From left, Diane Comer, R.N., Heather Brown, R.N., and Robyn Pracht, R.N., look on as Eric Sullivan, M.S.N., R.N., posts a care quality indicator number at the NICU nurses station. (photo by Anne Rayner)
NICU’s openness on quality measures spurs improvement
Recently, clinical nurse educator Eric Sullivan, M.S.N., R.N., stuck the number “100” on a poster outside the Neonatal Intensive Care Unit nurses' station at the Monroe Carell Jr. Children's Hospital at Vanderbilt.
The number indicated an achievement — the longest stretch of days without the report of a central line-associated blood stream infection (CLABSI) in the unit. The public posting of this milestone is just one example of a bold, new approach to quality improvement.
“Initially there was some apprehension on the unit about posting the NICU's rates, but over time, staff members have become increasingly invested in the project,” Sullivan said. “Now, there is a strong sense of ownership among all team members. Previously, the longest time without a CLABSI was 85 days, and when the number dropped back down to zero, there was a buzz around the unit. The nurses wanted to find out what happened,” Sullivan said.
It's not a matter of blame when an infection breaks the streak in the NICU, but rather an opportunity to join together, pore over details and ferret out the cause.
From that collaboration comes a stream of small changes that continuously improves care. The poster is just one example. Others include publications, membership in statewide collaborations, open documentation and sharing of quality indicators like hand washing.
“The first broad, hospital-wide quality project we did three years ago was to examine accuracy of our patient identification bands,” said Paul Hain, M.D., associate chief of staff at Children's Hospital.
“We found more than 20 percent of our ID bands had some kind of problem, and that some areas of the hospital did better than others.”
Hain and his colleagues used the information to create a template for change and improvement that was very successful, reducing ID band errors to 1 percent today. Then, they wrote and published an article in Quality and Safety in Health Care, openly discussing the issue at Vanderbilt and how it was fixed.
“It is part of our commitment to transparency, so we can learn from each other and accelerate improvements in care. We collaborate because we are all in the same industry for the same purpose,” said Julie Morath, R.N., M.S., VUMC's chief quality and safety officer.
This openness and transparency is demonstrated in several ways.
Recently, a graph was e-mailed to all staff and faculty documenting a low hand-washing rate of 52 percent at Children's Hospital last October and the improvement to a still-too-low 72 percent by this March. The e-mail was accompanied by a note from hospital CEO Kevin Churchwell, M.D., encouraging staff and faculty to work together to achieve 100 percent compliance.
While the information might seem potentially embarrassing to the hospital, the simple act of sharing it openly may be the best way to drive change.
Tom Talbot, M.D. M.P.H., Chief Hospital Epidemiologist, said sharing information creates buy-in and collaboration from all levels and disciplines, and that change in culture is the single biggest reason for success of these programs.
“For a long time, one of the beauties of medicine was the autonomy, but we can no longer operate in silos. It is not that we are stifling individual decision-making. Using the best evidence, we partner with the frontline to provide the framework upon which individualized care can be delivered.
“It's like building a car — the framework is designed so each one starts the same way, runs the same way and has the same safety features, yet each car can be driven in a way that meets the driver's needs,” Talbot said.
The clear posting of the number of days between CLABSI infections is a practice other units are considering. Openly sharing shortfalls in quality with other hospitals and collaborating on checklists and other tools to improve is already an important part of many quality improvement projects around the Medical Center.
“This transparency unleashes the wisdom of the front line and an abundance of resources to deal with the complexities associated with the level of care we give in the hospital and clinic settings today,” Morath said.