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A Primer on QualityImprovementMethodologyin Neonatology
Dan L. Ellsbury,
MD
*, Robert Ursprung,
MD, MMSc
This article provides a pragmatic approach to quality improvement (QI) in the neonatalintensive care unit (NICU) setting. The ‘‘model for improvement,’’ as described byLangleyandcoworkers
andheavilyusedbytheInstituteforHealthcareImprovement,serves as the foundation for the approach. The model for improvement is based onthree core questions, followed by cycles of testing: What is one trying to accomplish?How will one know that a change represents an improvement? What changes can bemade that will result in continuous improvement?Inthepracticaluseofthemodelforimprovement,theauthorshavefounditusefultomodify it in the format of ‘‘seven questions to consider when designing a QI project.’’1. Which problem should one select?2. Who will be on the project team?3. What is the goal?4. What will one measure?5. How will one analyze the measurements?6. What changes will one make to create an improvement?7. How will one test the changes?This format can serve as a template for virtually any QI project. In the remainder of this article these questions are reviewed in detail and specific examples are providedto highlight the practical use of this methodology.
WHICH PROBLEM SHOULD ONE SELECT?
To start, review the NICU’s outcome data, focusing on mortality and the morbiditiesmost commonly encountered in the NICU. In addition to standard NICU databases
Center for Research, Education, and Quality, Pediatrix Medical Group, 1301 Concord Terrace,Sunrise, FL 33323, USA* Corresponding author.
E-mail address:
KEYWORDS
Change
Model for Improvement
NICU
Quality improvement
Clin Perinatol 37 (2010) 87–99doi:10.1016/j.clp.2010.01.005
0095-5108/10/$ – see front matter
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2010 Elsevier Inc. All rights reserved.
(eg, Pediatrix Medical Group, Vermont Oxford Network, California Perinatal QualityCare Collaborative), many hospitals collect a variety of data on nosocomial infections,breast-feeding, mortality, length of stay, and other outcomes. When possible, bench-mark the center’s outcomes to both a national data set and to your own center’shistorical outcomes. If available, compare your center’s outcomes with other centersproviding the same level of care (eg, a level II NICU should compare outcomes withother level II NICUs and avoid comparisons with level IIIC NICUs).
Modifi-able problems characteristically demonstrate large center-to-center variability, andare responsive to current evidence-based interventions.
An Example of a Good Project
As an example, consider reducing catheter-associated bloodstream infection(CABSI). On review of data one notes the baseline CABSI rate is fairly high comparedwith network data and has not been improving. CABSIs are clinically very importantand are modifiable by improvements in the process of inserting and maintainingcentral lines. This is an excellent project for a QI team to pursue.
An Example of a Poor Project
Another example is reducing periventricular leukomalacia (PVL). A review of the cen-ter’s baseline PVL rate shows it is low compared with network benchmarks. Of note,there seems to be little numerical difference between the best and worst performingnetworkNICUs.AlthoughPVLisclinicallyimportant,theincidenceinthecenterisrela-tively low, and there are few evidence-based interventions available to impact its inci-dence. Essentially, PVL does not seem to be a major problem in this NICU, and onecannot do much beyond standard clinical care to reduce it. As a result, PVL isa poor project for most QI teams to pursue.
WHO SHOULD BE ON THE PROJECT TEAM?
NICU care involves a large number of personnel who interact with an infant in a varietyof ways; the sine qua non of an effective QI team is its multidisciplinary composition.The specific make-up of the team depends on the project and the goals for success.Ideally, teams should be of modest size, approximately 5 to 7 people, to facilitatecommunication and promote ‘‘ownership’’ of the project. Smaller teams may not besufficiently multidisciplinary, nor have enough people to carry out the work. Too largea team can make it difficult to keep all members effectively involved.
Different prob-lemsrequire different team compositions. Three elements should beconsidered whenselecting the QI team: system leadership, clinical technical expertise, and day-to-dayleadership.
System Leadership
At least one individual should have enough authority to affect changes in the specifictarget area. It is difficult to improve if the team does not have the authoritative leader-ship to implement change.
Clinical Technical Expertise
Include people who have expert knowledge of the key processes involved in theproject. Lack of knowledge regarding key project processes may result in faulty anal-ysis and flawed improvement approaches. Include personnel with basic QI training tokeep the team focused while following standard QI methodology.
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Day-To-Day Leadership: Project Champion
Everyprojectneedsaspark.Itiscriticaltoincludeateammemberwhodrivestheday-to-day progress of the project. Often this person is someone who is highly invested inthe targeted outcome. The enthusiasm and momentum that this ‘‘project champion’’brings to the team is crucial. Many projects do not get past the talking stage withoutthis type of person on the team.
Team Flexibility
Each team should be constructed to fit thespecific problem. If specialized informationis needed for certain aspects of a project, ad hoc committees can be added and usedin a focused fashion. A common ad hoc group is a parent committee or council thatcan be consulted for a family perspective on various issues on various projects.
EXAMPLES OF EFFECTIVE TEAM COMPOSITION
Project: Improving Nasal Continuous Positive Airway Pressure Use to DecreaseBronchopulmonary Dysplasia
The QI team might include a respiratory therapist, physician, nurse practitioner, nurse,and nurse educator. The team would have the background and authority to introducenew equipment and expertise to train the NICU staff.
Project: Reducing Medication Errors by Use of Standardized Order Sets
The QI team might include a physician, nurse practitioner, pharmacist, informationtechnology specialist, and nurse. This team composition would provide the back-ground and authority to develop and introduce new standardized order sets.
What is the Goal?
The QI project team must write a goal statement. To be useful, the goal statementshould be realistic and specific, and include numerical targets for specific measures.Further, the goal statement should include a time frame forthe project. Without a cleargoal, teamwork may be impaired. Many projects are plagued by goals that are toooptimistic and vaguely defined.
Examples of goal definition
The goal statement ‘‘we will eliminate bronchopulmonary dysplasia (BPD)’’ lacksa timeline and is neither specific nor tangible. This approach sets the team up forfailure. The following goal statement is clear, specific, and realistic: ‘‘through theimproved use of continuous positive airway pressure, we will decrease BPD, asdefined as a room air oxygen saturation of less than 90% at 36 weeks postmenstrualage, in babies less than 1500 g, from our baseline of 40% to 30% within 9 months.’’
What Will One Measure?
Measurement for QI is often misunderstood. Many individuals desire to implementresearch measurement methodology in their QI projects. This concept is understand-able,becausemostneonatologistshaveparticipated inresearchatsomepointintheircareersandreadtheresearch literature onaregularbasis.Unfortunately,thisbiascanslowimprovement,wasteresources,andcauseconfusionwhendevelopingmeasuresfor QI projects.
Key point: QI is not clinical research
Measurement for QI is different from measurement for clinical research. QI typically isfocused on the implementation of current knowledge, not the creation of new
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