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Why Quality Improvement?
Transforming Perinatal Care Via Quality
Collaboration
Martin J. McCaffrey MD, CAPT USN (Ret)
For PQCNC
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PQCNC Initiatives
55 hospitals with maternity/newborn/NICUservices have participated
207 teams in 9 initiatives Currently 90 teams in the field
SIVB, EHM NICU, EHM Nursery, NCABSI
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Charting the Quality Course
Despite sound science there is widevariation in perinatal outcomes
If knowledge is good why is there variation? How can we account for variation in
outcomes?
Etiologies of variationMethods of analysisUnexplained sources of variation
What if anything can we do about thisvariation?
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Sources for Variation
Risk and case mix Chance Unexplained
Quality of care
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Sources of Unexplained Variation
People Practices and processesTechnology
Organizational structure and culture
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Sources of Variation: People
ClinicalCognitiveTechnicalSubspecialty expertise
SocialLeadershipCommunicationTeamworkKnowledge, skills and experience vary
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Sources of Variation: PeopleNICU Subspecialty Coverage
0
10
20
30
40
50
60
70
80
90
100
Genetic
s GINe
phEn
do IDHe
me
Pulm
o
Neuro
Card
Anesth
Surgery
Network
NC
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Sources of Variation: SocialLeadership
Baker G R et al. Pediatrics 2003;111:e419-e425
2003 by American Academy of Pediatrics
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Sources of Variation: SocialTeamwork Disconnect
10
48% 48%54%
59%
83%88% 90% 93%
0
10
20
30
40
50
60
70
80
90
100
L&D RN/OB O R RN/Surgeon ICU RN/MD CRNA/Anesthesiologist
Physicians and RN Collaboration
RN rates Physician Physician rates RN
Huang DT et al. Crit Care Med. 2007 Jan;35(1):165-76.
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Sources of Variation:
Practice and Processes
Variation among centersLargest systems which exist to benchmark
variability of NICU outcomes
VON (600+ NICUs), Pediatrix (200+ NICUs), CPQCC (120NICU in Ca), NICHD (16 NICUs selected by NICHD
nationally)
VON PQCNC Report
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Antenatal Steroid Use in CA 2005-2007
12
Lee HC et al. Antenatal steroid administration for premature neonates in California
From 2005-2007. Obstet Gynecol. 2011 Mar;117(3):603-9.
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Antenatal Steroid Use in CA 2005-2007
13
Lee HC et al. Antenatal steroid administration for premature neonates in California
From 2005-2007. Obstet Gynecol. 2011 Mar;117(3):603-9.
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Antenatal Steroid Use in France
Burguet A et al. Very preterm birth: who has access to antenatal corticosteroid therapy?Paediatric and Perinatal Epidemiology Volume 24, Issue 1, pages 6374, January 2010
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Sources of Variation:
Practice and Processes
Variation within centersLack of standardizationUneven compliance
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Variation Within PQCNC Centers
Feeding advances Holding feedingsPDA treatment
Initiation of antibiotics Use of caffeine Criteria for intubation
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Sources of Variation:
Technology
Neonatal Unit Monitors Ventilators Infusion Pumps ECMO
Hospital CPOE Imaging Laboratory Pharmacy
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Sources of Variation:
Organizational Factors
Structure Volume Staffing Finances Unit design
Culture Beliefs Behaviors Relationships
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NICU Volume and Mortality
Rogowski JA. JAMA. 2004;291(2):202-209.
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Measuring nursing workload in
neonatal intensive care
Journal of Nursing Management
Volume 14, Issue 3, pages 227-234, 14 MAR 2006 DOI: 10.1111/j.1365-2934.2006.00609.xhttp://onlinelibrary.wiley.com/doi/10.1111/j.1365-2934.2006.00609.x/full#f2
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Types of organizational cultures
Baker G R et al. Pediatrics 2003;111:e419-e425
2003 by American Academy of Pediatrics
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Radar plot of organizational culture
Baker G R et al. Pediatrics 2003;111:e419-e425
2003 by American Academy of Pediatrics
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The Culture of an Organization
The extent to which individuals and groupswill commit to improving the quality andvalue of care in the unit
Individual and organizational willingness toactively learn, adapt and modify behaviorbased on new evidence or lessons learned
The readiness to reward behavior andactivities that is consistent with thesevalues
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Beliefs About Infection
Are nosocomial infections inevitable or
preventable for infants < 32 weeks?
Low Infection NICU: The majority are preventable if youfollow through with hand washing, keeping the sterilefield and doing what we are supposed to do.
High Infection NICU: Nosocomial infections areinevitable with the babies decreased immune system, theenvironment and how we handle babies
makesinfection inevitable.
Diana Luan, RN, PhD, Doctoral Dissertation submitted to Dartmouth College
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Why We Cant Do This
Tiny babies with central lines get infections We need a bigger budget & better
equipment
Our patients are different We cant monitor each other Our doctors dont think its possible Our nurses dont think its possible
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We Can Do This
28 NCABSI NICUs with no infections sinceDec 2011
12 NCABSI NICUS with average of 150line days per month with no infections
since Dec 2011
6 NCABSI NICUS with average of at least300 line days per month with no infections
since Dec 2011
Were making changes are we
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We re making changes, are we
changing culture?
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Sources of Unexplained Variation
Contributing to Quality of Care
People Practices and processesTechnology
Organizational structure and culture
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Summary
Risk and chance do not explain all variation Multiple sources of unexplained variationThe interaction among all these potentialsources likely amplifies variation
Possible combinations is very largeWhat can we do about variation in
attempting
to optimize NICU care?
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Studying the Problem
Formal Science: RCTsGold standard for controlling chance and biasLong time horizonCan never evaluate all contributions to variation
or test all interventionsDifficult to assess interactions
Pragmatic Science: Quality ImprovementMinor interventions can be assessed Interventions can be alteredAccept multiple sources of variationReal time learning amongst multiple partners
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Deploying the Science of Quality
Improvement
Best practice is known or Dramatic variation (we cant all be right)What is known is not consistently applied
Variable performance relative to potential
When inaction is inappropriatebut action without reflection is unwise
Berwick DM. Developing and testing changes in delivery of care.Ann Int med 1998 128:651-656
Partnering With Families & Patients: Gabby
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Partnering With Families & Patients: Gabby
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Keys to Success
Defining Value Empower leadership from the fieldClear aim, measureable goal
Data supports the work Lean, flexible and necessary
Sustainable change changes culture Partner with patients and families
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Transforming Perinatal Healthcare
Empower leadership from the field Clear aim, measureable goalData supports the work Lean, flexible and necessary
Sustainable change changes culture Partner with patients and families Incentivize collaboration
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Data
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Transforming Perinatal Healthcare
Empower leadership from the field Clear aim, measureable goalData supports the work Lean, flexible and necessary
Sustainable change changes culture Partner with patients and families Incentivize collaboration
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TEAMWORK
None of us is as stupid alone as all of us are togetherwww.despair.com
TEAMWORK
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TEAMWORK
Alone we can do
so little, together wecan do so much.