber DNP, MSN, RN-OB
  5. Farrell, Maureen E. MD
  6. Shah, Neel T. MD
  7. Greene, Naomi PhD
  8. Gregory, Kimberly D. MD, MPH


Background: The low-risk cesarean delivery (CD) rate is an established performance indicator for providers in maternity care for quality improvement purposes.


Purpose: Our objectives were to assess nurse performance using adjusted nurse-level CD rates and to compare methods of identifying nurse outliers.


Methods: We conducted a retrospective, cohort study of 6970 births attended by 181 registered nurses in one hospital's maternity unit. Adjusted and unadjusted nurse-level CD rates were compared and agreement between 3 definitions (statistical, top decile, over a benchmark) of outliers calculated.


Results: Adjusted nurse-level CD rates varied from 5.5% to 53.2%, and the unadjusted rates varied from 5% to 50%. Risk adjustment had little impact on the ranking of nurses, and outliers were consistently identified by 3 definitions.


Conclusions: Trade-offs between statistical certainty and feasibility need to be considered when classifying nurse outliers. Findings can help target interventions to improve nurse performance.