1. Empowering the Front Lines Salem Hospital NICU Quality Improvement We will make each baby and family the center of our care. We will be compassionate and support each family as we share in the care of their infant and as they nurture their baby. NICU Leadership Team July 28, 2008

2. Goals for today Familiarize you with the Vermont Oxford Network and our participation in it Update on Salem Hospital NICU performance Update on current Salem Hospital NICU Quality Improvement work Arrange for you to visit the NICU with a focus on further supporting our work and helping us engage our staff

3. Vermont Oxford Network (VON) Started in 1988 Two databases –VLBW infants (632 centers, 48,768 infants in 2006) –Expanded DB (164 centers, 88,583 infants in 2006) –Reports Annual reports in September Nightingale Web site Collaboratives –Two year QI Collaboratives –Internet Based Collaboratives Multi-center research trials Annual Quality Congress

4. Salem NICU Participation in VON Database since 2004 NIC/Q Collaboratives –NIC/Q 2007 and NIC/Q 2009 I-NIC/Q collaboratives –Decreasing Late NICU infections –Value Compass –Neonatal Encephalopathy/Hypothermia Research –Hypothermia registry (treatment/follow up) –Nurse staffing

5. NICU Key Areas of Work Implement Evidence Based Clinical Practice changes and standardize clinical processes Optimal management of intravascular devices for neonates Safer care –Improved resuscitation and stabilization and admission care –No late infections –Meet SH standards for regulatory patient safety goals Communication and Teamwork training and implementation Developmental care Family centered care More equitable care for both babies and families Increase individual staff engagement and capabilities around key areas of work Support “Her Place” Be environmentally greener Develop a measurement system related to the work we are doing and connects us to the Quality Improvement work of our hospital

6. NICU Measurement System Based on Dartmouth System –Patient Outcomes--Clinical Value Compass –Unit Quality—Balanced Scorecard –Additional supportive measures—Dashboard Linked to Family Birth Center and Salem Hospital Quality Initiatives –Cascading measures

7. Functional (Babies returning to FU Clinic)  “My family adjusting well to having baby at home”  “I feel good about my ability to care for my family and myself”  Neurodevelopmental FU status Clinical Value Compass (Patient Population in Parenthesis) Biological/Clinical (500-1500, all admits)  Survival w/o morbidity  Weight gain and head circumference growth velocity  Late infection rate Cost (500-1500, all admits)  LOS Patient/Family Satisfaction  Satisfaction with Kangaroo Care (all families interviewed)  Press Ganey Overall Score (all)  Press Ganey Overall Rank (all) Unit of analysis is patient

8. Database reports Outcome and process measures –Key performance measures Risk adjusted –1 year, 3 year Comparisons –Network: VON average and 10th, 25th, 75th percentile centers –US centers –Type A,B,C centers –Northwest Newborn Centers

9. NICU Risk Adjusted Outcomes Mortality Complications –Lung injury- pneumothorax, CLD –Brain injury-hemorrhage (IVH), ischemic (PVL) –Eye injury-ROP –Bowel injury-NEC –Late Infections-Noso, CON, LBI, Fungal Survival without morbidity Length of stay for Survivors

10. VLBW Births/Year

13. Expanded Database Admits

16. NICU Comparative Outcomes Top 25% Top 10% Above mean Below mean

17. Salem: VON Key Performance Measures in Color 501-1500 Gram Birth Weight

18. Salem: VON Key Performance Measures in Color All NICU Admissions

19. Core Processes: what are we trying to perfect?  Time to hypothermia tx for HIE  Compliance with patient safety regulations  MRSA colonization conversions/month  ROP exams per AAP guideline  Spanish interpreter use rate  % IV running in < 30 minutes in < 33 EGA babies  FCC score  # of PAC goals accomplished / year (11 goals)  Rate admit temp < 36.5, 500-1500 gm BW  Nutrition bundle success rate Core Processes: what are we trying to perfect?  Time to hypothermia tx for HIE  Compliance with patient safety regulations  MRSA colonization conversions/month  ROP exams per AAP guideline  Spanish interpreter use rate  % IV running in < 30 minutes in < 33 EGA babies  FCC score  # of PAC goals accomplished / year (11 goals)  Rate admit temp < 36.5, 500-1500 gm BW  Nutrition bundle success rate Customer Satisfaction: how should we appear to our customers?  NDNQI joy in NICU question  NDNQI autonomy question  # of referrals o neonatal o maternal Customer Satisfaction: how should we appear to our customers?  NDNQI joy in NICU question  NDNQI autonomy question  # of referrals o neonatal o maternal Innovation and Learning: how will we enhance our ability to change and improve?  NDNQI Professional development score  Engagement Survey Results  RN Neonatal Certification # or % of staff  Years NICU experience / staff Innovation and Learning: how will we enhance our ability to change and improve?  NDNQI Professional development score  Engagement Survey Results  RN Neonatal Certification # or % of staff  Years NICU experience / staff Green / Financial: How will we help sustain our organization’s mission, our community and our planet?  KPI measures  # of referrals o neonatal o maternal  Pounds plastic recycled/year  # of NICU people supporting Her Place Green / Financial: How will we help sustain our organization’s mission, our community and our planet?  KPI measures  # of referrals o neonatal o maternal  Pounds plastic recycled/year  # of NICU people supporting Her Place Balanced Scorecard unit of analysis is microsystem = NICU

20. o 5 minute Apgar < 7 o Days between late infections o Quarterly Reports on VON clinical outcomes o “Gimme 5” rate o NICU shift huddles o Video Resus and Communication/Teamwork participation o HIE/Hypothermia complications o Kangaroo Care episodes/patient day/month o Frequency our baby’s physician updated us o Time from NP culture to contact isolation for MRSA + babies o Hand Hygiene compliance o Patient safety knowledge regarding Universal Protocol (time outs) o Weaning from incubator audit o ROP exam measures o # of IV starts o 5 individual feeding bundle practices o # NICU Nursing Vacancies o Rate of Turnover from dissatisfaction o Attendance rate at PAC meetings o # of PAC families o $$ provided to international NICU o Time/$$ provided to local community organization o White Boards complete (bedside) o Non English family white boards complete (bedside) NICU Dashboard Measures that support the Value Compass and Balanced Scorecard

21. Salem Hospital (Macrosystem) Women and Children’s Services (Mesosystem) NICU (Microsystem) Quality and Safety Inpatient Mortality Harms/100 patients Central line related infections National Standards of Care Resources/Flow 5 minute Apgar < 7 Newborn stabilization measures NICU measures Perinatal Trigger tool (harms/100 patients) C/S < 30 minutes IHI bundles Communication/teamwork measures Survival without morbidity Late infection measures Gimme 5 Compliance with National Patient Safety Goals Length of Stay Stewardship Operating margin Number of admissions Green building KPI determinations (unit specific)KPI measures # of Maternal and Neonatal Referrals Recycling; styrofoam use $ to international NICU Relationships Patient satisfaction NDNQI Measures Physician satisfaction Patient Satisfaction NDNQI Measures Family Satisfaction Kangaroo care satisfaction Physician communication satisfaction Nursing vacancies/resignations for dissatisfaction NDNQI measures IHI family participation score Professional Excellence NDNQI Measures Best Medical Staff Empowering the front line (microsystem training) NDNQI measures Communication/Teamwork education Fetal monitoring training Participation in Video resuscitation reviews Participation in education Staff engagement in QI work (VON) NDNQI measures Cascading Measures