PQCNC SIVB2 LS2 Quality Collaboration

7/31/2019 PQCNC SIVB2 LS2 Quality Collaboration

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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


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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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Accounting for Risk and Chance

Risk Adjustment ModelsVON Risk Adjustment ModelSNAPPE scoring methods

ChanceVariety of statistical methods

Bayesian Shrinkage Analysis


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Sources of Unexplained Variation

People Practices and processes Technology 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

9

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)

OB Research Networks (Obstetrix)VON PQCNC Report


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Antenatal Steroid Use in CA 2005-2007

11

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

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 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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Practice and Processes

Variation within centersLack of standardizationUneven compliance


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Variation Within PQCNC Centers

Evaluation of patients in triage Methods of InductionEvaluation of labor progressTechnologyStaff

Ability to execute a CS


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Technology

Equipment Infusion Pumps Monitoring Systems

Hospital CPOE Imaging Laboratory Pharmacy


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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




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Radar plot of organizational culture




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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

W ki h


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Were 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


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Why We Must Do This


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Why We Must Do This


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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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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.

Helen Keller

Documents

PQCNC SIVB2 LS2 Quality Collaboration