DOI: 10.1097/JPN.0000000000000102
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Interdisciplinary Teamwork and the Power of a Quality Improvement Collaborative in Tertiary Neonatal Intensive Care Units Theresa R. Grover, MD; Eugenia K. Pallotto, MD; Beverly Brozanski, MD; Anthony J. Piazza, MD; John Chuo, MD; Susan Moran, DNP, NNP-BC; Richard McClead, MD; Teresa Mingrone, MSN, RN; Lorna Morelli, ADN, RN; Joan R. Smith, PhD, NNP-BC ABSTRACT Significant gaps in healthcare quality and outcomes can be reduced via quality improvement collaboratives (QICs), which improve care by leveraging data and experience from multiple organizations. The Children’s Hospital Neonatal Consortium Collaborative Initiatives for Quality Improvement team developed an infrastructure for neonatal QICs. We describe the structure and components of an effective multi-institutional neonatal QIC that implemented the “SLUG Bug” project designed to reduce central line-associated bloodstream infections (CLABSIs). The operational infrastructure of SLUG Bug involved 17 tertiary care neonatal intensive care units with a goal
Author Affiliation: Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado (Drs Grover and Moran); Children’s Mercy Hospital and the Department of Pediatrics, University of Missouri School of Medicine, Kansas City, Missouri (Dr Pallotto); Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania (Dr Brozanski and Ms Mingrone); Children’s Healthcare of Atlanta at Egleston and Emory University School of Medicine, Atlanta, Georgia (Dr Piazza); Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (Dr Chuo); Nationwide Children’s Hospital, Columbus, Ohio (Dr McClead); Children’s Hospital Association, Overland Park, Kansas (Ms Morelli); and St Louis Children’s Hospital and Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, Missouri (Dr Smith). Disclosure: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Corresponding Author: Theresa R. Grover, MD, University of Colorado School of Medicine, 13121 E. 17th Ave, MS 8402, Aurora, CO 80045 ([email protected]). Submitted for publication: October 28, 2014; accepted for publication: February 15, 2015. The Journal of Perinatal & Neonatal Nursing
to reduce CLABSI in high-risk neonates. Clinical Practice Recommendations were produced, and the Institute of Healthcare Improvement Breakthrough Series provided the framework for the collaborative. Process measures studied the effectiveness of the collaborative structure. CLABSI rates decreased by 20% during a 12-month study period. Compliance bundle reporting exceeded 80%. A QIC score of 2.5 or more (“improvement”) was achieved by 94% of centers and a score 4 or more (“significant improvement”) was achieved by 35%. Frequent interactive project meetings, well-defined project metrics, continual shared learning opportunities, and individual team coaching were key QIC success components. Through a coordinated approach and committed leadership, QICs can effectively implement change and improve the care of neonates with complex diagnoses and rare diseases. Key Words: CHNC, CHND, neonatal intensive care unit, quality improvement, quality improvement collaborative
espite major advances in pediatric and neonatal critical care, serious gaps in healthcare quality and outcomes exist. Landmark reports including To Err Is Human and Crossing the Quality Chasm highlight the ongoing risk to patient quality and safety and call for a redesign of the health system to focus on healthcare delivery that is safe, effective, patientcentered, timely, efficient, and equitable.1–3 Quality improvement collaboratives (QICs) are commonly used as an implementation strategy to bridge the gap between recommended and actual care and to accelerate the translation of evidence into clinical practice, resulting in improved quality of care and health outcomes.4–6
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Quality improvement collaboratives capitalize on collective experience and evidence to effect and sustain improvement in healthcare.7,8 To successfully achieve these objectives in a health system, it is imperative to develop new collaborative approaches to improve the provision of healthcare. Quality improvement collaboratives are an integral facet of the healthcare system, and have been utilized in inpatient, critical care, and ambulatory medicine settings, and across all age ranges and medical specialties.6 Some QICs were implemented in response to local or national mandates to improve healthcare (eg, the California Perinatal Quality Care Collaborative, the Ohio Perinatal Quality Collaborative, and the Solutions for Patient Safety),9–11 whereas others originate from grassroot efforts by individual groups of clinicians in response to gaps in care specific to their specialty (the Vermont Oxford Network, National Association of Children’s Hospitals and Related Institutions, now Children’s Hospital Association [CHA]).12,13 Quality improvement collaboratives have addressed a myriad of clinical topics, including patient safety, prevention of hospital-associated conditions, or disease-specific conditions (eg, sepsis and bronchopulmonary dysplasia). In many cases, QICs have achieved significant improvements in the provision of care with a reduction in healthcare costs, but others have shown modest improvement or an inability to sustain improvement over time.14–17 The Children’s Hospital Neonatal Consortium (CHNC) Collaborative Initiatives for Quality Improvement (CIQI) team originated to develop an infrastructure for ongoing QI collaborative studies for neonatal patients referred to tertiary care neonatal intensive care units (NICUs). Neonates and infants with rare and complex medical conditions are referred to these NICUs.18 A collaborative approach to improving the care of these high-risk infants allows for aggregation of data across multiple sites and leverages the vast clinical experience among its members. The CHNC CIQI team was initiated by clinicians and relies on voluntary participation by its multidisciplinary teams. The mission of the Children’s Hospital Neonatal Database (CHND) CIQI is to identify generalizable practices for neonatal care that, when standardized across NICUs, improves outcomes. Few detailed manuals outlining the elements of QICs or evidence-based descriptions of the most effective strategies to implement multicenter collaboratives have been published.15 In this article, we describe the structure and components of the CHND’s new, multi-institutional neonatal QIC, and highlight our inaugural study in which we effectively reduced central line-associated bloodstream infections (CLABSIs) across participating institutions. 180
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METHODS The CHND began data collection in 2010 and prospectively captures clinical data on all infants admitted to participating tertiary NICUs in the United States.18 As of 2014, the CHND includes 28 tertiary referral hospitals with at least a level IIIC NICU designation, more than 400 admissions annually, more than 25 inpatient beds, and more than 50% outborn admissions, and representing all geographic regions of the United States. Membership is voluntary, and supported by the CHA. Chart abstractors at each site underwent prospective training including review of clinical definitions, participation in web-based seminar tutorials, and casebased practice. Both initial and biannual measurements of interrater agreement scores were calculated at each site; more than 90% intrasite concordance in abstraction was required for initial and continued participation in the CHND. Each center has ongoing Institutional Review Board approval for participation in the database. A key component necessary for the creation of a new QIC was a leadership team responsible for developing the necessary infrastructure to support and maintain ongoing QI projects. The CHND was developed as a grassroots effort by a voluntary interdisciplinary team of neonatal clinicians in response to the limited knowledge available regarding best practices for infants at these tertiary NICUs with complex diagnoses and rare diseases.18 As the database was under development, participating teams recognized the importance of working together across institutions to improve care through collaborative quality improvement. The CHNC CIQI steering committee was formed in 2009 and is composed of 8 physicians and neonatal nurse practitioners with expertise and training in QI methodology. This group develops the structure for the CHNC collaborative projects, coordinates the selection of new projects, supports the project management team, serves as clinical experts for each collaborative, and functions as the liaison with the CHA, which provides analytic and administrative support. The aim of the CHNC CIQI team is to improve the care of neonates and enable the completion of meaningful collaborative QI projects by achieving the targets set for defined measures. A key driver diagram provides the tool to communicate this shared mental model (see Figure 1). With support from the CHND and CHA, the inaugural collaborative project for the CHNC CIQI team was “SLUG Bug” (Standardizing Line Care Under Guideline recommendations), which was designed to reduce CLABSIs in high-risk neonatal patients.19 The CIQI steering committee designed an operational infrastructure to implement and support the participation April/June 2015
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Figure 1. Children’s Hospitals Neonatal Consortium Collaborative Initiatives for Quality Improvement key driver diagram.
of 17 CHND centers in the SLUG Bug collaborative. The Institute of Healthcare Improvement (IHI) collaborative framework provided the foundation for this project.7 A thorough systematic literature review, results of a benchmarking survey exploring current CLABSI reduction practices, and expert opinion were the basis for the development of a Clinical Practice Recommendation (CPR) document for the project. CLABSI prevention practices in the CPR included hand hygiene, central line insertion practices, central line maintenance (including line care and removal), and root cause analysis. The rationale for using CLABSI prevention practices in the form of a rigorously developed CPR document, where participating centers could choose which components to implement, rather than a traditional bundle where all components must be implemented, was to respect each center’s local resources and previous work The Journal of Perinatal & Neonatal Nursing
done in many of the NICUs at the microsystem level. Orchestrated testing methodology20 was used to determine the impact of each of 4 independent dichotomous variables: sterile versus clean tubing change technique, hub care practice compliance monitoring versus not monitoring, central venous catheter line entry access limitation versus no specific limitations, and central venous catheter line removal tracking versus no tracking policy. Compliance monitoring was a key component of each of the factors implemented to reduce CLABSI to ensure that practice change had occurred. The primary outcome measure for the SLUG Bugs collaborative was CLABSI rates using the National Healthcare Safety Network’s definition of CLABSI.21 Baseline CLABSI rates were obtained for 12 months before the start of the project, the SLUG Bugs “study period” lasted 12 months, and was followed by a 12-month “sustain period” during which more limited data were collected. Data www.jpnnjournal.com
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analysis included monthly central line days; CLABSI events; and compliance with several factors, including use of insertion checklist, scrubbing the hub of central lines, staff hand hygiene, use of sterile technique for line changes, and documentation of daily assessment of need for central line by the medical team. Statistical experts were consulted for the design and interpretation of data. In addition to the primary outcomes of the SLUG Bug collaborative project, process measures were examined by the CIQI team to determine the effectiveness of the collaborative process. These included the percentage of eligible CHNC centers participating in the collaborative, percentage of centers with complete data reporting, and percentage of participating centers who reached an improvement level of 2.5 (“changes tested”) and 4.0 (“significant improvement”) out of a possible 5.0 (“outstanding sustainable results”) on the IHI Collaborative Assessment Scale.22 Scores for the IHI Collaborative Assessment Scale were self-reported by the center and validated by an independent faculty advisor on the CIQI Steering Committee. QIC structure and components The QI collaborative utilized the IHI Breakthrough Series (IHI BS)7 to design and implement a welldefined infrastructure including the “Project Development Team” and “Project Management Team.” Each of the 2 teams was assigned specific responsibilities deemed essential to a successful collaborative project (see Table 1).
Project Development Team The Project Development Team included a multidisciplinary team of 10 content experts who volunteered to develop the project framework. The team participated in 2 face-to-face meetings that included training and education in QI methodology to ensure similar base-
line knowledge of QI methods. Subsequent meetings focused efforts on project development. Expert panel: The Project Development Team performed a comprehensive review of the medical literature related to the prevention of CLABSI, with specific attention to the neonatal population. Relevant publications were assigned levels of evidence, and a rigorous systematic clinical practice guideline methodology was applied utilizing the AGREE-II tool (Appraisal of Guidelines for Research and Evaluation).23 A survey was sent to all participating centers in the CHNC to determine current practices associated with central line care, and use of those practices were stratified by high- and lowperforming center baseline CLABSI rates. The Project Development Team drafted “Clinical Practice Recommendations” on the basis of on this systematic literature review, site survey (eg, benchmarking), and expert opinion. Project design: The Project Development Team was responsible for outlining the project charter, determining the SMART (Specific, Measurable, Attainable, Relevant, Timely) aims, process/outcome/balancing measures, timeline, and statistical design of the study. The data collection process utilized the IHI extranet site, and initial PDSA (Plan-Do-Study-Act) cycles were outlined and shared with local teams. Administrative role: The Project Development Team recruited CHNC centers to enroll in the SLUG Bug collaborative project through e-mail and at the CHNC annual meeting. Local site leaders and teams were recruited, and each local team signed a data access and participation agreement. Local teams were encouraged to obtain support from senior executive team members and identify team champions and involve key stakeholders. The Project Development Team obtained approval by the American Board of Pediatrics for Maintenance of Certification (MOC) Part 4 credit for neonatal physicians participating in the collaborative project.
Table 1. Key components of QI collaborative structure Project Development Team Content experts for Clinical Practice Recommendations Project charter, driver diagrams, process map Statistical design PDSA cycles Identify local site leaders Manage team enrollment Maintenance of certification approval
Project Management Team Annual in-person planning session Develop content for monthly web-based project meetings for the collaborative Design and present QI education series Conduct weekly team huddles Insure local team compliance with data entry Data collection and interpretation Conduct PDSA cycles Faculty advisors
Abbreviation: PDSA, Plan-DO-Study-Act.
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Project Management Team The Project Management Team was composed of volunteer physicians and nurse leaders from CHND centers. This team held web-based conference calls every 2 weeks to track the progress of the collaborative, develop new PDSA cycles to share with local centers, and prepare both the monthly meeting and educational sessions for the collaborative group. Learning sessions: Multiple interorganizational learning activities were offered to collaborative participants. An annual in-person meeting was hosted by the QI content experts on the Project Development Team and Project Management Team to discuss the progress of the collaborative, share successes and struggles, and discuss data findings with the participating multidisciplinary teams. Monthly web-based team meetings were organized and led by the Project Management Team and were typically attended by at least one representative from each site. The agenda of this monthly meeting included blinded data review and compliance reporting of each center, “round robin” discussions of local center barriers and breakthroughs, and team presentations outlining success of struggles with implementation of the project, using an “All Teach-All Learn” philosophy.24 In addition, weekly “huddle” meetings were held for 30 minutes to facilitate learning among teams to resolve barriers and sustain motivation in a more intimate format to foster transparency and sharing. Examples of topics addressed during the huddle calls included sterile tubing change technique, compliance audits, hand hygiene, and MOC process. A QI education series was presented by QI experts as webinars on specific topics related to QI science and methodology. Monthly meetings and the QI education series were recorded, and the audio, slide sets, and accompanied documents were available on the CHA Web site. Web-based evaluation was available after each session, and team suggestions were incorporated by the management team as necessary. A listserv was accessible to all members for clarification or questions related to the project. Data management: Data were entered and analyzed on a rolling basis utilizing the IHI extranet system. Teams entered local data and had real-time access to graphic representation of their data and composite data for the collaborative, including data snapshots and run charts. The Project Management Team analyzed data on a monthly basis and presented composite data at the monthly meeting in the form of run charts and U charts. PDSA cycles: On the basis of results and feedback from participating centers, multiple PDSA cycles were implemented over the course of the collaborative. The Project Management Team suggested and shared PDSA The Journal of Perinatal & Neonatal Nursing
cycles with local teams to facilitate change. Examples of collaborative PDSA cycles included engagement of local teams on monthly calls, data presentation, identifying opportunities for the Project Management Team to support teams having difficulty with implementation, and identifying methods to celebrate success. Individual centers also implemented local PDSA cycles to improve site-specific practices. Faculty advisors: Members of the Project Management Team were assigned to a center to provide oversight and feedback throughout the project as “faculty advisors.” These advisors ensured timely and accurate data collection for assigned centers, provided advice to the local team to help overcome specific barriers or challenges, and kept local centers engaged.
RESULTS The collaborative CLABSI rate decreased from a baseline rate of 1.33/1000 line days to a rate of 1.08/1000 line days, a 20% decrease, by the end of the 12-month study period.19 Eleven of the 17 centers showed a decrease in CLABSI rates during the study period, and sterile tubing change technique had the strongest effect, independently decreasing CLABSI rate by 0.82/1000 line days. In addition, this significant improvement in CLABSI rates was sustained during the 12 months after the study period. Successful implementation of the collaborative project was measured by specific process metrics. Seventeen of the 24 eligible CHNC centers (71%) participated in the SLUG Bugs QIC by implementing change and submitting data. Compliance with data reporting was consistently more than 80% for all participating centers (see Figure 2). Of the 17 participating centers, 16 (94%) achieved an IHI Collaborative Assessment Scale score of 2.5 or more (“improvement”), with 6 centers achieving a score of 4 or more (“significant improvement”) and 3 centers achieving a score of 4.5 (“sustainable improvement”) (see Figure 3).
DISCUSSION Quality improvement collaboratives are now an accepted approach to implementing change and improving care across centers. The efficacy of collaborative improvement networks is variable11,12 and likely related to the organizational structure of the QICs and the methods in which information is shared between participating centers. In this article, we describe the inaugural project for the CHNC in which our multicenter collaborative utilized the IHI Breakthrough Series model to achieve reduction in CLABSI rates at participating CHNC centers. The success of this project was based www.jpnnjournal.com
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Figure 2. Compliance with complete data reporting for collaborative measures (percentage of participating centers with complete data entry each month during the collaborative).
on the establishment of a framework of a well-defined improvement process that utilized an interdisciplinary team. Collaborative improvement networks can be complicated to develop, and as a result are relatively infrequent. These networks are critically important in pediatrics, as the relatively small number of patients at individual institutions often limits studies to singlecenter case series. Within neonatal medicine, several other neonatal networks have demonstrated improvement in CLABSI rates through collaborative efforts, including the Vermont Oxford Network, California Perinatal Quality Care Collaborative, and the Ohio Perinatal Quality Collaborative.9–13 Further efforts are warranted to expand on the experience of and test the effectiveness of these existing networks, and to develop new collaborative networks. Successful collaboratives share important qualities, including organizational support and a basic foundation of knowledge about QI methodology so that a “com-
Figure 3. IHI Collaborative Assessment Scale scores at the conclusion of the SLUG Bugs collaborative. A score of more than 3 demonstrates “improvement” as defined by the IHI. 184
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mon language” exists among participants. A focus on measurable and well-defined outcomes and interdisciplinary teamwork emphasizing a shared mental model, a sense of community and transparency, and respect for local culture are key. In addition, collaboratives must employ effective use of technology for data collection and communication and methods to overcome obstacles to participation and successful local implementation of the project. The CHNC CIQI used the basic structure of the IHI Breakthrough Series8 and designed a strategy for ongoing education and data sharing among the participants with an emphasis on shared learning. Recruiting an expert panel of clinicians that included both nurses and physicians and a PDT to develop CPR and outline the specific components of the collaborative project was a key component of success. These experts, many clinical leaders of participating centers, were able to give a perspective to the variation of care across sites, thus achieving local support of the project. Multidisciplinary efforts that capitalize on the shared expertise and collaboration of both physicians and nurse leaders are likely to be the most successful. Although we followed the overall structure of the IHI Breakthrough Series, several components of the CIQI structure were felt to have had a positive influence on the collaborative process. As previously stated, a CPR document was drafted utilizing a comprehensive literature review and expert opinion—including neonatologists, infectious disease specialists, and nurses who were central line experts-–as well as information gathered through a survey of participating centers that was compared with baseline center CLABSI rates. This allowed the group to incorporate successful practices that were already in place in some centers, and to encourage these successful local practices when appropriate. Developing a sense of community and shared April/June 2015
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purpose among the participants was a challenge given the geographic constraints, but we found that frequent interaction and shared experiences of both nurses and physicians enhanced the experience for many participants. In addition to monthly team meetings, we found weekly, brief “huddle” sessions and frequent contact from assigned faculty advisors to be particularly helpful. Each of these 30-minute informal sessions engaged participants to discuss one particular topic at a time in greater detail, and fostered an atmosphere of continual, shared learning. Discussions during the monthly meetings and huddle calls specifically helped teams by offering suggestions to improve motivation and engagement of front-line staff, increase the number of audits for project metrics, and to teach staff how to implement new techniques such as sterile tubing change. A “Golden Collaborative Award” was given to one center each month at the recommendation of the faculty advisor for having overcome a specific barrier and met the project goals. Building a sense of community was critical in developing the respect and trust necessary to allow for transparency. Although the primary focus of the SLUG Bug collaborative was the clinical improvement project, the inclusion of process metrics and tracking of compliance and participation of each local center allowed us to determine the success of the collaborative infrastructure. Specifically, we found that the local support and resources for improvement projects varied considerably from center to center, and that an ongoing commitment by the Project Management Team, and specifically the faculty advisors, was critical to ensure that we met the goals of the collaborative. In several instances, the faculty advisors were able to identify solutions to local barriers and provide the support needed for compliance with the project components. The effectiveness of this strategy was often evident during follow-up contact and documented on monthly progress reports by the centers. Participation in the QIC was voluntary, so executive-level institutional support was crucial to ensure that teams had the necessary resources available for data collection and investment of staff time. Working together, we enhanced the QI capacity for the CHND network of institutions through the development of a framework for collaborative work, and established the foundation for ongoing multicenter collaborative projects. Together, these institutions demonstrated improvement in the provision of care to highrisk neonatal patients. The combination of newly available CHND data showing widespread variation in care and an effective collaborative framework sets the stage for ongoing multicenter improvement for this unique group of patients. Key components of the success of The Journal of Perinatal & Neonatal Nursing
this project were frequent educational and project meetings contributing to a sense of team effort, clear and well-defined project metrics and improvement strategies, continual shared learning opportunities, and oversight by an interdisciplinary Project Management Team to ensure accurate and timely data collection for analysis. We found that through a coordinated approach and committed leadership team, a multicenter collaborative approach can be a feasible and effective method to implement change and improve the quality of care of high-risk neonatal patients.
References 1. Kohn LT, Corrigan JM, Donaldson MS, eds. To err Is Human: Building a Safer Health System. Institute of Medicine (US) Committee on Quality of Health Care in America. National Academies Press; 2000. 2. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academies Press; 2001. 3. Kelley MA, Tucci JM. Bridging the quality chasm. BMJ. 2001; 323(7304):61–62. 4. Newton PJ, Halcomb EJ, Davidson PM, Denniss AR. Barriers and facilitators to the implementation of the collaborative method: reflections from a single site. Qual Saf Health Care. 2007;16:409–414. 5. Vos L, D¨uckers ML, Wagne C, van Merode G. Applying the quality improvement collaborative method to process redesign: a multiple case study. Implement Sci. 2010;5:19. 6. Lannon CM, Peterson LE. Pediatric collaborative networks for quality improvement and research. Acad Pediatr. 2013; 13:S69–S74. 7. IHI (Institute for Healthcare Improvement). The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement. Boston, IHI Innovation Series White Paper; 2003. 8. Kilo CM. A framework of collaborative improvement: lessons from the Institute for Healthcare Improvement’s breakthrough series. Qual Manag Health Care. 1998;6(4):1–14. 9. Gould JB. The role of regional collaboratives: The California perinatal quality care collaborative model. Clin Perinatol. 2010;37:71–86. 10. Kaplan HC, Lannon C, Walsh MC, Donovan EF. Ohio Perinatal Quality Collaborative. Ohio statewide qualityimprovement collaborative to reduce late-onset sepsis in preterm infants. Pediatrics. 2011;127(3):427–435. 11. Solutions for Patient Safety. http://solutionsforpatientsafety. org/. Published 2014. Accessed October 27, 2014. 12. Horbar JD. The Vermont Oxford Network: evidence-based quality improvement for neonatology. Pediatrics. 1999;103 (1 suppl E):350–359. 13. Miller MR, Griswold M, Harris JM, et al. Decreasing PICU catheter-associated blood-stream infections: NACHRI’s quality transformation efforts. Pediatrics. 2010;125(2): 206–213. 14. Schouten LM, Hulscher ME, van Everdingen JJ, Huijsman R, Grol RP. Evidence for the impact of quality improvement collaboratives. BMJ. 2010;336(7659):1491–1494. 15. Nadeem E, Olin SS, Hill LC, Hoagwood KE, Horwitz SM. Understanding the components of quality improvement collaboratives: a systematic literature review. Milbank Q. 2013;91(2):354–394. www.jpnnjournal.com
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16. Billett AL, Colletti RB, Mandel KE, Miller M, Muething SE, Sharek PH, Lannon DM. Exemplar pediatric collaborative improvement networks: achieving results. Pediatrics. 2013;131(suppl 4):196–203. 17. Payne NR, Finkelstein MJ, Liu M, Kaempf JW, Sharek PJ, Olsen S. NICU practices and outcomes associated with 9 years of quality improvement collaboratives. Pediatrics. 2010;125(3):437–446. 18. Murthy K, Dykes FD, Padula MA, et al. The children’s hospitals neonatal database: an overview of patient complexity, outcomes and variation in care. J Perinatol. 2014;34(8): 582–586. 19. Piazza A, Brozanski B, Chou J, et al. In an Orchestrated Design Paradigm a Children’s Hospital NICU Quality Improvement Collaborative Decreased CLABSI Rates. Washington, DC: Presented at the Pediatric Academic Society Annual Meeting; 2013.
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20. Moen RD, Nolan TW, Provost LP. Quality Improvement Through Planned Experimentation. 3rd ed. McGraw-Hill; 2012. 21. Centers for Disease Control and Prevention. Outline for health care-associated infection surveillance. http://www .cdc.gov/ncidod/dhqp/pdf/surveillance/OutlineForHAI Surveillance.pdf. 22. Institute for Healthcare Improvement: Assessment Scale for Collaboratives. http://www.ihi.org/resources/Pages/Tools/ AssessmentScaleforCollaboratives.aspx. Published 2004. Accessed October 28, 2014. 23. Makarski J, Brouwers MC. The AGREE Enterprise: a decade of advancing clinical practice guidelines. Implement Sci. 2014;9:103. 24. Nembhard IM. All teach, all learn, all improve: the role of interorganizational learning in quality improvement collaboratives. Health Care Manage Rev. 2012;37(2):154–164
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C 2015 Wolters Kluwer Health, Inc. All rights reserved. J Perinat Neonat Nurs r Volume 29 Number 2, 179–186 r Copyright
Interdisciplinary Teamwork and the Power of a Quality Improvement Collaborative in Tertiary Neonatal Intensive Care Units Theresa R. Grover, MD; Eugenia K. Pallotto, MD; Beverly Brozanski, MD; Anthony J. Piazza, MD; John Chuo, MD; Susan Moran, DNP, NNP-BC; Richard McClead, MD; Teresa Mingrone, MSN, RN; Lorna Morelli, ADN, RN; Joan R. Smith, PhD, NNP-BC ABSTRACT Significant gaps in healthcare quality and outcomes can be reduced via quality improvement collaboratives (QICs), which improve care by leveraging data and experience from multiple organizations. The Children’s Hospital Neonatal Consortium Collaborative Initiatives for Quality Improvement team developed an infrastructure for neonatal QICs. We describe the structure and components of an effective multi-institutional neonatal QIC that implemented the “SLUG Bug” project designed to reduce central line-associated bloodstream infections (CLABSIs). The operational infrastructure of SLUG Bug involved 17 tertiary care neonatal intensive care units with a goal
Author Affiliation: Children’s Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado (Drs Grover and Moran); Children’s Mercy Hospital and the Department of Pediatrics, University of Missouri School of Medicine, Kansas City, Missouri (Dr Pallotto); Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania (Dr Brozanski and Ms Mingrone); Children’s Healthcare of Atlanta at Egleston and Emory University School of Medicine, Atlanta, Georgia (Dr Piazza); Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (Dr Chuo); Nationwide Children’s Hospital, Columbus, Ohio (Dr McClead); Children’s Hospital Association, Overland Park, Kansas (Ms Morelli); and St Louis Children’s Hospital and Goldfarb School of Nursing at Barnes-Jewish College, St. Louis, Missouri (Dr Smith). Disclosure: The authors have disclosed that they have no significant relationships with, or financial interest in, any commercial companies pertaining to this article.
Corresponding Author: Theresa R. Grover, MD, University of Colorado School of Medicine, 13121 E. 17th Ave, MS 8402, Aurora, CO 80045 ([email protected]). Submitted for publication: October 28, 2014; accepted for publication: February 15, 2015. The Journal of Perinatal & Neonatal Nursing
to reduce CLABSI in high-risk neonates. Clinical Practice Recommendations were produced, and the Institute of Healthcare Improvement Breakthrough Series provided the framework for the collaborative. Process measures studied the effectiveness of the collaborative structure. CLABSI rates decreased by 20% during a 12-month study period. Compliance bundle reporting exceeded 80%. A QIC score of 2.5 or more (“improvement”) was achieved by 94% of centers and a score 4 or more (“significant improvement”) was achieved by 35%. Frequent interactive project meetings, well-defined project metrics, continual shared learning opportunities, and individual team coaching were key QIC success components. Through a coordinated approach and committed leadership, QICs can effectively implement change and improve the care of neonates with complex diagnoses and rare diseases. Key Words: CHNC, CHND, neonatal intensive care unit, quality improvement, quality improvement collaborative
espite major advances in pediatric and neonatal critical care, serious gaps in healthcare quality and outcomes exist. Landmark reports including To Err Is Human and Crossing the Quality Chasm highlight the ongoing risk to patient quality and safety and call for a redesign of the health system to focus on healthcare delivery that is safe, effective, patientcentered, timely, efficient, and equitable.1–3 Quality improvement collaboratives (QICs) are commonly used as an implementation strategy to bridge the gap between recommended and actual care and to accelerate the translation of evidence into clinical practice, resulting in improved quality of care and health outcomes.4–6
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Quality improvement collaboratives capitalize on collective experience and evidence to effect and sustain improvement in healthcare.7,8 To successfully achieve these objectives in a health system, it is imperative to develop new collaborative approaches to improve the provision of healthcare. Quality improvement collaboratives are an integral facet of the healthcare system, and have been utilized in inpatient, critical care, and ambulatory medicine settings, and across all age ranges and medical specialties.6 Some QICs were implemented in response to local or national mandates to improve healthcare (eg, the California Perinatal Quality Care Collaborative, the Ohio Perinatal Quality Collaborative, and the Solutions for Patient Safety),9–11 whereas others originate from grassroot efforts by individual groups of clinicians in response to gaps in care specific to their specialty (the Vermont Oxford Network, National Association of Children’s Hospitals and Related Institutions, now Children’s Hospital Association [CHA]).12,13 Quality improvement collaboratives have addressed a myriad of clinical topics, including patient safety, prevention of hospital-associated conditions, or disease-specific conditions (eg, sepsis and bronchopulmonary dysplasia). In many cases, QICs have achieved significant improvements in the provision of care with a reduction in healthcare costs, but others have shown modest improvement or an inability to sustain improvement over time.14–17 The Children’s Hospital Neonatal Consortium (CHNC) Collaborative Initiatives for Quality Improvement (CIQI) team originated to develop an infrastructure for ongoing QI collaborative studies for neonatal patients referred to tertiary care neonatal intensive care units (NICUs). Neonates and infants with rare and complex medical conditions are referred to these NICUs.18 A collaborative approach to improving the care of these high-risk infants allows for aggregation of data across multiple sites and leverages the vast clinical experience among its members. The CHNC CIQI team was initiated by clinicians and relies on voluntary participation by its multidisciplinary teams. The mission of the Children’s Hospital Neonatal Database (CHND) CIQI is to identify generalizable practices for neonatal care that, when standardized across NICUs, improves outcomes. Few detailed manuals outlining the elements of QICs or evidence-based descriptions of the most effective strategies to implement multicenter collaboratives have been published.15 In this article, we describe the structure and components of the CHND’s new, multi-institutional neonatal QIC, and highlight our inaugural study in which we effectively reduced central line-associated bloodstream infections (CLABSIs) across participating institutions. 180
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METHODS The CHND began data collection in 2010 and prospectively captures clinical data on all infants admitted to participating tertiary NICUs in the United States.18 As of 2014, the CHND includes 28 tertiary referral hospitals with at least a level IIIC NICU designation, more than 400 admissions annually, more than 25 inpatient beds, and more than 50% outborn admissions, and representing all geographic regions of the United States. Membership is voluntary, and supported by the CHA. Chart abstractors at each site underwent prospective training including review of clinical definitions, participation in web-based seminar tutorials, and casebased practice. Both initial and biannual measurements of interrater agreement scores were calculated at each site; more than 90% intrasite concordance in abstraction was required for initial and continued participation in the CHND. Each center has ongoing Institutional Review Board approval for participation in the database. A key component necessary for the creation of a new QIC was a leadership team responsible for developing the necessary infrastructure to support and maintain ongoing QI projects. The CHND was developed as a grassroots effort by a voluntary interdisciplinary team of neonatal clinicians in response to the limited knowledge available regarding best practices for infants at these tertiary NICUs with complex diagnoses and rare diseases.18 As the database was under development, participating teams recognized the importance of working together across institutions to improve care through collaborative quality improvement. The CHNC CIQI steering committee was formed in 2009 and is composed of 8 physicians and neonatal nurse practitioners with expertise and training in QI methodology. This group develops the structure for the CHNC collaborative projects, coordinates the selection of new projects, supports the project management team, serves as clinical experts for each collaborative, and functions as the liaison with the CHA, which provides analytic and administrative support. The aim of the CHNC CIQI team is to improve the care of neonates and enable the completion of meaningful collaborative QI projects by achieving the targets set for defined measures. A key driver diagram provides the tool to communicate this shared mental model (see Figure 1). With support from the CHND and CHA, the inaugural collaborative project for the CHNC CIQI team was “SLUG Bug” (Standardizing Line Care Under Guideline recommendations), which was designed to reduce CLABSIs in high-risk neonatal patients.19 The CIQI steering committee designed an operational infrastructure to implement and support the participation April/June 2015
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Figure 1. Children’s Hospitals Neonatal Consortium Collaborative Initiatives for Quality Improvement key driver diagram.
of 17 CHND centers in the SLUG Bug collaborative. The Institute of Healthcare Improvement (IHI) collaborative framework provided the foundation for this project.7 A thorough systematic literature review, results of a benchmarking survey exploring current CLABSI reduction practices, and expert opinion were the basis for the development of a Clinical Practice Recommendation (CPR) document for the project. CLABSI prevention practices in the CPR included hand hygiene, central line insertion practices, central line maintenance (including line care and removal), and root cause analysis. The rationale for using CLABSI prevention practices in the form of a rigorously developed CPR document, where participating centers could choose which components to implement, rather than a traditional bundle where all components must be implemented, was to respect each center’s local resources and previous work The Journal of Perinatal & Neonatal Nursing
done in many of the NICUs at the microsystem level. Orchestrated testing methodology20 was used to determine the impact of each of 4 independent dichotomous variables: sterile versus clean tubing change technique, hub care practice compliance monitoring versus not monitoring, central venous catheter line entry access limitation versus no specific limitations, and central venous catheter line removal tracking versus no tracking policy. Compliance monitoring was a key component of each of the factors implemented to reduce CLABSI to ensure that practice change had occurred. The primary outcome measure for the SLUG Bugs collaborative was CLABSI rates using the National Healthcare Safety Network’s definition of CLABSI.21 Baseline CLABSI rates were obtained for 12 months before the start of the project, the SLUG Bugs “study period” lasted 12 months, and was followed by a 12-month “sustain period” during which more limited data were collected. Data www.jpnnjournal.com
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analysis included monthly central line days; CLABSI events; and compliance with several factors, including use of insertion checklist, scrubbing the hub of central lines, staff hand hygiene, use of sterile technique for line changes, and documentation of daily assessment of need for central line by the medical team. Statistical experts were consulted for the design and interpretation of data. In addition to the primary outcomes of the SLUG Bug collaborative project, process measures were examined by the CIQI team to determine the effectiveness of the collaborative process. These included the percentage of eligible CHNC centers participating in the collaborative, percentage of centers with complete data reporting, and percentage of participating centers who reached an improvement level of 2.5 (“changes tested”) and 4.0 (“significant improvement”) out of a possible 5.0 (“outstanding sustainable results”) on the IHI Collaborative Assessment Scale.22 Scores for the IHI Collaborative Assessment Scale were self-reported by the center and validated by an independent faculty advisor on the CIQI Steering Committee. QIC structure and components The QI collaborative utilized the IHI Breakthrough Series (IHI BS)7 to design and implement a welldefined infrastructure including the “Project Development Team” and “Project Management Team.” Each of the 2 teams was assigned specific responsibilities deemed essential to a successful collaborative project (see Table 1).
Project Development Team The Project Development Team included a multidisciplinary team of 10 content experts who volunteered to develop the project framework. The team participated in 2 face-to-face meetings that included training and education in QI methodology to ensure similar base-
line knowledge of QI methods. Subsequent meetings focused efforts on project development. Expert panel: The Project Development Team performed a comprehensive review of the medical literature related to the prevention of CLABSI, with specific attention to the neonatal population. Relevant publications were assigned levels of evidence, and a rigorous systematic clinical practice guideline methodology was applied utilizing the AGREE-II tool (Appraisal of Guidelines for Research and Evaluation).23 A survey was sent to all participating centers in the CHNC to determine current practices associated with central line care, and use of those practices were stratified by high- and lowperforming center baseline CLABSI rates. The Project Development Team drafted “Clinical Practice Recommendations” on the basis of on this systematic literature review, site survey (eg, benchmarking), and expert opinion. Project design: The Project Development Team was responsible for outlining the project charter, determining the SMART (Specific, Measurable, Attainable, Relevant, Timely) aims, process/outcome/balancing measures, timeline, and statistical design of the study. The data collection process utilized the IHI extranet site, and initial PDSA (Plan-Do-Study-Act) cycles were outlined and shared with local teams. Administrative role: The Project Development Team recruited CHNC centers to enroll in the SLUG Bug collaborative project through e-mail and at the CHNC annual meeting. Local site leaders and teams were recruited, and each local team signed a data access and participation agreement. Local teams were encouraged to obtain support from senior executive team members and identify team champions and involve key stakeholders. The Project Development Team obtained approval by the American Board of Pediatrics for Maintenance of Certification (MOC) Part 4 credit for neonatal physicians participating in the collaborative project.
Table 1. Key components of QI collaborative structure Project Development Team Content experts for Clinical Practice Recommendations Project charter, driver diagrams, process map Statistical design PDSA cycles Identify local site leaders Manage team enrollment Maintenance of certification approval
Project Management Team Annual in-person planning session Develop content for monthly web-based project meetings for the collaborative Design and present QI education series Conduct weekly team huddles Insure local team compliance with data entry Data collection and interpretation Conduct PDSA cycles Faculty advisors
Abbreviation: PDSA, Plan-DO-Study-Act.
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Project Management Team The Project Management Team was composed of volunteer physicians and nurse leaders from CHND centers. This team held web-based conference calls every 2 weeks to track the progress of the collaborative, develop new PDSA cycles to share with local centers, and prepare both the monthly meeting and educational sessions for the collaborative group. Learning sessions: Multiple interorganizational learning activities were offered to collaborative participants. An annual in-person meeting was hosted by the QI content experts on the Project Development Team and Project Management Team to discuss the progress of the collaborative, share successes and struggles, and discuss data findings with the participating multidisciplinary teams. Monthly web-based team meetings were organized and led by the Project Management Team and were typically attended by at least one representative from each site. The agenda of this monthly meeting included blinded data review and compliance reporting of each center, “round robin” discussions of local center barriers and breakthroughs, and team presentations outlining success of struggles with implementation of the project, using an “All Teach-All Learn” philosophy.24 In addition, weekly “huddle” meetings were held for 30 minutes to facilitate learning among teams to resolve barriers and sustain motivation in a more intimate format to foster transparency and sharing. Examples of topics addressed during the huddle calls included sterile tubing change technique, compliance audits, hand hygiene, and MOC process. A QI education series was presented by QI experts as webinars on specific topics related to QI science and methodology. Monthly meetings and the QI education series were recorded, and the audio, slide sets, and accompanied documents were available on the CHA Web site. Web-based evaluation was available after each session, and team suggestions were incorporated by the management team as necessary. A listserv was accessible to all members for clarification or questions related to the project. Data management: Data were entered and analyzed on a rolling basis utilizing the IHI extranet system. Teams entered local data and had real-time access to graphic representation of their data and composite data for the collaborative, including data snapshots and run charts. The Project Management Team analyzed data on a monthly basis and presented composite data at the monthly meeting in the form of run charts and U charts. PDSA cycles: On the basis of results and feedback from participating centers, multiple PDSA cycles were implemented over the course of the collaborative. The Project Management Team suggested and shared PDSA The Journal of Perinatal & Neonatal Nursing
cycles with local teams to facilitate change. Examples of collaborative PDSA cycles included engagement of local teams on monthly calls, data presentation, identifying opportunities for the Project Management Team to support teams having difficulty with implementation, and identifying methods to celebrate success. Individual centers also implemented local PDSA cycles to improve site-specific practices. Faculty advisors: Members of the Project Management Team were assigned to a center to provide oversight and feedback throughout the project as “faculty advisors.” These advisors ensured timely and accurate data collection for assigned centers, provided advice to the local team to help overcome specific barriers or challenges, and kept local centers engaged.
RESULTS The collaborative CLABSI rate decreased from a baseline rate of 1.33/1000 line days to a rate of 1.08/1000 line days, a 20% decrease, by the end of the 12-month study period.19 Eleven of the 17 centers showed a decrease in CLABSI rates during the study period, and sterile tubing change technique had the strongest effect, independently decreasing CLABSI rate by 0.82/1000 line days. In addition, this significant improvement in CLABSI rates was sustained during the 12 months after the study period. Successful implementation of the collaborative project was measured by specific process metrics. Seventeen of the 24 eligible CHNC centers (71%) participated in the SLUG Bugs QIC by implementing change and submitting data. Compliance with data reporting was consistently more than 80% for all participating centers (see Figure 2). Of the 17 participating centers, 16 (94%) achieved an IHI Collaborative Assessment Scale score of 2.5 or more (“improvement”), with 6 centers achieving a score of 4 or more (“significant improvement”) and 3 centers achieving a score of 4.5 (“sustainable improvement”) (see Figure 3).
DISCUSSION Quality improvement collaboratives are now an accepted approach to implementing change and improving care across centers. The efficacy of collaborative improvement networks is variable11,12 and likely related to the organizational structure of the QICs and the methods in which information is shared between participating centers. In this article, we describe the inaugural project for the CHNC in which our multicenter collaborative utilized the IHI Breakthrough Series model to achieve reduction in CLABSI rates at participating CHNC centers. The success of this project was based www.jpnnjournal.com
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Figure 2. Compliance with complete data reporting for collaborative measures (percentage of participating centers with complete data entry each month during the collaborative).
on the establishment of a framework of a well-defined improvement process that utilized an interdisciplinary team. Collaborative improvement networks can be complicated to develop, and as a result are relatively infrequent. These networks are critically important in pediatrics, as the relatively small number of patients at individual institutions often limits studies to singlecenter case series. Within neonatal medicine, several other neonatal networks have demonstrated improvement in CLABSI rates through collaborative efforts, including the Vermont Oxford Network, California Perinatal Quality Care Collaborative, and the Ohio Perinatal Quality Collaborative.9–13 Further efforts are warranted to expand on the experience of and test the effectiveness of these existing networks, and to develop new collaborative networks. Successful collaboratives share important qualities, including organizational support and a basic foundation of knowledge about QI methodology so that a “com-
Figure 3. IHI Collaborative Assessment Scale scores at the conclusion of the SLUG Bugs collaborative. A score of more than 3 demonstrates “improvement” as defined by the IHI. 184
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mon language” exists among participants. A focus on measurable and well-defined outcomes and interdisciplinary teamwork emphasizing a shared mental model, a sense of community and transparency, and respect for local culture are key. In addition, collaboratives must employ effective use of technology for data collection and communication and methods to overcome obstacles to participation and successful local implementation of the project. The CHNC CIQI used the basic structure of the IHI Breakthrough Series8 and designed a strategy for ongoing education and data sharing among the participants with an emphasis on shared learning. Recruiting an expert panel of clinicians that included both nurses and physicians and a PDT to develop CPR and outline the specific components of the collaborative project was a key component of success. These experts, many clinical leaders of participating centers, were able to give a perspective to the variation of care across sites, thus achieving local support of the project. Multidisciplinary efforts that capitalize on the shared expertise and collaboration of both physicians and nurse leaders are likely to be the most successful. Although we followed the overall structure of the IHI Breakthrough Series, several components of the CIQI structure were felt to have had a positive influence on the collaborative process. As previously stated, a CPR document was drafted utilizing a comprehensive literature review and expert opinion—including neonatologists, infectious disease specialists, and nurses who were central line experts-–as well as information gathered through a survey of participating centers that was compared with baseline center CLABSI rates. This allowed the group to incorporate successful practices that were already in place in some centers, and to encourage these successful local practices when appropriate. Developing a sense of community and shared April/June 2015
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purpose among the participants was a challenge given the geographic constraints, but we found that frequent interaction and shared experiences of both nurses and physicians enhanced the experience for many participants. In addition to monthly team meetings, we found weekly, brief “huddle” sessions and frequent contact from assigned faculty advisors to be particularly helpful. Each of these 30-minute informal sessions engaged participants to discuss one particular topic at a time in greater detail, and fostered an atmosphere of continual, shared learning. Discussions during the monthly meetings and huddle calls specifically helped teams by offering suggestions to improve motivation and engagement of front-line staff, increase the number of audits for project metrics, and to teach staff how to implement new techniques such as sterile tubing change. A “Golden Collaborative Award” was given to one center each month at the recommendation of the faculty advisor for having overcome a specific barrier and met the project goals. Building a sense of community was critical in developing the respect and trust necessary to allow for transparency. Although the primary focus of the SLUG Bug collaborative was the clinical improvement project, the inclusion of process metrics and tracking of compliance and participation of each local center allowed us to determine the success of the collaborative infrastructure. Specifically, we found that the local support and resources for improvement projects varied considerably from center to center, and that an ongoing commitment by the Project Management Team, and specifically the faculty advisors, was critical to ensure that we met the goals of the collaborative. In several instances, the faculty advisors were able to identify solutions to local barriers and provide the support needed for compliance with the project components. The effectiveness of this strategy was often evident during follow-up contact and documented on monthly progress reports by the centers. Participation in the QIC was voluntary, so executive-level institutional support was crucial to ensure that teams had the necessary resources available for data collection and investment of staff time. Working together, we enhanced the QI capacity for the CHND network of institutions through the development of a framework for collaborative work, and established the foundation for ongoing multicenter collaborative projects. Together, these institutions demonstrated improvement in the provision of care to highrisk neonatal patients. The combination of newly available CHND data showing widespread variation in care and an effective collaborative framework sets the stage for ongoing multicenter improvement for this unique group of patients. Key components of the success of The Journal of Perinatal & Neonatal Nursing
this project were frequent educational and project meetings contributing to a sense of team effort, clear and well-defined project metrics and improvement strategies, continual shared learning opportunities, and oversight by an interdisciplinary Project Management Team to ensure accurate and timely data collection for analysis. We found that through a coordinated approach and committed leadership team, a multicenter collaborative approach can be a feasible and effective method to implement change and improve the quality of care of high-risk neonatal patients.
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