My primary research interest is the effect of health system design on quality of care and outcomes for sick newborns. This interest includes health care delivery design at the macro-system level as well as organizational context at the hospital and neonatal intensive care unit level. In addition, I am interested in the use of information technology to support families, care professionals, and policy makers in their efforts to provide optimal care to sick infants.

Clinical Focus

  • Neonatal-Perinatal Medicine

Academic Appointments

Administrative Appointments

  • Chief Quality Officer, California Perinatal Quality Care Collaborative (2018 - Present)
  • Chief Scientific Officer, California Perinatal Quality Care Collaborative (2017 - 2018)
  • Core Lead For Health Organization Performance, Center for Policy, Outcomes and Prevention, Department of Pediatrics, Stanford University (2014 - Present)
  • Director, Perinatal Health Systems Research, Department of Pediatrics, Stanford University School of Medicine (2013 - Present)

Honors & Awards

  • Marie McCormick Lectureship in Health Services Research and Epidemiology, Harvard Newborn Medicine (10/19/2017)
  • Social Disparities in NICU Care, NICHD (R01) (04/01/2016)
  • Dashboard of Racial/Ethnic Disparity in the Care Provided by NICUs, NICHD (R01) (12/01/2015)
  • WISER Study, NICHD (R01) (08/01/2015)

Boards, Advisory Committees, Professional Organizations

  • Member, Academy Health (2010 - Present)
  • Member, Society for Pediatric Research (2009 - Present)
  • Fellow, American Academy of Pediatrics (2006 - Present)

Professional Education

  • Fellowship:Harvard Medical School (2005) MA
  • Certificate, Rice University, Houston, TX, Medical and Healthcare Management (2010)
  • Residency:Tufts Medical Center Graduate Medical Education (2002) MA
  • Certificate, Intermountain Healthcare, Advanced Training Program in Quality Improvement (2008)
  • Board Certification: Neonatal-Perinatal Medicine, American Board of Pediatrics (2005)
  • Board Certification: Pediatrics, American Board of Pediatrics (2002)
  • MPH, Harvard School of Public Health (2005)
  • Neonatologist, Harvard University, School of Medicine, Boston, MA (2005)
  • Residency:St Josefskrankenhaus (1999) Germany
  • Pediatrician, Tufts University, School of Medicine, Boston, MA (2002)
  • Medical Education:Albert-Ludwigs-University Freiburg (1997) Germany
  • MD, Albert-Ludwigs-University, Freiburg, Germany (1997)

Community and International Work

  • Vermont Oxford Network


    Strategies to promote health care provider well being and improve quality of care

    Populations Served

    Health care workers, patients and families in the neonatal intensive care unit setting



    Ongoing Project


    Opportunities for Student Involvement


  • California Perinatal Quality Care Collaborative


    Achieving care excellence for sick newborns and their families across the state

    Partnering Organization(s)

    California Maternal Quality Care Collaborative

    Populations Served

    Newborns and mothers across California



    Ongoing Project


    Opportunities for Student Involvement


  • Improving NICU Care in Mexico, Monterrey, Mexico


    Quality improvement

    Partnering Organization(s)

    Tech de Monterrey

    Populations Served

    Preterm infants



    Ongoing Project


    Opportunities for Student Involvement


Research & Scholarship

Current Research and Scholarly Interests

Funded by NIH R01 grants:

1) Development and application of composite measure of NICU quality - Baby-MONITOR

2) High reliability, safety culture and caregiver resilience as modifiers of care quality

3) Modifiable racial/ethnic disparities in quality of care delivery

4) Effectiveness of regionalized care delivery systems for preterm newborns

Clinical Trials

  • Web-based Implementation for the Science of Enhancing Resilience Study Recruiting

    Resilience means a healthcare provider's ability to cope, recover, and learn from stressful events, as well as their access to resources that promote health and well-being. Neonatal intensive care unit (NICU) health professionals' need to have particularly good resilience, because their work is extremely stressful and their patients, fragile preterm infants, require their undivided attention. The investigators propose a feasible and engaging intervention to enhance resilience among NICU health professionals promoting their ability to provide safe care.

    View full details


2018-19 Courses

Stanford Advisees


All Publications

  • Perinatal Risk Factors and Outcome Coding in Clinical and Administrative Databases. Pediatrics Tawfik, D. S., Gould, J. B., Profit, J. 2019


    BACKGROUND AND OBJECTIVES: Administrative databases may allow true population-based studies and quality improvement endeavors, but the accuracy of billing codes for capturing key risk factors and outcomes needs to be assessed. We sought to describe the performance of a statewide administrative database and the clinical database from the California Perinatal Quality Care Collaborative (CPQCC).METHODS: This population-based retrospective cohort study linked key perinatal risk factors and outcomes from the 133-unit CPQCC database to relevant billing codes from administrative maternal and newborn inpatient discharge records, for 50631 infants born from 2006 to 2012. Using the CPQCC record as the gold standard, we calculated the positive predictive value, negative predictive value, and Matthews correlation coefficient for each item, then evaluated comparative performance across units.RESULTS: The Matthews correlation coefficient was highest (>0.7; strong positive correlation) for multiple delivery, Cesarean delivery, very low birth weight, maternal hypertension, maternal diabetes, patent ductus arteriosus, in-hospital death, patent ductus arteriosus and retinopathy of prematurity surgeries, extracorporeal life support, and intraventricular hemorrhage. Maternal chorioamnionitis, fetal distress, retinopathy of prematurity staging, chronic lung disease, and pneumothorax were the least reliably coded. Maternal factors and delivery details were more reliably coded in the maternal inpatient record than the newborn inpatient record.CONCLUSIONS: Several important perinatal risk factors and outcomes are highly congruent between these administrative and clinical databases. Several subjective risk factors and outcomes are appropriate targets for data improvement initiatives. The ability for timely extraction of administrative inpatient data will be key to their usefulness in quality metrics.

    View details for DOI 10.1542/peds.2018-1487

    View details for PubMedID 30626622

  • Patient- and Family-Centered Care as a Dimension of Quality. American journal of medical quality : the official journal of the American College of Medical Quality Dhurjati, R., Sigurdson, K., Profit, J. 2018: 1062860618814312

    View details for DOI 10.1177/1062860618814312

    View details for PubMedID 30501498

  • The Correlation Between Neonatal Intensive Care Unit Safety Culture and Quality of Care. Journal of patient safety Profit, J., Sharek, P. J., Cui, X., Nisbet, C. C., Thomas, E. J., Tawfik, D. S., Lee, H. C., Draper, D., Sexton, J. B. 2018


    OBJECTIVES: Key validated clinical metrics are being used individually and in aggregate (Baby-MONITOR) to monitor the performance of neonatal intensive care units (NICUs). The degree to which perceptions of key components of safety culture, safety climate, and teamwork are related to aspects of NICU quality of care is poorly understood. The objective of this study was to test whether NICU performance on key clinical metrics correlates with caregiver perceptions of safety culture.STUDY DESIGN: Cross-sectional study of 6253 very low-birth-weight infants in 44 NICUs. We measured clinical quality via the Baby-MONITOR and its nine risk-adjusted and standardized subcomponents (antenatal corticosteroids, hypothermia, pneumothorax, healthcare-associated infection, chronic lung disease, retinopathy screen, discharge on any human milk, growth velocity, and mortality). A voluntary sample of 2073 of 3294 eligible professional caregivers provided ratings of safety and teamwork climate using the Safety Attitudes Questionnaire. We examined NICU-level variation across clinical and safety culture ratings and conducted correlation analysis of these dimensions.RESULTS: We found significant variation in clinical and safety culture metrics across NICUs. Neonatal intensive care unit teamwork and safety climate ratings were correlated with absence of healthcare-associated infection (r = 0.39 [P = 0.01] and r = 0.29 [P = 0.05], respectively). None of the other clinical metrics, individual or composite, were significantly correlated with teamwork or safety climate.CONCLUSIONS: Neonatal intensive care unit teamwork and safety climate were correlated with healthcare-associated infections but not with other quality metrics. Linkages to clinical measures of quality require additional research.This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

    View details for PubMedID 30407963

  • In Reply-Burnout Is Not Associated With Increased Medical Errors. Mayo Clinic proceedings Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C., Dyrbye, L., Tutty, M., West, C. P., Shanafelt, T. D. 2018; 93 (11): 1683–84

    View details for DOI 10.1016/j.mayocp.2018.08.014

    View details for PubMedID 30392548

  • Birth Hospitalization Costs and Days of Care for Mothers and Neonates in California, 2009-2011. The Journal of pediatrics Phibbs, C. S., Schmitt, S. K., Cooper, M., Gould, J. B., Lee, H. C., Profit, J., Lorch, S. A. 2018


    OBJECTIVE: To provide population-based estimates of the hospital-related costs of maternal and newborn care, and how these vary by gestational age and birth weight.STUDY DESIGN: We conducted a retrospective analysis of 2009-2011 California in-hospital deliveries at nonfederal hospitals with the infant and maternal discharge data successfully (96%) linked to birth certificates. Cost-to-charge ratios were used to estimate costs from charges. Physician hospital payments were estimated by mean diagnosis related group-specific reimbursement and costs were adjusted for inflation to December 2017 values. After exclusions for incomplete or missing data, the final sample was 1 265 212.RESULTS: The mean maternal costs for all in-hospital deliveries was $8204, increasing to $13 154 for late preterm (32-36 weeks) and $22 702 for very preterm (<32 weeks) mothers. The mean cost for all newborns was $6389: $2433 for term infants, $22 102 for late preterm, $223 931 for very preterm infants, and $317 982 for extremely preterm infants (<28 weeks). Preterm infants were 8.1% of cases but incurred 60.9% of costs; for very preterm and extremely preterm infants, these shares were 1.0% and 36.5%, and 0.4% and 20.0%, respectively. Overall, mothers incurred 56% of the total costs during the delivery hospitalization.CONCLUSIONS: Both maternal and neonatal costs are skewed, with this being much more pronounced for infants. Preterm birth is much more expensive than term delivery, with the additional costs predominately incurred by the infants. The small share of infants who require extensive stays in neonatal intensive care incur a large share of neonatal costs and these costs have increased over time.

    View details for DOI 10.1016/j.jpeds.2018.08.041

    View details for PubMedID 30297293

  • Predicting Successful Neonatal Retro-Transfer to a Lower Level of Care. The Journal of pediatrics Kunz, S. N., Dukhovny, D., Profit, J., Mao, W., Miedema, D., Zupancic, J. A. 2018


    Up to 20% of newborn infants retro-transferred to a lower level of care require readmission to a higher-level facility. In this study, we developed and validated a prediction rule (The Rule for Elective Transfer between Units for Recovering Neonates [RETURN]) to identify clinical characteristics of infants at risk for failing retro-transfer.

    View details for DOI 10.1016/j.jpeds.2018.09.010

    View details for PubMedID 30291023

  • Stillbirth and Live Birth at Periviable Gestational Age: A Comparison of Prevalence and Risk Factors. American journal of perinatology Carmichael, S. L., Blumenfeld, Y. J., Mayo, J. A., Profit, J., Shaw, G. M., Hintz, S. R., Stevenson, D. K. 2018


    OBJECTIVE: We compared the prevalence of and risk factors for stillbirth and live birth at periviable gestational age (20-25 weeks).STUDY DESIGN: This is a cohort study of 2.5 million singleton births in California from 2007 to 2011. We estimated racial-ethnic prevalence ratios and used multivariable logistic regression for risk factor comparisons.RESULTS: In this study, 42% of deliveries at 20 to 25 weeks' gestation were stillbirths, and 22% were live births who died within 24 hours. The prevalence of delivery at periviable gestation was 3.4 per 1,000 deliveries among whites, 10.9 for blacks, 3.5 for Asians, and 4.4 for Hispanics. Nonwhite race-ethnicity, lower education, uninsured status, being U.S. born, older age, obesity, smoking, pre-pregnancy hypertension, nulliparity, interpregnancy interval, and prior preterm birth or stillbirth were all associated with increased risk of both stillbirth and live birth at 20 to 25 weeks' gestation, compared with delivery of a live birth at 37 to 41 weeks.CONCLUSION: Inclusion of stillbirths and live births in studies of deliveries at periviable gestations is important.

    View details for DOI 10.1055/s-0038-1670633

    View details for PubMedID 30208499

  • Variations in Neonatal Antibiotic Use PEDIATRICS Schulman, J., Profit, J., Lee, H. C., Duenas, G., Bennett, M. V., Parucha, J., Jocson, M. L., Gould, J. B. 2018; 142 (3)


    We sought to identify whether and how the NICU antibiotic use rate (AUR), clinical correlates, and practice variation changed between 2013 and 2016 and attempted to identify AUR ranges that are consistent with objectively determined bacterial and/or fungal disease burdens.In a retrospective cohort study of >54 000 neonates annually at >130 California NICUs from 2013 to 2016, we computed nonparametric linear correlation and compared AURs among years using a 2-sample test of proportions. We stratified by level of NICU care and participation in externally organized stewardship efforts.By 2016, the overall AUR declined 21.9% (95% confidence interval [CI] 21.9%-22.0%), reflecting 42 960 fewer antibiotic days. Among NICUs in externally organized antibiotic stewardship efforts, the AUR declined 28.7% (95% CI 28.6%-28.8%) compared with 16.2% (95% CI 16.1%-16.2%) among others. The intermediate NICU AUR range narrowed, but the distribution of values did not shift toward lower values as it did for other levels of care. The 2016 AUR correlated neither with proven infection nor necrotizing enterocolitis. The 2016 regional NICU AUR correlated with surgical volume (ρ = 0.53; P = .01), mortality rate (ρ = 0.57; P = .004), and average length of stay (ρ = 0.62; P = .002) and was driven by 3 NICUs with the highest AUR values (30%-57%).Unexplained antibiotic use has declined but continues. Currently measured clinical correlates generally do not help explain AUR values that are above the lowest quartile cutpoint of 14.4%.

    View details for PubMedID 30177514

  • Correction: Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of perinatology : official journal of the California Perinatal Association Sigurdson, K., Morton, C., Mitchell, B., Profit, J. 2018


    The original HTML version of this Article incorrectly showed the copyright holder to be 'Nature America, Inc., part of Springer Nature', when the correct copyright holder is 'The Authors 2018'. This has been corrected in the HTML version of the Article. The PDF version was correct from the time of publication.

    View details for PubMedID 30042468

  • Physician Burnout, Well-being, and Work Unit Safety Grades in Relationship to Reported Medical Errors. Mayo Clinic proceedings Tawfik, D. S., Profit, J., Morgenthaler, T. I., Satele, D. V., Sinsky, C. A., Dyrbye, L. N., Tutty, M. A., West, C. P., Shanafelt, T. D. 2018


    OBJECTIVE: To evaluate physician burnout, well-being, and work unit safety grades in relationship to perceived major medical errors.PARTICIPANTS AND METHODS: From August 28, 2014, to October 6, 2014, we conducted a population-based survey of US physicians in active practice regarding burnout, fatigue, suicidal ideation, work unit safety grade, and recent medical errors. Multivariate logistic regression and mixed-effects hierarchical models evaluated the associations among burnout, well-being measures, work unit safety grades, and medical errors.RESULTS: Of 6695 responding physicians in active practice, 6586 provided information on the areas of interest: 3574 (54.3%) reported symptoms of burnout, 2163 (32.8%) reported excessive fatigue, and 427 (6.5%) reported recent suicidal ideation, with 255 of 6563 (3.9%) reporting a poor or failing patient safety grade in their primary work area and 691 of 6586 (10.5%) reporting a major medical error in the prior 3 months. Physicians reporting errors were more likely to have symptoms of burnout (77.6% vs 51.5%; P<.001), fatigue (46.6% vs 31.2%; P<.001), and recent suicidal ideation (12.7% vs 5.8%; P<.001). In multivariate modeling, perceived errors were independently more likely to be reported by physicians with burnout (odds ratio [OR], 2.22; 95% CI, 1.79-2.76) or fatigue (OR, 1.38; 95% CI, 1.15-1.65) and those with incrementally worse work unit safety grades (OR, 1.70; 95% CI, 1.36-2.12; OR, 1.92; 95% CI, 1.48-2.49; OR, 3.12; 95% CI, 2.13-4.58; and OR, 4.37; 95% CI, 2.06-9.28 for grades of B, C, D, and F, respectively), adjusted for demographic and clinical characteristics.CONCLUSION: In this large national study, physician burnout, fatigue, and work unit safety grades were independently associated with major medical errors. Interventions to reduce rates of medical errors must address both physician well-being and work unit safety.

    View details for DOI 10.1016/j.mayocp.2018.05.014

    View details for PubMedID 30001832

  • Never judge a book by its cover: how NICU evaluators reach conclusions about quality of care. Journal of perinatology : official journal of the California Perinatal Association Dhurjati, R., Wahid, N., Sigurdson, K., Morton, C. H., Kaplan, H. C., Gould, J. B., Profit, J. 2018


    OBJECTIVE: To identify key features in the NICU care delivery context that influence quality of care delivery.STUDY DESIGN: Qualitative study using in-depth, semi-structured interviews with 10 NICU quality experts with extensive experience conducting NICU site visits and evaluating quality of care. Analyses were performed using the method of constant comparison based on grounded theory.RESULTS: Qualitative analysis yielded three major themes: (1) the foundation for high quality care is a cohesive unit culture, characterized by open communication, teamwork, and engagement of families; (2) effective linkages between measurement and improvement action is necessary for continuous improvement; and (3) NICU capacity for improvement is sustained by active support, exchange of skills, and resources from the hospital.CONCLUSIONS: Team cohesion, engagement of families, culture of improvement supported by measurement and institutional support from the hospital are some of the key contextual and managerial features critical to high-quality NICU care.

    View details for DOI 10.1038/s41372-018-0092-0

    View details for PubMedID 29593356

  • Improving Uptake of Key Perinatal Interventions Using Statewide Quality Collaboratives. Clinics in perinatology Pai, V. V., Lee, H. C., Profit, J. 2018; 45 (2): 165–80


    Regional and statewide quality improvement collaboratives have been instrumental in implementing evidence-based practices and facilitating quality improvement initiatives within neonatology. Statewide collaboratives emerged from larger collaborative organizations, like the Vermont Oxford Network, and play an increasing role in collecting and interpreting data, setting priorities for improvement, disseminating evidence-based clinical practice guidelines, and creating regional networks for synergistic learning. In this review, we highlight examples of successful statewide collaborative initiatives, as well as challenges that exist in initiating and sustaining collaborative efforts.

    View details for DOI 10.1016/j.clp.2018.01.013

    View details for PubMedID 29747881

  • Work-life balance behaviours cluster in work settings and relate to burnout and safety culture: a cross-sectional survey analysis. BMJ quality & safety Schwartz, S. P., Adair, K. C., Bae, J., Rehder, K. J., Shanafelt, T. D., Profit, J., Sexton, J. B. 2018


    Healthcare is approaching a tipping point as burnout and dissatisfaction with work-life integration (WLI) in healthcare workers continue to increase. A scale evaluating common behaviours as actionable examples of WLI was introduced to measure work-life balance.(1) Explore differences in WLI behaviours by role, specialty and other respondent demographics in a large healthcare system. (2) Evaluate the psychometric properties of the work-life climate scale, and the extent to which it acts like a climate, or group-level norm when used at the work setting level. (3) Explore associations between work-life climate and other healthcare climates including teamwork, safety and burnout.Cross-sectional survey study completed in 2016 of US healthcare workers within a large academic healthcare system.10 627 of 13 040 eligible healthcare workers across 440 work settings within seven entities of a large healthcare system (81% response rate) completed the routine safety culture survey. The overall work-life climate scale internal consistency was α=0.830. WLI varied significantly among healthcare worker role, length of time in specialty and work setting. Random effects analyses of variance for the work-life climate scale revealed significant between-work setting and within-work setting variance and intraclass correlations reflected clustering at the work setting level. T-tests of top versus bottom WLI quartile work settings revealed that positive work-life climate was associated with better teamwork and safety climates, as well as lower personal burnout and burnout climate (p<0.001).Problems with WLI are common in healthcare workers and differ significantly based on position and time in specialty. Although typically thought of as an individual difference variable, WLI appears to operate as a climate, and is consistently associated with better safety culture norms.

    View details for DOI 10.1136/bmjqs-2018-007933

    View details for PubMedID 30309912

  • Disparities in NICU quality of care: a qualitative study of family and clinician accounts. Journal of perinatology : official journal of the California Perinatal Association Sigurdson, K., Morton, C., Mitchell, B., Profit, J. 2018


    To identify how family advocates and clinicians describe disparities in NICU quality of care in narrative accounts.Qualitative analysis of a survey requesting disparity stories at the 2016 VON Quality Congress. Accounts (324) were from a sample of RNs (n = 114, 35%), MDs (n = 109, 34%), NNPs (n = 55, 17%), RN other (n = 4, 1%), clinical other (n = 25, 7%), family advocates (n = 16, 5%), and unspecified (n = 1, <1%).Accounts (324) addressed non-exclusive disparities: 151 (47%) language; 97 (30%) culture or ethnicity; 72 (22%) race; 41 (13%) SES; 28 (8%) drug use; 18 (5%) immigration status or nationality; 16 (4%) sexual orientation or family status; 14 (4%) gender; 10 (3%) disability. We identified three types of disparate care: neglectful care 85 (26%), judgmental care 85 (26%), or systemic barriers to care 139 (44%).Nearly all accounts described differential care toward families, suggesting the lack of equitable family-centered care.

    View details for PubMedID 29622778

  • Network analysis: a novel method for mapping neonatal acute transport patterns in California. Journal of perinatology Kunz, S. N., Zupancic, J. A., Rigdon, J., Phibbs, C. S., Lee, H. C., Gould, J. B., Leskovec, J., Profit, J. 2017; 37 (6): 702-708


    The objectives of this study are to use network analysis to describe the pattern of neonatal transfers in California, to compare empirical sub-networks with established referral regions and to determine factors associated with transport outside the originating sub-network.This cross-sectional database study included 6546 infants <28 days old transported within California in 2012. After generating a graph representing acute transfers between hospitals (n=6696), we used community detection techniques to identify more tightly connected sub-networks. These empirically derived sub-networks were compared with state-defined regional referral networks. Reasons for transfer between empirical sub-networks were assessed using logistic regression.Empirical sub-networks showed significant overlap with regulatory regions (P<0.001). Transfer outside the empirical sub-network was associated with major congenital anomalies (P<0.001), need for surgery (P=0.01) and insurance as the reason for transfer (P<0.001).Network analysis accurately reflected empirical neonatal transfer patterns, potentially facilitating quantitative, rather than qualitative, analysis of regionalized health care delivery systems.Journal of Perinatology advance online publication, 23 March 2017; doi:10.1038/jp.2017.20.

    View details for DOI 10.1038/jp.2017.20

    View details for PubMedID 28333155

  • Factors Associated With Provider Burnout in the NICU PEDIATRICS Tawfik, D. S., Phibbs, C. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Trockel, M., Profit, J. 2017; 139 (5)


    NICUs vary greatly in patient acuity and volume and represent a wide array of organizational structures, but the effect of these differences on NICU providers is unknown. This study sought to test the relation between provider burnout prevalence and organizational factors in California NICUs.Provider perceptions of burnout were obtained from 1934 nurse practitioners, physicians, registered nurses, and respiratory therapists in 41 California NICUs via a validated 4-item questionnaire based on the Maslach Burnout Inventory. The relations between burnout and organizational factors of each NICU were evaluated via t-test comparison of quartiles, univariable regression, and multivariable regression.Overall burnout prevalence was 26.7% ± 9.8%. Highest burnout prevalence was found among NICUs with higher average daily admissions (32.1% ± 6.4% vs 17.2% ± 6.7%, P < .001), higher average occupancy (28.1% ± 8.1% vs 19.9% ± 8.4%, P = .02), and those with electronic health records (28% ± 11% vs 18% ± 7%, P = .03). In sensitivity analysis, nursing burnout was more sensitive to organizational differences than physician burnout in multivariable modeling, significantly associated with average daily admissions, late transfer proportion, nursing hours per patient day, and mortality per 1000 infants. Burnout prevalence showed no association with proportion of high-risk patients, teaching hospital distinction, or in-house attending presence.Burnout is most prevalent in NICUs with high patient volume and electronic health records and may affect nurses disproportionately. Interventions to reduce burnout prevalence may be of greater importance in NICUs with ≥10 weekly admissions.

    View details for DOI 10.1542/peds.2016-4134

    View details for Web of Science ID 000400371500040

    View details for PubMedID 28557756

  • Teamwork in the NICU Setting and Its Association with Health Care-Associated Infections in Very Low-Birth-Weight Infants. American journal of perinatology Profit, J., Sharek, P. J., Kan, P., Rigdon, J., Desai, M., Nisbet, C. C., Tawfik, D. S., Thomas, E. J., Lee, H. C., Sexton, J. B. 2017


    Background and Objective Teamwork may affect clinical care in the neonatal intensive care unit (NICU) setting. The objective of this study was to assess teamwork climate across NICUs and to test scale-level and item-level associations with health care-associated infection (HAI) rates in very low-birth-weight (VLBW) infants. Methods Cross-sectional study of the association between HAI rates, defined as any bacterial or fungal infection during the birth hospitalization, among 6,663 VLBW infants cared for in 44 NICUs between 2010 and 2012. NICU HAI rates were correlated with teamwork climate ratings obtained in 2011 from 2,073 of 3,294 eligible NICU health professionals (response rate 63%). The relation between HAI rates and NICU teamwork climate was assessed using logistic regression models including NICU as a random effect. Results Across NICUs, 36 to 100% (mean 66%) of respondents reported good teamwork. HAI rates were significantly and independently associated with teamwork climate (odds ratio, 0.82; 95% confidence interval, 0.73-0.92, p = 0.005), such that the odds of an infant contracting a HAI decreased by 18% with each 10% rise in NICU respondents reporting good teamwork. Conclusion Improving teamwork may be an important element in infection control efforts.

    View details for DOI 10.1055/s-0037-1601563

    View details for PubMedID 28395366

  • Variation in quality report viewing by providers and correlation with NICU quality metrics. Journal of perinatology Wahid, N., Bennett, M. V., Gould, J. B., Profit, J., Danielsen, B., Lee, H. C. 2017


    To examine variation in quality report viewing and assess correlation between provider report viewing and neonatal intensive care unit (NICU) quality.Variation in report viewing sessions for 129 California Perinatal Quality Care Collaborative NICUs was examined. NICUs were stratified into tertiles based on their antenatal steroid (ANS) use and hospital-acquired infection (HAI) rates to compare report viewing session counts.The number of report viewing sessions initiated by providers varied widely over a 2-year period (median=11; mean=25.5; s.d.=45.19 sessions). Report viewing was not associated with differences in ANS use. Facilities with low HAI rates had less frequent report viewing. Facilities with high report views had significant improvements in HAI rates over time.Available audit and feedback reports are utilized inconsistently across California NICUs despite evidence that report viewing is associated with improvements in quality of care delivery. Further studies are needed for reports to reach their theoretical potential.Journal of Perinatology advance online publication, 6 April 2017; doi:10.1038/jp.2017.44.

    View details for DOI 10.1038/jp.2017.44

    View details for PubMedID 28383536

  • Trends in Patent Ductus Arteriosus Diagnosis and Management for Very Low Birth Weight Infants PEDIATRICS Ngo, S., Profit, J., Gould, J. B., Lee, H. C. 2017; 139 (4)


    To examine yearly trends of patent ductus arteriosus (PDA) diagnosis and treatment in very low birth weight infants.In this retrospective cohort study of very low birth weight infants (<1500 g) between 2008 and 2014 across 134 California hospitals, we evaluated PDA diagnosis and treatment by year of birth. Infants were either inborn or transferred in within 2 days after delivery and had no congenital abnormalities. Intervention levels for treatment administered to achieve ductal closure were categorized as none, pharmacologic (indomethacin or ibuprofen), both pharmacologic intervention and surgical ligation, or ligation only. Multivariable logistic regression was used to assess risk factors for PDA diagnosis and treatment.PDA was diagnosed in 42.8% (12 002/28 025) of infants, with a decrease in incidence from 49.2% of 4205 infants born in 2008 to 38.5% of 4001 infants born in 2014. Pharmacologic and/or surgical treatment was given to 30.5% of patients. Between 2008 and 2014, the annual rate of infants who received pharmacologic intervention (30.5% vs 15.7%) or both pharmacologic intervention and surgical ligation (6.9% vs 2.9%) decreased whereas infants who were not treated (60.5% vs 78.3%) or received primary ligation (2.2% vs 3.0%) increased.There is an increasing trend toward not treating patients diagnosed with PDA compared with more intensive treatments: pharmacologic intervention or both pharmacologic intervention and surgical ligation. Possible directions for future study include the impact of these trends on hospital-based and long-term outcomes.

    View details for DOI 10.1542/peds.2016-2390

    View details for Web of Science ID 000398602400016

    View details for PubMedID 28562302

  • Burnout in the neonatal intensive care unit and its relation to healthcare-associated infections. Journal of perinatology Tawfik, D. S., Sexton, J. B., Kan, P., Sharek, P. J., Nisbet, C. C., Rigdon, J., Lee, H. C., Profit, J. 2017; 37 (3): 315-320


    To examine burnout prevalence among California neonatal intensive care units (NICUs) and to test the relation between burnout and healthcare-associated infection (HAI) rates in very low birth weight (VLBW) neonates.Retrospective observational study of provider perceptions of burnout from 2073 nurse practitioners, physicians, registered nurses and respiratory therapists, using a validated four-item questionnaire based on the Maslach Burnout Inventory. The relation between burnout and HAI rates among VLBW (<1500 g) neonates from each NICU was evaluated using multi-level logistic regression analysis with patient-level factors as fixed effects.We found variable prevalence of burnout across the NICUs surveyed (mean 25.2±10.1%). Healthcare-associated infection rates were 8.3±5.1% during the study period. Highest burnout prevalence was found among nurses, nurse practitioners and respiratory therapists (non-physicians, 28±11% vs 17±19% physicians), day shift workers (30±3% vs 25±4% night shift) and workers with 5 or more years of service (29±2% vs 16±6% in fewer than 3 years group). Overall burnout rates showed no correlation with risk-adjusted rates of HAIs (r=-0.133). Item-level analysis showed positive association between HAIs and perceptions of working too hard (odds ratio 1.15, 95% confidence interval 1.04-1.28). Sensitivity analysis of high-volume NICUs suggested a moderate correlation between burnout prevalence and HAIs (r=0.34).Burnout is most prevalent among non-physicians, daytime workers and experienced workers. Perceptions of working too hard associate with increased HAIs in this cohort of VLBW infants, but overall burnout prevalence is not predictive.Journal of Perinatology advance online publication, 17 November 2016; doi:10.1038/jp.2016.211.

    View details for DOI 10.1038/jp.2016.211

    View details for PubMedID 27853320

  • Got spirit? The spiritual climate scale, psychometric properties, benchmarking data and future directions. BMC health services research Doram, K., Chadwick, W., Bokovoy, J., Profit, J., Sexton, J. D., Sexton, J. B. 2017; 17 (1): 132-?


    Organizations that encourage the respectful expression of diverse spiritual views have higher productivity and performance, and support employees with greater organizational commitment and job satisfaction. Within healthcare, there is a paucity of studies which define or intervene on the spiritual needs of healthcare workers, or examine the effects of a pro-spirituality environment on teamwork and patient safety. Our objective was to describe a novel survey scale for evaluating spiritual climate in healthcare workers, evaluate its psychometric properties, provide benchmarking data from a large faith-based healthcare system, and investigate relationships between spiritual climate and other predictors of patient safety and job satisfaction.Cross-sectional survey study of US healthcare workers within a large, faith-based health system.Seven thousand nine hundred twenty three of 9199 eligible healthcare workers across 325 clinical areas within 16 hospitals completed our survey in 2009 (86% response rate). The spiritual climate scale exhibited good psychometric properties (internal consistency: Cronbach α = .863). On average 68% (SD 17.7) of respondents of a given clinical area expressed good spiritual climate, although assessments varied widely (14 to 100%). Spiritual climate correlated positively with teamwork climate (r = .434, p < .001) and safety climate (r = .489, p < .001). Healthcare workers reporting good spiritual climate were less likely to have intentions to leave, to be burned out, or to experience disruptive behaviors in their unit and more likely to have participated in executive rounding (p < .001 for each variable).The spiritual climate scale exhibits good psychometric properties, elicits results that vary widely by clinical area, and aligns well with other culture constructs that have been found to correlate with clinical and organizational outcomes.

    View details for DOI 10.1186/s12913-017-2050-5

    View details for PubMedID 28189142

  • Relationship of Hospital Staff Coverage and Delivery Room Resuscitation Practices to Birth Asphyxia. American journal of perinatology Tu, J. H., Profit, J., Melsop, K., Brown, T., Davis, A., Main, E., Lee, H. C. 2017; 34 (3): 259-263


    Objective The objective of this study was to assess utilization of specialist coverage and checklists in perinatal settings and to examine utilization by birth asphyxia rates. Design This is a survey study of California maternity hospitals concerning checklist use to prepare for delivery room resuscitation and 24-hour in-house specialist coverage (pediatrician/neonatologist, obstetrician, and obstetric anesthesiologist) and results linked to hospital birth asphyxia rates (preterm and low weight births were excluded). Results Of 253 maternity hospitals, 138 responded (55%); 59 (43%) indicated checklist use, and in-house specialist coverage ranged from 38% (pediatrician/neonatologist) to 54% (anesthesiology). In-house coverage was more common in urban versus rural hospitals for all specialties (p < 0.0001), but checklist use was not significantly different (p = 0.88). Higher birth volume hospitals had more specialist coverage (p < 0.0001), whereas checklist use did not differ (p = 0.3). In-house obstetric coverage was associated with lower asphyxia rates (odds ratio: 0.34; 95% confidence interval [CI]: 0.20, 0.58) in a regression model accounting for other providers. Checklist use was not associated with birth asphyxia (odds ratio: 1.12; 95% CI: 0.75, 1.68). Conclusion Higher birth volume and urban hospitals demonstrated greater in-house specialist coverage, but checklist use was similar across all hospitals. Current data suggest that in-house obstetric coverage has greater impact on asphyxia than other specialist coverage or checklist use.

    View details for DOI 10.1055/s-0036-1586505

    View details for PubMedID 27487231

  • If Health Care Teams Had to Win Championships. American journal of medical quality Dhurjati, R., Salas, E., Profit, J. 2017: 1062860616686684-?

    View details for DOI 10.1177/1062860616686684

    View details for PubMedID 28064518

  • Do trials reduce uncertainty? Assessing impact through cumulative meta-analysis of neonatal RCTs. Journal of perinatology : official journal of the California Perinatal Association Hay, S. C., Kirpalani, H., Viner, C., Soll, R., Dukhovny, D., Mao, W. Y., Profit, J., DeMauro, S. B., Zupancic, J. A. 2017


    To assess the impact of the latest randomized controlled trial (RCT) to each systematic review (SR) in Cochrane Neonatal Reviews.We selected meta-analyses reporting the typical point estimate of the risk ratio for the primary outcome of the latest study (n=130), mortality (n=128) and the mean difference for the primary outcome (n=44). We employed cumulative meta-analysis to determine the typical estimate after each trial was added, and then performed multivariable logistic regression to determine factors predictive of study impact.For the stated primary outcome, 18% of latest RCTs failed to narrow the confidence interval (CI), and 55% failed to decrease the CI by ⩾20%. Only 8% changed the typical estimate directionality, and 11% caused a change to or from significance. Latest RCTs did not change the typical estimate in 18% of cases, and only 41% changed the typical estimate by at least 10%. The ability to narrow the CI by >20% was negatively associated with the number of previously published RCTs (odds ratio 0.707). Similar results were found in analysis of typical estimates for the outcomes of mortality and mean difference.Across a broad range of clinical questions, the latest RCT failed to substantially narrow the CI of the typical estimate, to move the effect estimate or to change its statistical significance in a majority of cases. Investigators and grant peer review committees should consider prioritizing less-studied topics or requiring formal consideration of optimal information size based on extant evidence in power calculations.Journal of Perinatology advance online publication, 7 September 2017; doi:10.1038/jp.2017.126.

    View details for DOI 10.1038/jp.2017.126

    View details for PubMedID 28880258

  • Racial/Ethnic Disparity in NICU Quality of Care Delivery. Pediatrics Profit, J., Gould, J. B., Bennett, M., Goldstein, B. A., Draper, D., Phibbs, C. S., Lee, H. C. 2017


    Differences in NICU quality of care provided to very low birth weight (<1500 g) infants may contribute to the persistence of racial and/or ethnic disparity. An examination of such disparities in a population-based sample across multiple dimensions of care and outcomes is lacking.Prospective observational analysis of 18 616 very low birth weight infants in 134 California NICUs between January 1, 2010, and December 31, 2014. We assessed quality of care via the Baby-MONITOR, a composite indicator consisting of 9 process and outcome measures of quality. For each NICU, we calculated a risk-adjusted composite and individual component quality score for each race and/or ethnicity. We standardized each score to the overall population to compare quality of care between and within NICUs.We found clinically and statistically significant racial and/or ethnic variation in quality of care between NICUs as well as within NICUs. Composite quality scores ranged by 5.26 standard units (range: -2.30 to 2.96). Adjustment of Baby-MONITOR scores by race and/or ethnicity had only minimal effect on comparative assessments of NICU performance. Among subcomponents of the Baby-MONITOR, non-Hispanic white infants scored higher on measures of process compared with African Americans and Hispanics. Compared with whites, African Americans scored higher on measures of outcome; Hispanics scored lower on 7 of the 9 Baby-MONITOR subcomponents.Significant racial and/or ethnic variation in quality of care exists between and within NICUs. Providing feedback of disparity scores to NICUs could serve as an important starting point for promoting improvement and reducing disparities.

    View details for DOI 10.1542/peds.2017-0918

    View details for PubMedID 28847984

  • Context in Quality of Care: Improving Teamwork and Resilience. Clinics in perinatology Tawfik, D. S., Sexton, J. B., Adair, K. C., Kaplan, H. C., Profit, J. 2017; 44 (3): 541–52


    Quality improvement in health care is an ongoing challenge. Consideration of the context of the health care system is of paramount importance. Staff resilience and teamwork climate are key aspects of context that drive quality. Teamwork climate is dynamic, with well-established tools available to improve teamwork for specific tasks or global applications. Similarly, burnout and resilience can be modified with interventions such as cultivating gratitude, positivity, and awe. A growing body of literature has shown that teamwork and burnout relate to quality of care, with improved teamwork and decreased burnout expected to produce improved patient quality and safety.

    View details for DOI 10.1016/j.clp.2017.04.004

    View details for PubMedID 28802338

  • Association Between Neonatal Intensive Care Unit Admission Rates and Illness Acuity. JAMA pediatrics Schulman, J., Braun, D., Lee, H. C., Profit, J., Duenas, G., Bennett, M. V., Dimand, R. J., Jocson, M., Gould, J. B. 2017


    Most neonates admitted to a neonatal intensive care unit (NICU) are born at gestational age (GA) of 34 weeks or more. The degree of uniformity of admission criteria for these infants is unclear, particularly at the low-acuity end of the range of conditions warranting admission.To describe variation in NICU admission rates for neonates born at GA of 34 weeks or more and examine whether such variation is associated with high illness acuity or designated facility level of care.Cross-sectional study of 35 921 NICU inborn admissions of GA at 34 weeks or more during calendar year 2015, using a population database of inborn NICU admissions at 130 of the 149 hospitals in California with a NICU. The aggregate service population comprised 358 453 live births. The individual NICU was the unit of observation and analysis. The analysis was stratified by designated facility level of care and correlations with the percentage admissions with high illness acuity were explored. The hypothesis at the outset of the study was that inborn admission rates would correlate positively with the percentage of admissions with high illness acuity.Live birth at GA of 34 weeks or more.Inborn NICU admission rate.Of the total of 358 453 live births at GA of 34 weeks or more, 35 921 infants were admitted to a NICU and accounted for 79.2% of all inborn NICU admissions; 4260 (11.9%) of these admissions met high illness acuity criteria. Inborn admission rates varied 34-fold, from 1.1% to 37.7% of births (median, 9.7%; mean [SD], 10.6% [5.8%]). Percentage with high illness acuity varied 40-fold, from 2.4% to 95% (median, 11.3%; mean, 13.2% [9.9%]). Inborn admission rate correlated inversely with percentage of admissions with high illness acuity (Spearman ρ = -0.3034, P < .001). Among regional NICUs capable of caring for patients with the highest degree of illness and support needs, inborn admission rate did not significantly correlate with percentage of admissions with high illness acuity (Spearman ρ = -0.21, P = .41).Percentage of admissions with high illness acuity does not explain 34-fold variation in NICU inborn admission rates for neonates born at GA of 34 weeks or more. The findings are consistent with a supply-sensitive care component and invite future investigation to clarify the lower-acuity end of the range of conditions considered to warrant neonatal intensive care.

    View details for PubMedID 29181499

  • The associations between work-life balance behaviours, teamwork climate and safety climate: cross-sectional survey introducing the work-life climate scale, psychometric properties, benchmarking data and future directions. BMJ quality & safety Sexton, J. B., Schwartz, S. P., Chadwick, W. A., Rehder, K. J., Bae, J., Bokovoy, J., Doram, K., Sotile, W., Adair, K. C., Profit, J. 2016


    Improving the resiliency of healthcare workers is a national imperative, driven in part by healthcare workers having minimal exposure to the skills and culture to achieve work-life balance (WLB). Regardless of current policies, healthcare workers feel compelled to work more and take less time to recover from work. Satisfaction with WLB has been measured, as has work-life conflict, but how frequently healthcare workers engage in specific WLB behaviours is rarely assessed. Measurement of behaviours may have advantages over measurement of perceptions; behaviours more accurately reflect WLB and can be targeted by leaders for improvement.1. To describe a novel survey scale for evaluating work-life climate based on specific behavioural frequencies in healthcare workers.2. To evaluate the scale's psychometric properties and provide benchmarking data from a large healthcare system.3. To investigate associations between work-life climate, teamwork climate and safety climate.Cross-sectional survey study of US healthcare workers within a large healthcare system.7923 of 9199 eligible healthcare workers across 325 work settings within 16 hospitals completed the survey in 2009 (86% response rate). The overall work-life climate scale internal consistency was Cronbach α=0.790. t-Tests of top versus bottom quartile work settings revealed that positive work-life climate was associated with better teamwork climate, safety climate and increased participation in safety leadership WalkRounds with feedback (p<0.001). Univariate analysis of variance demonstrated differences that varied significantly in WLB between healthcare worker role, hospitals and work setting.The work-life climate scale exhibits strong psychometric properties, elicits results that vary widely by work setting, discriminates between positive and negative workplace norms, and aligns well with other culture constructs that have been found to correlate with clinical outcomes.

    View details for DOI 10.1136/bmjqs-2016-006032

    View details for PubMedID 28008006

  • Comparing NICU teamwork and safety climate across two commonly used survey instruments BMJ QUALITY & SAFETY Profit, J., Lee, H. C., Sharek, P. J., Kan, P., Nisbet, C. C., Thomas, E. J., Etchegaray, J. M., Sexton, B. 2016; 25 (12): 954-961


    Measurement and our understanding of safety culture are still evolving. The objectives of this study were to assess variation in safety and teamwork climate and in the neonatal intensive care unit (NICU) setting, and compare measurement of safety culture scales using two different instruments (Safety Attitudes Questionnaire (SAQ) and Hospital Survey on Patient Safety Culture (HSOPSC)).Cross-sectional survey study of a voluntary sample of 2073 (response rate 62.9%) health professionals in 44 NICUs. To compare survey instruments, we used Spearman's rank correlation coefficients. We also compared similar scales and items across the instruments using t tests and changes in quartile-level performance.We found significant variation across NICUs in safety and teamwork climate scales of SAQ and HSOPSC (p<0.001). Safety scales (safety climate and overall perception of safety) and teamwork scales (teamwork climate and teamwork within units) of the two instruments correlated strongly (safety r=0.72, p<0.001; teamwork r=0.67, p<0.001). However, the means and per cent agreements for all scale scores and even seemingly similar item scores were significantly different. In addition, comparisons of scale score quartiles between the two instruments revealed that half of the NICUs fell into different quartiles when translating between the instruments.Large variation and opportunities for improvement in patient safety culture exist across NICUs. Important systematic differences exist between SAQ and HSOPSC such that these instruments should not be used interchangeably.

    View details for DOI 10.1136/bmjqs-2014-003924

    View details for PubMedID 26700545

  • Characteristics of neonatal transports in California JOURNAL OF PERINATOLOGY Akula, V. P., Gould, J. B., Kan, P., Bollman, L., Profit, J., Lee, H. C. 2016; 36 (12): 1122-1127


    To describe the current scope of neonatal inter-facility transports.California databases were used to characterize infants transported in the first week after birth from 2009 to 2012.Transport of the 22 550 neonates was classified as emergent 9383 (41.6%), urgent 8844 (39.2%), scheduled 2082 (9.2%) and other 85 (0.4%). In addition, 2152 (9.5%) were initiated for delivery attendance. Most transports originated from hospitals without a neonatal intensive care unit (68%), with the majority transferred to regional centers (66%). Compared with those born and cared for at the birth hospital, the odds of being transported were higher if the patient's mother was Hispanic, <20 years old, or had a previous C-section. An Apgar score <3 at 10 min of age, cardiac compressions in the delivery room, or major birth defect were also risk factors for neonatal transport.As many neonates receive transport within the first week after birth, there may be opportunities for quality improvement activities in this area.Journal of Perinatology advance online publication, 29 September 2016; doi:10.1038/jp.2016.102.

    View details for DOI 10.1038/jp.2016.102

    View details for Web of Science ID 000389735700019

    View details for PubMedID 27684413

  • Opportunities for maternal transport for delivery of very low birth weight infants. Journal of perinatology Robles, D., Blumenfeld, Y. J., Lee, H. C., Gould, J. B., Main, E., Profit, J., Melsop, K., Druzin, M. 2016


    To assess frequency of very low birth weight (VLBW) births at non-level III hospitals.Retrospective cohort study using linked California birth certificate and discharge data of 2008 to 2010 for deliveries of singleton or first-born infant of multiple gestations with birth weight 400 to 1500 g. Delivery rates by neonatal level of care were obtained. Risk of delivery at non-level III centers was estimated in univariable and multivariable models.Of the 1 508 143 births, 13 919 (9.2%) were VLBW; birth rate at non-level III centers was 14.9% (8.4% in level I and 6.5% in level II). Median rate of VLBW births was 0.3% (range 0 to 4.7%) annually at level I and 0.5% (range 0 to 1.6%) at level II hospitals. Antepartum stay for >24 h occurred in 14.0% and 26.9% of VLBW births in level I and level II hospitals, respectively.Further improvement is possible in reducing VLBW infant delivery at suboptimal sites, given the window of opportunity for many patients.Journal of Perinatology advance online publication, 29 September 2016; doi:10.1038/jp.2016.174.

    View details for DOI 10.1038/jp.2016.174

    View details for PubMedID 27684426

  • Estimating Length of Stay by Patient Type in the Neonatal Intensive Care Unit AMERICAN JOURNAL OF PERINATOLOGY Lee, H. C., Bennett, M. V., Schulman, J., Gould, J. B., Profit, J. 2016; 33 (8): 751-757


    Objective Develop length of stay prediction models for neonatal intensive care unit patients. Study Design We used data from 2008 to 2010 to construct length of stay models for neonates admitted within 1 day of age to neonatal intensive care units and surviving to discharge home. Results Our sample included 23,551 patients. Median length of stay was 79 days when birth weight was < 1,000 g, 46 days for 1,000 to 1,500 g, 21 days for 1,500 to 2,500 g, and 8 days for ≥2,500 g. Risk factors for longer length of stay varied by weight. Units with shorter length of stay for one weight group had shorter lengths of stay for other groups. Conclusion Risk models for comparative assessments of length of stay need to appropriately account for weight, particularly considering the cutoff of 1,500 g. Refining prediction may benefit counseling of families and health care systems to efficiently allocate resources.

    View details for DOI 10.1055/s-0036-1572433

    View details for PubMedID 26890437

  • Impact of antenatal steroids on intraventricular hemorrhage in very-low-birth weight infants JOURNAL OF PERINATOLOGY Wei, J. C., Catalano, R., Profit, J., Gould, J. B., Lee, H. C. 2016; 36 (5): 352-356


    To determine the association between antenatal steroids administration and intraventricular hemorrhage rates.We used cross-sectional data from the California Perinatal Quality Care Collaborative during 2007 to 2013 for infants ⩽32 weeks gestational age. Using multivariable logistic regression, we evaluated the effect of antenatal steroids on intraventricular hemorrhage, stratified by gestational age.In 25 979 very-low-birth weight infants, antenatal steroid use was associated with a reduction in incidence of any grade of intraventricular hemorrhage (odds ratio=0.68, 95% confidence interval: 0.62, 0.75) and a reduction in incidence of severe intraventricular hemorrhage (odds ratio=0.51, 95% confidence interval: 0.45, 0.58). This association was seen across gestational ages ranging from 22 to 29 weeks.Although current guidelines recommend coverage for preterm birth at 24 to 34 weeks gestation, our results suggest that treatment with antenatal steroids may be beneficial even before 24 weeks of gestational age.

    View details for DOI 10.1038/jp.2016.38

    View details for Web of Science ID 000374914900006

    View details for PubMedID 27010109

  • The Association of Level of Care With NICU Quality. Pediatrics Profit, J., Gould, J. B., Bennett, M., Goldstein, B. A., Draper, D., Phibbs, C. S., Lee, H. C. 2016; 137 (3): 1-9


    Regionalized care delivery purportedly optimizes care to vulnerable very low birth weight (VLBW; <1500 g) infants. However, a comprehensive assessment of quality of care delivery across different levels of NICUs has not been done.We conducted a cross-sectional analysis of 21 051 VLBW infants in 134 California NICUs. NICUs designated their level of care according to 2012 American Academy of Pediatrics guidelines. We assessed quality of care delivery via the Baby-MONITOR, a composite indicator, which combines 9 risk-adjusted measures of quality. Baby-MONITOR scores are measured as observed minus expected performance, expressed in standard units with a mean of 0 and an SD of 1.Wide variation in Baby-MONITOR scores exists across California (mean [SD] 0.18 (1.14), range -2.26 to 3.39). However, level of care was not associated with overall quality scores. Subcomponent analysis revealed trends for higher performance of Level IV NICUs on several process measures, including antenatal steroids and any human milk feeding at discharge, but lower scores for several outcomes including any health care associated infection, pneumothorax, and growth velocity. No other health system or organizational factors including hospital ownership, neonatologist coverage, urban or rural location, and hospital teaching status, were significantly associated with Baby-MONITOR scores.The comprehensive assessment of the effect of level of care on quality reveals differential opportunities for improvement and allows monitoring of efforts to ensure that fragile VLBW infants receive care in appropriate facilities.

    View details for DOI 10.1542/peds.2014-4210

    View details for PubMedID 26908663

  • Postnatal growth failure in very low birthweight infants born between 2005 and 2012. Archives of disease in childhood. Fetal and neonatal edition Griffin, I. J., Tancredi, D. J., Bertino, E., Lee, H. C., Profit, J. 2016; 101 (1): 50-55


    Postnatal growth restriction is common in preterm infants and is associated with long-term neurodevelopmental impairment. Recent trends in postnatal growth restriction are unclear.Birth and discharge weights from 25 899 Californian very low birthweight infants (birth weight 500-1500 g, gestational age 22-32 weeks) who were born between 2005 and 2012 were converted to age-specific Z-scores and analysed using multivariable modelling.Birthweight Z-score did not change between 2005 and 2012. However, the adjusted discharge weight Z-score increased significantly by 0.168 Z-scores (0.154, 0.182) over the study period, and the adjusted fall in weight Z-score between birth and discharge decreased significantly between those dates (by 0.016 Z-scores/year). The proportion of infants who were discharged home below the 10th weight-for-age centile or had a fall in weight Z-score between birth and discharge of >1 decreased significantly over time. The comorbidities most associated with poorer postnatal growth were medical or surgical necrotising enterocolitis, isolated gastrointestinal perforation and severe retinopathy of prematurity, which were associated with an adjusted mean reduction in discharge weight Z-score of 0.24, 0.57, 0.46 and 0.32, respectively. Chronic lung disease was not a risk factor after accounting for length of stay.Postnatal, but not prenatal, growth improved among very low birthweight infants between 2005 and 2012. Neonatal morbidities including necrotising enterocolitis, gastrointestinal perforations and severe retinopathy of prematurity have significant negative effects on postnatal growth.

    View details for DOI 10.1136/archdischild-2014-308095

    View details for PubMedID 26201534

  • Optimal Criteria Survey for Preresuscitation Delivery Room Checklists. American journal of perinatology Brown, T., Tu, J., Profit, J., Gupta, A., Lee, H. C. 2016; 33 (2): 203-207


    Objective To investigate the optimal format and content of delivery room reminder tools, such as checklists. Study Design Voluntary, anonymous web-based surveys on checklists and reminder tools for neonatal resuscitation were sent to clinicians at participating hospitals. Summary statistics including the mean and standard deviation of the survey items were calculated. Several key comparisons between groups were completed using Student t-test. Results Fifteen hospitals were surveyed and 299 responses were collected. Almost all (96%) respondents favored some form of a reminder tool. Specific reminders such as "check and prepare all equipment" (mean 3.69, SD 0.81) were ranked higher than general reminders and personnel reminders such as "introduction and assigning roles" (mean 3.23, SD 1.08). Rankings varied by profession, institution, and deliveries attended per month. Conclusions Clinicians perceive a benefit of a checklist for neonatal resuscitation in the delivery room. Preparation of equipment was perceived as the most important use for checklists.

    View details for DOI 10.1055/s-0035-1564064

    View details for PubMedID 26368913

  • Neonatal networks: clinical research and quality improvement SEMINARS IN FETAL & NEONATAL MEDICINE Profit, J., Soll, R. F. 2015; 20 (6): 410-415


    Worldwide, neonatal networks have been formed to address both the research and quality improvement agenda of neonatal-perinatal medicine. Neonatal research networks have led the way in conducting many of the most important clinical trials of the last 25 years, including studies of cooling for hypoxic-ischemic encephalopathy, delivery room management with less invasive support, and oxygen saturation targeting. As we move into the future, increasing numbers of these networks are tackling quality improvement initiatives as a priority of their collaboration. Neonatal quality improvement networks have been in the forefront of the quality movement in medicine and, in the 21st century, have contributed to many of the reported improvements in care. In the coming years, building and maintaining this community of care is critical to the success of neonatal-perinatal medicine.

    View details for DOI 10.1016/j.siny.2015.09.001

    View details for Web of Science ID 000367484300006

  • Needs assessment to improve neonatal intensive care in Mexico PAEDIATRICS AND INTERNATIONAL CHILD HEALTH Weiss, K. J., Kowalkowski, M. A., Trevino, R., Cabrera-Meza, G., Thomas, E. J., KAPLAN, H. C., Profit, J. 2015; 35 (3): 213-219
  • Regional variation in antenatal corticosteroid use: a network-level quality improvement study. Pediatrics Profit, J., Goldstein, B. A., TAMARESIS, J., Kan, P., Lee, H. C. 2015; 135 (2): e397-404


    Examination of regional care patterns in antenatal corticosteroid use (ACU) rates may be salient for the development of targeted interventions. Our objective was to assess network-level variation using California perinatal care regions as a proxy. We hypothesized that (1) significant variation in ACU exists within and between California perinatal care regions, and (2) lower performing regions exhibit greater NICU-level variability in ACU than higher performing regions.We undertook cross-sectional analysis of 33 610 very low birth weight infants cared for at 120 hospitals in 11 California perinatal care regions from 2005 to 2011. We computed risk-adjusted median ACU rates and interquartile ranges (IQR) for each perinatal care region. The degree of variation was assessed using hierarchical multivariate regression analysis with NICU as a random effect and region as a fixed effect.From 2005 to 2011, mean ACU rates across California increased from 82% to 87.9%. Regional median (IQR) ACU rates ranged from 68.4% (24.3) to 92.9% (4.8). We found significant variation in ACU rates among regions (P < .0001). Compared with Level IV NICUs, care in a lower level of care was a strongly significant predictor of lower odds of receiving antenatal corticosteroids in a multilevel model (Level III, 0.65 [0.45-0.95]; Level II, 0.39 [0.24-0.64]; P < .001). Regions with lower performance in ACU exhibited greater variability in performance.We found significant variation in ACU rates among California perinatal regions. Regional quality improvement approaches may offer a new avenue to spread best practice.

    View details for DOI 10.1542/peds.2014-2177

    View details for PubMedID 25601974

  • Hospital variation and risk factors for bronchopulmonary dysplasia in a population-based cohort. JAMA pediatrics Lapcharoensap, W., Gage, S. C., Kan, P., Profit, J., Shaw, G. M., Gould, J. B., Stevenson, D. K., O'Brodovich, H., Lee, H. C. 2015; 169 (2)


    Bronchopulmonary dysplasia (BPD) remains a serious morbidity in very low-birth-weight (VLBW) infants (<1500 g). Deregionalization of neonatal care has resulted in an increasing number of VLBW infants treated in community hospitals with unknown impact on the development of BPD.To identify individual risk factors for BPD development and hospital variation of BPD rates across all levels of neonatal intensive care units (NICUs) within the California Perinatal Quality Care Collaborative.Retrospective cohort study (January 2007 to December 2011) from the California Perinatal Quality Care Collaborative including more than 90% of California's NICUs. Eligible VLBW infants born between 22 to 29 weeks' gestational age.Varying levels of intensive care.Bronchopulmonary dysplasia was defined as continuous supplemental oxygen use at 36 weeks' postmenstrual age. A combined outcome of BPD or mortality prior to 36 weeks was used. Multivariable logistic regression accounting for hospital as a random effect and gestational age as a risk factor was used to assess individual risk factors for BPD. This model was applied to determine risk-adjusted rates of BPD across hospitals and assess associations between levels of care and BPD rates.The study cohort included 15 779 infants, of which 1534 infants died prior to 36 weeks' postmenstrual age. A total of 7081 infants, or 44.8%, met the primary outcome of BPD or death prior to 36 weeks. Combined BPD or death rates across 116 NICUs varied from 17.7% to 73.4% (interquartile range, 38.7%-54.1%). Compared with level IV NICUs, the risk for developing BPD was higher for level II NICUs (odds ratio, 1.23; 95% CI, 1.02-1.49) and similar for level III NICUs (odds ratio, 1.04; 95% CI, 0.95-1.14).Bronchopulmonary dysplasia or death prior to 36 weeks' postmenstrual age affects approximately 45% of VLBW infants across California. The wide variability in BPD occurrence across hospitals could offer insights into potential risk or preventive factors. Additionally, our findings suggest that increased regionalization of NICU care may reduce BPD among VLBW infants.

    View details for DOI 10.1001/jamapediatrics.2014.3676

    View details for PubMedID 25642906

  • Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis. JAMA pediatrics Kastenberg, Z. J., Lee, H. C., Profit, J., Gould, J. B., Sylvester, K. G. 2015; 169 (1): 26-32


    There has been a significant expansion in the number of low-level and midlevel neonatal intensive care units (NICUs) in recent decades. Infants with necrotizing enterocolitis represent a high-risk subgroup of the very low-birth-weight (VLBW) (<1500 g) population that would benefit from focused regionalization.To describe the current trend toward deregionalization and to test the hypothesis that infants with necrotizing enterocolitis represent a particularly high-risk subgroup of the VLBW population that would benefit from early identification, increased intensity of early management, and possible targeted triage to tertiary hospitals.A retrospective cohort study was conducted of NICUs in California. We used data collected by the California Perinatal Quality Care Collaborative from 2005 to 2011 to assess mortality rates among a population-based sample of 30 566 VLBW infants, 1879 with necrotizing enterocolitis, according to the level of care and VLBW case volume at the hospital of birth.Level and volume of neonatal intensive care at the hospital of birth.In-hospital mortality.There was a persistent trend toward deregionalization during the study period and mortality rates varied according to the level of care. High-level, high-volume (level IIIB with >100 VLBW cases per year and level IIIC) hospitals achieved the lowest risk-adjusted mortality. Infants with necrotizing enterocolitis born into midlevel hospitals (low-volume level IIIB and level IIIA NICUs) had odds of death ranging from 1.42 (95% CI, 1.08-1.87) to 1.51 (95% CI, 1.05-2.15, respectively). In the final year of the study, just 28.6% of the infants with necrotizing enterocolitis were born into high-level, high-volume hospitals. For infants born into lower level centers, transfer to a higher level of care frequently occurred well into the third week of life.These findings represent an immediate opportunity for local quality improvement initiatives and potential impetus for the regionalization of important NICU resources.

    View details for DOI 10.1001/jamapediatrics.2014.2085

    View details for PubMedID 25383940

  • Postnatal growth failure in very low birthweight infants born between 2005 and 2012 ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Griffin, I. J., Tancredi, D. J., Bertino, E., Lee, H. C., Profit, J. 2015; 101 (1): 50-55
  • The smallest of the small: short-term outcomes of profoundly growth restricted and profoundly low birth weight preterm infants. Journal of perinatology : official journal of the California Perinatal Association Griffin, I. J., Lee, H. C., Profit, J., Tancedi, D. J. 2015


    Objective:Survival of preterm and very low birth weight (VLBW) infants has steadily improved. However, the rates of mortality and morbidity among the very smallest infants are poorly characterized.Study Design:Data from the California Perinatal Quality Care Collaborative for the years 2005 to 2012 were used to compare the mortality and morbidity of profoundly low birth weight (ProLBW, birth weight 300 to 500 g) and profoundly small for gestational age (ProSGA, <1st centile for weight-for-age) infants with very low birth weight (VLBW, birth weight 500 to 1500 g) and appropriate for gestational age (AGA, 5th to 95th centile for weight-for-age) infants, respectively.Result:Data were available for 44 561 neonates of birth weight <1500 g. Of these, 1824 were ProLBW and 648 were ProSGA. ProLBW and ProSGA differed in their antenatal risk factors from the comparison groups and were less likely to receive antenatal steroids or to be delivered by cesarean section. Only 14% of ProSGA and 21% of ProLBW infants survived to hospital discharge, compared with >80% of AGA and VLBW infants. The largest increase in mortality in ProSGA and ProLBW infants occurred prior to 12 h of age, and most mortality happened in this time period. Survival of the ProLBW and ProSGA infants was positively associated with higher gestational age, receipt of antenatal steroids, cesarean section delivery and singleton birth.Conclusion:Survival of ProLBW and ProSGA infants is uncommon, and survival without substantial morbidity is rare. Survival is positively associated with receipt of antenatal steroids and cesarean delivery.Journal of Perinatology advance online publication, 15 January 2015; doi:10.1038/jp.2014.233.

    View details for DOI 10.1038/jp.2014.233

    View details for PubMedID 25590218

  • Exposure to Leadership WalkRounds in neonatal intensive care units is associated with a better patient safety culture and less caregiver burnout BMJ QUALITY & SAFETY Sexton, J. B., Sharek, P. J., Thomas, E. J., Gould, J. B., Nisbet, C. C., Amspoker, A. B., Kowalkowski, M. A., Schwendimann, R., Profit, J. 2014; 23 (10): 814-822


    Leadership WalkRounds (WR) are widely used in healthcare organisations to improve patient safety. The relationship between WR and caregiver assessments of patient safety culture, and healthcare worker burnout is unknown.This cross-sectional survey study evaluated the association between receiving feedback about actions taken as a result of WR and healthcare worker assessments of patient safety culture and burnout across 44 neonatal intensive care units (NICUs) actively participating in a structured delivery room management quality improvement initiative.Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. More WR feedback was associated with better safety culture results and lower burnout rates in the NICUs. Participation in WR and receiving feedback about WR were less common in NICUs than in a benchmarking comparison of adult clinical areas.WR are linked to patient safety and burnout. In NICUs, where they occurred more often, the workplace appears to be a better place to deliver and to receive care.

    View details for DOI 10.1136/bmjqs-2013-002042

    View details for Web of Science ID 000342375400004

  • Burnout in the NICU setting and its relation to safety culture BMJ QUALITY & SAFETY Profit, J., Sharek, P. J., Amspoker, A. B., Kowalkowski, M. A., Nisbet, C. C., Thomas, E. J., Chadwick, W. A., Sexton, J. B. 2014; 23 (10): 806-813


    Burnout is widespread among healthcare providers and is associated with adverse safety behaviours, operational and clinical outcomes. Little is known with regard to the explanatory links between burnout and these adverse outcomes.(1) Test the psychometric properties of a brief four-item burnout scale, (2) Provide neonatal intensive care unit (NICU) burnout and resilience benchmarking data across different units and caregiver types, (3) Examine the relationships between caregiver burnout and patient safety culture.Cross-sectional survey study.Nurses, nurse practitioners, respiratory care providers and physicians in 44 NICUs.Caregiver assessments of burnout and safety culture.Of 3294 administered surveys, 2073 were returned for an overall response rate of 62.9%. The percentage of respondents in each NICU reporting burnout ranged from 7.5% to 54.4% (mean=25.9%, SD=10.8). The four-item burnout scale was reliable (α=0.85) and appropriate for aggregation (intra-class correlation coefficient-2=0.95). Burnout varied significantly between NICUs, p<0.0001, but was less prevalent in physicians (mean=15.1%, SD=19.6) compared with non-physicians (mean=26.9%, SD=11.4, p=0.0004). NICUs with more burnout had lower teamwork climate (r=-0.48, p=0.001), safety climate (r=-0.40, p=0.01), job satisfaction (r=-0.64, p<0.0001), perceptions of management (r=-0.50, p=0.0006) and working conditions (r=-0.45, p=0.002).NICU caregiver burnout appears to have 'climate-like' features, is prevalent, and associated with lower perceptions of patient safety culture.

    View details for DOI 10.1136/bmjqs-2014-002831

    View details for Web of Science ID 000342375400003

  • Baby-MONITOR: A Composite Indicator of NICU Quality. Pediatrics Profit, J., Kowalkowski, M. A., Zupancic, J. A., Pietz, K., Richardson, P., Draper, D., Hysong, S. J., Thomas, E. J., Petersen, L. A., Gould, J. B. 2014; 134 (1): 74-82


    NICUs vary in the quality of care delivered to very low birth weight (VLBW) infants. NICU performance on 1 measure of quality only modestly predicts performance on others. Composite measurement of quality of care delivery may provide a more comprehensive assessment of quality. The objective of our study was to develop a robust composite indicator of quality of NICU care provided to VLBW infants that accurately discriminates performance among NICUs.We developed a composite indicator, Baby-MONITOR, based on 9 measures of quality chosen by a panel of experts. Measures were standardized, equally weighted, and averaged. We used the California Perinatal Quality Care Collaborative database to perform across-sectional analysis of care given to VLBW infants between 2004 and 2010. Performance on the Baby-MONITOR is not an absolute marker of quality but indicates overall performance relative to that of the other NICUs. We used sensitivity analyses to assess the robustness of the composite indicator, by varying assumptions and methods.Our sample included 9023 VLBW infants in 22 California regional NICUs. We found significant variations within and between NICUs on measured components of the Baby-MONITOR. Risk-adjusted composite scores discriminated performance among this sample of NICUs. Sensitivity analysis that included different approaches to normalization, weighting, and aggregation of individual measures showed the Baby-MONITOR to be robust (r = 0.89-0.99).The Baby-MONITOR may be a useful tool to comprehensively assess the quality of care delivered by NICUs.

    View details for DOI 10.1542/peds.2013-3552

    View details for PubMedID 24918221

  • Consequences of the Affordable Care Act for Sick Newborns. Pediatrics Profit, J., Wise, P. H., Lee, H. C. 2014

    View details for PubMedID 25311609

  • Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care A Randomized Trial JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Petersen, L. A., Simpson, K., Pietz, K., Urech, T. H., Hysong, S. J., Profit, J., Conrad, D. A., Dudley, R. A., Woodard, L. D. 2013; 310 (10): 1042-1050


    Pay for performance is intended to align incentives to promote high-quality care, but results have been contradictory.To test the effect of explicit financial incentives to reward guideline-recommended hypertension care.Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg, nurses, pharmacists).Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports.Among a random sample, number of patients achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients prescribed guideline-recommended medications, and number who developed hypotension.Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the combined, individual, and practice-level interventions, respectively. The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other incentive groups did not show a significant change compared with controls for this outcome. For medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61% to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to 80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, -0.28% to 9.28%), respectively. These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect of the incentive was not sustained after a washout.Individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls. Further research is needed on the factors that contributed to these Identifier: NCT00302718.

    View details for DOI 10.1001/jama.2013.276303

    View details for Web of Science ID 000324133400021

    View details for PubMedID 24026599

  • Variations in Definitions of Mortality Have Little Influence on Neonatal Intensive Care Unit Performance Ratings JOURNAL OF PEDIATRICS Profit, J., Gould, J. B., Draper, D., Zupancic, J. A., Kowalkowski, M. A., Woodard, L., Pietz, K., Petersen, L. A. 2013; 162 (1): 50-U320


    To measure the influence of varying mortality time frames on performance rankings among regional neonatal intensive care units (NICUs) in a large state.We performed a cross-sectional data analysis of very low birth weight infants receiving care at 24 level 3 NICUs. We tested the effect of 4 definitions of mortality: (1) death between admission and end of birth hospitalization or up to 366 days; (2) death between 12 hours of age and the end of birth hospitalization or up to 366 days; (3) death between admission and 28 days; and (4) death between 12 hours of age and 28 days. NICUs were ranked by quantifying their deviation from risk-adjusted expected mortality and dividing them into 3 tiers: top 6, bottom 6, and in between.There was wide interinstitutional variation in risk-adjusted mortality for each definition (observed minus expected z-score range, -6.08 to 3.75). However, mortality-based NICU rankings and classification into performance tiers were very similar for all institutions in each of our time frames. Among all 4 definitions, NICU rank correlations were high (>0.91). Few NICUs changed relative to a neighboring tier with changes in definitions, and none changed by more than one tier.The time frame used to ascertain mortality had little effect on comparative NICU performance.

    View details for DOI 10.1016/j.jpeds.2012.06.002

    View details for Web of Science ID 000312915900012

    View details for PubMedID 22854328

  • Nurse-to-Patient Ratios and Neonatal Outcomes: A Brief Systematic Review NEONATOLOGY Sherenian, M., Profit, J., Schmidt, B., Suh, S., Xiao, R., Zupancic, J. A., DeMauro, S. B. 2013; 104 (3): 179-183


    Higher patient-to-nurse ratios and nursing workload are associated with increased mortality in the adult intensive care unit (ICU). Most neonatal ICUs (NICUs) in the United Kingdom do not meet national staffing recommendations. The impact of staffing on outcomes in the NICU is unknown.To determine how nurse-to-patient ratios or nursing workload affects outcomes in the NICU.Two authors (M.S., S.S.) searched PubMed, Medline, and EMBASE for eligible studies. Included studies reported on both the outcomes of infants admitted to a NICU and nurse-to-patient ratios or workload, and were published between 1/1990 and 4/2010 in any language. The primary outcome was mortality before discharge, relative to nurse-to-patient ratios. Secondary outcomes were intraventricular hemorrhage, daily weight gain, days on assisted ventilation, days on oxygen and nosocomial infection. Study quality was assessed with the STROBE checklist.Seven studies met the inclusion criteria. Three reported on the same group of patients. Only four studies reported death before discharge from the NICU relative to nurse-to-patient ratios. Three reported an association between lower nurse-to-patient ratios and higher mortality, and one reported just the opposite. Because each study used a different definition of nurse staffing, a meta-analysis could not be performed.Nurse-to-patient ratios appear to affect outcomes of neonatal intensive care, but limitations of the existing literature prevent clear conclusions about optimal staffing strategies. Evidence-based standards for staffing could impact public policy and lead to improvements in patient safety and decreased rates of adverse outcomes. More research on this subject, including a standard and valid measure of nursing workload, is urgently needed.

    View details for DOI 10.1159/000353458

    View details for Web of Science ID 000325241900005

    View details for PubMedID 23941740

  • Correlation of Neonatal Intensive Care Unit Performance Across Multiple Measures of Quality of Care JAMA PEDIATRICS Profit, J., Zupancic, J. A., Gould, J. B., Pietz, K., Kowalkowski, M. A., Draper, D., Hysong, S. J., Petersen, L. A. 2013; 167 (1): 47-54


    To examine whether high performance on one measure of quality is associated with high performance on others and to develop a data-driven explanatory model of neonatal intensive care unit (NICU) performance.We conducted a cross-sectional data analysis of a statewide perinatal care database. Risk-adjusted NICU ranks were computed for each of 8 measures of quality selected based on expert input. Correlations across measures were tested using the Pearson correlation coefficient. Exploratory factor analysis was used to determine whether underlying factors were driving the correlations.Twenty-two regional NICUs in California.In total, 5445 very low-birth-weight infants cared for between January 1, 2004, and December 31, 2007.Pneumothorax, growth velocity, health care-associated infection, antenatal corticosteroid use, hypothermia during the first hour of life, chronic lung disease, mortality in the NICU, and discharge on any human breast milk.The NICUs varied substantially in their clinical performance across measures of quality. Of 28 unit-level correlations, 6 were significant (ρ < .05). Correlations between pairs of measures of quality of care were strong (ρ ≥ .5) for 1 pair, moderate (range, ρ ≥ .3 to ρ < .5) for 8 pairs, weak (range, ρ ≥ .1 to ρ < .3) for 5 pairs, and negligible (ρ < .1) for 14 pairs. Exploratory factor analysis revealed 4 underlying factors of quality in this sample. Pneumothorax, mortality in the NICU, and antenatal corticosteroid use loaded on factor 1; growth velocity and health care-associated infection loaded on factor 2; chronic lung disease loaded on factor 3; and discharge on any human breast milk loaded on factor 4.In this sample, the ability of individual measures of quality to explain overall quality of neonatal intensive care was modest.

    View details for DOI 10.1001/jamapediatrics.2013.418

    View details for Web of Science ID 000316797500010

    View details for PubMedID 23403539

  • Do practicing clinicians agree with expert ratings of neonatal intensive care unit quality measures? JOURNAL OF PERINATOLOGY Kowalkowski, M., Gould, J. B., Bose, C., Petersen, L. A., Profit, J. 2012; 32 (4): 247-252


    To assess the level of agreement when selecting quality measures for inclusion in a composite index of neonatal intensive care quality (Baby-MONITOR) between two panels: one comprised of academic researchers (Delphi) and another comprised of academic and clinical neonatologists (clinician).In a modified Delphi process, a panel rated 28 quality measures. We assessed clinician agreement with the Delphi panel by surveying a sample of 48 neonatal intensive care practitioners. We asked the clinician group to indicate their level of agreement with the Delphi panel for each measure using a five-point scale (much too high, slightly too high, reasonable, slightly too low and much too low). In addition, we asked clinicians to select measures for inclusion in the Baby-MONITOR based on a yes or no vote and a pre-specified two-thirds majority for inclusion.In all, 23 (47.9%) of the clinicians responded to the survey. We found high levels of agreement between the Delphi and clinician panels, particularly across measures selected for the Baby-MONITOR. Clinicians selected the same nine measures for inclusion in the composite as the Delphi panel. For these nine measures, 74% of clinicians indicated that the Delphi panel rating was 'reasonable'.Practicing clinicians agree with an expert panel on the measures that should be included in the Baby-MONITOR, enhancing face validity.

    View details for DOI 10.1038/jp.2011.199

    View details for Web of Science ID 000302189200002

    View details for PubMedID 22241483

  • The Safety Attitudes Questionnaire as a tool for benchmarking safety culture in the NICU ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Profit, J., Etchegaray, J., Petersen, L. A., Sexton, J. B., Hysong, S. J., Mei, M., Thomas, E. J. 2012; 97 (2): F127-F132


    Neonatal intensive care unit (NICU) safety culture, as measured by the Safety Attitudes Questionnaire (SAQ), varies widely. Associations with clinical outcomes in the adult intensive care unit setting make the SAQ an attractive tool for comparing clinical performance between hospitals. Little information is available on the use of the SAQ for this purpose in the NICU setting.To determine whether the dimensions of safety culture measured by the SAQ give consistent results when used as a NICU performance measure.Cross-sectional survey of caregivers in 12 NICUs, using the six scales of the SAQ: teamwork climate, safety climate, job satisfaction, stress recognition, perceptions of management and working conditions. NICUs were ranked by quantifying their contribution to overall risk-adjusted variation across the scales. Spearman rank correlation coefficients were used to test for consistency in scale performance. The authors then examined whether performance in the top four NICUs in one scale predicted top four performance in others.There were 547 respondents in 12 NICUs. Of 15 NICU-level correlations in performance ranking, two were >0.7, seven were between 0.4 and 0.69, and the six remaining were <0.4. The authors found a trend towards significance in comparing the distribution of performance in the top four NICUs across domains with a binomial distribution p=0.051, indicating generally consistent performance across dimensions of safety culture.A culture of safety permeates many aspects of patient care and organisational functioning. The SAQ may be a useful tool for comparative performance assessments among NICUs.

    View details for DOI 10.1136/archdischild-2011-300612

    View details for Web of Science ID 000301633800010

    View details for PubMedID 22337935

  • Neonatal intensive care unit safety culture varies widely ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Profit, J., Etchegaray, J., Petersen, L. A., Sexton, J. B., Hysong, S. J., Mei, M., Thomas, E. J. 2012; 97 (2): F120-F126


    Variation in healthcare delivery and outcomes in neonatal intensive care units (NICUs) may be partly explained by differences in safety culture.To describe NICU care giver assessments of safety culture, explore variability within and between NICUs on safety culture domains, and test for association with care giver characteristics.NICU care givers in 12 hospitals were surveyed using the Safety Attitudes Questionnaire (SAQ), which has six scales: teamwork climate, safety climate, job satisfaction, stress recognition, perception of management and working conditions. Scale means, SDs and percent positives (percent agreement) were calculated for each NICU.There was substantial variation in safety culture domains among NICUs. Composite mean score across the six domains ranged from 56.3 to 77.8 on a 100-point scale and NICUs in the top four NICUs were significantly different from the bottom four (p<0.001). Across the six domains, respondent assessments varied widely, but were least positive on perceptions of management (3%-80% positive; mean 33.3%) and stress recognition (18%-61% positive; mean 41.3%). Comparisons of SAQ scale scores between NICUs and a previously published adult ICU cohort generally revealed higher scores for NICUs. Composite scores for physicians were 8.2 (p=0.04) and 9.5 (p=0.02) points higher than for nurses and ancillary personnel.There is significant variation and scope for improvement in safety culture among these NICUs. The NICU variation was similar to variation in adult ICUs, but NICU scores were generally higher. Future studies should validate whether safety culture measured with the SAQ correlates with clinical and operational outcomes in NICUs.

    View details for DOI 10.1136/archdischild-2011-300635

    View details for Web of Science ID 000301633800009

    View details for PubMedID 21930691

    View details for PubMedCentralID PMC3845658

  • Perils and Opportunities of Comparative Performance Measurement ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Profit, J., Woodard, L. D. 2012; 166 (2): 191-194

    View details for Web of Science ID 000301211000015

    View details for PubMedID 22312179

  • Treating Chronically Ill People with Diabetes Mellitus with Limited Life Expectancy: Implications for Performance Measurement JOURNAL OF THE AMERICAN GERIATRICS SOCIETY Woodard, L. D., Landrum, C. R., Urech, T. H., Profit, J., Virani, S. S., Petersen, L. A. 2012; 60 (2): 193-201


    To develop an algorithm to identify individuals with limited life expectancy and examine the effect of limited life expectancy on glycemic control and treatment intensification in individuals with diabetes mellitus.Individuals with diabetes mellitus and coexisting congestive heart failure, chronic obstructive pulmonary disease, dementia, end-stage liver disease, and/or primary or metastatic cancer with limited life expectancy were identified. To validate the algorithm, 5-year mortality was assessed in individuals identified as having limited life expectancy. Rates of meeting performance measures for glycemic control between individuals with and without limited life expectancy were compared. In individuals with uncontrolled glycosylated hemoglobin (HbA(1c) ) levels, the effect of limited life expectancy on treatment intensification within 90 days was examined.One hundred ten Department of Veterans Affairs facilities; October 2006 to September 2007.Eight hundred eighty-eight thousand six hundred twenty-eight individuals with diabetes mellitus.HbA(1c) ; treatment intensification within 90 days of index HbA(1c) reading.Twenty-nine thousand sixteen (3%) participants had limited life expectancy. Adjusting for age, 5-year mortality was five times as high in participants with limited life expectancy than in those without. Participants with limited life expectancy had poorer glycemic control than those without (glycemic control: 77.1% vs 78.1%; odds ratio (OR) = 0.84, 95% confidence interval (CI) = 0.81-0.86) and less-frequent treatment intensification (treatment intensification: 20.9% vs 28.6%; OR = 0.71, 95% CI = 0.67-0.76), even after controlling for patient-level characteristics.Participants with limited life expectancy were less likely than those without to have controlled HbA(1c) levels and to receive treatment intensification, suggesting that providers treat these individuals less aggressively. Quality measurement and performance-based reimbursement systems should acknowledge the different needs of this population.

    View details for DOI 10.1111/j.1532-5415.2011.03784.x

    View details for Web of Science ID 000300677400001

    View details for PubMedID 22260627

  • Formal selection of measures for a composite index of NICU quality of care: Baby-MONITOR JOURNAL OF PERINATOLOGY Profit, J., Gould, J. B., Zupancic, J. A., Stark, A. R., WALL, K. M., Kowalkowski, M. A., Mei, M., Pietz, K., Thomas, E. J., Petersen, L. A. 2011; 31 (11): 702-710


    To systematically rate measures of care quality for very low birth weight infants for inclusion into Baby-MONITOR, a composite indicator of quality.Modified Delphi expert panelist process including electronic surveys and telephone conferences. Panelists considered 28 standard neonatal intensive care unit (NICU) quality measures and rated each on a 9-point scale taking into account pre-defined measure characteristics. In addition, panelists grouped measures into six domains of quality. We selected measures by testing for rater agreement using an accepted method.Of 28 measures considered, 13 had median ratings in the high range (7 to 9). Of these, 9 met the criteria for inclusion in the composite: antenatal steroids (median (interquartile range)) 9(0), timely retinopathy of prematurity exam 9(0), late onset sepsis 9(1), hypothermia on admission 8(1), pneumothorax 8(2), growth velocity 8(2), oxygen at 36 weeks postmenstrual age 7(2), any human milk feeding at discharge 7(2) and in-hospital mortality 7(2). Among the measures selected for the composite, the domains of quality most frequently represented included effectiveness (40%) and safety (30%).A panel of experts selected 9 of 28 routinely reported quality measures for inclusion in a composite indicator. Panelists also set an agenda for future research to close knowledge gaps for quality measures not selected for the Baby-MONITOR.

    View details for DOI 10.1038/jp.2011.12

    View details for Web of Science ID 000296590600003

    View details for PubMedID 21350429

    View details for PubMedCentralID PMC3205234

  • Clinical Benefits, Costs, and Cost-Effectiveness of Neonatal Intensive Care in Mexico PLOS MEDICINE Profit, J., Lee, D., Zupancic, J. A., Papile, L., Gutierrez, C., Goldie, S. J., Gonzalez-Pier, E., Salomon, J. A. 2010; 7 (12)


    Neonatal intensive care improves survival, but is associated with high costs and disability amongst survivors. Recent health reform in Mexico launched a new subsidized insurance program, necessitating informed choices on the different interventions that might be covered by the program, including neonatal intensive care. The purpose of this study was to estimate the clinical outcomes, costs, and cost-effectiveness of neonatal intensive care in Mexico.A cost-effectiveness analysis was conducted using a decision analytic model of health and economic outcomes following preterm birth. Model parameters governing health outcomes were estimated from Mexican vital registration and hospital discharge databases, supplemented with meta-analyses and systematic reviews from the published literature. Costs were estimated on the basis of data provided by the Ministry of Health in Mexico and World Health Organization price lists, supplemented with published studies from other countries as needed. The model estimated changes in clinical outcomes, life expectancy, disability-free life expectancy, lifetime costs, disability-adjusted life years (DALYs), and incremental cost-effectiveness ratios (ICERs) for neonatal intensive care compared to no intensive care. Uncertainty around the results was characterized using one-way sensitivity analyses and a multivariate probabilistic sensitivity analysis. In the base-case analysis, neonatal intensive care for infants born at 24-26, 27-29, and 30-33 weeks gestational age prolonged life expectancy by 28, 43, and 34 years and averted 9, 15, and 12 DALYs, at incremental costs per infant of US$11,400, US$9,500, and US$3,000, respectively, compared to an alternative of no intensive care. The ICERs of neonatal intensive care at 24-26, 27-29, and 30-33 weeks were US$1,200, US$650, and US$240, per DALY averted, respectively. The findings were robust to variation in parameter values over wide ranges in sensitivity analyses.Incremental cost-effectiveness ratios for neonatal intensive care imply very high value for money on the basis of conventional benchmarks for cost-effectiveness analysis. Please see later in the article for the Editors' Summary.

    View details for DOI 10.1371/journal.pmed.1000379

    View details for Web of Science ID 000285499600006

    View details for PubMedID 21179496

    View details for PubMedCentralID PMC3001895

  • Improving benchmarking by using an explicit framework for the development of composite indicators: an example using pediatric quality of care IMPLEMENTATION SCIENCE Profit, J., Typpo, K. V., Hysong, S. J., Woodard, L. D., Kallen, M. A., Petersen, L. A. 2010; 5


    The measurement of healthcare provider performance is becoming more widespread. Physicians have been guarded about performance measurement, in part because the methodology for comparative measurement of care quality is underdeveloped. Comprehensive quality improvement will require comprehensive measurement, implying the aggregation of multiple quality metrics into composite indicators.To present a conceptual framework to develop comprehensive, robust, and transparent composite indicators of pediatric care quality, and to highlight aspects specific to quality measurement in children.We reviewed the scientific literature on composite indicator development, health systems, and quality measurement in the pediatric healthcare setting. Frameworks were selected for explicitness and applicability to a hospital-based measurement system.We synthesized various frameworks into a comprehensive model for the development of composite indicators of quality of care. Among its key premises, the model proposes identifying structural, process, and outcome metrics for each of the Institute of Medicine's six domains of quality (safety, effectiveness, efficiency, patient-centeredness, timeliness, and equity) and presents a step-by-step framework for embedding the quality of care measurement model into composite indicator development.The framework presented offers researchers an explicit path to composite indicator development. Without a scientifically robust and comprehensive approach to measurement of the quality of healthcare, performance measurement will ultimately fail to achieve its quality improvement goals.

    View details for DOI 10.1186/1748-5908-5-13

    View details for Web of Science ID 000275430000001

    View details for PubMedID 20181129

    View details for PubMedCentralID PMC2831823

  • Patient-to-Nurse Ratios and Outcomes of Moderately Preterm Infants PEDIATRICS Profit, J., Petersen, L. A., McCormick, M. C., Escobar, G. J., Coleman-Phox, K., Zheng, Z., Pietz, K., Zupancic, J. A. 2010; 125 (2): 320-326


    Moderately preterm infants (30-34(6/7) weeks' gestational age) represent the largest population of NICU residents. Whether their clinical outcomes are associated with differences in NICU nurse-staffing arrangements has not been assessed. The objective of this study was to test the influence of patient-to-nurse ratios (PNRs) on outcomes of care provided to moderately preterm infants.Using data from a prospective, multicenter, observational cohort study of 850 moderately preterm infants from 10 NICUs in California and Massachusetts, we tested for associations between PNR and several important clinical outcomes by using multivariate random-effects models. To correct for the influence of NICU size, we dichotomized the sample into those with an average daily census of <20 or > or =20 infants.Overall, we found few clinically significant associations between PNR and clinical outcomes of care. Mean PNRs were higher in large compared with small NICUs (2.7 vs 2.1; P < .001). In bivariate analyses, an increase in PNR was associated with a slightly higher daily weight gain (5 g/day), greater gestational age at discharge, any intraventricular hemorrhage, and severe retinopathy of prematurity. After controlling for case mix, NICU size, and site of care, an additional patient per nurse was associated with a decrease in daily weight gain by 24%. Other variables were no longer independently associated with PNR.In this population of moderately preterm infants, the PNR was associated with a decrease in daily weight gain, but was not associated with other measures of quality. In contrast with findings in the adult intensive care literature, measured clinical outcomes were similar across the range of nurse-staffing arrangements among participating NICUs. We conclude that the PNR is not useful for profiling hospitals' quality of care delivery to moderately preterm infants.

    View details for DOI 10.1542/peds.2008-3140

    View details for Web of Science ID 000275942900017

    View details for PubMedID 20064868

    View details for PubMedCentralID PMC3151172

  • Delayed Pediatric Office Follow-up of Newborns After Birth Hospitalization PEDIATRICS Profit, J., Cambric-Hargrove, A. J., Tittle, K. O., Pietz, K., Stark, A. R. 2009; 124 (2): 548-554


    Key recommendations of the American Academy of Pediatrics guideline on management of severe hyperbilirubinemia in healthy infants of >or=35 weeks' gestation include predischarge screening for risk of subsequent hyperbilirubinemia, follow-up at 3 to 5 days of age, and lactation support. Little information is available on contemporary compliance with follow-up recommendations.To assess timing and content of the first newborn office visit after birth hospitalization in urban and suburban pediatric practices in Houston, Texas.We reviewed office records for the first visit within 4 weeks of birth during January through July 2006 for apparently healthy newborns with a gestational age of >or=35 weeks or birth weight of >or=2500 g seen within a pediatric provider network. For each pediatrician, we selected every fifth patient up to a total of 6.Of 845 records abstracted, 698 (83%) were eligible for analysis. Infants were seen by 136 pediatricians in 39 practices. They had vaginal (64%) or cesarean (36%) deliveries at 20 local hospitals, of which 17 had routine predischarge bilirubin screening policies. Only 37% of all infants, 44% of vaginally delivered infants, and 41% of exclusively breastfed infants were seen before 6 days of age. Thirty-five percent of the infants were seen after 10 days of age. Among 636 infants seen at

    View details for DOI 10.1542/peds.2008-2926

    View details for Web of Science ID 000268377000015

    View details for PubMedID 19651578

    View details for PubMedCentralID PMC3155409

  • Pay for performance is growing up ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Profit, J., Petersen, L. A. 2007; 161 (7): 713-714

    View details for Web of Science ID 000247699000016

    View details for PubMedID 17606837

  • Implementing pay-for-performance in the neonatal intensive care unit PEDIATRICS Profit, J., Zupancic, J. A., Gould, J. B., Petersen, L. A. 2007; 119 (5): 975-982


    Pay-for-performance initiatives in medicine are proliferating rapidly. Neonatal intensive care is a likely target for these efforts because of the high cost, available databases, and relative strength of evidence for at least some measures of quality. Pay-for-performance may improve patient care but requires valid measurements of quality to ensure that financial incentives truly support superior performance. Given the existing uncertainty with respect to both the effectiveness of pay-for-performance and the state of quality measurement science, experimentation with pay-for-performance initiatives should proceed with caution and in controlled settings. In this article, we describe approaches to measuring quality and implementing pay-for-performance in the NICU setting.

    View details for DOI 10.1542/peds.2006-1565

    View details for Web of Science ID 000246153300014

    View details for PubMedID 17473099

    View details for PubMedCentralID PMC3151255

  • Neonatal intensive care unit census influences discharge of moderately preterm infants PEDIATRICS Profit, J., McCormick, M. C., Escobar, G. J., Richardson, D. K., Zheng, Z., Coleman-Phox, K., Roberts, R., Zupancic, J. A. 2007; 119 (2): 314-319


    The timely discharge of moderately premature infants has important economic implications. The decision to discharge should occur independent of unit census. We evaluated the impact of unit census on the decision to discharge moderately preterm infants.In a prospective multicenter cohort study, we enrolled 850 infants born between 30 and 34 weeks' gestation at 10 NICUs in Massachusetts and California. We divided the daily census from each hospital into quintiles and tested whether discharges were evenly distributed among them. Using logistic regression, we analyzed predictors of discharge within census quintiles associated with a greater- or less-than-expected likelihood of discharge. We then explored parental satisfaction and postdischarge resource consumption in relation to discharge during census periods that were associated with high proportions of discharge.There was a significant correlation between unit census and likelihood of discharge. When unit census was in the lowest quintile, patients were 20% less likely to be discharged when compared with all of the other quintiles of unit census. In the lowest quintile of unit census, patient/nurse ratio was the only variable associated with discharge. When census was in the highest quintile, patients were 32% more likely to be discharged when compared with all of the other quintiles of unit census. For patients in this quintile, a higher patient/nurse ratio increased the likelihood of discharge. Conversely, infants with prolonged lengths of stay, an increasing Score for Neonatal Acute Physiology II, and minor congenital anomalies were less likely to be discharged. Infants discharged at high unit census did not differ from their peers in terms of parental satisfaction, emergency department visits, home nurse visits, or rehospitalization rates.Discharges are closely correlated with unit census. Providers incorporate demand and case mix into their discharge decisions.

    View details for DOI 10.1542/peds.2005-2909

    View details for Web of Science ID 000243942000011

    View details for PubMedID 17272621

    View details for PubMedCentralID PMC3151170

  • Moderately premature infants at Kaiser Permanente Medical Care Program in California are discharged home earlier than their peers in Massachusetts and the United Kingdom ARCHIVES OF DISEASE IN CHILDHOOD-FETAL AND NEONATAL EDITION Profit, J., Zupancic, J. A., McCormick, M. C., Richardson, D. K., Escobar, G. J., Tucker, J., Tarnow-Mordi, W., Parry, G. 2006; 91 (4): F245-F250


    To compare gestational age at discharge between infants born at 30-34(+6) weeks gestational age who were admitted to neonatal intensive care units (NICUs) in California, Massachusetts, and the United Kingdom.Prospective observational cohort study.Fifty four United Kingdom, five California, and five Massachusetts NICUs.A total of 4359 infants who survived to discharge home after admission to an NICU.Gestational age at discharge home.The mean (SD) postmenstrual age at discharge of the infants in California, Massachusetts, and the United Kingdom were 35.9 (1.3), 36.3 (1.3), and 36.3 (1.9) weeks respectively (p = 0.001). Compared with the United Kingdom, adjusted discharge of infants occurred 3.9 (95% confidence interval (CI) 1.4 to 6.5) days earlier in California, and 0.9 (95% CI -1.2 to 3.0) days earlier in Massachusetts.Infants of 30-34(+6) weeks gestation at birth admitted and cared for in hospitals in California have a shorter length of stay than those in the United Kingdom. Certain characteristics of the integrated healthcare approach pursued by the health maintenance organisation of the NICUs in California may foster earlier discharge. The California system may provide opportunities for identifying practices for reducing the length of stay of moderately premature infants.

    View details for DOI 10.1136/adc.2005.075093

    View details for Web of Science ID 000238845800003

    View details for PubMedID 16449257

    View details for PubMedCentralID PMC2672723