65
Quality improvement

Quality assurance

Clinical governance and quality improvement are frameworks for assuring the quality of clinical services and improving them (Fig. 65.1). They are key issues for all who provide care for newborn infants.

Fig. 65.1 Framework for quality assurance.

Clinical audit

Aims to assess patient care and outcomes through systematic comparison against explicit standards. Change is then implemented and re-audit follows. The audit cycle is shown in Fig. 65.2, and questions about audit are addressed in Table 65.1. More recently neonatal services have been using quality improvement (QI) methodology to implement improvements in care. This uses PDSA (plan-do-study-act) cycles with run-charts to show progress over time. It has the advantage of continuous measurement of outcomes rather than ‘snapshots’ of data at specific time points as measured by audit. PDSA is described in Fig. 65.3. Changes should be evidence based and action plans should be SMART (specific, measurable, achievable, realistic and timely).

Fig. 65.2 The audit cycle.

Table 65.1 The clinical audit process.

Who should be involved?	All health professionals (multi-disciplinary)
How are topics selected?	Observing current practice
	Clinical incidents, complaints and claims, etc.
Design?	Set or identify standards
	Identify data sample
	Only collect relevant data
Analysis and recommendations	Were standards met?
	Feedback results
	Identify improvements
	Develop an action plan
	Re-audit to check improvement

Fig. 65.3 The PDSA cycle to rapidly initiate change in practice and evaluate it.

Simulation

Simulation has become an important component of quality assurance in neonatal care. Clinical scenarios are used to train multidisciplinary teams in a safe and educational environment, sometimes using sophisticated models. Widely used in life support courses, e.g. neonatal resuscitation and emergencies, and increasingly for simulated emergencies in the neonatal unit, delivery room and lying-in (postnatal) wards. It can also be used to develop human factor skills in leadership, teamworking and communication. It also allows training in some practical or uncommon procedures before performing them on patients. Simulation can be used to re-create critical incidents identified through risk reporting systems and can also identify latent risks (accidents waiting to happen) that can be fed back into the risk management system of the unit.

Critical incident reporting (Table 65.2)

It is important that the whole neonatal team develops a culture of quality and safety. Reporting critical incidents, not only those that have caused harm but also those that could have caused harm are a key component of quality assurance. The most common and serious critical incidents in neonatal practice and ways to minimize their occurrence are considered in Chapter 66.

Table 65.2 Questions and answers about critical incidents.

What are they?	Unexpected events that cause or could cause harm to the patient. Include near-misses
Who should report them?	Everyone
What should be reported?	The facts
Why report?	To identify causes
	To develop a strategy to prevent recurrence
	To act as warning for complaints/litigation
	To provide information for external monitoring
Who is to blame?	A no-blame culture should be developed – disciplinary action will not follow except where acts or omissions are malicious, criminal, or constitute professional misconduct
What level of investigation is required?	Depends on extent of harm to the patient and assessment of likelihood of recurrence by taking the whole circumstance of the event into account, not just the incident itself
	If risk of harm or recurrence is high, perform root cause analysis
What is root cause analysis?	A structured method used to analyze serious adverse events with the goal of identifying contributing factors
What if major harm has occurred or major damage to the organization?	Because of potential litigation, the hospital risk management group and senior managers should be informed. A more detailed, formal causal analysis (FMEA, failure mode and effect analysis) should be undertaken

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Questions

Are there any quality improvement initiatives specifically for neonatal care?

Many local and national initiatives, but the most comprehensive dedicated to neonatal care is the Vermont-Oxford Neonatal Quality Improvement Collaboratives Program.

It aims to improve the quality and safety of medical care for newborn infants and their families by:

• providing an information resource which also uses material from other disciplines in health-care and other high-reliability organizations, e.g. aviation industry
• providing expert faculty
• promoting four key habits to improve outcome (Fig. 65.4)
• organizing collaborative safety improvement projects, e.g. reducing nosocomial infection, by visits between units or via the internet
• voluntary, anonymous collection of errors on internet.

Fig. 65.4 Four key habits for better outcomes promoted by the Vermont–Oxford Network.

(Reproduced with permission of J. Horbar, Vermont–Oxford Network.)

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Questions

How can parents help improve quality in the NICU?

• Offering family-centred care is crucial to support families at a time of high stress and to enable successful bonding with their baby.
• Parent representatives should be involved in the management of neonatal networks and in the development of new services.
• Family integrated care is an innovative program in some units. Pioneered in Canada, parents provide most of the care for their baby, even in the NICU. Nurses and doctors teach and support parents who may provide some highly technical care. This approach has been shown to improve outcomes such as improved weight gain, reduced sepsis and increased rate of breastfeeding at discharge.

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