Empowering the Front LinesSalem Hospital NICU Quality Improvement

We will make each baby and family the center of our care. We will be compassionate and support each family as we share in

the care of their infant and as they nurture their baby.

NICU Leadership TeamJuly 28, 2008

Goals for today

• Familiarize you with the Vermont Oxford Network and our participation in it

• Update on Salem Hospital NICU performance

• Update on current Salem Hospital NICU Quality Improvement work

• Arrange for you to visit the NICU with a focus on further supporting our work and helping us engage our staff

Vermont Oxford Network (VON)• Started in 1988• Two databases

– VLBW infants (632 centers, 48,768 infants in 2006)

– Expanded DB (164 centers, 88,583 infants in 2006)

– Reports• Annual reports in September• Nightingale Web site

• Collaboratives– Two year QI Collaboratives– Internet Based Collaboratives

• Multi-center research trials

• Annual Quality Congress

Salem NICU Participation in VON• Database since 2004• NIC/Q Collaboratives

– NIC/Q 2007 and NIC/Q 2009

• I-NIC/Q collaboratives– Decreasing Late NICU infections– Value Compass– Neonatal Encephalopathy/Hypothermia

• Research– Hypothermia registry (treatment/follow up)– Nurse staffing

NICU Key Areas of Work

• Implement Evidence Based Clinical Practice changes and standardize clinical processes• Optimal management of intravascular devices for neonates • Safer care

– Improved resuscitation and stabilization and admission care – No late infections– Meet SH standards for regulatory patient safety goals

• Communication and Teamwork training and implementation• Developmental care• Family centered care • More equitable care for both babies and families• Increase individual staff engagement and capabilities around key areas of work• Support “Her Place” • Be environmentally greener• Develop a measurement system related to the work we are doing and connects us to the

Quality Improvement work of our hospital

NICU Measurement System

• Based on Dartmouth System– Patient Outcomes--Clinical Value Compass– Unit Quality—Balanced Scorecard– Additional supportive measures—Dashboard

• Linked to Family Birth Center and Salem Hospital Quality Initiatives– Cascading measures

Functional (Babies returning to FU Clinic)“My family adjusting well to having baby at home”“I feel good about my ability to care for my family and myself”Neurodevelopmental FU status

Clinical Value Compass

(Patient Population in Parenthesis)

Biological/Clinical (500-1500 , all admits)Survival w/o morbidityWeight gain and head circumference growth velocity Late infection rate

Cost (500-1500, all admits)LOS

Patient/Family Satisfaction Satisfaction with Kangaroo Care (all families interviewed)Press Ganey Overall Score (all)Press Ganey Overall Rank (all)

• Unit of analysis is patient

Database reports • Outcome and process measures

– Key performance measures

• Risk adjusted – 1 year, 3 year

• Comparisons– Network: VON average and 10th, 25th, 75th

percentile centers– US centers– Type A,B,C centers– Northwest Newborn Centers

NICU Risk Adjusted Outcomes

• Mortality

• Complications– Lung injury- pneumothorax, CLD– Brain injury-hemorrhage (IVH), ischemic (PVL)– Eye injury-ROP– Bowel injury-NEC– Late Infections-Noso, CON, LBI, Fungal

• Survival without morbidity

• Length of stay for Survivors

VLBW Births/Year

0

5

10

15

20

25

30

35

Births/year

2004

2005

2006

Expanded Database Admits

329

363

392

290300

310320330340

350360370380

390400

# admits

2004

2005

2006

NICU Comparative Outcomes

Top 25%

Top 10%

Above mean

Below mean

Measure Salem 2006 Salem 2004-6 VON VON-10th VON-25thpneumothorax 0 1 4 0 2.2

PVL 0 2 3 0 0CLD 7 7 26 6.3 14.3NEC 3 4 5 0 2.4

Severe IVH 4 2 6 0 5Severe ROP 0 0 9 0 1.6

LBI 7 3 11 1.5 5.5CNS 3 3 12 0 3.7

NOSO 10 6 20 5 10FUNGAL 0 0 2 0 0

MORTALITY 3 6 14 5.6 9.4DEATH/MORBIDITY 19 20 50 29.4 40AVE TOTAL LOS 43.6 58 49.9 57.2

Salem: VON Key Performance Measures in Color501-1500 Gram Birth Weight

Salem: VON Key Performance Measures in ColorAll NICU Admissions

2006 (392) 2004-06 (1082) VON VON 10th VON-25thpneumothorax 4 3 5 1.6 2.9

CLD 4 3 21 3.7 10.5NEC 1 0 2 0 0.6LBI 1 0 3 0.4 1CNS 0 0 3 0 3.9

NOSO 1 1 5 0.7 2.3FUNGAL 0 0 1 0 0

SURVIVAL 99 99 95 98.6 97.9SURVIVAL W/O MORBIDITY 90.3 86.5 87.6 82.8

AVE TOTAL LOS 10.8 10.8 21.8 13.2 16.2Adjusted Mean Total LOS 10 10.4 11.5

Core Processes: what are we trying to perfect?Time to hypothermia tx for HIECompliance with patient safety regulationsMRSA colonization conversions/monthROP exams per AAP guideline Spanish interpreter use rate% IV running in < 30 minutes in < 33 EGA babies FCC score # of PAC goals accomplished / year (11 goals)Rate admit temp < 36.5, 500-1500 gm BWNutrition bundle success rate

Core Processes: what are we trying to perfect?Time to hypothermia tx for HIECompliance with patient safety regulationsMRSA colonization conversions/monthROP exams per AAP guideline Spanish interpreter use rate% IV running in < 30 minutes in < 33 EGA babies FCC score # of PAC goals accomplished / year (11 goals)Rate admit temp < 36.5, 500-1500 gm BWNutrition bundle success rate

Customer Satisfaction: how should we appear to our customers?

NDNQI joy in NICU question NDNQI autonomy question# of referrals

oneonatalomaternal

Customer Satisfaction: how should we appear to our customers?

NDNQI joy in NICU question NDNQI autonomy question# of referrals

oneonatalomaternal

Innovation and Learning: how will we enhance our ability to change and

improve? NDNQI Professional development scoreEngagement Survey Results RN Neonatal Certification # or % of staffYears NICU experience / staff

Innovation and Learning: how will we enhance our ability to change and

improve? NDNQI Professional development scoreEngagement Survey Results RN Neonatal Certification # or % of staffYears NICU experience / staff

Green / Financial: How will we help sustain our organization’s mission, our

community and our planet? KPI measures# of referrals

oneonatalomaternal

Pounds plastic recycled/year # of NICU people supporting Her Place

Green / Financial: How will we help sustain our organization’s mission, our

community and our planet? KPI measures# of referrals

oneonatalomaternal

Pounds plastic recycled/year # of NICU people supporting Her Place

Balanced Scorecard • unit of analysis is microsystem = NICU

o 5 minute Apgar < 7o Days between late infections o Quarterly Reports on VON clinical outcomes o “Gimme 5” rate o NICU shift huddles o Video Resus and Communication/Teamwork participationo HIE/Hypothermia complications o Kangaroo Care episodes/patient day/month o Frequency our baby’s physician updated us o Time from NP culture to contact isolation for MRSA + babies o Hand Hygiene complianceo Patient safety knowledge regarding Universal Protocol (time outs)o Weaning from incubator audit o ROP exam measureso # of IV starts o 5 individual feeding bundle practices o # NICU Nursing Vacancieso Rate of Turnover from dissatisfactiono Attendance rate at PAC meetingso # of PAC familieso $$ provided to international NICU o Time/$$ provided to local community organizationo White Boards complete (bedside) o Non English family white boards complete (bedside)

NICU Dashboard• Measures that support the Value Compass and Balanced Scorecard

Salem Hospital (Macrosystem)

Women and Children’s Services

(Mesosystem)

NICU(Microsystem)

Quality and Safety

Inpatient MortalityHarms/100 patients Central line related infectionsNational Standards of CareResources/Flow

5 minute Apgar < 7Newborn stabilization measuresNICU measuresPerinatal Trigger tool (harms/100 patients)C/S < 30 minutesIHI bundlesCommunication/teamwork measures

Survival without morbidityLate infection measuresGimme 5Compliance with National Patient Safety GoalsLength of Stay

Stewardship

Operating margin Number of admissions Green building

KPI determinations (unit specific) KPI measures # of Maternal and Neonatal Referrals Recycling; styrofoam use$ to international NICU

Relationships

Patient satisfaction NDNQI MeasuresPhysician satisfaction

Patient SatisfactionNDNQI Measures

Family SatisfactionKangaroo care satisfactionPhysician communication satisfactionNursing vacancies/resignations for dissatisfaction NDNQI measures IHI family participation score

Professional Excellence

NDNQI MeasuresBest Medical Staff Empowering the front line (microsystem training)

NDNQI measuresCommunication/Teamwork educationFetal monitoring training

Participation in Video resuscitation reviewsParticipation in educationStaff engagement in QI work (VON)NDNQI measures

Cascading Measures