Medical safety and quality awareness in neonatal intensive care

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Authors

Mileder L, Schwindt E, Hogeveen M, Thiele N, Ares S

Target group

Neonates, infants, parents, and families

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Patient safety and quality improvement activities need to be fully integrated in clinical practice.

Rationale

Infants admitted to a neonatal intensive care unit (NICU) are at a high risk of being harmed by lapses in quality or safety. (1) Specific issues of neonatal patient safety include medication and nutrition errors, errors in respiratory care, infections due to invasive procedures and neonatal care in general, patient identification errors, and diagnostic errors. (2)

Improving patient safety is an important component of high-quality care and requires a safety-oriented culture and the support of an appropriate system for the identification of, investigation of, and learning from quality issues. (3) Although there are several schemes for quality improvement, awareness, local leadership and implementation are critical to improving outcomes for ill neonates and infants.(4-9) Furthermore, structure, data monitoring, and culture are important determinants of any quality programme in neonatal care. (10)

A quality system needs to be championed at the hospital board level but is led from within the interprofessional neonatal team, supported by the quality improvement staff. Structural components include dedicated education and training as well as a system capturing data to monitor key indicators as prioritised by the neonatal team. The healthcare team should develop a safety culture in which transparency, blame-free reporting and the development of learning from clinical events reported within the system are valued. Units and hospitals should establish an advisory board to coordinate and direct quality improvement initiatives.

Benefits

Reduced clinical errors and patient harm (4-9,11,12)
Reduced length of hospital stay (7,8,13)
Improved patient outcome (4-9), including improved perinatal outcome through interprofessional and interdisciplinary team training (14,15)
Identifying care processes prone to errors/prone to cause patient harm (4,9,16)
Improved safety climate (5,7,9,17)
Improved incident reporting (4,8,9,18)
Improved teamwork (5,8,9,19)
Improved well-being of frontline staff and less staff turnover (8,9,18,20)
Improved patient/family satisfaction (8,9,21,22)
Prioritisation of improvement projects (4,7-9)
Reduced liability claims (23)

Components of the standard

Component

Grading of evidence

Indicator of meeting the standard

For parents and family

Parents and families are informed by healthcare professionals about patient safety and quality awareness in neonatal intensive care.

B (Moderate quality)

Patient information sheet¹

Parents are invited to provide feedback during and after the NICU stay.

B (Moderate quality)

Parent feedback

Parent representatives are invited to provide input and feedback in staff education and training on patient safety.

B (Moderate quality)

Training documentation

Parents are encouraged to report recognised incidents and receive confidential, timely feedback (see standard “Threat, error and success reporting: How to effectively practice error management”).

B (Moderate quality)

Parent feedback

Parents are members of the NICU quality improvement board.

B (Moderate quality)

Guideline

For healthcare professionals

A unit guideline on patient safety and quality awareness is adhered to by all healthcare professionals.

B (Moderate quality)

Guideline

Training on patient safety, safe equipment use (see standard “Safe equipment use”) and quality improvement including participation in team-oriented simulation training is attended regularly by all staff.

B (Moderate quality)

Training documentation

All healthcare professionals are actively engaged in quality improvement projects and training.

B (Moderate quality)

Audit report², guideline, training documentation

Healthcare professionals report all recognised safety incidents (see standard “Threat, error and success reporting: How to effectively practice error management”) and are involved in finding clinically feasible, effective solutions.

B (Moderate quality)

Audit report², clinical records

A blame-free culture is established.

B (Moderate quality)

Staff feedback

Team briefings are regularly performed before critical events or planned interventions. (24,25)

B (Moderate quality)

Guideline

Debriefing of clinical events is attended regularly by all staff in order to reflect on performance and to identify areas for improvement. (26-28)

B (Moderate quality)

Healthcare professional feedback, minutes of debriefing

For neonatal unit

A unit guideline on patient safety and quality awareness, including tools for evaluation and improvements measures, is available and regularly updated.

B (Moderate quality)

Guideline

Clear roles and responsibilities in patient safety and quality improvement are allocated, including a designated clinical lead for patient safety.

B (Moderate quality)

Audit report², guideline

An anonymous, easily to access clinical incident reporting system is provided (see standard “Threat, error and success reporting: How to effectively practice error management”).

B (Moderate quality)

Audit report², guideline

Regular patient safety and quality improvement meetings are held based on reported clinical incidents and appropriate counteracting actions are developed and undertaken, including follow-up of their effectiveness.

B (Moderate quality)

Audit report², guideline

Individual participation with quality improvement/patient safety initiatives is included in yearly performance reviews.

B (Moderate quality)

Audit report², training documentation

Quantitative data, which is relevant to patient safety and quality improvement, is collected objectively (see standard “Quality indicators”).

B (Moderate quality)

Audit report², clinical records

For hospital

Regular training on patient safety, safe equipment use (see standard “Safe equipment use”) and quality improvement including participation in team-oriented simulation training is ensured for all healthcare professionals.

B (Moderate quality)

Training documentation

A clear policy and structure for “no-blame reporting of incidents” is available (see standard “Threat, error and success reporting: How to effectively practice error management”).

B (Moderate quality)

Guideline, audit report²

Quality monitoring and improvement is given priority by the whole hospital management team (see standard “Quality indicators”).

B (Moderate quality)

Guideline, audit report²

Neonatal quality improvement activity is actively supported by the hospital quality management team.

B (Moderate quality)

Audit report²

Transparent benchmarking in comparison to other neonatal services is supported and facilitated (see standard “Quality indicators”).

B (Moderate quality)

Audit report²

For health service

A national guideline on neonatal patient safety and quality awareness is available and regularly updated.

B (Moderate quality)

Guideline

Quality indicators and learning points from patient safety and quality awareness initiatives are shared and compared across the healthcare system (see standard “Quality indicators”).

B (Moderate quality)

Audit reports²

¹The indicator “patient information sheet” is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.

²The indicator “audit report” can also be defined as a benchmarking report.

Where to go

Further development

Grading of evidence

For parents and family

Actions to actively include parents in patient safety and quality improvement should be developed, evaluated and implemented, such as family-centred rounds or active parental engagement in safety processes. (29,30)

A (Moderate quality)

For healthcare professionals

Develop educational interventions based on locally reported safety incidents. (31)

A (Low quality)

Improve educational interventions targeting patient safety and quality improvement.

A (Low quality)

Develop interventions at system level based on locally reported incidents to improve the efficiency and safety of the working environment.

A (Low quality)

For neonatal unit

Recognise patient safety and quality improvement as central clinical tasks and dedicate appropriate resources, for example for a dedicated interdisciplinary and interprofessional safety team. (32,33)

A (Moderate quality)

For hospital

Recognise patient safety and quality improvement as central clinical tasks and dedicate appropriate resources, for example for a dedicated interdisciplinary and interprofessional safety team. (32,33)

A (Moderate quality)

For health service

Establish regular international benchmarking.

B (Moderate quality)

Getting started

Initial steps

For parents and family

Parents are explicitly informed by healthcare professionals about patient safety and quality awareness in neonatal intensive care.
Parents are encouraged to report recognized incidents.

For healthcare professionals

Attend training on patient safety and quality improvement including participation in team-oriented simulation training.
Report incidents using available hospital structures.
Analyse incidents and develop appropriate practice improvements, including follow-up of their effectiveness.
Perform team briefings regularly before critical events or planned interventions.
Perform clinical event debriefings regularly to reflect on performance and to identify areas for improvement.

For neonatal unit

Develop and implement a unit guideline on patient safety and quality awareness.
Develop information material on patient safety and quality awareness in neonatal intensive care for parents.
Foster an open patient safety culture by starting with regular team training and patient safety and quality improvement meetings.

For hospital

Support healthcare professionals to participate in training on patient safety/quality improvement including regular participation in team-oriented simulation training.
Facilitate learning from local incidents and from those of other departments.
Designate a qualified, full-time quality improvement manager.

For health service

Develop and implement a national guideline on patient safety and quality awareness.
Compare quality indicators and establish a national peer review programme for patient safety and quality awareness initiatives.

A lot of attention is being dedicated to improving the quality of neonatal care, as the extremely vulnerable and seriously ill patients in a NICU are at a high risk of being harmed by lapses in quality or safety. Nevertheless, improving healthcare quality has proven to be a challenging undertaking that foremost requires long-term dedication. It has become clear that the science of improvement, human factors, and implementation are indispensable in increasing the quality of care and patient safety. While acknowledging that no single system will fit all NICUs, this standard attempts to highlight the most relevant topics and tools that NICUs can apply in their quest for quality management and improvement.

Since the publication of the landmark report “To err is human”(4), the quality and patient safety movement, which had taken off with a slow start, has gained more and more momentum. Numerous initiatives and organisations dedicated to quality improvement have been created, such as the Institute for Healthcare Improvement in the USA and the Health Foundation in the UK. Research in the fields of healthcare quality, patient safety, implementation, innovation, and human factors has exploded. As the research and knowledge of safety and quality has increasingly been shared, it became evident that a number of basic requirements for improvement are necessary for all healthcare settings.

Figure 1 adapted from Haraden & Staines, 2015 (10)

First of all, a system or structure for Quality and Patient Safety Management (QPSM) needs to be in place. Roles, tasks and responsibilities have to be defined. It needs to be clear who is doing what, and who is accountable for which components of the management system. This needs to be facilitated and supported actively by boards, directors, and (middle) management; quality management will undoubtedly fail when it is simply added to the everyday tasks and activities of the engaged frontline staff. Another necessity relates to improving skills. Frontline staff and management involved in quality improvement need to collaborate with co-workers schooled in change management, as healthcare professionals usually are not trained in the skills for developing and implementing new processes, procedures etc.

Next to this, each NICU needs to determine what data to monitor and in what way. In order to be able to prioritise, implement, monitor, adapt and create success of any improvement initiative, quantitative data, which is relevant to the addressed problem, need to be collected objectively (see standard “Quality indicators”).

The last pillar of QPSM is culture. How is the safety climate in a NICU, a hospital, a country? Is there a “just culture” (5,36) where openly discussing errors and mistakes is not only possible without fear for repercussions, but in fact welcomed as an opportunity to learn? In this respect, leading by example is one of the most powerful modes of improving the safety culture in any setting. Directors and heads of departments that welcome feedback on their own deficiencies and lack of adhering to relevant standards and guidelines will likely see an increase in commitment from frontline staff and patients/parents. Next to leadership in setting the standard for the desired work-related behaviours, they also need to facilitate regular teamwork and team-oriented training. Teamwork is more and more recognised as the foundation of healthcare and, thus, needs to be consistently addressed. (17) As has been proven numerous times, expert teamwork is not created by simply putting a number of experts together, but requires training, both in acute care settings such as the NICU as well as in other settings such as for instance an outpatient department. (37) Healthcare frontline staff are well trained professionals in their field of expertise, however, the non-technical skills that are required for effective teamwork quite often have not received the attention they require. Communication, leadership, decision-making, stress and risk management, as well as developing a shared understanding of the situation are topics of training, education, and discussion that must be addressed. Especially interdisciplinary and interprofessional simulation training allows training and rehearsing these essential non-technical skills. (38,39) Debriefing of actual clinical events further supports teamwork improvement. (26-28)

Improving patient safety, teamwork, and unit culture also relate to the notion that patients and families should be welcomed as members of the team, as, for example, medication errors are more often recognized in integrated care. (12) Therefore, engaging parents “as partners in safety” has been suggested to improve the safety of neonatal care. (40) Shared decision making is another integral part of patient and parent engagement. (41) However, integrating parents in the NICU team can be quite challenging and there may be a number of barriers. For instance, the events surrounding the birth of a preterm child can be extremely stressing for parents, thus decreasing their ability to make shared decisions, or the frontline staff feel they cannot properly discuss the decisions during the rounds if the parents are present. These potential issues obviously need to be explored and dealt with before teaming up with parents can reach its full potential. Several initiatives have been launched worldwide, so what remains is learning from each other, and from the parents/families, in how to best achieve safe, patient-centred and reliable care for the most vulnerable, i.e. the NICU patients. (42)

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