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Safe and Healthy Beginnings (SHB) Improvement Project

QuIIN: Home to national pediatric improvement networks
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SHB Aim
 
The Safe and Healthy Beginnings improvement project, the pilot project of the AAP’s Quality Improvement Innovation Network (QuIIN) aimed to test measures, strategies, and tools (with 22 clinical teams) based on three key aspects of the AAP’s revised hyperbilirubinemia guidelines (Pediatrics. 2004;114:297-316):      
                        
  • Assessment of risk for severe hyperbilirubinemia prior to hospital discharge
  • Breastfeeding support
  • Care coordination between the nursery and primary care
The SHB improvement project aimed to answer the following questions:
 
  1. What measures and measurement approach can newborn nurseries and primary care practices feasibly implement to assess their performance of care processes related to hyperbilirubinemia, exclusive breastfeeding, and safe transition of care from hospital to medical home?
  2. What tools and strategies will enable newborn nurseries and primary care practices to improve care processes related to hyperbilirubinemia, exclusive breastfeeding, and safe transition of care from hospital to medical home
  3. What factors contribute to or inhibit newborn nurseries’ and primary care practices’ ability to improve care processes related to hyperbilirubinemia, exclusive breastfeeding, and safe transition of care from hospital to medical home?
  4. What changes should be made to the tools, strategies and measurement approach to better support newborn nurseries’ and primary care practices’ implementation of care processes related to hyperbilirubinemia, exclusive breastfeeding, and safe transition of care from hospital to medical home?

 

SHB Example Measures

Newborn Nursery Example Measures
 
Measure Name & Description
How Calculated
% infants put to breast in first hour of life. (Process)
Target Population:
All breastfeeding newborn infants admitted to NBN in target hospital
Numerator:
# infants admitted to NBN whose mothers initiate breastfeeding and are put to breast at <= 1 hour age
Denominator:
All breastfeeding newborn infants admitted to NBN in target hospital whose charts are reviewed
% infants who have documentation in chart that parents were counseled to breastfeed 8-12 times/day. (Process)
Target Population:
All breastfeeding newborn infants admitted to NBN in target hospital
Numerator:
# infants with documentation in chart that parents were counseled to breastfeed 8-12 times/day
Denominator:
All breastfeeding newborn infants admitted to NBN in target hospital whose charts are reviewed
% infants who have documentation in chart of at least 2 formal evaluations of breastfeeding (Process)
Target Population:
All breastfeeding newborn infants admitted to NBN in target hospital
Numerator:
# infants with documentation in chart of 2 formal evaluations of breastfeeding
Denominator:
All breastfeeding newborn infants admitted to NBN in target hospital whose charts are reviewed
% infants who have documentation of hour-specific bilirubin levels on chart. (Process)
Target Population:
All newborn infants admitted to NBN in target hospital
Numerator:
# infants who have hour-specific bilirubin levels on chart
Denominator:
All newborn infants admitted to NBN in target hospital whose charts are reviewed
% nurseries using graphs based on age in hours, gestational age, and clinical condition to initiate phototherapy (Process)
Target Population:
All participating newborn nurseries
Numerator:
# newborn nurseries self-reporting that they use hour and gestational age specific graphs to initiate phototherapy
Denominator:
All participating newborn nurseries
% infants with risk of subsequent hyperbilirubinemia documented in chart. (Process)
Target Population:
All newborn infants admitted to NBN in target hospital
Numerator:
# infants who have risk of subsequent hyperbilirubinemia documented in chart
Denominator:
All newborn infants admitted to NBN in target hospital whose charts are reviewed
% infants who have documentation of parent counseling about jaundice.
(Process)
Target Population:
All newborn infants admitted to NBN in target hospital
Numerator:
# infants who have documentation of parent counseling about jaundice in chart
Denominator:
All newborn infants admitted to NBN in target hospital
% infants who have on-time follow-up visit scheduled (3-5 days). (Process)
Target Population:
All newborn infants admitted to NBN in target hospital
Numerator:
# infants who have follow-up visit scheduled at 3-5 days
Denominator:
All newborn infants admitted to NBN in target hospital whose charts are reviewed
% infants who have documentation of medical home in chart. (Process)
Target Population:
All newborn infants admitted to NBN in target hospital
Numerator:
# infants who have name of primary care provider documented in chart
Denominator:
All newborn infants admitted to NBN in target hospital whose charts are reviewed
% infants who have documentation of date and time of follow-up visit in chart. (Process)
Target Population:
All newborn infants admitted to NBN in target hospital
Numerator:
# infants who have date and time of follow-up visit documented
Denominator:
All newborn infants admitted to NBN in target hospital whose charts are reviewed
% nurseries using standard tool to assess readiness for discharge. (Process)
Target Population:
All participating newborn nurseries
Numerator:
# nurseries reporting use of standard tool to assess readiness for discharge
Denominator:
All participating newborn nurseries
% infants whose charts were sent to medical home before follow-up visit (Process)
Target Population:
All newborn infants admitted to NBN in target hospital
Numerator:
# infants whose charts were sent to medical home before follow-up visit
Denominator:
All newborn infants admitted to NBN in target hospital
 
 
Primary Care Practice Example Measures
 
 Measure Name & Description
 How Calculated
% infants with documentation of assessment of frequency and adequacy of breastfeeding at first visit. (Process)
Target Population:
All breastfeeding newborn infants attending target practice for initial visit
Numerator:
# infants who have documented assessment of frequency and adequacy of breastfeeding at first visit
Denominator:
All breastfeeding newborn infants attending target practice for initial visit whose charts are reviewed
% infants for whom vitamin D was prescribed. (Process)
Target Population:
All breastfeeding newborn infants attending target practice for initial visit
Numerator:
# infants who have documentation of prescription of Vitamin D
Denominator:
All breastfeeding newborn infants attending target practice for initial visit whose charts are reviewed
% infants who have documentation of hyperbilirubinemia assessment at initial PMD visit (Process)
Target Population
All newborn infants attending target practice for initial visit
Numerator:
# infants who have documented hyperbilirubinemia assessment at initial visit
Denominator:
All newborn infants attending target practice for initial visit whose charts are reviewed
% infants whose initial newborn visit occurs at 3-5 days of age. (Outcome)
Target Population:
All newborn infants attending target practice for initial visit
Numerator:
# infants who attend follow-up visit at 3-5 days of age
Denominator:
All newborn infants attending target practice for initial visit whose charts are reviewed
% infants whose hospital records are received by PMD before follow-up visit. (Process)
Target Population:
All newborn infants attending target practice for initial visit
Numerator:
# infants whose records are available at initial visit
Denominator:
All newborn infants attending target practice for initial visit whose charts are reviewed

 
SHB Teams
Twenty-two clinical teams were selected from the Quality Improvement Innovation Network as part of the SHB improvement project; 10 teams represented newborn nurseries, while 12 teams represented primary care practice. Each team consisted of a physician leader plus 2 other members of the practice (generally a nurse and an administrator). Click here to see a list of all of the clinical teams.
 
Clinical teams were responsible for:
 
  • Collecting simple data through chart reviews and other practice feedback tools at baseline and monthly throughout the project; reviewing monthly run charts
  • Working with other members of their nursery’s or practice’s clinical team to improve care processes related to hyperbilirubinemia, exclusive breastfeeding, and transition of care from hospital to medical home
  • Participating in 2 face-to-face learning sessions (e.g., one near the beginning of the project and one near the end)
  • Learning the quality improvement methodology (Model for Improvement and implementing Plan, Do, Study, Act [PDSA] cycles)
  • Sharing learnings with other participating nurseries and practices
  • Using e-mail and the Internet on a regular basis for ongoing support, information, and communication among practice teams
  • Testing innovations in care delivery to improve preventive and developmental service health outcomes
  • Participating in monthly office team conference calls
  • If participant was a clinic manager, participating in monthly office/practice managers conference calls
  • If owned by a health care institution, seeking Institutional Review Board approval for participation in the intervention
Project Design
Safe and Healthy Beginnings used the Model for Improvement quality improvement methodology. Twenty-two clinical teams participated in an adapted learning collaborative to use, modify, and test tools around hyperbilirubinemia, breastfeeding support, and coordination of care and provide feedback and suggestions for improvement of the tools. The tools selected and tested were to assist in the implementation of the AAP’s 2004 evidence based clinical practice guideline on Hyperbilirubinemia. Testing occurred over 8 months using Plan, Do, Study, Act (PDSA) cycles. The overall design of the improvement project included:
 
  • Baseline assessments: Clinical teams assessed their current level of performance with respect to implementation of care processes related to hyperbilirubinemia, exclusive breastfeeding, and safe transition of care from hospital to medical home.
  • Learning Session 1: Clinical teams were oriented to the draft SHB materials/tools, received results from baseline assessments, and were trained on the quality improvement methodology (Model for Improvement) for implementing process changes in a face-to-face session.
  • 5-month testing phase: Clinical teams developed a plan to improve care processes related to hyperbilirubinemia assessment, exclusive breastfeeding, and safe transition from hospital to medical home; utilized PDSA cycles to test tools, measures, and data collection instruments related to same; and reviewed monthly run charts.
  • Monthly conference calls: Clinical teams shared results of their tests with project faculty and other teams, questions were answered, and specific topics were discussed.
  • Learning Session 2: Clinical teams provided essential feedback on the prototype toolkit and strategies used for implementation in a face-to-face session. Clinical teams also participated in sessions around sustainability efforts, clinical topic areas, and successes and challenges.

Project Data Collection included:

Resources for Clinical Teams
 
A special thanks to our Safe and Healthy Beginnings Expert Group:
 
  • Carole Lannon, MD, MPH, FAAP, Co-Chairperson
    Center for Health Care Quality
  • Ann R. Stark, MD, FAAP, Co-Chairperson
    Baylor College of Medicine
  • Vinod "Vinny" Bhutoni, MD, FAAP
    Stanford University School of Medicine
  • Debra Bogen, MD, FAAP
    Children's Hospital of Pittsburg
  • Joseph Allen Craig, MD, FAAP
    Rocky Mountain Youth Clinics
  • Lori Beth Feldman-Winter, MD, FAAP
    Children's Regional Hospital at Cooper University Hospital
  • Kaye Gable, MD, FAAP
    Moses Cone Hospital
  • Gordon Benjamin Glade, MD, FAAP
    University of Utah School of Medicine and Utah Valley Pediatrics
  • M. Jeffrey Maisels, MD, FAAP
    William Beaumont Hospital
 
timeline
SHB Toolkit
 
As a result of this project, these tested tools are now available for widespread use. Tools are included in Safe and Healthy Beginnings: A Resource Toolkit for Hospitals and Physicians' Offices.
 
The SHB Toolkit is endorsed by Child Health Corporation of America and The Joint Commission.
 
SHB Toolkit Demo (when the file opens, click on the play arrow to see the demo)
Safe and Healthy Beginnings was in partnership with the Center for Health Care Quality (CHCQ) at James M. Anderson Center for Health System Excellence and funded by the AAP, McNeil Consumer Healthcare, and the Centers for Research and Education in Therapeutics (CERTS)
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