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Developing a Unit-Based Quality Improvement Program in a Large Neonatal ICU

09/23/2021

By M. Eva Dye, DNP, APRN, NNP-BC

Quality improvement (QI) initiatives can improve patient outcomes but tackling a QI project can be daunting. The task is even larger when scaling up and coordinating multiple teams and projects within a unit, clinic, or organization. 

In 2015, our Neonatal Intensive Care Unit (NICU) at Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, set a goal to build a program to support our QI teams. Our efforts are detailed in the October issue of The Joint Commission Journal on Quality and Patient Safety (JQPS). 

We developed both a mission and global aim for our program:
Mission: Improve outcomes for infants and families in the NICU
Global aim: Develop a multidisciplinary, unit-based QI program to facilitate existing improvement teams and grow new teams to target areas of improvement

Program Pillars
We wanted to make the process of doing QI work less daunting and to ensure that our QI projects and teams were coordinated. To develop our program, we used QI methodology – setting aims, completing tests, and measuring to see what worked – basically “QI to improve QI.”   

We developed six pillars or key drivers that guide our program:

  • Shared vision for QI in the NICU – engaged unit and hospital leadership and developed a QI dashboard
  • QI team capacity – provided education for QI teams and leaders and embedded mentors on improvement teams to provide methodological support
  • QI team capability – conducted needs assessments of improvement teams to identify what teams needed to be successful
  • Actionable data for improvement – developed a secure, streamlined, and shared database to ease data collection and reduce redundant data collection between teams
  • Culture of improvement – improved transparency of outcome data with staff to engage the entire unit
  • QI team/project integration with external collaboratives – leveraged collaboratives outside our organization to augment our improvement team initiatives

Multidisciplinary Teams
One of the key components of our program and what I consider the “secret sauce” that makes our program successful is our multidisciplinary QI leadership team. Our QI leadership team started meeting monthly (and continues to meet) as we built our program and consists of a:

  • physician
  • advanced practice nurse
  • registered nurse
  • respiratory therapist
  • quality advisor from our hospital’s Performance Management and Improvement Department

Working together and meeting regularly has enabled us to avoid silos of information that often occur between disciplines in large units. We each bring a unique perspective which allows for program improvements that benefit the entire unit. This multidisciplinary focus is repeated on our improvement teams as well.

Improvements in Outcomes
We saw improvements in our outcomes as we coordinated and developed our QI program. Our preterm infants improved their growth, and our unit had fewer infections. We also made improvements in:

  • evidence-based respiratory care of ventilated patients (increased use of volume-targeted ventilation)
  • the number of infants receiving breast milk
  • decreasing unplanned extubations

Our program and access to actionable data also allow us to recognize areas where there is still need for improvement. We continue to work on reducing bronchopulmonary dysplasia and intraventricular hemorrhage – two common morbidities of extreme prematurity. Addressing these problems requires coordination across multiple project teams and use of all our program pillars to improve the care of our tiny patients. 

M. Eva Dye, DNP, APRN, NNP-BC, is an Assistant Professor at Vanderbilt University School Nursing and a Neonatal Nurse Practitioner in the Department of Pediatrics, Division of Neonatology, at Vanderbilt University Medical Center, Nashville.