Closing the Gaps: Eliminating Chance in Neonatology Quality Efforts

In a recent webinar hosted by the American College of Healthcare Executives (ACHE), Amit Agrawal, MD, FAAP, Envision’s Regional Medical Director of Neonatology in Arizona, and Bridget Buzzella, MD, FAAP, Envision’s Regional Medical Director of Neonatology in Colorado and Kansas, gave a presentation discussing a number of methodologies aimed at improving neonatology outcomes, chief among them establishing a sustainable and effective quality improvement program.

No team can eliminate every possibility of negative neonatal outcomes, but when quality improvement initiatives fail to account for all of the key drivers of performance, they can develop significant blind spots. Regardless of the effort and desire to change, these blind spots inevitably leave outcomes up to chance.

By establishing a sustainable quality program supported by a multidisciplinary team that can leverage meaningful data, neonatology departments can minimize those negative outcomes that result from chance.

What Does an Airtight Neonatology Quality Program Look Like?

Cohesive, Multidisciplinary Quality Improvement Teams

Sustainable neonatology quality programs understand and prioritize the key drivers of clinical outcomes. That being said, it’s difficult to understand outcomes and establish relationships between individual metrics in a silo. Consider the link between maternal and neonatal care. If neonatologists focus solely on neonatal care, we lose half of our battle with quality improvement.

A sustainable program should be large, diverse and cohesive. Why? A holistic, multidisciplinary review of data is key to developing true data insights. Metrics and outcomes don’t tell the whole story; they just tell you where to look.

As such, neonatology quality programs should include a collaborative, multidisciplinary team of clinical and non-clinical teammates who can connect the dots. An interdepartmental team can help identify which metrics to target in alignment with hospital goals and help hospitals identify quality solutions by closing the gap between the numbers and the story behind them.

Quality Programs Customized to Patient Communities

Quality has to be tailored to community needs. One size does not fit all.

As such, each facility should implement quality programs that has a specific impact on its own patient community. For instance, quality programs at a facility whose patient community has a high incidence of gestational diabetes should focus on implementing targeted protocols directly related to understanding that rate of incidence and more effectively caring for moms and babies at risk for gestational diabetes.

Is There Something Wrong with Traditional Quality Improvement Processes?

Traditional quality improvement processes include a review of negative outcomes, the introduction of a solution, and then a later review of new data to determine whether or not that solution was successful in improving outcomes.

What’s missing from this approach? It tracks outcomes, but it doesn’t track the process.

The traditional setup attributes an improved outcome without knowing if the intervention was consistent and actually impacted the outcome. As such, this setup creates a gap wherein outcomes are left up to chance.

If an intervention or solution is utilized just 50 percent of the time, improved outcomes cannot be attributed to that solution. That gap in understanding your intervention and the impact it has exists frequently. Having insight into the entire process removes chance from the equation and allows a facility to say with certainty that any improvement is attributable to the interventions of the quality program.

Smaller NICUs are More Vulnerable

Insights into quality processes become especially important for small NICUs because smaller populations are predisposed to significant statistical variability year-to-year. In a population of only 30 or 50 patient cases of a given complication, one or two cases can significantly alter quality metrics. In these cases, the numbers can’t tell the whole story.

Gaining True Insight Into Quality Processes

A good way to identify the causes of a given issue is to look for patterns.

Consider this example: Envision Physician Services implemented a quality improvement process to combat increased incidence of necrotizing enterocolitis (NEC), a significant illness that can damage the intestines of premature infants. Envision’s quality team established a feeding protocol to improve outcomes for those patients. However, when the data reflected improvement one year after that intervention occurred, we still couldn’t say with certainty that new feeding protocols were responsible for that improvement. As such, the quality team began monitoring quality processes, researching and assessing key drivers.

We don’t always have to reinvent the wheel during this process. There has been plenty of previous work done on what drives reductions in NEC. We know that consistent feeding protocols, human milk and early feedings all lead to less incidence of the disease. These insights have already been researched. Once we understood that these drivers were being practiced consistently, we could finally say that our NEC rates had decreased because of the meaningful consistency with the implemented processes.

Quality teams should focus on the established key drivers that they may be missing. By identifying these key drivers, we can tailor our approach to quality in a meaningful way.

Properly Leveraging Clinical Data

Sustainable quality programs have to be able to collect, store and review data in real time. Tracking this data and making it accessible to all team members in real time creates transparency—a key part of effecting change and ensuring consistent outcomes. With this transparency, the inevitable notion of “educational decay” can be mitigated by addressing deviation in process consistency real-time. 

The frequency with which a facility reviews this mined data is also important. Monthly and quarterly meetings to review data among team members serve a vital purpose, as do year-end reviews. However, without more frequent reviews, developing true insight into the story behind the data can be a difficult task.

Of course, none of this is possible without buy-in, which is quite often a sticking point. Meaningful change doesn’t occur unless the team implementing the new quality program has a professional and personal commitment to drive that change. Thankfully, there are a number of ways to foster those connections.

Change Isn’t Always Fun—or Welcome

It’s tough to know what the response to an innovative idea is going to be. New implementations that disrupt established workflows can create resistance. People get set in their ways and may scoff at change, seeing new protocols as superfluous and a waste of the extra effort being asked of them. So how do we achieve buy-in?

1. Establish a Personal Connection to the Cause

   Helping the team establish personal stakes in the success of the quality program is an important part of achieving buy-in. Leadership must clearly communicate not only what is expected of its teammates, but also define the markers of success and how each individual can impact outcomes. Communicating in this way can help build each individual’s investment in the program.

2. Lead by Example

   Buy-in starts from the top. If we expect clinical and non-clinical teammates to adhere to new quality protocols, hospital and departmental leadership must first demonstrate a commitment to those protocols. Strong leaders play an integral role in managing an integrated team, so those in leadership positions have to be vigilant in their support of the quality program.

3. Demonstrate Value Through Metrics

   Quality metrics play a vital role in proving the value of newly implemented procedures. Sharing data with both leadership and the entire team on a routine basis will help ensure that each member of the team understands the “why” for all of their new protocols.

4. Implement a Multidisciplinary Approach

   We previously expressed the value that an interdepartmental team has to understanding metrics, but collaboration between departments can also validate the overall importance of the quality program. When individuals from multiple departments meet, teammates notice, and seeing those people come together can open eyes to the value the hospital places on that team’s efforts.