Beyond the Dashboard: A Chart-Review–Driven Quality Improvement Initiative to Safely Reduce the Primary Cesarean Rate in a Community Teaching Hospital

Background. The nulliparous, term, vertex, singleton (NTVS) primary cesarean rate (PCO2) is a core hospital quality metric, yet administrative dashboards capture little of the clinical reasoning behind each cesarean. Our 2024 baseline department PCO2 was 34%, above the institutional goal of <24%. To direct improvement, a Voluntary Review of Quality of Care (VRQC) committee performed an external assessment of our practice and data, helping identify the highest-yield areas for focused review. We hypothesized that detailed, case-by-case chart review—beyond what the dashboard captured—would reveal modifiable drivers of cesarean overuse and guide targeted, in-hospital interventions. Methods. Single-center quality improvement initiative. For the 2024 baseline, every NTVS delivery (n=400) underwent manual chart review, with a focused review of all NTVS cesareans (n=140). Abstracted variables included primary cesarean indication (chart-adjudicated vs. dashboard-documented), adequacy of neuraxial analgesia, APGARs and umbilical cord gas (base excess, pH) for fetal-intolerance cases, labor onset (spontaneous vs. induction) and induction indication, induction methods (Cervidil, misoprostol, AROM, oxytocin), Bishop score for risk-reducing and term inductions, midwifery vs. physician management and covering provider, and patient race, ethnicity, and language. Baseline findings drove multi-component interventions launched January 2025: an analgesia bundle, a fetal-monitoring education stream, a standardized Bishop-directed induction protocol, and twice-yearly individualized, blinded provider feedback reports. The full cohort was re-reviewed for 2025 (n=544). Groups were compared using the Fisher exact test. Results. Chart review reclassified 33% of cesarean indications miscoded in the dashboard in 2024 (26% in 2025). Baseline drivers included inadequate neuraxial analgesia (19.1% of cesareans, 62.5% of which were maternal-request cases), fetal-intolerance cesareans that largely lacked objective evidence of acidemia at delivery, and the highest cesarean rates in the cohort among risk-reducing (43%) and term (42%) NTVS inductions. Following intervention, the department PCO2 fell from 34% to 29%. The largest improvement was among NTVS induction cesareans, which decreased from 43% to 28% (Δ −15.0 percentage points; Fisher p=0.0155). Neuraxial analgesia optimization rose from 80.1% to 92.4%. PCO2 declined in both patients of color (39.3% → 32.9%) and white, non-Hispanic patients (33.2% → 28.1%), improving roughly 5–6 percentage points in each group; however, the racial disparity persisted. Conclusion. A chart-review–informed quality improvement program incorporating individualized provider feedback safely reduced the NTVS primary cesarean rate—most markedly for induction-related cesareans—while improving labor analgesia and exposing systematic limitations of dashboard data. Improvement occurred in parallel across racial groups rather than disproportionately benefiting white patients, counter to national trends; nonetheless, a persistent disparity remains.