Elsevier

Academic Pediatrics

Volume 13, Issue 6, Supplement, November–December 2013, Pages S75-S83
Academic Pediatrics

QI in Clinical Settings
Quality Improvement Initiatives in Neonatal Intensive Care Unit Networks: Achievements and Challenges

https://doi.org/10.1016/j.acap.2013.04.014Get rights and content

Abstract

Neonatal intensive care unit networks that encompass regions, states, and even entire countries offer the perfect platform for implementing continuous quality improvement initiatives to advance the health care provided to vulnerable neonates. Through cycles of identification and implementation of best available evidence, benchmarking, and feedback of outcomes, combined with mutual collaborative learning through a network of providers, the performance of health care systems and neonatal outcomes can be improved. We use examples of successful neonatal networks from across North America to explore continuous quality improvement in the neonatal intensive care unit, including the rationale for the formation of neonatal networks, the role of networks in continuous quality improvement, quality improvement methods and outcomes, and barriers to and facilitators of quality improvement.

Section snippets

Rationale for CQI Initiatives in the Neonatal Intensive Care Unit

An imperative for embracing CQI in the NICU is that from the 1960s to the 1990s, major advances in perinatal care, such as the regionalization of perinatal health care, administration of antenatal steroids, surfactant replacement therapy, and newer modalities of assisted ventilation and nutritional support, led to significant reductions in mortality and short-term morbidities for preterm and very low birth weight (VLBW) infants.5, 6, 7, 8, 9 However, since then, several reports have suggested a

Role of Networks in CQI

The advent of networks focusing on CQI can be traced to Wennberg and colleagues, who showed that small-area variations can be used to study the relative effectiveness of differing medical practices and technologies, and that feedback of information concerning variation in practices can modify physician practices.22, 23 Variations in practices are important because they are natural experiments that reflect the practice patterns of small groups of physicians and because they can be used to

Risk Adjustment

A major concern about multi-institutional outcome comparisons, even within a country or region, is that one may be considering apples and oranges because of differences in patient risks, practices, resources, and other variables. Consequently, most networks use some form of risk adjustment in their benchmarking systems, which usually includes basic patient characteristics such as gestational age, birth weight, gender, perinatal risks, mode of delivery, and illness severity at admission. As

CQI Methods in the NICU

Many definitions and frameworks for quality improvement have been developed and adapted for use in health care settings and contexts.28, 29, 30, 31 Within the specific setting of the NICU, CQI initiatives are ongoing across the world,32, 33, 34 and although they may all take slightly different approaches, there are some elements that are common to most, if not all. These components include use of the best available evidence to support practice change, adaptation of practice changes to each

Outcomes of CQI in the NICU

In terms of the impact and effectiveness of CQI collaboratives, while their use is widespread, their results have been mixed (Table). A systematic review by Schouten et al in 200843 concluded that “the evidence underlying quality improvement collaboratives is positive but still limited and that the effects cannot be predicted with great certainty.” Several of the larger NICU CQI collaboratives, including CNN-EPIQ,34 various state-based initiatives, such as the CPQCC,32and other networks such as

Determinants of Successful Health Care Quality Improvement

Key success factors for health care quality improvement include strong administrative and performance improvement leadership, effective oversight, involvement of expert quality improvement staff, physician involvement and accountability, active staff involvement and buy-in, effective use of data for decision making, and effective communication strategy.75 The culture of the organization implementing the practice changes is also important. According to VON, some potentially better practices for

Future Challenges and Opportunities

To fully leverage the power of neonatal networks and optimize care for the developing infant, CQI initiatives targeting neonatal care should incorporate not only practice changes within the NICU, but also management of the pregnant woman and post-NICU discharge interventions. Use of mixed methods for data analysis may provide additional insights because context and organizational factors are the key to successful quality improvement efforts. At the same time, more pragmatic and less time

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    The views expressed in this report are those of the authors and do not necessarily represent those of the US Department of Health and Human Services, the Agency for Healthcare Research and Quality or the American Board of Pediatrics Foundation.

    The authors declare that they have no conflict of interest.

    Publication of this article was supported by the Agency for Healthcare Research and Quality and the American Board of Pediatrics Foundation.

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