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Evidence-Based Quality Improvement in Neonatal and Perinatal Medicine: The Neonatal Intensive Care Quality Improvement Collaborative Experience

^a Department of Pediatrics, University of Vermont, Burlington, Vermont
^b Vermont Oxford Network, Burlington, Vermont
^c Paul E. Plsek & Associates, Inc, Roswell, Georgia

Key Words: quality improvement • safety • neonatal intensive care

Abbreviations: VON, Vermont Oxford Network • NIC/Q 2002, Neonatal Intensive Care Quality Improvement Collaborative 2002 • PBP, potentially better practice

This supplement is a collection of original articles written by participants in the Vermont Oxford Network (VON) Neonatal Intensive Care Quality Improvement Collaborative 2002 (NIC/Q 2002). It is the third in a planned series of supplements that began in January 1999 with the electronic supplement in Pediatrics titled "Evidenced-Based Quality Improvement in Neonatal and Perinatal Medicine"¹ and continued in April 2003 with "Evidenced-Based Quality Improvement in Neonatal and Perinatal Medicine: The NIC/Q 2000 Experience."²

The premise of this series is that the quality of practices in clinical, organizational, and operational care for newborn infants and their families can be improved dramatically using the 4 key habits for improvement³: (1) systems thinking; (2) a habit for change; (3) evidenced-based clinical science; and (4) multicenter, multidisciplinary collaborative learning. This current collection represents the work of the NIC/Q 2002 Evidenced-Based Quality Improvement Collaborative in Neonatology. The articles in this collection provide a detailed description of a multiinstitutional improvement collaborative. They should be of interest to health care providers as they pertain both to the NICU setting specifically and to collaborative quality improvement in general.

The collaborative, sponsored by the VON, comprised multidisciplinary teams from NICUs in the United States and Canada. The 46 centers in the NIC/Q 2002 collaborative were selected on the basis of willingness to make the personal and financial commitment to join the project with an annual fee, as well as funding travel expenses for the teams. Each center was responsible for determining whether local Institutional Review Board approval was necessary for participation. The 46 centers and their key personnel are listed in Appendix 1. They include many sites from the NIC/Q and NIC/Q 2000 collaboratives. These teams worked together from March 2000 through October 2003 with the guidance of expert faculty and staff (Appendix 2) to identify, test, and implement change ideas that are designed to improve the quality and safety of care. We refer to these change ideas as "potentially better practices" (PBPs), rather than the more commonly used term "best practices," to indicate that there is uncertainty and that what is best in 1 setting may not be in another. Some of the change ideas are based on strong scientific evidence, whereas others are based on expert opinions, benchmarking site visits, family recommendations, and group discussions. The strength and evidence for the PBPs was assessed by the teams using the Muir Gray classification system.⁴ The PBP recommendations were documented using the Potentially Better Practice Concept Worksheet (Fig 1). In addition to developing PBPs, patient safety was a strong underlying theme of the collaborative, which worked closely with the Center for Patient Safety in Neonatal Intensive Care funded by the Agency for Healthcare Research and Quality.

View larger version (36K): [in this window] [in a new window]   FIGURE 1 Potentially Better Practice Concept Worksheet used by exploratory-group teams to record their PBPs. Courtesy of the VON.

This supplement includes articles from 6 of the exploratory groups. There are 2 articles from each of the groups; the first describes the development of PBPs, and the second describes the implementation and testing of these practices. The final section includes 5 additional articles that developed out of the collaborative work in the areas of oxygen saturation targeting, standards for nasal cannula oxygen administration, sucrose for analgesia, treatment of infants at the margins of viability, and management of high-order multiple births. The authors for this collection are volunteers from the participants of the NIC/Q 2002 exploratory groups. Some of the authors have published widely in the past, whereas others are acting as first author for the first time. The most important aspect of this collection is the dedication and teamwork demonstrated by all of the participants in the collaborative. Their interest in improving the quality and safety of care for high-risk newborn infants and their families is to be commended.

Another important point is that PBPs that are presented in this collection are just that: "potentially" better. These are only recommended potentially better practices, not scientifically proven "best" practices. The practices that are described in this collection do not represent guidelines or consensus statements. It is possible that if subjected to rigorous randomized trials, then some of the PBPs might not be supported and would need to be revised or deleted. The PBPs are not endorsed by the VON; rather, these practices are the work product of multidisciplinary teams that are involved in a multicenter quality improvement collaborative. They are only a work in progress. We are sharing them with the hope that they will be used as a starting point for assessing and improving practices in NICUs beyond our collaborative.

	APPENDIX 1: NIC/Q 2002 PARTICIPATING CENTERS

TOP APPENDIX 1: NIC/Q 2002... APPENDIX 2: NIC/Q 2002... REFERENCES

 
Advocate Lutheran General Children's Hospital, Park Ridge, IL
Raghbir Benawra, MD

Diane Boyle, RN, MBA

Jeffrey A. George, DO

Kim Jenkins, RN

Nancy Marshall, RRT

Susan Okuno-Jones, RN, MA

Akron Children's Hospital, Akron, OH
Anand Kantak, MD

Judy Ohlinger, RNC, MSN

Debbie Seiber, RNC, BSN, CNNP

Dana Nelson, RN, MSN, CNS

Justin Lavin, MD

Jeff Butler, MD

and all other team members from Akron Children's Hospital, Summa Health System, and Akron General Medical Center

Baptist Children's Hospital, Miami, FL
Frederique Auguste, RN

Elizabeth Rall, RN

Ivette DeLeon, RRT

Sandy Seaton, RN

Ernesto Valdes, MD

Andrew Kairalla, MD

Barbara Bush Children's Hospital at Maine Medical Center, Portland, ME
Daniel Sobel, MD

Jani Kinder, RN

Annette Kissen, NNP

Debbie Igo, RT

Heidi Towes, RN

Lynn Lagerstrom

Baylor University Medical Center, Dallas, TX
Tammy Marnell, RN

Pam S. McKinley, RN

Vance Redfield, MD

Gloria Allen, RN

Diane Weiss, RN, NNP

Gordon Hill, PharmD

Benefis Healthcare, Great Falls, MT
Evelyn D. Rider, MD

Beckett Perkins, NNP

Rob Archer, RRT

Cheryl Worden, RN

Heather Lilly, RN

Carle Foundation Hospital, Urbana, IL
William Stratton, MD

Kim Gelke, MD

Donna Belcher, RN, MS

Carey Gaede, RN, BSN

Lisa Davis, RNC, BSN

Kathey Voelker, NNP

Central Mississippi Medical Center, Jackson, MS
Luretha Smith, CNNP

John Rawson, MD

Paula Metzger, CRN

Patricia Johnson, RN

Children's Hospitals & Clinics, Minneapolis, MN
Nathaniel R. Payne, MD

M.J. Crosby, RNC, MS

Janet Lissick, RCP

Marty Lewis-Hunstiger, RN

Children's Hospitals & Clinics, St Paul, MN
Erik Hagen, MD

Gabriela Ferski, RN, MPH

Kathleen Schoenbeck, RN

Nancy Schult, RN

Nancy Watkins, NNP

David Lynch-Salamon, MD

Children's Hospital & Research Center at Oakland, Oakland, CA
Richard Powers, MD

Nick Mickas, MD

Linda LeFrak, RN, CNS

Leslie Burrows, RN

Teresa Proctor, RN

Pamela Koch, RN

Children's Hospital at Bronson, Kalamazoo, MI
Gerald Purdy, MD

Mary Steinke, RN

Linda Smith, RN

Jamie McCune, RN

Bettina Muscara, RN

Peg Malnight, RN

Children's Hospital of Illinois at OSF St Francis Medical Center, Peoria, IL
Julie Hodges, RN, BSN

James R. Hocker, MD

Susan B. Ramiro, MD

Lorraine Easton, RN

Elaine Hartmann, RN, MS, NNP

Pat Hegwood, RN, BSN, MA

Children's Hospital of Orange County, Orange, CA
Sudeep Kukreja, MD

Karen MacGillivray, RN

Mindy Morris, MS, CNNP

Linda Glenn, MN

Julie Hall, RN

Children's Mercy Hospital, Kansas City, MO
Jodi Jackson, MD

Michael Sheehan, MD

Mary Kay Leick-Rude, RNC, MSN

Barbara Haney, RNC, MSN, CPNP

Sherri Leeks, NNP

Betsi Anderson, RN, BSN, CPHQ

Children's Neonatal Services, Columbus, OH
Alfred Gest, MD

Tamara Wallace, RNC, MS, CNNP

Judy Hanlon, RNC, MSN, CNNP

Patricia Silver, RRT, Med

Dartmouth-Hitchcock Medical Center, Lebanon, NH
William H. Edwards, MD

Caryn Spielman McCoy, MSN, RN

Melinda Warren, RN, BSN

Kim Knoerlein, MSN, ARNP

Stephanie Trout Berman, RNC

Tammy Lambert BSN, RNC

DeVos Children's Hospital, Grand Rapids, MI
Amy Atwater, RN

Joan Rikli, RN, MSN, PNP

Kara Coker, CNS

Mitchell DeJonge, Neonatologist

Nancy DeNolf, NNP

Barb McGorty, RT

Exempla St Joseph Hospital, Denver, CO
Susan Jajczyk, RN

Diane Johnston, RN

Terri Sandoval, RN

John Van Bibber, NNP

Christinia Ukrainski, MD

Alfonso Pantoja, MD

Fairview-University Hospital, Minneapolis, MN
Margaret Harder, RN, MA

William Rosen, MD

Beverly Rose, RNC

Marla Mills, RN, CNP

Rose Weber, RNC

Geisinger Medical Center, Danville, PA
Paula Jacobs, CRNP

Jody Bachman, RN

Darlene Mensinger, RN

Carol Gerber, RN

Maureen Lloyd, RN

Lauren Johnson-Robbins, MD

Hackensack University Medical Center, Hackensack, NJ
Krystyna Toczylowski, RN, MSN

Cassandra Martin-Walters, RN, MSN

Harold Perl, MD

Michelle Lasker, MD

Kathy Cohen, RNC

Sue Thorsland, MS, RD, CNSD

Inova Fairfax Hospital for Children, Falls Church, VA
Claire Pagano, RN, MGA

Jill Duncan, RN, MSN, MPH

Mark Fowler, MD

Barbara Hall, RN, NNP

Jo Cooper, RN, BSN

Becky Beck, MA

Jackson-Madison County General Hospital, Jackson, TN
Betty Beverly-Brown, RN, MSHA

Tammy Hardee, RN

Stalita Jo Rivers, RN

Allie Smith, RN, MSN

Wendy Moore, RN, BSN

Joe DiMaggio Children's Hospital, Portland, OR
Tamara Bledsoe, RNC, MSN, NNP

Kathy Kamp, RNC, ASN

Jennifer Igo, RNC, BSN

Susan Gutierrez, RNC, BSN

Robert Hoopes, RNC, BSN

Bella Cabrera, RNC, MSN

Lee Memorial Health System, Fort Myers, FL
William Liu, MD

Michelle Waddell, RNC

Pam Laferriere, RNC, ARNP

Brad Baumgardner, RRT, BS

Sandra Eanes-McGugan, RN, BSN

Candace Pemberton, RN

Legacy Emanuel Children's Hospital, Portland, OR
Cathy Robinson, RN

Louise M. Baxter, MD

Sharon Baker, PharmD

Frances McGovern, RRT

Kerri B. Norman, RPh

Katya Bulaevskaya, MSN, RNC, CNS

Lucile Packard Children's Hospital, Palo Alto, CA
William Rhine, MD

Deirdre McAllister, RN

Carol Kibler, RN

Christina Almgren, PNP

Linda Cerini, RN

Paul Sharek, MD, MPH

Methodist Hospital, Indianapolis, IN
Mitsy Halbert, RRT

Howard Harris, MD

Debra Hutchens, RN, NNP

Rita Kenney, RN

Charles Njinimbam, MD

Roberta Roesler, RNC, MSN

Miami Valley Hospital, Dayton, OH
Rheta Caravantes, MNSc, CNS, RNC

Kathy Mason, RNC

Brenda Burkholder, MSN, CNP, RNC

Theresa Puthoff, PharmD

Tammy Samiec, MD

Mission Hospital, Asheville, NC
Anne Ramirez, RN, MSN

Barb Prieur, RRT, RCP

Donna Cravener, BSN

Ginny Raviotta, RN, MN

Charles Yoder, MD

Tammy Cody, LCSW

New Hanover Regional Medical Center, Wilmington, NC
Debra McLendon, RN

Debbie Lockey, RN

Susan Miller, RN

George McLean, RT

Patty White, RN

Pamela Davison, RN

Parkview Hospital, Fort Wayne, IN
Joel Secrest, MD

Lori Norton, RN

Laura Michael, RN

Maria Freeman, RN

Jim Moehring, RRT

Pat Carteaux, RN

Providence St Vincent Medical Center, Portland, OR
Joseph Kaempf, MD

Robert Gallegos, RT

Donna Shackelford, RN

Mark Tomlinson, MD

Cindy Arduza, NNP

Mara Zabari, RN, MPA-HA

Rockford Memorial Hospital, Rockford, IL
Pat Ittmann, DO

Ona Fofah, MD

Barb Prochnicki

Anthony Lathrop

Pat Fett

Sue Swanson

Laura Rissman

Ruth Meinhardt

Sparrow Hospital, Lansing, MI
Padmani Karna, MD

Susan Davis, RN

Sandy Geller, RN

Carolyn Herrington, RN

Patricia Kaldor, RRT

Melody Sowers, RT

St Barnabas Medical Center, Livingston, NJ
Shyan Sun, MD

Kamtorn Vangvanichyakorn, MD

Joyce Major, RN

Eileen Steffen, RN

St John Hospital and Medical Center, Detroit, MI
Deepak Patel, MD

Gayle Novack, BSN, MA, RN

Renato Casabar, MD

Sandra Scerri, BSN, RNC

Amy Donato, RN

Ali Rabbani, MD

St John's Mercy Medical Center, St Louis, MO
Jay Brenner, MD

Mary Bekebrede, RANK

Lisa Finley, RNC

Kelly Burch, PharmD

Mary DAngelo, NNP

Jeanne Fischesser, NNP

Sunnybrook & Women's College, Health Sciences Center, Toronto, Ontario, Canada
Michael S. Dunn, MD

Maureen C. Reilly, RRT

Denise Zayack, RN, BA

The Children's Hospital at Providence Alaska, Anchorage, AK
Jack Jacob, MD

Mary Diel, RNC

Deb Sims, RNC

Carol Van de Rostyne, RN, ANP

Jeannie Bieganski, RN

Suzanne Nash, RN, CM

Vermont Children's Hospital at Fletcher Allen Health Care, Burlington, VT
Anne M. Johnston, MD

Charles E. Mercier, MD

Candice E. Bullock

Michele Bouchard, RN

Merja K. Cahoon, RNC, NNP

Deborah Rowell, RN, NNP

Wake Forest University Medical Center, Winston-Salem, NC
Steven M. Block, MD

Constance Purkey, RN

Diane Hudson-Barr, RN, PhD

Tonya Oliver, MA, RNC

Kristi Coe, MA, RNC

Amanda Butler, RN

Wesley Medical Center, Wichita, KS
Paula Delmore, MSN

Frances Hampton, MSN

Susan Laudert, MD

Natalie Reynolds, BSN

Amy Koehn, ARNP

Woman's Hospital, Baton Rouge, LA
Alston Dunbar, III, MD

Betsy Swett, RNC

Melanie Perkins, RN

John Dugas, RRT

Cliff Richardson, RNC, NNP

Yakima Valley Medical Center, Yakima, WA
Elizabeth L. Engelhardt, MD

Chris King, RN

Linda Haralson, RN

Diane Padilla, RN

Diana Frampton, RN

Kristin Crites, RN

	APPENDIX 2: NIC/Q 2002 FACULTY AND STAFF

TOP APPENDIX 1: NIC/Q 2002... APPENDIX 2: NIC/Q 2002... REFERENCES

 
Jeffrey D. Horbar, MD

NIC/Q Director

Chief Executive and Scientific Officer

Vermont Oxford Network

Burlington, VT

Paul E. Plsek, MS

NIC/Q Co-Director

Paul E. Plsek & Associates, Inc

Roswell, GA

Kathy Leahy, RN, NNP

NIC/Q Coordinator

Vermont Oxford Network

Burlington, VT

Marie Abraham

Institute for Family Centered Care

Old Lyme, CT

Sunny Anand, DPhil, MBBS

Morris & Hettie Oakley Endowed Chair of Critical Care Medicine

Professor of Pediatrics, Anesthesiology, Pharmacology, Neurobiology & Developmental Sciences

UAMS College of Medicine

Director, Pain Neurobiology Laboratory

Arkansas Children's Hospital Research Institute

Little Rock, AR

Barbara Bauman, MPA, MSN, RN

Independent Health care Consultant

Tavernier, FL

Joseph Carpenter, MS

Director of Technical Operations

Vermont Oxford Network

Burlington, VT

Nancy Morse Cloutier

Meeting Coordinator

Vermont Oxford Network

Burlington, VT

William Edwards, MD

Professor of Pediatrics

Children's Hospital at Dartmouth

Lebanon, NH

Pam Ford

Special Projects Assistant

Vermont Oxford Network

Burlington, VT

Donald A. Goldmann, MD

Professor of Pediatrics

Harvard Medical School

Boston Children's Hospital

Boston, MA

Jay P. Goldsmith, MD

Chairman Emeritus

Department of Pediatrics

Ochsner Clinic Foundation Hospital

New Orleans, LA

James Gray, MD

Assistant Professor of Pediatrics

Harvard Medical School

Boston, MA

Louis Halamek, MD

Associate Professor of Pediatrics

Stanford University

Palo Alto, CA

James Handyside

Improvision

London, Ontario, Canada

Maria Hill, RN, MS, CMAC

Senior Consultant

Center for Case Management

Cedarburg, WI

Celeste Johnston, RN, DEd

Professor School of Nursing

McGill University

Montreal, Quebec, Canada

Hannah King, MPH

Senior Consultant

Kaiser Permanente

Oakland, CA

Meena LaCorte, MD

Associate Professor of Clinical Pediatrics

Weill Cornell Medical College

New York, NY

Nancy Leahy-Jacklow

Independent Consultant

Arlington Heights, IL

Jerold F. Lucey, MD

President

Vermont Oxford Network

Burlington, VT

Deb Miller, BSC

St Joseph's Health Care London

London, Ontario, Canada

Diane Miller, MBA

Director

Institute for Healthcare Improvement

Bellevue, WA

Julianne Nickerson, MSW

Parent Consultant

Center for Patient Safety in Neonatal Intensive Care

Underhill, VT

Janice Schriefer, DrPH, MSN, MBA

Independent Healthcare Consultant

Pittsford, NY

Roger F. Soll, MD

Associate Professor of Pediatrics

University of Vermont College of Medicine

Burlington, VT

Gautham Suresh, MD, DM

Assistant Professor, Department of Pediatrics

Medical University of South Carolina

Charleston, SC

Robert Ursprung, MD

Acting Co-Director of Quality Improvement

Pediatrix Medical Group

Fort Worth, TX

Elizabeth Wojciechowski, PhD, APN

Clinical Education Manager

Rehabilitation Institute

Chicago, IL

	ACKNOWLEDGMENTS

 
Publication of this supplement was supported by Centers for Disease Control and Prevention grant H75/CCH124687. The Center for Patient Safety in Neonatal Intensive Care was funded by Agency for Healthcare Research and Quality grant HS11583.

	FOOTNOTES

 
Accepted Jul 18, 2006.

Address correspondence to Jeffrey D. Horbar, MD, Vermont Oxford Network, 33 Kilburn St, Burlington, VT 05401. E-mail: horbar{at}vtoxford.org

The authors have indicated they have no financial relationships relevant to this article to disclose.

	REFERENCES

TOP APPENDIX 1: NIC/Q 2002... APPENDIX 2: NIC/Q 2002... REFERENCES

 

1. Horbar JD, Gould JB. Evidence-based quality improvement in neonatal and perinatal medicine. Pediatrics. 1999;103 :203 –393[Medline]
2. Horbar JD, Plsek PE, Leahy K, Schriefer JA. Evidenced-based quality improvement in neonatal and perinatal medicine: The NIC/Q 2000 experience. Pediatrics. 2003;111 (4). Available at: www.pediatrics.org/cgi/content/full/111/4/SE1/e395
3. Plsek PE. Quality improvement methods in clinical medicine. Pediatrics. 1999;103 :203 –214[Medline]
4. Muir Gray JA. Evidenced-Based Health Care: How to Make Health Policy and Management Decisions. London, England: Churchill Livingstone; 1997

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This Article Extract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Horbar, J. D. Articles by Leahy, K. Search for Related Content PubMed Articles by Horbar, J. D. Articles by Leahy, K. Related Collections Premature & Newborn

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