EHM NCC 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)

–  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 63–74, January 2010

Sources of Variation: Practice and Processes
•  Variation within centers
–  Lack of standardization –  Uneven compliance

Variation Within PQCNC Centers
•  •  •  •  •  •  Feeding advances Holding feedings PDA treatment Initiation of antibiotics Use of caffeine Criteria for intubation

Sources of Variation: Technology
•  Neonatal Unit
–  Monitors –  Ventilators –  Infusion Pumps –  ECMO

•  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 babies…makes infection inevitable.”
Diana Luan, RN, PhD, Doctoral Dissertation submitted to Dartmouth College

Why We Can’t Do This
•  Tiny babies with central lines get infections •  We need a bigger budget & better equipment •  Our patients are different •  We can’t monitor each other •  Our doctors don’t think its possible •  Our nurses don’t 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

We’re 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 can’t 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

Partnering With Families & Patients: Gabby

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

Transforming Perinatal Healthcare
•  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 •  Incentivize collaboration

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

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