Tag: neonatal

Creating Quality Improvement New Year Resolutions: Maternal and Newborn Care

Are you among the hospitals who are seeking to improve quality? Have you explored the Psychology of Quality Improvement?

Elizabeth Rochin, PhD, RN, NE-BC | December 13, 2023

Posted under: Maternal Health, Quality of Care

Hospitals across the country are looking forward to 2024 and sharing the vision of their strategic plans. If you are among the hospitals who are seeking to improve quality, have you explored the Psychology of Quality Improvement?

Last week, I joined others from across the United States at the National Institute for Children’s Health Quality (NICHQ) National Network of Perinatal Quality Collaboratives Annual Meeting. Rhode Island is fortunate to be one of many states funded to support its perinatal quality collaborative.

Many topics were consistently mentioned and I wanted to bring awareness to one of those topics here. Postpartum readmissions were one of the issues being addressed, and how we can continue to bring awareness to the key drivers of readmission.

According to the National Perinatal Information Center, between 2018 – 2022, the most frequently reported diagnosis related to postpartum readmission is preeclampsia. Severe hypertension and preeclampsia have continued to rise over the past five years, and that trend does not seem to be changing. Fortunately, there have been great strides in reductions in readmission due to infection, and postpartum hemorrhage has been relatively stable over the past five years.



Preeclampsia is not only the driver for postpartum readmission, but it has been a driver for cesarean birth as well. During the years 2018 – 2022, the NPIC Perinatal Database follows coded reasons for cesarean birth, and preeclampsia has had the highest increase over this same five year period.



Many hospitals are seeking resources to impact the rate of preeclampsia and hypertension that are being seen in obstetric units. Maternal morbidity and mortality discussions and review committees (MMRCs) continue to review maternal deaths associated with preeclampsia/severe hypertension/stroke and have finally begun to explore the impact that racism may have had in diagnosing/addressing/treating/responding to hypertension in Black women.

One of the most critical areas addressed during the NNPQC meeting was the Psychology of Quality Improvement. Yes, there is a foundational approach to QI projects that cannot be overstated. Dr. Veronica Gillespie-Bell (Louisiana) provided an outstanding primer on Creating Change and Managing Resistance (yes, managing the resistance to change). There are those who will embrace change. And there are those who will resist change. But there is a way ahead. And here are the secrets:

  • Define the change through an effective vision

  • Communicating the change

  • Building an improvement team(MUST include frontline staff)

  • Develop reinforcement strategies

  • Assess the climate for change—cultural, commitment, capacity readiness

  • Creating culture for change

  • Select the model for change

  • Understanding and managing resistance

  • Celebrate small wins


**normalization of deviance can completely derail change management**

It is very important to address normalization of deviance (NoD) within change management. NoD has been mentioned several times in these blogs over the past year. If you need a refresher, check out our previous discussions. Become familiar with the term. There are reasons that, on average, it takes 17 years to translate research to practice. This is one of them.

Are your frontline teams drivers or mere passengers in the quality improvement process? How can you leverage the bench strength of your teams to effectively create changes in patient care? If your frontline teams do not have an active role in your quality improvement initiatives, you are missing a critical voice in successful (and sustainable!!) change.

  • Are they ready to engage in QI work?

  • Did the team have any input in creating the QI project?

  • Are there identified champions and informal leaders who can contribute a diverse lens to the process?

  • Is there bandwidth available?

  • How many other projects and initiatives are underway?

  • Is this considered a priority among many others? Who is communicating that priority? (“This is something we have been told to do” versus “We have an opportunity to improve patient care and maternal outcomes”)

  • Is the team multidisciplinary and includes all facets of care?


It is important to include your patients and families in your quality improvement initiatives, particularly if the target population is patients. Let’s use maternal severe hypertension for a moment.

  • Do you have patients with lived experience on your Quality Improvement projects? How are you ensuring that diverse voices are a part of your work?

  • Have your patients reviewed your preeclampsia/hypertension discharge materials? Do they understand them? Are they in a language they understand?

  • Are you disaggregating your outcomes data by race and ethnicity? Are your time to treatment outcomes similar, or do you have glaring differences in treatment outcomes?


No matter your priority for this next year, whether it is maternal hypertension, postpartum hemorrhage, safely reducing primary cesarean birth, sepsis, maternal mental health, or other healthcare needs, creating a strategy to implement change in practice or process can take time. But let’s face it…our patients don’t have 17 years to implement change. They are relying on us now to provide the highest quality of evidence-based care.

As part of your New Year resolutions, think about adding sustainable change to your strategy. Change and sustainable change are two different concepts. Quality and patient safety are at or near the top of many hospitals’ strategic plans in 2024 and beyond, with many including high reliability as a metric of success. Achieving these goals are possible, but only with the cumulative efforts of data, knowledge, commitment to equity, and action. And yes, the psychology of quality improvement.

Here's to sustainable change and outstanding quality improvement in 2024. Happy New Year

If your team would like to incorporate sustainable quality improvement in your organization, NPIC can support your strategy. Reach out to us to learn more.
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How Did We Get Here? Creating and Sustaining Supportive Team Environments

During Neonatal Nurses Week, not only should we be focused on the outstanding work of our neonatal nursing colleagues, but how can we promote collaborative teamwork that undergirds outstanding neonatal care? How can we best support our nursing teams in caring for the smallest and most fragile of patients?

Elizabeth Rochin, PhD, RN, NE-BC | September 14, 2023

Posted under: Other, Quality of Care

During this Neonatal Nurses Week, not only should we be focused on the outstanding work of our neonatal nursing colleagues, but how can we promote collaborative teamwork that undergirds outstanding neonatal care? Sometimes it is easier said than done, but one thing is sure: committing to and caring for our patients AND each other, should be our rallying cry.

Unfortunately, the news cycle of late has been rife with discussions of patient harm resulting from communication challenges and failures within teams:
  • April Valentine: Young woman who died while in labor. Nurses reported they could not call the doctor as they would “cuss them out.”

  • Lucy Letby: NICU nurse in the UK found guilty of murdering seven babies in a neonatal unit and convicted of trying to kill six others. Physicians and others came forward with their concerns, only to be told to “apologize to Lucy” for impugning her of wrongdoing.
As this is Neonatal Nurses Week, I thought I would briefly explore chain-of-command opportunities in the NICU. How can we best support our nursing teams in caring for the smallest and most fragile of patients? Instead, I found a litany of information related to bullying…nurse/nurse, nurse/physician, physician/physician. And I must say, I was not expecting that. While the majority of my work of late has been to support communication challenges in the obstetric setting, perhaps we should also focus on the NICU environment.

Committing to and caring for others, including each other, should be our rallying cry.

Here are two NICU examples I thought I would share, one from a nurse and one from a physician:

Nurse:
“Guess who just got bullied out of their new NICU job? It’s me. This is the most catty, cliquey, TOXIC work environment I have ever seen. I have been yanked off of orientation, belittled, completely unsupported, and now my preceptor says I need to ‘rethink if this is really for me.’ Like…. I have 4+ years of experience, have worked COVID ICU, charged, precepted, been asked to be House Sup…. I know I’m not dumb. But [gosh], they made me feel small. Anyone else go through this? Feeling pretty alone and discouraged right now. Luckily a past job is taking me back and I’m getting out of here.”

Physician:
“The presence of incivility is not new to medicine, and certainly not foreign to us in the NICU environment. Over the past two decades, I have seen several situations develop in different institutions that create an environment where it is uncomfortable, threatening, or unsafe to conduct oneself fluidly as part of a highly functioning team. Incivility can arise simply from people choosing to disregard or disrespect one another’s opinions, or it can manifest more blatantly in the form of harsh public criticism or the deliberate dissemination of misinformation that deteriorates trust levels.” https://www.medela.us/breastfeeding-professionals/blog/going-toxic-in-the-nicu-dealing-with-workplace-negativity

Think about that. Deliberate dissemination of misinformation. Deteriorating trust levels? The question is so timely…how did we get here?

And as I thought about this more, I kept coming back to the patient safety bundles developed by the Alliance for Innovation on Maternal Health (AIM). The 5 Rs, (readiness, recognition, response, reporting/systems learning/respectful interactions) create a consistent and standardized approach to improving patient care. And may even support team synergy and col
But what if there were a Team Communication Patient Care Bundle? What would that look like? How can we establish consistent, standardized ways of meaningful teamwork, enhancing communication, and improving patient outcomes?

So, the real question should be “where do we go from here?” and “How can we work collaboratively to create the best environment for patients AND our teams?”

Here is a start. I hope you will help me finish it.

Readiness
Every hospital Board/Trustees:
  • As part of Governance, routinely assess work environment/psychological safety and establish metrics to evaluate hospital leadership.
  • Expectations of transparency related to patient harm resulting from communication failures.
  • Understand the scope of Directors and Officers Insurance Liability (D & O)/General Liability (GL) in the event of serious maternal/neonatal harm/death that was the direct result of a documented/known team communication challenge (incivility/bullying/intimidation).
  • Yearly Board assessment that includes organizational psychological safety metrics.
Every hospital
  • Establish parameters, expectations, and accountabilities for team communication and share documents and reports openly.
  • Establish a definition of incivility/bullying/intimidation and hold all employees accountable to expectations.
  • Assess psychological safety within units and share findings with all team members, including between/within disciplines.
  • Establish a centralized and representative team to evaluate serious maternal/neonatal harm stemming from potential/real communication failures.
  • Train staff on team communication skills annually/per policy (TeamSTEPPS as an example).
  • Establish a chain-of-command system that is developed and agreed upon by all stakeholders and broadly communicates plans for escalation, including real-time communication tracking.

Recognition and Prevention
Every Unit
  • Provide ongoing education to all team members related to communication expectations and accountability.
  • As a team, identify high-risk and high-stress situations that may facilitate communication challenges.
  • Use simulation as a guide and teaching tool for critical conversations.
  • Collaborative physician/provide/nursing leadership that role models teamwork and open communication style.

Response
Every Unit
  • In the event of a serious communication failure, stabilize the patient as needed/supportive care for the impacted staff member(s).
  • Use a standard, facility-wide reporting system for potential/real patient care challenges related to team communication.
  • Establish a rapid response team/process that can be available to any unit to support communication challenges within patient care.
  • Consistent and equitable actions for behaviors/interactions requiring intervention.
  • Use of Employee Assistance Program (EAP) for support/counseling within serious communication failures/patient events.

Reporting and Systems Learning
Every unit
  • Celebrate improvements in team cohesion and communication at every opportunity.
  • Perform multidisciplinary reviews of any patient care errors that may be the result of team communication failures.
  • Monitor rate of event reports related to team communication issues/errors/failures.

Respectful, Equitable, and Supportive Team Cohesion
Every unit
  • Assess for and act upon real/perceived team communication challenges based on bias, discrimination, or racism.
  • Establish debriefing process for patient harm as a result of communication failures.
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