Defining and Measuring Quality


Neonatal intensive care is a complex and multidimensional activity, which the measurement of its quality should reflect. Although individual quality measures contain important information, summarizing performance by combining information from multiple measures provides a global assessment of NICU quality and enables comparisons across NICUs. The Baby-MONITOR is the only formally developed composite measure of the quality of NICU care. By combining individual measures into a single metric the Baby-MONITOR simplifies and summarizes complex issues, highlights trends, and fosters broad systems-based approaches to improving quality.

The Baby-MONITOR was developed using a rigorous and systematic process: we developed a theoretical framework for composite measurement of NICU quality; engaged a national panel of experts in a modified Delphi experiment to select measure components; and a national sample of clinicians validated the measures. The full development and validation process is described in our 2014 publication in Pediatrics, Baby-MONITOR: a composite indicator of NICU quality.

Baby-MONITOR plays a key role in our lab's work and research to further develop this indicator continues. We have applied the Baby-MONITOR to evaluate racial and ethnic disparities in the quality of NICU care, examine associations between level of care and NICU quality, and measure the impact of social and built environment factors on neonatal outcomes. 

Composite Baby-MONITOR scores for 22 California NICUs

Baby-MONITOR subcomponent scores by level of care

Analyzing Care Networks

We are applying network analysis tools to evaluate the quality of care delivery across regionalized neonatal intensive care delivery networks. In collaboration with Jure Leskovec, PhD, and Marinka Zitnik, PhD in the Department of Computer Science at Stanford and Sarah Kunz, MD, MPH and John Zupancic, MD, ScD, at Harvard University, we are analyzing patient flow across hospitals and its effect on clinical outcomes. 

The map at left from our recent publication (link below) represents acute neonatal transports in California. Each "node" represents one hospital. Node shape denotes NICU acuity (circles - lowest acuity; squares - middle acuity; rectangles - highest acuity) and node size denotes number of transfers into that hospital. The transfer networks that were uncovered through our analysis are represented by node color.  

Related Publications:

Network analysis: a novel method for mapping neonatal acute transport patterns in California

Acuity-Adjusted Nurse Staffing

Despite concerted efforts to improve the quality of health care delivery, patients continue to receive highly variable care and suffer serious harm as a result. Nurse staffing has been linked to improved patient outcomes, but evaluation of the contribution of nurses is not adjusted to the nursing needs of heterogeneous patients. Led by Daniel Tawfik, MD, this project will create and validate an acuity-adjusted nurse staffing metric in the neonatal intensive care unit setting. This metric will allow a more granular understanding of the multi-level factors that drive variation in patient outcomes, provide benchmarks for nurse staffing across NICUs, and could be applied to other health care settings as well.

Related Publications:

Nurse-to-patient ratios and neonatal outcomes: A brief systematic review

NICU Context

Context refers to organizational, managerial or cultural features that influence quality of NICU care delivery and the success of quality improvement efforts. Given the significant variation that exists in clinical outcomes of newborns across NICUs, we need to better understand features in the NICU care delivery context that drive quality of care and can be modified to improve quality.

Our recent publication in the Journal of Perinatology idenfied key features at the unit and organizational level that influence quality of NICU care. These features include the physical and cultural environment of care, measurement infrastructure that supports improvement and administrative and material support from the hospital. The figure below shows features that collectively constitute the context for quality in the NICU.

Results of the study will be used to help individual NICUs improve and create the conditions that are conducive for delivering high quality of care. Based on these results, we have developed a tool to assess the care delivery context and the identify the strengths and weaknesses of individual NICUs. Future directions for this work include incorporating strategies for actively modifying context to improve the effectiveness of collaborative quality improvement efforts.

Related Publications:

Never judge a book by its cover: how NICU evaluators reach conclusions about quality of care.

Family-Centered Care

Premature birth and hospitalization in the NICU separates infants from their families for a prolonged period with potential negative consequences for infant-family bonding and long-term developmental outcomes. Family-centered care (FCC) is an approach to care delivery that recognizes the central role families play in the physical, cognitive and psychosocial development of the infant. FCC engages families as collaborators and essential partners in the NICU care team- encouraging family presence in the NICU and an active role in caring for the infant.  FCC has been endorsed by leading professional organizations but its application across NICUs remains inconsistent. To improve NICU performance on FCC, we need objective measures, which are currently lacking. We are addressing this gap by working with NICU families and a national panel of experts to develop measures that can be used to evaluate FCC, compare performance across NICUs and identify areas of improvement.