Quality Improvement for NICU babies

Practice-Based and Lifelong Learning – 3.1: Evaluate the performance of individuals and systems to identify opportunities for improvement.

One of the parts of the LSI curriculum at OSU is the Applied Health Systems Science Program. Part of this program includes a medical student led QI project to identify a system failure and work on the implementation of an improvement for it. For my QI project, I have been working with a group on decreasing post-surgical neonatal hypothermia at Nationwide Children’s Hospital. The initial problem statement for the project is shown below.

Initial problem statement for QI project

Working on this project has been an interesting challenge for our group as none of us have ever rotated through the NICU before, limiting our knowledge on the work flow in this system. However, this has allowed us to learn a lot from our multi-disciplinary colleagues to understand process details and possible areas of improvement. We have been able to attend the peri-op quality improvement meetings that include many team members including nurses, respiratory therapists, and doctors to get feedback on our QI project as well as hear about the many other projects they are working on to improve NICU and peri-operative care.

Another challenge for our project has been inconsistent availability of data. Not long after we started our project, there was a change in data analysis personnel. This has meant that although data has been collected regarding peri-operative neonatal body temperatures, most of it has not been available for our analysis. We have also found that there is a very small sample size of patients to work with, as there are not that many surgeries on NICU patients each month. This has made it difficult for our group to work on system improvements, especially as our project is over the course of a year, a relatively short time compared to the frequency of surgeries and hypothermic events. However, neonatal postoperative hypothermia is still an important issue at NCH that needs to be addressed, so with guidance from our mentor we have been working on improving it.

Our group created a cause and effect fishbone diagram to brainstorm contributing factors to post-operative hypothermia.

Fishbone diagram showing contributing factors to neonatal postoperative hypothermia

We then brought this diagram to the QI meeting to hear feedback and receive input about on other contributing factors. We also sought ideas for interventions to improve temperatures, and rated these ideas based on ease of implementation and size of opportunity for improvement. The diagram below is an opportunity payoff matrix we used to help prioritize the interventions that were brainstormed to determine which intervention to attempt initially.

Opportunity Payoff Matrix

Based on this matrix, we will try to implement a perioperative champion as a first intervention to improve post-operative temperatures for neonates. This will include creating an intraoperative and postoperative temperature check protocol to help increase the number of data points we have in the operative and postoperative period and potentially keep patients away from the hypothermic cutoff. This may also help us better understand contributing factors to postoperative hypothermia to allow for more interventions in the future. The process map below shows where our intervention will affect the process.

Process map with intervention

Right now, we are working on the improvement phase of the DMAIC model for our QI project. We have thought of possible solutions for root causes and selected the solution we want to implement. However, we are still developing the improvement plan for piloting and implementation. By the end of the year, the goal is to implement or intervention and collect data for 4 weeks of this intervention so we can evaluate the results, as well as work on the Control portion of the DMAIC model. Working on this QI project has taught me a lot about the quality improvement process, and I am excited to keep learning about QI as we move forward with our intervention and control process. This experience will also help me in residency and beyond as I continue to work on quality improvement. QI is now a requirement for ACGME residency, so the lessons I am learning now will serve me well as I continue to work on projects  to improve systems and better serve patients.