Developing Tools to Enhance the Adaptive Capacity (Safety II) of Health Care Providers at a Children's Hospital.

Current safety efforts in health care use Safety I (find and fix), which has benefits and shortcomings. Safety leaders in multiple industries realize that complex adaptive systems require a new approach-Safety II (proactive safety). Our goal was to develop practical, usable tools to spread Safety II and resilience engineering competencies to clinical frontline staff. Using our prior research and Plan-Do-Study-Act cycles, we developed tools to enhance Safety II competencies that individuals with various backgrounds could understand. Tools address recognizing (Pause to Predict), responding (IDEA), and learning (Feed Forward). These are being taught organizationally in a unit-by-unit sequence. Use of these tools is expected to prompt a shift toward a more proactive mental model of safety that we want our frontline providers to adopt. Coordinating the expertise of bedside clinicians during unprecedented events can safely expand the boundaries of conditions under which we can provide high-quality care by increasing individuals' and subsequently our systems' adaptive capacity. We believe this is the first work describing attempts to operationalize Safety II concepts broadly in a health care organization.

A multidisciplinary quality improvement effort to reduce bronchopulmonary dysplasia incidence.

BACKGROUND: Bronchopulmonary Dysplasia (BPD) is the most common prematurity complication. Although several practices have been proposed for BPD prevention, none of these in isolation prevent BPD. METHODS: Our initiative focused on two key drivers: oxygen management and noninvasive ventilation strategies. We created best practice guidelines and followed outcome measures using Shewhart control charts. RESULTS: PDSAs of protocols preceded a large-scale rollout of a "0.21 by 28" campaign in 2014 leading to a special cause reduction in the "any BPD" rate, and a decrease in severe BPD (from 57 to 29%). At the end of 2017, we reinvigorated the project, which led to dramatic decreases in the "any BPD" rate to 41% and the "severe BPD" rate to 21%. CONCLUSIONS: A multidisciplinary QI initiative focused on process improvement geared towards the pathophysiological contributors of BPD has successfully reduced the rate of BPD in an all referral level IV NICU.

A Quality Improvement Approach to Reduce Unplanned Extubation in the NICU While Avoiding Sedation and Restraints.

The unplanned extubation (UE), a common adverse event in the neonatal intensive care unit (NICU), may result in airway trauma, cardiopulmonary resuscitation, and, in extreme cases, death. As part of the Nationwide Children's Hospital NICU's effort to optimize NICU graduates' neurodevelopmental outcomes, skin-to-skin care of intubated infants is encouraged, while sedation and restraints to prevent UE are strongly discouraged. This project aimed to decrease the UE rate from 1.85 to 1.5 per 100 endotracheal tube (ETT) days. METHODS: The project occurred in a 114-bed, level-IV NICU with approximately 850 admissions per year and 100% outborn infants. A multidisciplinary team began biweekly meetings to review all UE events, later separating these into preventable and nonpreventable. Important ongoing tests of change included assigning a single process owner for UE reporting, ensuring proper ETT securement, and using 2 clinical staff during patient and/or ETT manipulation. RESULTS: Early in the project, enhanced detection led to an increased rate from 1.85 to 3.26 per 100 ETT days. However, identifying preventable events empowered staff to decrease the frequency to 2.03 per 100 ETT days. In August 2017, an ETT taping method change produced an increase in special causes due to decreased compliance. However, when securement methods were enhanced, noncompliance reversed and is now trending favorably. CONCLUSIONS: Decreasing UE in a neurodevelopmentally friendly unit, which avoids sedation and restraints, is challenging. Using a multidisciplinary quality improvement approach and after appropriately capturing events, we reduced UE, with the highest impact of intervention being ETT securement standardization.

Improved Safety Culture and Teamwork Climate Are Associated With Decreases in Patient Harm and Hospital Mortality Across a Hospital System.

OBJECTIVES: Improved safety and teamwork culture has been associated with decreased patient harm within specific units in hospitals or hospital groups. Most studies have focused on a specific harm type. This study's objective was to document such an association across an entire hospital system and across multiple harm types. METHODS: The Safety Attitudes Questionnaire (SAQ) was administered to all clinical personnel (including physicians) before, 2 years after, and 4 years after establishing a comprehensive patient safety/high-reliability program at a major children's hospital. Resultant data were analyzed hospital-wide as well as by individual units, medical sections, and professional groups. RESULTS: Safety attitude scores improved over the 3 surveys (P < 0.05) as did teamwork attitude scores (P = nonsignificant). These increases were accompanied by contemporaneous statistically significant decreases in all-hospital harm (P < 0.01), serious safety events (P < 0.001), and severity-adjusted hospital mortality (P < 0.001). Differences were noted between physicians' and nurses' views on specific safety and teamwork items within individual units, with nursing scores often lower. These discipline-specific differences decreased with time. CONCLUSIONS: Improved safety and teamwork climate as measured by SAQ are associated with decreased patient harm and severity-adjusted mortality. Discrepancies in SAQ scores exist between different professional groups but decreased over time.

Center, Gestational Age, and Race Impact End-of-Life Care Practices at Regional Neonatal Intensive Care Units.

OBJECTIVE: To assess the impact of intercenter variation and patient factors on end-of-life care practices for infants who die in regional neonatal intensive care units (NICUs). STUDY DESIGN: We conducted a retrospective cohort analysis using the Children's Hospital Neonatal Database during 2010-2016. A total of 6299 nonsurviving infants cared for in 32 participating regional NICUs were included to examine intercenter variation and the effects of gestational age, race, and cause of death on 3 end-of-life care practices: do not attempt resuscitation orders (DNR), cardiopulmonary resuscitation within 6 hours of death (CPR), and withdrawal of life-sustaining therapies (WLST). Factors associated with these practices were used to develop a multivariable equation. RESULTS: Dying infants in the cohort underwent DNR (55%), CPR (21%), and WLST (73%). Gestational age, cause of death, and race were significantly and differently associated with each practice: younger gestational age (<28 weeks) was associated with CPR (OR 1.7, 95% CI 1.5-2.1) but not with DNR or WLST, and central nervous system injury was associated with DNR (1.6, 1.3-1.9) and WLST (4.8, 3.7-6.2). Black race was associated with decreased odds of WLST (0.7, 0.6-0.8). Between centers, practices varied widely at different gestational ages, race, and causes of death. CONCLUSIONS: From the available data on end-of-life care practices for regional NICU patients, variability appears to be either individualized or without consistency.

Writing Group Increases Quality Improvement Writing Competency.

Quality improvement (QI) is critically important in current medical practice. Although many QI courses teach improvement science and methods, formal education in writing QI manuscripts for academic journal publication is lacking. The authors developed a QI Writing program, consisting of educational sessions with both coach and peer mentors, to improve comfort and productivity in preparing QI manuscripts for publication. Program participants conducted pre- and post-course QI writing skills self-evaluations in 4 competency domains: SQUIRE guidelines, writing for peer-reviewed journals, QI publication submission steps, and critically examining QI results. Course success was measured by the number of manuscripts submitted for publication. QI writing competencies doubled in 3 of 4 domains and increased 70% in the fourth. Fifteen of 17 (88%) course participants submitted manuscripts to a peer-reviewed journal, and 12 have been accepted to date. A formal writing group with didactic content and committed mentors increases QI writing competencies and manuscript submissions to peer-reviewed journals.

Clinical Decision Support to Improve Dosing Weight Use in Infants with Neonatal Abstinence Syndrome.

INTRODUCTION: Opioid abuse in the United States is a public health emergency. From 2000 to 2009, prenatal maternal opiate use increased from 1.19 to 5.63 per 1,000 births, with up to 80% of in utero opioid-exposed infants requiring pharmacotherapy. This study aimed to increase the percentage of neonatal abstinence syndrome (NAS) medication orders based on birth weight (BW) in neonates admitted to a neonatal intensive care unit with a principal diagnosis of NAS from 29% to 90%, within 4 months of project initiation, and to sustain this for 6 months. METHODS: This project occurred at an academic medical center with 5,000 deliveries per year and a 49-bed Level III neonatal intensive care unit. We used the Institute for Healthcare Improvement methodology, largely focusing interventions on clinical decision support (CDS) tools. We plotted all measures on Shewhart charts, and Nelson rules differentiated special versus common cause variation. RESULTS: The percent of orders based on BW increased from 29% to 78% after implementing multiple interventions focused primarily on CDS. However, this later decreased to 48% as workarounds began. There was also a significant decrease in the length of stay variability, which persisted throughout the project. DISCUSSION: CDS is a helpful tool to guide prescribing behavior; however, workarounds can negate its usefulness. Standardized use of BW for weight-based NAS medication prescribing can decrease the length of stay variability. Further studies are needed using a human factors approach to minimize workarounds in CDS and potentially decrease the length of stay in neonates with NAS.

Optimizing patient flow in a multidisciplinary haemophilia clinic using quality improvement methodology.

INTRODUCTION: Multidisciplinary clinics in academic settings are often inefficient and can lead to lengthy clinic visits for patients and staff. AIM: We aimed to use quality improvement (QI) methodology and a multidisciplinary approach to optimize outpatient comprehensive haemophilia clinic flow. METHODS: At baseline, a multidisciplinary QI team created a key driver diagram to identify drivers of haemophilia clinic flow. Identified drivers included patient needs/scheduling, provider flow and laboratory/research requirements. From December 2016 to August 2017, value stream mapping (VSM) was used to identify barriers to clinic flow, and plan-do-study-act cycles were used to address these barriers. Interventions included (a) standardizing the order in which providers saw patients to enable time-sensitive laboratories, (b) improving HTC team meeting functionality, (c) optimizing a visual management board and implementing a flow coordinator, (d) initiating a team huddle prior to clinic start and (e) modifying the clinic appointment template. Timely laboratory draw was used as a surrogate marker of clinic flow, and VSM utilization percentage was used as an objective measure of efficiency. RESULTS: We did not demonstrate a statistically significant improvement in timed laboratory draws; however, clinic utilization percentage increased by 30%, which resulted in adding point-of-care musculoskeletal ultrasound services without lengthening clinic duration. CONCLUSION: Quality improvement methodology is an effective means of improving clinic utilization in a multidisciplinary clinic.

Safety and feasibility of skin-to-skin care for surgical infants: A quality improvement project.

BACKGROUND: Skin-to-skin care (SSC) for infants improves physiologic stability, pain perception, brain development, parental bonding, and overall survival. Using quality improvement (QI) methodology, this project aimed to increase SSC for surgical infants in the neonatal intensive care unit (NICU). METHODS: A multidisciplinary working group composed of key NICU stakeholders instituted a needs assessment querying perceptions and concerns about SSC. Based on survey results, multiple system level interventions were implemented. Data for surgical infants receiving SSC during hospitalization were tracked over time using the electronic health record. RESULTS: Overall, 315 infants requiring a surgical consult were admitted to the NICU in the first 12 months of the project. After six months, SSC rates in this group increased from 51% to 60.5% (p < 0.01) and were sustained for 12 months. After one year, nursing staff reporting that they were somewhat to very comfortable providing SSC for surgical infants increased from 44% to 75% (p = 0.001) and the percent of nurses providing SSC for a surgical infant increased from 12% to 37% (p = 0.001). Inadvertent extubation did not significantly increase after implementation of the QI project. CONCLUSIONS: Using QI methodology and multidisciplinary engagement, SSC was integrated safely into the routine care of surgical infants in the NICU. LEVEL OF EVIDENCE: Level V.

Use of Electronic Health Record Integration for Down Syndrome Guidelines.

OBJECTIVES: Established guidelines from the American Academy of Pediatrics for the care of patients with Down syndrome are often not followed. Our goal was to integrate aspects of the guidelines into the electronic health record (EHR) to improve guideline adherence throughout a child's life span. METHODS: Two methods of EHR integration with age-based logic were created and implemented in June 2016: (1) a best-practice advisory that prompts an order for referral to genetics; and (2) a health maintenance record that tracks completion of complete blood cell count and/or hemoglobin testing, thyrotropin testing, echocardiogram, and sleep study. Retrospective chart review of patients with Down syndrome and visits to locations with EHR integration (NICUs, primary care centers, and genetics clinics) assessed adherence to the components of EHR integration; the impact was analyzed through statistical process control charts. RESULTS: From July 2015 to October 2017, 235 patients with Down syndrome (ages 0 to 32 years) had 466 visits to the EHR integration locations. Baseline adherence for individual components ranged from 51% (sleep study and hemoglobin testing) to 94% (echocardiogram). EHR integration was associated with a shift in adherence to all select recommendations from 61.6% to 77.3% (P < .001) including: genetic counseling, complete blood cell count and/or hemoglobin testing, thyrotropin testing, echocardiogram, and sleep study. CONCLUSIONS: Integrating specific aspects of Down syndrome care into the EHR can improve adherence to guideline recommendations that span the life of a child. Future quality improvement should be focused on older children and adults with Down syndrome.

Safety II Behavior in a Pediatric Intensive Care Unit.

: media-1vid110.1542/5763093009001PEDS-VA_2018-0018Video Abstract BACKGROUND AND OBJECTIVE: Safety I error elimination concepts are focused on retrospectively investigating what went wrong and redesigning system processes and individual behaviors to prevent similar future occurrences. The Safety II approach recognizes complex systems and unpredictable circumstances, mandating flexibility and resilience within systems and among individuals to avoid errors. We hypothesized that in our high-complexity and high-risk PICU, Safety II concepts contribute to its remarkably low adverse drug event rate. Our goal was to identify how this microsystem enacts Safety II. METHODS: We conducted multidisciplinary focus group sessions with PICU members using nonleading, open-ended questions to elicit free-form conversation regarding how safety occurs in their unit. Qualitatively analyzing transcripts identified system characteristics and behaviors potentially contributing to low adverse drug event rates in PICU. Researchers skilled in qualitative methodologies coded transcripts to identify key domains and common themes. RESULTS: Four domains were identified: (1) individual characteristics, (2) relationships and interactions, (3) structural and environmental characteristics, and (4) innovation approaches. The themes identified in the first 3 domains are typically associated with Safety I and adapted for Safety II. Themes in the last domain (innovation approaches) were specific to Safety II, which were layered on Safety I to improve results under unusual situations. CONCLUSIONS: Safety II behavior in this unit was based on strong Safety I behaviors adapted to the Safety II environment plus innovation behaviors specific to Safety II situations. We believe these behaviors can be taught and learned. We intend to spread these concepts throughout the organization.

Interprofessional QI Training Enhances Competency and QI Productivity Among Graduates: Findings From Nationwide Children's Hospital.

PURPOSE: Significant resources are expended on quality improvement (QI) training courses. The authors sought to determine whether education provided in QI course training improves self-assessed QI content competence and QI-related productivity among course graduates. METHOD: "Quality Improvement Essentials" is a four-month didactic and experiential course designed to prepare multidisciplinary professionals to participate in and lead QI efforts at Nationwide Children's Hospital (NCH). This study used a milestone-based self-assessment survey of graduates from 2012 to 2014 to gauge change in participants' self-assessed QI competency after course completion. Four competency domains were evaluated: QI knowledge; testing and implementing change using teams; data management and analysis; and spreading and sustaining science. Metrics for assessing individual QI productivity were presentation or publication of QI work outside NCH; local, regional, or national QI teaching; serving on a local, regional, or national QI committee; appointment as a QI leader; involvement in an internal or external QI collaborative; and leading a maintenance of certification Part IV project approved by NCH. RESULTS: Course participation more than doubled participants' self-assessed QI competence across all four domains. Gains continued after the course, increasing with time rather than degrading. Self-assessed competency increase was significantly associated with increased QI productivity. CONCLUSIONS: Self-assessed QI competence dramatically improved after participation in an educational course and continued to increase over time. Increased self-assessed QI competency correlated with increased individual QI productivity. Further studies are necessary to fully evaluate "return on investment" for this type of course.

Integrating a Geneticist in a Multidisciplinary Clinic for Down Syndrome Increases Commitment to Genetic Counseling.

BACKGROUND: Although most physicians and genetic professionals are familiar with Down syndrome, many families do not have experience with Down syndrome before having a child diagnosed. The American Academy of Pediatrics has specific recommendations for genetic counseling and chromosome analysis for Down syndrome. LOCAL PROBLEM: The literature indicates that adherence to completion of appropriately timed genetic counseling is low at 31%. This study was initiated to determine our adherence rates and to improve if needed. METHODS: In the Down syndrome clinic at Nationwide Children's Hospital, a subspecialty clinic in the Division of Developmental and Behavioral Pediatrics, a genetic counselor was on-call but did not routinely attend. The intervention consisted of multidisciplinary care with the presence of a clinical geneticist. Statistical Process Control Charts and Fisher's exact test were used to determine the impact of the intervention. RESULTS: Our baseline rate of adherence to genetic counseling was similar to previous publications. Direct genetics involvement in the Down syndrome clinic in place of an on-call genetic counselor led to significant improvement in adherence to genetic counseling recommendations over a 6-month period from 35% to 62%, P < 0.001 and sustained for 6 months. Postclinic adherence rates and subanalyses by age showed similar results. The final postvisit adherence rate of 89% in February 2017 demonstrates continued improvement. Geneticist involvement allowed chromosome reports uploading and karyotype listing in electronic medical records. IMPLICATIONS AND LESSONS LEARNED: Genetic counseling in newborns with Down syndrome is important, yet was often not received at Nationwide Children's Hospital before this study. Integrating a geneticist resulted in improvement. Implementing similar models at other institutions can ensure that the correct genetic testing is completed, results documented and families counseled appropriately.

Skin Rounds: A Quality Improvement Approach to Enhance Skin Care in the Neonatal Intensive Care Unit.

BACKGROUND: Skin injuries are common among neonatal intensive care unit (NICU) patients and may lead to significant complications. Standardized methods of preventing, detecting, and treating skin injuries are needed. PURPOSE: The aim of this project was to standardize the assessment, documentation, and tracking of skin injuries among hospitalized neonatal patients and to determine the incidence of pressure ulcers in this patient population. METHODS: (1) Creation of an interdisciplinary skin team to identify skin injuries through weekly skin rounds. (2) Assessment of all patients at least twice daily for the presence of skin injuries. Interventions were implemented upon identification of a skin injury. Pressure ulcers of Stage II or more were further assessed by wound/ostomy nurses. FINDINGS: A total of 2299 NICU patients were hospitalized and assessed between July 2011 and December 2015. After the initiation of skin rounds, the baseline incidence of pressure ulcers increased from 0.49 per 1000 patient days to 4.6 per 1000 patient days, reflecting an improvement in detection and reporting. The most common skin injuries detected included erythema, skin tears, and ecchymosis; the most common cause of injuries was medical devices. IMPLICATIONS FOR PRACTICE: A dedicated skin team can improve the detection and reporting of skin injuries among NICU patients. Determination of the incidence of pressure ulcers in this population is critical to develop targeted interventions. IMPLICATIONS FOR RESEARCH: Further research is needed to determine the most effective interventions to prevent and treat skin injuries among hospitalized neonates.