We collaborated with Duke Center for Healthcare Safety and Quality collaborators Drs. J. Bryan Sexton and Kathryn C. Adair on a study investigating the relationship between health care worker assessments of good institutional support for “second victims” and organizational safety culture and well-being in The Joint Commission Journal on Quality and Patient Safety.

Our cross-sectional study looked at 2016 data collected from 10,627 health care workers (HCWs) as part of the Safety, Communication, Operational Reliability, and Engagement (SCORE) survey. The percentage of HCWs who reported being aware of at least one colleague (second victim) in their work setting who has been emotionally traumatized by an unanticipated clinical event was 36.3%. We found that perceived institutional support for second victims, based on a single item metric, was significantly associated with better safety culture and lower emotional exhaustion.

KEY TAKEAWAY: Good institutional support for “second victims” predicts better safety culture and well-being in a large sample of health care workers.

Funding: This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD084679- 01).

Dr. Profit and a few colleagues that served on the 2020 Birth Settings in America study committee for the National Academies of Science, Engineering, and Medicine collaborated on an editorial in which they argue the COVID-19 pandemic can be a catalyst for improved and more flexible maternity care systems that emphasize safety for all mothers, infants, and providers in the American Journal of Public Health.

Previous work by this group of authors highlighted the growing proportion of women that have given birth at home or at freestanding birth centers in recent years. While the risk of SARS-CoV-2 infection for pregnant women is unclear, new reports indicate that concerns about hospital-acquired infections, visitation, and separation policies may be driving an additional shift towards home and freestanding birth center births. The health system has responded to the change in demand with emergency legislation to increase midwifery services for births outside of the hospital and reallocation of low-risk births to midwifes in temporary birth spaces or in the home or birth center. During the pandemic, mothers may opt for home or birth center births late in pregnancy, leaving concerns about preparation for emergency post-partum transfers among already resource-strapped hospitals. Access to PPE, testing for patients, and use of contact tracing may also be limited for midwifes lacking collaborative relationships with hospitals. The authors provide several recommendations for improving the fragmented maternity care system that is particularly vulnerable during the COVID-19 pandemic, including enhancing granularity for planned and actual birth setting in the birth certificate, ensuring that SARS-CoV-2-positive pregnant mothers should deliver in hospital, and that a minimum but adequate number of providers and supports attend births in all settings. 

KEY TAKEAWAY: The current pandemic and potential future contagions may further drive the shift to home and birth center births, therefore it is crucial that steps are taken to improve maternity care systems in order to prioritize safety for mothers, infants, and providers.

Drs. Dhurjati Ravi and Jochen Profit of the ProfitLab published a recent article on the value of strong NICU safety culture in promoting high quality of care and improved outcomes for vulnerable infants in the Journal of Perinatology.

Safety culture is critical in the delivery of high quality care for patients. In the NICU, safety culture that focuses on identifying and minimizing errors is crucial. Measurement is a key step towards improving NICU safety culture and involves inclusion of health care worker and family stakeholders, selection of a culture assessment tool, collection and interpretation of data, and a plan of action to implement change. Once the measurement step is complete, an intervention can be implemented to address a specific focus area. Some examples of interventions shown to improve safety culture include executive walk rounds, relational coordination, team training, and operational improvements. In addition to initial efforts to measure, identify strengths and opportunities, and carefully select an intervention, an organizational commitment to sustained change and continuous improvement is crucial for better patient outcomes and safety culture. 

KEY TAKEAWAY: Changing safety culture in the NICU requires a systematic approach building on staff and leadership buy-in and commitment to sustained improvement through targeted intervention and continuous measurement.

Stanford Neonatology Fellow Dr. Greg Goldstein and members of our lab investigated the impact of human milk use on racial/ethnic disparities in necrotizing enterocolitis (NEC) in Pediatric Research.

NEC is a complication of prematurity that has historically affected 5-10% of very low birthweight (VLBW) infants with a 20-30% mortality rate and can lead to life-long disability. The incidence of NEC has declined from 7% to 5% in recent years, coinciding with standardization of feeding protocols and promotion of human milk use during the same time period. Our team of researchers sought to investigate whether vulnerable racial/ethnic groups – disproportionately more likely to have higher mortality and other newborn complications than do premature non-Hispanic white infants – have seen a similar decline in incidence of NEC. Using a population-based retrospective cohort approach, we examined NEC outcomes data in the CPQCC database for premature or VLBW infants born from 2008-2017. The results showed an overall relative decline in NEC incidence of 47% from 2008-2017, but the racial/ethnic divide widened. We observed ~60% higher incidence of NEC in Hispanic and non-Hispanic Black infants as compared to the incidence in non-Hispanic white infants. Our causal mediation analysis further indicated a potentially protective role of human milk use in lowering NEC incidence. Future quality improvement initiatives addressing NEC rates should consider lactation supports and human milk use as targets. 

KEY TAKEAWAY: Despite recent reductions in incidence of NEC in California, racial/ethnic disparities in rates remain. Human milk use during and after discharge may mediate the observed racial/ethnic disparity in NEC incidence. 

Dr. Profit and international neonatologist collaborators from the International Neonatal COVID-19 Consortium published an editorial summarizing their May 2020 article on international comparison of guidelines for neonatal care and offer some recommendations for future work in Pediatric Research.

The recent article from this group compared COVID-19-related guidelines for neonatal care across 20 countries, finding differences in recommendations for viral testing, PPE use, and family visits. There is limited evidence of COVID-19 infection in NICUs internationally, but the “para-COVID” effects may be widespread. Short supply of health care workers, ventilators, physical space, and finances as well of diversion of resources to adult care settings may affect neonatal care. The authors call for the formation of a Neonatal International Collaborative Group for rapid information exchange and collaborative neonatal disaster preparedness in the face of a future pandemic that may disproportionately affect neonates. A forthcoming article in the Journal of Perinatology will detail a follow-up effort on the “para-COVID” effects of the pandemic on neonatal care providers in low and middle income countries.

Our lab conducted focus groups and qualitative interviews with family members whose infants received care in the NICU to understand their needs and barriers to high quality family-centered care in Qualitative Health Research.

Modern models of optimal care in the NICU incorporate the provision of appropriate resources and psychosocial supports for families. This idea of family-centered care has been associated with better infant and parent outcomes, but we do not know much about inequities in NICU family member experiences, particularly for families of color and those of low SES. Our researchers sought to understand these gaps through semi-structured interviews and focus groups with NICU family members. While participants provided an encouraging glimpse into the high quality clinical care and feeling of support from their care teams, our analysis highlights several important challenges to receipt of equitable family-centered care. Among these challenges were lack of knowledge/ambivalence or conflict with social workers, health care worker judgment of family member absence at the bedside, inconsistent nurse continuity of care, and sporadic access to translation services. We propose that in order to address inequities in family-centered care, mutual trust and power sharing should be emphasized in any future QI intervention.

KEY TAKEAWAY: Mutual trust and power sharing between NICU family members and care team underlie the successful implementation of family-centered care in the NICU. CPQCC now has 30 NICUs collecting family-centered care measures to further this work and shed light on unmet NICU family needs.

Funding: The Stanford University Maternal and Child Health Research Institute Postdoctoral Fellowship; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD083368-01, PI Jochen Profit).

Stanford medical student Emily Pang presented an abstract for the PAS Academic Conference on quality of care in California Safety Net Hospitals to a virtual audience. She was awarded the 2020 Academic Pediatric Association (APA) Research Award for Best Abstract by a Student for this collaboration. Emily has worked with our lab and the CPQCC Health Equity Taskforce.

We explored whether care and outcomes among very low birth weight (VLBW) infants differed according to whether hospitals were categorized as safety net or non-safety net. The analysis included a cohort of 24,799 infants born at 139 CA hospitals from 2014-2018. Black and Hispanic infants were more likely to receive care in safety net hospitals. As outcomes, we used survival without major morbidity, the Baby-MONITOR (a measure of NICU quality), and neonatal mortality. We observed no significant differences in survival without major morbidity or Baby-MONITOR scores. We found a small increase in neonatal mortality rate in safety net hospitals.

KEY TAKEAWAY: In contrast to recent literature from New York City, we found little differences in performance between safety net and non-safety net NICUs.

Funding: This work was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD083368; R01 HD084667 PI Profit).

Link to abstract: https://2020.pas-meeting.org/wp-content/uploads/Neo-Perinatal-Care-Delivery-Epi-SHR-So-Much-Variation-Session-Details-rev-b-1.pdf

Recording of presentation (free with registration): https://www.gotostage.com/channel/6e18e489a7ba4eabbc2d372c93c09318/recording/401828c45105423bb3139c01e175e40d/watch?source=CHANNEL

In collaboration with the California Perinatal Quality Care Collaborative (CPQCC), we have published a paper showing improved survival without major morbidity for very low birth weight infants across California in Pediatrics.

This article examines the trends in survival without major morbidity and its individual components in individuals born from 2008-2017 in California. Survival without major morbidity (SMM) was defined as the absence of death during birth hospitalization, chronic lung disease, severe peri-intraventricular hemorrhage, nosocomial infection, necrotizing enterocolitis, severe retinopathy of prematurity or related surgery, and cystic periventricular leukomalacia. In a cohort of 49,333 infants from 142 hospitals during this 9-year period, SMM increased by 4.7%. For the final 3 years, all hospitals were reassigned to the top quartile of care quality and SMM was recalculated to determine any difference. The results of this analysis indicate that 621 additional infants, or 6.6% of infants annually for this time period, would have survived without major morbidity had all hospitals performed similarly to the top quartile. This result is impressive given that over this time period, NICUs have been saving infants that are more premature, smaller, and more complex.

KEY TAKEAWAY: The authors recommend the implementation of quality-improvement collaboratives to optimize perinatal outcomes and increase rates of survival without major morbidity.

FUNDING: Sponsored in part by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant R01 HD087425). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Eunice Kennedy Shriver National Institute of Child Health and Human Development or National Institutes of Health. Funded by the National Institutes of Health (NIH).

Link to Article: https://pediatrics.aappublications.org/content/early/2020/06/16/peds.2019-3865

Dr. Jochen Profit co-founded an international consortium of neonatologists and published a 21-country survey on care of the newborn during the COVID-19 pandemic in Pediatric Research. This work has been presented at Stanford, Harvard, Oxford and the CPQCC.

Beginning in early March of 2020, Dr. Profit and an international collaborating group of authors sought to exchange information on the effect of the COVID-19 pandemic on newborn health in their respective countries. This initial exchange led to an effort to request local and national management guidelines from a selection of neonatologist representatives around the world. A convenience sample of 23 experts from 21 countries was approached with a structured questionnaire. Results indicate that half of the institutions surveyed adopted national guidelines, while the others used local guidelines. PPE was recommended universally during neonatal management in the delivery room, but there was large variation in guidelines regarding sites for centralization of care for symptomatic and/or SARS-CoV-2-positive infants. While more guidelines are currently available regarding respiratory support plans for infected or symptomatic infants, few institutions had established recommendations for this situation. For viral testing, nasopharyngeal swabs were most commonly recommended. Only a small number of institutions described steps taken to address psychological care for parents or healthcare workers (HCW) affected by COVID-19. While in many cases there was overall agreement in neonatal care practices, divergence was observed in multiple areas. This lack of standardization may be a function of variable prevalence of cases and clinical uncertainty. While the impact of COVID-19 on newborn health is low, evidence suggests the international neonatal community was largely unprepared for a pandemic of this scale.

KEY TAKEAWAY: The authors conclude that there is a glaring need for an international neonatal consortium on disaster preparedness and clinical guidelines that can be referenced during the next pandemic.

Link to free article: https://www.nature.com/articles/s41390-020-0976-5.pdf

Dr. Profit presented an abstract for the PAS Academic Conference to a virtual audience comparing early neonatal mortality rates by birth setting in America from 2006-2017. A companion abstract presentation by Profit lab analyst Daniel Helkey, MPH will take place virtually on July 21^st at 12:25 pm PDT. The link to register for this presentation can be found here.

This work originated with Dr. Jochen Profit’s service on the NASEM committee. The percentage of home births (HB) or freestanding birth centers (FBC) births has increased over the past decade in the United States. Literature from the US has also consistently demonstrated increased neonatal mortality. However, this literature has been criticized for potential biases, some of which favor hospitals, and others that favor HB and FBC settings. We intended to trend and compare early neonatal mortality by intended birth setting and assess the severity of the existing biases. Period-linked vital statistics data on US births from 2007-2016 were used. HB and FBC births were associated with significantly elevated early mortality relative to midwife attended hospital births (Odds Ratio:4.3/4.2). Births occurring at home had significantly elevated early mortality for all years in the study considered individually. Biasing results against hospitals did not alter the conclusions.

KEY TAKEAWAY: Early neonatal mortality in HB and FBC settings is significantly increased. The authors recommend a substantial shift toward a more integrated maternity care system with appropriate safety and regulatory checks and balances.

Link to abstract: https://2020.pas-meeting.org/wp-content/uploads/Neo-Perinatal-Care-Delivery-Epi-HSR-Whats-Trending-rev-1.pdf

Recording of presentation (free with registration): https://www.gotostage.com/channel/6e18e489a7ba4eabbc2d372c93c09318/recording/50cdea563c6b4a4cb4eb8e18f715c139/watch?source=CHANNEL

We collaborated with Dr. Colm Travers, Associate Professor of Pediatrics at University of Alabama Birmingham, on a study exploring longitudinal trends in racial/ethnic disparities in care practices and outcomes among extremely preterm infants in the United States from 2002-2016. Dr. Travers presented his work during a recent Disparity Research Meeting with the CPQCC. The paper was published in JAMA Network Open.

Dr. Travers’ work considers whether there have been changes over the course of the 15 year study period regarding racial/ethnic disparities in care and outcomes. This observational study included data from 25 US academic medical centers and describes a cohort of 20,092 extremely preterm infants. Results indicated that hospital mortality decreased over time in all groups, and changes in rates of major morbidities largely did not differ by race/ethnicity. Rates of neurodevelopmental impairment increased across the study period in all groups. Disparities in care practices, including use of antenatal corticosteroids and cesarean delivery rates decreased over time.

KEY TAKEAWAY: In major academic centers across the United States, care and outcomes have improved and some racial/ethnic disparities have decreased. There appears to be a trade-off between better survival and increased long-term neurodevelopmental impairment despite reductions in major morbidities in the NICU. The authors recommend evidence-based medicine and quality improvement efforts to further improve outcomes for extremely preterm infants in all racial/ethnic groups.

Funding/Support: This study was funded by the grant RFA-HD-16-020 from the NICHD. The NICHD, the National Center for Research Resources, and the National Center for Advancing Translational Sciences provided grant support for the Neonatal Research Network’s Generic Database and Follow-up Studies through cooperative agreements.

Link to article: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2766928

As part of our Social Disparities in the NICU grant and in collaboration with investigators at UCSF, we published an article describing the social and built environment factors that contribute to inequities in NICU quality of care. The article was published in Journal of Perinatology.

We examined associations between the NICU catchment area, common neighborhood characteristics, and NICU care quality in a cohort of 15,901 infants from 119 NICUs in California born between 2008 and 2011. Quality of care was measured using the Baby-MONITOR composite index. The authors observed that NICUs serving a higher proportion of minority racial/ethnic patients and lower SES patients had lower quality scores. Additionally, NICUs with proximal areas of lower SES, greater percentage of minority residents, and more household crowding had overall lower quality scores. Catchment area neighborhood characteristics are being added to CPQCC health equity dashboard reports.

KEY TAKEAWAY: Multilevel social factors impact NICU quality of care, and tools like the CPQCC’s health equity dashboard can help providers perform a needs-assessment of their patients and address inequities.

Funding: Support for this study came from NIH/NICHD (R01HD084667, R01HD083368, R00ES021470).

Link to article: https://www.nature.com/articles/s41372-020-0647-8

We worked with a colleague from South Korea, Dr. Soon Min Lee, on a retrospective cohort study investigating the risks associated with small for gestational age (SGA) at birth and discharge among infants born to mothers of various Asian/Pacific islander (PI) races in Journal of Perinatology.

Dr. Lee’s article explores potential differences in SGA at birth and discharge for PI infants below 1500 grams or 23-28 weeks gestation born in California from 2008-2012. Using logistical regression, we observed significant differences in growth parameters, socioeconomic factors and some clinical morbidities. Indian race had the highest rates of SGA at birth and discharge at 29% and 63% respectively, with overall incidences at 21% and 50% for all races. Infants of same race were at higher risk of SGA compared with infants born to mixed race parents.

KEY TAKEAWAY: We argue for consideration of specific Asian race when evaluating preterm growth and question the appropriateness of grouping Asian/PI races together in perinatal outcomes research.

Funding: This work was supported by the March of Dimes Prematurity Research Center at Stanford University School of Medicine. JP contribution is supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01 HD084667-01, PI). This content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the March of Dimes.

Link to article: https://www.nature.com/articles/s41372-020-0601-9

Dr. Profit served on the National Academies of Sciences, Engineering, and Medicine (NASEM) Committee on Assessing Health Outcomes by Birth Settings. The report’s findings and recommendations were published here.

Childbirth is the largest category of hospital-based expenditures for public payers in the United States, with some of the highest rates of neonatal mortality and morbidities among high-income countries, specifically for Black and Native American women. The report describes several aspects of childbirth care delivery systems, including the history of maternal and newborn care in the United States, outcomes by birth setting, and issues in measuring clinical risks and outcomes by birth setting. The issues outlined include access to risk-appropriate prenatal and postpartum care and situations where women and newborns are subject to “too little” or “too much” care that can prove costly.

KEY TAKEAWAY: The authors highlight target areas for improvement in maternal and infant health that address mutable social determinants of health and focus on the structural inequities that are “historically rooted and deeply embedded in policies, laws, governance, and culture, such that power and resources are distributed differentially across characteristics of identity (race, ethnicity, gender, class, sexual orientation, and others)”

Link to report: https://www.nap.edu/catalog/25636/birth-settings-in-america-outcomes-quality-access-and-choice

Medical Director of the CMQCC, Dr. Elliott Main, publishes a cross-sectional study evaluating the impact of a hemorrhage QI collaborative on racial and ethnic disparities in severe maternal morbidity from hemorrhage in American Journal of Obstetrics and Gynecology.

Eliminating persistent racial/ethnic disparities in maternal mortality and morbidity is a public health priority. This study sought to evaluate the impact of a hemorrhage quality improvement collaborative on racial disparities in severe maternal morbidity (SMM) from hemorrhage. Dr. Main’s study used a cross-sectional methodology of 99 hospitals from 2011-2016 to determine whether a national maternal hemorrhage safety bundle consisting of 17 evidence-based recommendations for practice and care processes was effective. Baseline outcome measures from January 2011 – December 2014 were compared with those from October 2015 – December 2016. Obstetric hemorrhage was identified in approximately 6% of women in both time periods (56,865 at baseline and 144 20,278 during the post-intervention period). Several risk-factors for SMM from obstetric hemorrhage were eplored: mother’s sociodemographic characteristics (maternal age, education, parity, and insurance status), clinical factors (number of prenatal visits, pre-pregnancy body mass index, multiple pregnancy, chronic hypertension, gestational diabetes, prior cesarean delivery, labor induction, pre-term birth) and method of delivery.  Among the 54,311 women with obstetric hemorrhage at baseline, 42% were Hispanic, 29% were White, 15% were Asian, 5% were Black, and 7% were other race/ethnicity. Racial/ethnic distribution in the post-intervention period was similar to that reported in the baseline period. The total SMM rate in the baseline period was relatively stable and dropped continuously after the initiation of the QI collaborative, with a reduction of quarterly total SMM rate from 22% in the baseline to 18.6% in the post-intervention period. This reduction was observed in every racial/ethnic group, with absolute reductions ranging from 1% in Asian women and 9% in Black women.  The marked improvement in Black rates of SMM from  hemorrhage and the narrowing of Black-White difference are important findings suggesting QI  efforts can be effective in both improving maternal outcomes and reducing inequities in care  delivery for a specific medical condition.

Link to Article: https://www.ajog.org/article/S0002-9378(20)30034-X/fulltext

Dr. Jessica Liu publishes results from a study of Racial and Ethnic Disparities in Human Milk Intake at NICU Discharge among VLBW Infants in California in Journal of Pediatrics.

Provision of mother's milk is critical for very low birth weight (VLBW; ≤1500 g) infants during the birth hospitalization because it reduces the risk of infection and likelihood of other perinatal morbidities. Disparities in mother’s milk provision exist between racial and ethnic subgroups. Using linked neighborhood data and CPQCC data from 2008-2011 births, Dr. Liu employed multilevel cross-classified models to investigate extent to which infant and maternal health and demographic factors, hospital factors, and neighborhood-level factors independently and jointly impact disparities in human milk intake at NICU discharge. The overall rate of no human milk at discharge in this study cohort was 37.9%, with race/ethnicity specific observed rates of 32.2% among whites, 54.3 % among blacks, 39.1% among Hispanics, 26.7% among APIs, and 33.4% among other race/ethnicity. Researchers found that odds of no human milk at discharge were increased among blacks and whites with lower education compared with whites with higher education and Hispanics, regardless of education levels, were not different from whites with higher education. Disparities in human milk intake were seen in the lowest SES neighborhoods, but were no longer seen in the highest SES neighborhoods. Researchers concluded that significant racial/ethnic disparities in mother's milk provision at discharge exist for VLBW infants in California and solutions will require customized approaches that will vary by racial/ethnic group.

Link to Article: https://www.jpeds.com/article/S0022-3476(19)31601-4/fulltext

Dr. Jochen Profit publishes a perspective on value-driven patient safety in the Neonatal Intensive Care Unit in in Patient Safety Network’s Perspectives on Safety section.

Care provided in state-of-the-art Neonatal Intensive Care Units (NICUs) is outstanding and standardized across NICUs in the United States. However, prevalence rates of routine procedures such as blood laboratories and radiographs have remained the same for decades, often as a means to identify and protect against the worst case scenario. These interventions are underappreciated for the significant risks that they can carry, and as a result may cause more harm than good. Shifting the existing paradigm of these interventions requires a consideration of cultural and hierarchical factors that drive their continuation at current rates. The authors of this perspective propose a novel approach that is value-based and focused on eliminating interventions that are unlikely to have any clinical benefit. This approach uses a daily count of interventions (POKEs) to be discussed on rounds and a daily plan that only allows for those interventions that will add value and a foundation built on reinforcement from leadership and buy-in from all NICU providers. The care model the authors describe is one that has been employed at Intermountain Healthcare’s Dixie Regional Medical Center NICU in St. George for over 10 years, and in that time has led to a 50% reduction in POKEs, a 28% reduction in cost of care and a 21% reduction in length of NICU stay. The authors believe that this model has potential for application in NICUs across the country and merits consideration as preterm birth rates and healthcare costs both continue to rise. 

Link to Article: https://psnet.ahrq.gov/perspective/first-do-no-harm-value-driven-patient-safety-neonatal-intensive-care-unit#fig1

Dr. Daniel Tawfik publishes a systematic review exploring the relationship between Health Care Provider Burnout and Quality of Care in Annals of Internal Medicine.

Healthcare providers face a rapidly changing landscape of technology, care delivery methods, and regulations that increase risk for professional burnout. Recent attention on provider burnout has focused on reduced quality of care, with primary literature and systematic reviews employing retrospective observational designs. This lack of standardized approach to measurement and analysis increases the risk of bias, and creates difficulty in deciphering which of the apparent clinically significant results represent true effects. The present analysis sought to appraise this body of primary and review literature, developing an understanding of true effects within the field using a detailed evaluation for reporting biases. Dr. Tawfik conducted a systematic literature review and meta-analysis to provide summary estimations of the relation between provider burnout and quality of care, estimate study heterogeneity, and explore the potential of reporting bias in the field, following the PRISMA and MOOSE guidelines for methodology and reporting. The selected studies included all peer-reviewed publications reporting original investigations of healthcare provider burnout in relation to an assessment of quality of patient care. In line with the aforementioned reporting bias aim, Dr. Tawfik only included peer-reviewed publications and excluded any purely qualitative studies. Overall, 125 publications from 1994 through 2019 were included, encompassing 142 distinct study populations with a median sample size of 305. Providers from these publications included physicians, nurses, and other providers for a total of 241,457 healthcare providers evaluated. The majority of evidence suggests a relationship between provider burnout and impaired quality of care, consistent with recent reviews of various dimensions. Although the effect size in the published literature is modestly strong, the finding of excess significance supports the possibility of reporting bias causing exaggerated effects. The investigators recommend that future studies should attempt to reduce the risk of reporting biases, and that standardization and consensus on core outcomes may be useful for if appropriate targets can be identified. Some outcomes such as self-reported medical errors, low quality of care, and low patient safety score were particularly prevalent in the literature, but expert consensus is needed to curate an appropriate list of core outcomes for this field. In conclusion, healthcare provider burnout is consistently associated with reduced quality of care in the published literature. However, few rigorous studies exist and the effect size may be smaller than reported. It is not yet known whether curtailing burnout improves quality of care and/or whether improving quality of care reduces burnout, and adequately powered and designed randomized trials will be indispensable to answer these questions.

Link to Article: https://annals.org/aim/article-abstract/2752698/evidence-relating-health-care-provider-burnout-quality-care-systematic-review 

Dr. Krista Sigurdson publishes a systematic review of Racial and Ethnic Disparities in NICU care delivery in Journal of Pediatrics.

The contribution of NICU care to racial and ethnic disparities in outcomes is unclear. Dr. Sigurdson and investigators sought to conduct a systematic review of disparities literature related to quality of care for infants in the NICU setting, taking into account the contributions of societal, institutional, and interpersonal racism. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses guidelines and Donabedian’s structure process-outcome quality of care framework to review the literature on

racial and/or ethnic disparity in NICU quality of care delivery. Literature selected included English language articles retrieved and available in full text through March 6^th, 2018. Articles were divided into structure process-outcome according to their dominant theme, and further categorized thematically. Information extracted focused on racial and/or ethnic disparities in quality of care and potential mechanism(s) for disparities. Initial search yielded 566 records, 470 of which were unique citations. Title and abstract review resulted in 382 records. Appraisal of the full text of the remaining 88 records, along with the addition of 5 citations from expert consult or review of bibliographies, resulted in 41 articles being included. Results demonstrated that disparities in NICU quality of care exist at all levels (structure, process, outcome) and generally disadvantage infants of color, with some areas of exception. Two primary themes driving these disparities emerged. First, infants of color, especially black and Hispanic infants, are more likely to receive care in quality-challenged hospitals. Second, disparities also exist within NICUs. Although some overlap exists, strategies to address disparities may differ. In this review of racial and ethnic disparities in NICU quality of care, Dr. Sigurdson and investigators find strong evidence to suggest that disparities in neonatal outcomes are partly consequences of differential quality of care or access to high-quality care. Chronic stress caused by societal, institutional, or interpersonal racism may also play a causal role in preterm birth and authors of this review indicate that these factors are also causal factors for racial and ethnic disparities in NICU quality of care. Targeted QI efforts hold promise for improving racial and ethnic equity in care delivery and warrant consideration by care networks nationwide.

Link to Article: https://pediatrics.aappublications.org/content/144/2/e20183114?sso=1&sso_redirect_count=1&nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token

Dr. Jeffrey Horbar, CEO and Chief Scientific Officer of the Vermont Oxford Network, publishes a cohort study describing racial segregation and inequality in the NICU for VLBW and preterm infants in JAMA Pediatrics.

The investigators set out to determine the extent of racial and ethnic segregation and inequality of care of very low-birth-weight and very preterm infants across neonatal intensive care units (NICUs) in the United States. The selected population for this analysis included 134,871 infants from Vermont Oxford Network member NICUs that met criteria for classification as very-low birth weight (401-1500 g) and or were preterm (22-29 week gestation). Definitions of race and ethnicity were derived from the 2010 U.S. Census, and groups were finalized as non-Hispanic white, non-Hispanic black, Hispanic (any race),and non-Hispanic Asian categories, which we refer to as white, black, Hispanic, and Asian, respectively. Two indices were defined to quantify the extent of segregation and inequality for minority populations: the NICU segregation index and the NICU inequality index. The authors ranked NICUs based on the proportion of white infants from highest to lowest, and constructed Lorenz curves for the defined indices. To investigate regional differences in care, the weighted mean composite Baby-MONITOR score (an index of NICU care quality) for U.S. Census divisions and the distributions of race/ethnicity by region were determined. Linear regression at the hospital level was used to estimate the associations of racial distribution within hospitals and Baby-MONITOR scores with and without adjusting for region. The Lorenz curve for NICU segregation indicated that non-Hispanic white infants were segregated into different hospitals than white infants,  demonstrating substantial segregation of minority patients. The Lorenz curve for NICU inequality index indicated that non-Hispanic black infants were disproportionately treated at lower-quality NICUs. The investigators found substantial segregation in NICU care nationally, with black infants receiving care at lower-quality NICUs and Asian infants at higher-quality NICUs than white infants.  While the NICU inequality index for Asian infants may have been partially explained by the regions in which they resided, the concentration of black infants in lower-quality NICUs was not explained by region. Future research will explore the effects of sociodemographic factors and public policy on hospital quality, access, and choice for minority women and their infants.

Link to Article: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6503514/

Dr. Jessica Liu publishes findings on Disparities in Health Care-Associated Infections in American Journal of Perinatology

Health care-associated infection (HAI) is a serious complication among very low birth weight preterm infants. Very low birth weight preterm infants are especially susceptible to HAI as they are immune-incompetent, require prolonged hospitalization, and undergo frequent invasive procedures. Dr. Jessica Liu and her colleagues aimed to examine the multilevel risk factors for HAI among these infants. Using 2011-2015 CPQCC clinical and organizational data, researchers performed a retrospective analysis to determine infant level risk factor of HAI and test for the association of race/ethnicity on within and between hospital variation in HAI rates. Hispanics had significantly higher odds of infection, compared with white infants. Researchers also found significant variation in infection rates across participating NICUS, but race/ethnicity was not the major cause of this variation. Understanding the major drivers in variation across NICUs will be useful to identify solutions to reduce HAI in all very low birth weight preterm infants. For more information, refer to the CPQCC press release regarding this publication.

Disparities in severe maternal morbidity: prevalence, risk factors, and trends

Dr. Stephanie Leonard recently published an article in Annals of Epidemiology exploring the prevalence and trends concerning severe maternal morbidity (SMM). Using linked data from over 15 years of Californian births, Dr. Leonard and the team analyzed over 8 million live births and discovered that SMM prevalence varied by race/ethnicity. SMM prevalence was highest among non-Hispanic black women (1.63%) and lowest among non-Hispanic white women (0.84%). SMM rates increased by approximately 170% in all groups. Future studies look to further investigate the disparities present among the various racial/ethnic groups. For more information, refer to the CPQCC press release regarding this publication.

Dr. Daniel Tawfik publishes findings on Organizational Factors Affecting Physician Well-Being

With many U.S. pediatricians experiencing symptoms of professional burnout and additional emotional burden, it is imperative that we address this issue. Dr. Daniel Tawfik is first author in a Current Treatment Options Pediatrics article that highlights organizational opportunities to improve physician well-being including developing leaders, cultivating community and organizational culture, improving practice efficiency, and optimizing administrative policies. Leaders exert a great deal of influence on burnout and job satisfaction; thus, training high-quality physician leaders provides a great opportunity to combat burnout. In addition, community and culture heavily are crucial. Communities that promote teamwork, social support, and personal resilience development are likely to reduce the rate of burnout. Improving practice efficiency can decrease the imbalance between job demands and resources. Furthermore, administrative policies can affect work-home relations, so it is crucial that institutions are aware of the potential of stigmatization and prevent penalization for seeking support for burnout. For more information, refer to the CPQCC press release regarding this publication.

Dr. Ciaran C. Phibbs publishes findings on hospital-related costs of maternal and newborn care

Dr. Ciaran S. Phibbs is first author in a Journal of Pediatrics article that examines the costs of maternal and newborn care. Researchers retrospectively analyzed 2009-2011 data from California nonfederal hospitals, and costs were adjusted for inflation to December 2017 values. Both maternal and newborn costs were skewed with much of the additional costs incurred by the infant. For more information, refer to the CPQCC press release regarding this publication.

Perinatal Risk factors and Outcome Coding in Clinical and Administrative Databases

Dr. Daniel Tawfik has published an article in Pediatricsinvestigating the accuracy of billing codes for capturing key perinatal risk factors and outcomes. Researchers utilized data from the California Perinatal Quality Care Collaborative (CPQCC) and Office of Statewide Health Planning and Development (OSHPD) to conduct a population-based retrospective cohort study to determine the linkage between the databases and various risk factors. Several important perinatal risk factors and outcomes were reliably identified in a database, thereby providing a readily available resource for health services research investigations. For more information, refer to the CPQCC press release regarding this publication.

Assessing Capacity for Quality Improvement in Healthcare

Dr. Profit worked with collaborators from Duke University to assess improvement readiness (IR) of healthcare workers. The team conducted a cross-sectional study consisting of a five-item IR scale, demographics, safety culture scales and two open-ended questions. IR scores differed significantly by role, shift, shift length, and years in specialty. IR scores correlated significantly with safety culture scales. Linguistic analyses revealed that workers in low IR work settings used more negative emotion words while workers in high IR work settings were more positive. These findings were recently published in BMC Health Services Research. For more information, refer to the CPQCC press release regarding this publication.

Dr. Krista Sigurdson presents at the Stanford Maternal and Child Research Health Institute Inaugural Research Symposium

Dr. Krista Sigurdson recently presented her poster “Engaging Racially and Ethnically Diverse Families in Developing Measures of Family Centered Care in the Neonatal Intensive Care Unit (NICU)”. She discusses the importance of incorporating family engagement in generating measures for family centered care. Using the mixed methods approach, Dr. Sigurdson uncovered three areas for improvement: provider-family trust relationships, knowledge about the role of social workers, and continuity of care.

Dr. Profit leads a discussion on racial disparities in Tubingen, Germany

Dr. Profit recently traveled to Germany to give a talk on disparities in the NICU and its impact on families. He discussed the origins, literature, and efforts to address these disparities with a focus on qualitative family engagement. In addition, Dr. Profit explained the modified Delphi method used to generate family centered care measures and presented the top three measures that were selected by the expert panelists.

Dr. Profit publishes findings on the correlation between NICU safety culture and quality of care

Dr. Profit and his colleagues recently published an article in the Journal of Patient Safety that investigates the correlation of clinical metrics with NICU safety culture. In this study, clinical quality was measured via Baby-MONITOR, and safety and teamwork climate was assessed using the Safety Attitudes Questionnaire. Researchers found that NICU safety culture was correlated with healthcare-associated infections. For more information, refer to the CPQCC press release regarding this publication.

A cross-sectional survey analysis on work-life balance behaviours in BMJ Quality & Safety

Researchers conducted a cross-sectional survey to explore the role of demographics, psychometric properties, and work climate in work-life integration. Differences in work-life integration are associated with position and time in specialty and safety culture norms in the work climate. For more information, refer to the CPQCC press release regarding this publication.

Predicting Successful Retro-Transfer to a Lower Level of Care

A recent article in Journal of Pediatrics describes the development and predictive value of The Rule for Elective Transfer for Recovering Neonates (RETURN). For more information, refer to the CPQCC press release regarding this publication.

The Annual Vermont Oxford Network Quality Congress 2018

This weekend the Profit Lab traveled to Chicago to attend Vermont Oxford Network’s Annual Quality Congress. Dr. Profit led a breakout session to discuss the findings on the WISER study and its effects on decreasing burnout and improving resilience. The Profit Lab also participated in the poster session presenting four posters. Topics include racial and ethnic disparities within the NICU, healthcare-associated infection in VLBW infants, and the WISER study.

The Profit Lab also hosted the annual Dashboard Advisory Board meeting at VON. Drs. Ravi Dhurjati, Krista Sigurdson, and Jochen Profit conducted the second round of Delphi for the development of measures on family-centered care. 

Comparison of prevalence and risk factors of stillbirth and live birth at periviable gestational age

Minimal attention is given to the risk factors associated with stillbirth at periviable age. In a recently published article in the American Journal of Perinatology, Dr. Suzan Carmichael investigates the prevalence and risk factors associated with stillbirth at periviable ages and compares these numbers with live birth components. The study examined 2.5 million singleton births in California from 2007 to 2011. Results suggest there is some overlap in the etiologies of stillbirth and live birth at periviable gestational age. For more information, refer to the CPQCC press release regarding this publication.

Presentation to the Lucile Packard Children's Hospital Foundation

Dr. Profit led a presentation addressing disparities in NICU care and provided a synopsis of the CPQCC and its objectives. In addition, the presentation featured CPQCC in numbers and the CPQCC dashboard. Dr. Profit then summarized the ongoing research on disparities in the NICU and impact on the families and discussed potential solutions to combat those disparities.

Variations in Neonatal Antibiotic Use in Pediatrics

A recently published article in Pediatrics investigates the changes in NICU antibiotic use between 2013 and 2016. This study utilized data from the CPQCC-CCS NICUs in California and incorporated >54,000 neonates annually at >130 California NICUs. While unexplained antibiotic use continues, the overall and unexplained antibiotic use rate has declined. For more information, refer to the CPQCC press release regarding this publication.

Dr. Profit Co-I on RK Mellon Foundation Grant

Dr. Jason Wang (PI) received the RK Mellon Foundation grant with the overall goal to engage mothers and women at risk for preterm births with a mobile app to improve risk prediction, care coordination and mothers’ and infants’ adherence to recommended care with the ultimate effect of reducing preterm births and infant mortality. Dr. Profit will serve as a co-investigator on this exciting project. 

Stanford-Intermountain Collaborative Grant Receipient

Dr. Profit received the 2018 Intermountain-Stanford Collaboration Grant for the proposal: Less is More: Reducing Harm from Overuse of Invasive Procedures in the NICU. Dr. Profit will work with Dr. Ridout at Intermountain Healthcare to implement, evaluate and disseminate interventions that reduce harm to vulnerable infants from overuse of painful procedures in the neonatal intensive care setting. The work advances solutions to a largely unaddressed problem known to be a driver of poor quality and high costs. 

Invited Lecturer at 8th Annual McGill Neonatal Conference, Montreal, Canada

Dr. Profit was invited to present his research on "Combatting Burnout in the NICU" and "Disparity in NICU Care" at the conference. 

2018 International Conference on Patient and Family Centered Care

Dr. Jochen Profit, Dr. Krista Sigurdson, Dr. Linda Franck, and Lelis Vernon led a discussion on racial disparities at the 8^th International Conference on Patient- and Family-Centered Care in Baltimore. During the breakout session, Dr. Sigurdson discussed the development of measures on family-centered care which includes a modified Delphi with expert panelists and a qualitative component featuring family input. 

Dr. Daniel Tawfik publishes findings on the relationship between physician burnout, well-being, and work unit safety grades to reported medical errors

Dr. Daniel Tawfik recently published an article in Mayo Clinic Proceedings investigating the association between physician well-being and medical errors. Between August 2014 and October 2014, US physicians voluntarily participated in a national survey and provided information regarding basic demographics and professional characteristics. Analysis of the cross-sectional, national survey revealed an independent association between burnout, well-being, and work unit safety grades to perceived medical errors. For more information, refer to the CPQCC press release regarding this publication.

2018 Pediatric Academic Societies Meeting

The Profit Lab traveled to Toronto, Canada to present their posters at the Pediatric Academic Societies (PAS) meeting. 

Invited Speaker at MedNax Medical Director Meeting

Dr. Profit was invited to speak at the 2018 MedNax Medical Director's meeting. He presented on "Addressing Provider Burnout in Healthcare" during the plenary session. 

Dr. Krista Sigurdson publishes qualitative findings on racial and ethnic disparities in the NICU

At a large neonatal quality improvement conference in 2016, Dr. Profit invited the audience to contribute short anecdotes regarding times when they witnessed racial or ethnic disparities in quality of care in the NICU. Health care providers and family advocates from across the country contributed a total of 324 stories, which were qualitatively analyzed by Dr. Krista Sigurdson, the Profit Lab's postdoctoral research scholar in sociology. Dr. Sigurdson's findings were published in a recent paper in the Journal of Perinatology, detailing the common themes that emerged throughout these individual accounts of disparity. For more information, refer to the CPQCC press release regarding this publication.

Dr. Ravi Dhurjati publishes findings on factors that influence NICU quality of care

Dr. Ravi Dhurjati is the first author in a recent Journal of Perinatology research article that details the major themes influencing NICU quality of care delivery. Researchers selected and interviewed 10 NICU quality expert evaluators and qualitatively analyzed the semi-structured interviews. These interviews yielded three major themes that are necessary for the improvement of NICU quality care delivery: (1) cohesive unit culture, (2) effective linkages between measurement and improvement action, and (3) consistent hospital interaction. For more information, refer to the CPQCC press release regarding this publication.

Dr. Profit receives 2018 David Wirtschafter Award

The David Wirtschafter Award celebrates the work of a leader in neonatal quality improvement or a NICU QI team that has contributed not only within their unit but across the neonatal community. David Wirtschafter was a member of CPQCC since its inception in 1997. He was a servant leader as the chairman of the PQIP.  After chairing the PQIP for a decade, David remained active in the committee’s progression towards state wide QI initiatives and served as an expert panel member on CPQCC’s first collaborative in 2008. In addition, he was the inspiration behind the creation of the CPQCC QI toolkits and continues to participate actively on the Research subcommittee of the PQIP, thus making a lasting impact on the lives of newborns across the state of California. Dr. Profit was honored to be nominated and selected for this prestigious distinction.

Dr. Profit presents at the Gravens Conference

Dr. Profit and Lelis Vernon, Chair of the NICU Parent Advisory Council at Baptist Children's Hospital of Miami and Disparity Dashboard grant Advisory Board member, delivered a presentation entitled "Addressing Disparities in NICU Care" at the 31st Annual Gravens Conference on the Environment of Care for High-Risk Newborns. The talk reviewed the current literature on racial and ethnic disparities in NICU outcomes, discussed the impact that this has on families, and invited the audience complete a survey that asked for potential solutions to these issues. The lab expects to publish future research on the solutions gathered. 

Profit Lab has 9 abstracts accepted for presentation at PAS

The Profit Lab and its collaborators had 9abstracts accepted as poster presentations for the 2018 Pediatric Academic Societies (PAS) Meeting to be held in Toronto this May. Topics covered include factors associated with hypoxic ischemic encephalopathy, results from the WISER resilience intervention, a review of racial and ethnic disparities in NICU care, and many more. For a full list of poster presentations, please see the link below.

Profit Lab 2018 PAS Poster List

Two Profit Lab mentees receive CHRI grants

Dr. Daniel Tawfik, MD, and Dr. Krista Sigurdson, PhD, both received Pilot/Early Career awards from Stanford's Child Health Research Institute. Dr. Sigurdson will be using qualitative research tools to study family-centered care in the NICU and Dr. Tawfik will be developing a metric of nurse staffing.

VON Annual Quality Congress 2017

Members of the lab traveled to Chicago over the weekend to attend the Vermont Oxford Network's Annual Quality Congress. Dr. Profit moderated a plenary session discussion on the social determinants of health and Dr. Krista Sigurdson presented a poster on accounts of racial and ethnic disparities in the NICU. The new CPQCC report site Dashboard was also featured at a session on innovations from state quality collaboratives.

CPQCC Dashboard Poster

Dr. Profit awarded Marie McCormick Lectureship

Dr. Profit is this year's recipient of Beth Israel Deaconess Medical Center Department of Neonatology's Marie McCormick Lectureship in Health Services Research and Epidemiology. His presentation to the Division of Newborn Medicine discussed our recent work on safety culture and burnout in the NICU. 

American Conference on Physician Health 

Stanford Medicine hosted the first annual American Conference on Physician Health on October 12-13 in San Francisco. Several lab collaborators and projects were featured throughout the conference - Dr. Jochen Profit moderated a breakout session on Efficiency of Practice, Dr. Bryan Sexton presented on the effect on positive rounding in health care work settings, and Dr. Daniel Tawfik discussed our recent paper on the associations between work-life balance, teamwork climate, and safety climate.