SIVB and Quality Collaboration

Transforming Perinatal Care Via Quality Collaboration

Martin J. McCaffrey MD, CAPT USN (Ret) Clinical Professor of Pediatrics UNC School of Medicine For NCABSI and PQCNC

Charting the Quality Course

Despite sound science there is wide variation in perinatal outcomes If knowledge is good why is there variation? How can we account for variation in outcomes?
Etiologies of variation Methods of analysis Unexplained sources of variation

What if anything can we do about this variation?

Sources for Variation

Risk and case mix Chance Unexplained
Quality of care

Accounting for Risk and Chance

Risk Adjustment Models
VON Risk Adjustment Model SNAPPE scoring methods

Chance
Variety of statistical methods
Bayesian Shrinkage Analysis

Sources of Unexplained Variation

People Practices and processes Technology Organizational structure and culture

Sources of Variation: People

Clinical
Cognitive Technical Subspecialty expertise

Social
Leadership Communication Teamwork

Knowledge, skills and experience vary

Sources of Variation: People

NICU Subspecialty Coverage

100 90 80 70 60 50 40 30 20 10 0 Network NC

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Sources of Variation: Social

Leadership

Baker G R et al. Pediatrics 2003;111:e419-e425

2003 by American Academy of Pediatrics

Sources of Variation: Social

Teamwork Disconnect
Physicians and RN Collaboration
100

90
80

70 60
50

83% 48% 48%

88%
54%

90%

93% 59%

40
30

20
10 0

RN rates Physician
L&D RN/O B O R RN/Surgeon

Physician rates RN
ICU RN/MD CRNA/Anesthesiologist

Huang DT et al. Crit Care Med. 2007 Jan;35(1):165-76. 9

Sources of Variation: Practice and Processes

Variation among centers
Largest systems which exist to benchmark variability of NICU outcomes
VON (600+ NICUs), Pediatrix (200+ NICUs), CPQCC (120 NICU in Ca), NICHD (16 NICUs selected by NICHD nationally)

OB Research Networks (Obstetrix) VON PQCNC Report

Antenatal Steroid Use in CA 2005-2007

Lee HC et al. Antenatal steroid administration for premature neonates in California 11 From 2005-2007. Obstet Gynecol. 2011 Mar;117(3):603-9.

Antenatal Steroid Use in CA 2005-2007

Lee HC et al. Antenatal steroid administration for premature neonates in California 12 From 2005-2007. Obstet Gynecol. 2011 Mar;117(3):603-9.

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

Sources of Variation: Practice and Processes

Variation within centers
Lack of standardization Uneven compliance

Variation Within PQCNC Centers

Evaluation of patients in triage Methods of Induction Evaluation of labor progress
Technology Staff

Ability to execute a CS

Sources of Variation: Technology

Equipment
Infusion Pumps Monitoring Systems

Hospital
CPOE Imaging Laboratory Pharmacy

Sources of Variation: Organizational Factors

Structure
Volume Staffing Finances Unit design

Culture
Beliefs Behaviors Relationships

NICU Volume and Mortality

Rogowski JA. JAMA. 2004;291(2):202-209.

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.x http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2934.2006.00609.x/full#f2

Types of organizational cultures

Baker G R et al. Pediatrics 2003;111:e419-e425

2003 by American Academy of Pediatrics

Radar plot of organizational culture

Baker G R et al. Pediatrics 2003;111:e419-e425

2003 by American Academy of Pediatrics

The Culture of an Organization

The extent to which individuals and groups will commit to improving the quality and value of care in the unit Individual and organizational willingness to actively learn, adapt and modify behavior based on new evidence or lessons learned The readiness to reward behavior and activities that is consistent with these values

Beliefs About Infection

Are nosocomial infections inevitable or preventable for infants < 32 weeks?
Low Infection NICU: The majority are preventable if you follow through with hand washing, keeping the sterile field and doing what we are supposed to do. High Infection NICU: Nosocomial infections are inevitable with the babies decreased immune system, the environment and how we handle babiesmakes infection inevitable.
Diana Luan, RN, PhD, Doctoral Dissertation submitted to Dartmouth College

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

We Can Do This
28 NCABSI NICUs with no infections since Dec 2011 12 NCABSI NICUS with average of 150 line days per month with no infections since Dec 2011 6 NCABSI NICUS with average of at least 300 line days per month with no infections since Dec 2011

Were making changes, are we changing culture?

Sources of Unexplained Variation Contributing to Quality of Care

People Practices and processes Technology Organizational structure and culture

Summary
Risk and chance do not explain all variation Multiple sources of unexplained variation The interaction among all these potential sources likely amplifies variation Possible combinations is very large What can we do about variation in attempting to optimize NICU care?

Studying the Problem

Formal Science: RCTs
Gold standard for controlling chance and bias Long time horizon Can never evaluate all contributions to variation or test all interventions Difficult to assess interactions

Pragmatic Science: Quality Improvement

Minor interventions can be assessed Interventions can be altered Accept multiple sources of variation Real time learning amongst multiple partners

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 inappropriate but action without reflection is unwise
Berwick DM. Developing and testing changes in delivery of care. Ann Int med 1998 128:651-656

Why We Must Do This

Why We Must Do This

Keys to Success
Defining Value Empower leadership from the field Clear aim, measureable goal Data supports the work
Lean, flexible and necessary

Sustainable change changes culture Partner with patients and families

TEAMWORK

None of us is as stupid alone as all of us are together

www.despair.com

TEAMWORK

Alone we can do so little, together we can do so much.

Helen Keller