Janice Schriefer

The synergy of pathways and algorithms: two tools work better than one.

BACKGROUND Clinical quality improvement efforts at the Medical Center Hospital of Vermont (MCHV) led to the development of critical pathways, which show the ideal plan of care, and algorithms, which help clinicians make one of many complicated decisions within a plan of care. A synergy appears to develop when pathways and algorithms are used together. DEVELOPMENT OF PATHWAYS AND ALGORITHMS A steering committee supports and oversees pathway and algorithm efforts. A quarterly tracking report updating progress for all pathways and algorithms is circulated to all nurse managers, medical staff, and administrators. When combining pathways and algorithms, the pathway is created first. Algorithms are developed for trouble spots within a pathway. CORONARY ARTERY BYPASS GRAFT (CABG) PATIENTS Having developed the pathway for CABG patients, the CABG case management team meets monthly to review outcomes and variances. For example, an algorithm for managing atrial arrhythmias--the chief cause of variance for one months results--was developed. The combination of pathways and algorithms for CABG patients has resulted in a reduction of 2.5 days for total length of stay (including 1 day on the surgical intensive care unit [SICU]), for a mean cost savings of

Patient safety and quality improvement: an overview of QI.

3,500. Re-admission to the SICU, reintubation, and mortality rates have all decreased. CONCLUSION The idea of reaping the benefits of both pathways and algorithms is becoming more popular at MCHV, where teams use algorithms to improve on complicated processes underlying the pathways.

Interdisciplinary Simulation-based Training to Improve Delivery Room Communication

It is important for pediatric providers to be involved in quality improvement (QI) activities to improve children’s health outcomes.• The Model for Improvement asks several key questions related to a process, then uses Plan-Do-Study-Act(PDSA) cycles to implement, test, and spread changes.• Lean and Six Sigma methodologies can improve quality by increasing workflow efficiency and decreasing variation.• Root cause analysis (RCA) is a retrospective quality tool that helps determine factors contributing to errors and adverse events, so that improvements can be implemented.• Failure modes and effects analysis (FMEA) isa prospective quality tool that anticipates system vulnerabilities and helps develop risk reduction strategies.• Evidence-based interventions, such as best-practice guidelines, promote standardization and reduce errors and adverse events, especially in high-risk health-care settings.• Team training can improve communication and situational awareness to create a safer health-care environment.

Evaluation and Development of Potentially Better Practices for Perinatal and Neonatal Communication and Collaboration

Introduction Poor communication among obstetric and pediatric professionals is associated with adverse perinatal events leading to severe disability and neonatal mortality. This study evaluated the effectiveness of an interdisciplinary simulation-based training (SBT) program to improve delivery room communication between obstetric and pediatric teams. Methods Obstetric and pediatric teams participated in an SBT annually during 3 academic years, 2008–2011 (Y1–Y3), in a prospective, observational study. Eligible participants (n = 228) included attendings, fellows, house staff, midlevel providers, and nurses involved in delivery room care. Simulations were videotaped and evaluated using a validated 20-item checklist of best communication practices. Checklist scores were compared across years with the Kruskal-Wallis test. Providers were also surveyed annually regarding communication during actual deliveries using a standardized questionnaire. Ratings were analyzed using two-way analysis of covariance. Results At least 60% of eligible providers participated in 1 or more SBT sessions and completed surveys annually. Checklist scores on communication during SBT improved from Y1 (median, 6; interquartile range, 4) to Y3 (median, 11; interquartile range, 6) (P < 0.001). Survey results showed the perception of improvement over time in interteam communication during actual deliveries by obstetric (P < 0.005) and pediatric (P < 0.0001) providers. The obstetric team also perceived improved provider communication with the family (P < 0.05). Conclusions Communication during SBT as well as the perception of communication during actual deliveries improved across the study period. The potential of a checklist to standardize delivery room communication and improve patient outcomes merits further investigation.

Managing critical pathway variances.

Objective. The obstetric and neonatal exploratory focus group of the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative 2002 set out to improve collaboration, communication, and coordination between maternal and neonatal caregivers in 3 areas: the pregnancy at 22 to 26 weeks, measurement of maternal outcomes that are linked with neonatal outcomes, and team performance during high-risk delivery. Antepartum and intrapartum maternal attributes and interventions also were considered important measurements to identify practice variations and their relationship to neonatal outcomes for ongoing obstetric and neonatal collaboration. Methods. Potentially better practices were developed on the basis of evidence in the literature, expert opinion, and internal analysis at the participating perinatal centers. The potentially better practices include development of local guidelines at each center for the care and counseling of pregnant women who are at risk for delivering at the margin of viability; communication strategies for obstetric and neonatology providers relating to high-risk pregnancy treatment plans; team communication and performance at high-risk deliveries; design of organizational structures and processes that facilitate obstetric and neonatal collaboration; and development of perinatal data to evaluate effects of perinatal practices on maternal, fetal, and neonatal outcomes. Results. As a result of the project, participating centers developed local guidelines for pregnancies between 22 and 26 weeks, created a cross-center maternal database that currently is being linked to neonatal outcomes, and completed a pilot study on video simulation of neonatal–perinatal team communication. Conclusions. Increased understanding of practice variation in the management of care for infants who are at the margins of viability, locally developed guidelines, and a focus on improved team communication during delivery can be accomplished with a multicenter collaborative approach.

Implementation and case-study results of potentially better practices for collaboration between obstetrics and neonatology to achieve improved perinatal outcomes.

As the use of critical pathways expands at an increasing rate, we are faced with the issue of how to manage variances from the pathway. Variance management is not clearly defined in the literature, and many institutions search for the best approach. We have implemented a number of different techniques for variance management at Fletcher Allen Health Care. Our success benefits both patients and providers.

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

OBJECTIVE. The objective of this study was to make improvements in communication and collaboration between neonatal and obstetric specialties. Five NICUs from the Vermont Oxford Networks Evidence-Based Quality Improvement Collaborative in Neonatal and Perinatal Medicine tested potentially better practices that overlap obstetric and NICU care. METHODS. One area of practice improvement was the management of the pregnancy at the margin of viability. Another included the use of team training and video simulation to improve team performance during high-risk deliveries using aviation-based communication techniques. Another focus of the collaborative was the creation of a multicenter database to measure combined perinatal and neonatal outcomes. RESULTS. The principle outcomes are increased patient satisfaction with teamwork between neonatology and obstetric services and improved team response times for emergent deliveries and the increased use of team communication skills during video simulations of high-risk deliveries. CONCLUSIONS. Implementing these potentially better practices can result in improved communication and collaboration related to perinatal and neonatal care.

Improving Breastfeeding Support: A Community Health Improvement Project

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

Interobserver reliability of attending physicians and bedside nurses when using an inpatient paediatric respiratory score.

BACKGROUND Because of the brevity of the postpartum hospital stay, mothers and their newborns are discharged home before breastfeeding is well established. In 1992, feedback from patients who had given birth at Fletcher Allen Health Care (Burlington, VT) suggested a need for more consistent, expert, and timely assistance with breastfeeding in the hospital and better continuity of care during the first few weeks at home. QUALITY IMPROVEMENT TEAM: In 1993 a team developed objectives, analyzed the problem and possible solutions, and made eight recommendations on how the hospital could do more to promote breastfeeding. Implementation by team members and hospital staff included policy development, staff education, acquisition of funding, a visiting professorship, development of a lactation consultant coordinator and team, and patient surveys to evaluate the program. A late 1994 survey of 63 postpartum patients on their day of discharge indicated a high level of satisfaction with breastfeeding support in the hospital. CURRENT STATUS Activities are being undertaken for lactation consultation coverage, further policy development, implementation of nurse competency validation, improved patient and family education materials, and continued evaluation of the breastfeeding support program through patient surveys. CONCLUSION In the face of barriers such as the projects large scope, a paucity of internal team members, and a large number and variety of recommendations, some of the recommendations and follow-up plans have yet to be implemented. Yet the project has yielded improvements in care and provides a model of how hospitals can expand their traditional boundaries of care and quality improvement into community health issues.

Identification and collection of quality indicators for perinatal care.

AIMS AND OBJECTIVES This study aimed to determine the interobserver reliability between bedside nurses and attending physicians for a paediatric respiratory score as part of an asthma Integrated Care Pathway implementation. BACKGROUND An Integrated Care Pathway is one approach to improving quality of care for children hospitalised with asthma. Prior to implementation of the integrated care pathway, it was necessary to train nursing staff on the use of a respiratory assessment tool and to evaluate the interobserver reliability use of this tool. DESIGN Prospective study using a convenience sample of children hospitalised for a respiratory illness in an academic medical centre. METHODS The respiratory assessment used was the Paediatric Asthma Score. Bedside nurse-attending physician (27 different RNs and three attending paediatric hospitalists) pairs performed 71 simultaneous patient assessments on 20 patients. Intraclass correlation coefficient and kappa statistics were used to assess interobserver reliability. RESULTS The overall intraclass correlation coefficient was nearly perfect where κ = 0·95, 95% CI (0·92, 0·97) and overall kappa for reliability based on clinically relevant score breakpoints was also high with κ = 0·82, 95% CI (0·75, 0·90). The majority of subgroup analyses revealed substantial to almost perfect agreement across a variety of diagnoses, age ranges, and individual score components. CONCLUSIONS Bedside nurses, with support and training from attending physicians, can perform respiratory assessments that agree almost perfectly with those of attending physicians. RELEVANCE TO CLINICAL PRACTICE The use of an Integrated Care Pathway allows for optimal interprofessional collaboration between bedside nurses and attending physicians.