• Article
  • July 28, 2016

4 Quality Improvement Successes from Award-winning Hospitals

These children's hospital improvement teams led remarkable initiatives that are changing the way their hospitals work, from resident training to decreasing length of stay.

By Kaitie Marolf

Children's hospitals are distinct in the care they provide to children, but they face the same challenges as the entire health care industry: transforming the delivery system, improving patient safety and clinical care, and reducing waste. While one person with a vision can drive organizational change, it takes a team to make real improvement stick, especially in a large system.

Here are examples from four children's hospital improvement teams that stayed the course for something they believed would make a difference for their patients. Their successful examples could help your hospital achieve similar results. Meet the 2015 Pediatric Quality Award category winners.

Patient safety and the reduction of harm: radiation exposure reduction

Modified barium swallow studies (MBSS) are the most frequently performed, most often repeated, and highest dose fluoroscopy procedures in the pediatric radiology suite at Doernbecher Children's Hospital at OHSU. Although the hospital's median radiation exposure times were less than published averages, the organization wanted to improve.

"We know radiation exposure is linked to cancer," says Windy Stevenson, M.D., project lead. "The younger a patient is exposed, the higher the risk. Anything we can do to reduce exposure reduces the overall risk for the child."

Since the project began in 2012 with the goal of lowering radiation exposure to less than two minutes for each MBSS, 80 percent of studies have reached that goal (a 50 percent reduction), and patients' exposure has gone from 140 minutes per month to less than 100 minutes per month.

4 low-cost process improvements

Doernbecher Children's Hospital made these changes to reduce radiation exposure during MBSS.

Set a time limit goal. The team first decided it wanted to reduce each test to under two minutes. Radiologists decided this was a reasonable amount of time for a fluoroscopy. 

Use verbal alerts. To increase communication and help the team reach its time goal, the radiologist called out alerts at one minute of exposure and every 30 seconds following. "That changed the understanding in the room," Stevenson says. "Prior to that, the radiologist was the only one who knew how much time had elapsed."

To increase communication and help the team reach its time goal, the radiologist called out alerts at one minute of exposure and every 30 seconds following. "That changed the understanding in the room," Stevenson says. "Prior to that, the radiologist was the only one who knew how much time had elapsed."

Agree on the goal. Prior to this project, team members sometimes took longer to try to prove that aspiration was occurring. They later agreed the goal of the test is to assess the risk, not prove aspiration.

Create a pre-procedural evaluation process. Previously, patients met the speech language pathologist immediately before the test. The team added a meeting with the family beforehand to help all involved prepare before the risk of exposure was present. This included finding out if the child required a certain toy or food to help them make the test a success. "The fluoroscopy could take longer because we didn't have all of the tricks for that particular child figured out," Stevenson says.

Waste reduction/improved efficiency: decreased length of stay

To get its pediatric intensive care unit (PICU) started on a path of continuous QI, a Children's of Alabama PICU bedside nurse formed and led a QI team in its first project. After assessing common admissions diagnoses, the team members decided to standardize the process for postoperative spinal fusion patients and decrease their length of stay by one day with a standardized bundle of care. In October 2014, team members piloted the bundle of care on three patients.

They exceeded their length of stay goal when the patients were discharged within three days, as compared to six days for most patients before standardization. "The PICU's team goal was to prove a concept we could standardize and improve outcomes," says Leslie Hayes, M.D., project lead, medical director of patient safety, Health Services Administration. The hospital needed to decrease PICU length of stay for several diagnoses. "We had to understand the key motivators for each group of providers," Hayes says.

Areas of change for introductory QI projects

Here's how Children's Hospital of Alabama launched its project.

Brainstorm and map the process. The team made sure everyone involved with the project at any level was educated on QI and clearly understood his or her role. "We didn't make any assumptions about anyone's role in post-op care," Hayes says. "We had everybody at the table when we were mapping this out."

Implement several elements simultaneously. The bundle of care the team applied included a clear breakdown of care from PICU admission to transfer to the acute care floor including when the patient could begin ambulation and the removal of the catheter and arterial line.

Eliminate unnecessary lab draws. Instead of taking a full blood draw with blood gas, chemistry panel and blood count information twice following surgery, the team only took blood gases with hematocrits and sodium twice after surgery, which reduced the amount of testing needed.

Pilot a small group. Once the process was developed, the team worked closely with three patients to see how well it worked before setting the standards into practice. "We got fantastic feedback because in the past, we could not provide any standard information to the families and patients," Hayes says. "Families and staff appreciated how predictable it was."

Delivery system transformation: QI training in residency

Today's complex health care delivery system needs professionals knowledgeable in QI methods and techniques. Yet, according to Levine Children's Hospital, most medical students are graduating with little to no exposure to QI. To help prepare the next generation of the workforce to lead in QI, Levine's Department of Pediatrics reviewed its approach to resident training. The organization launched changes to its program in 2009, and the class of 2012 became the first graduates of the updated residency program.

The organization began working to improve QI knowledge while meeting the American College of Graduate Medical Education requirements for systems-based practice and practice-based learning. The hospital created a program that gives residents substantial responsibility as part of an interdisciplinary front- line care delivery team and uses improvement science to provide a standardized, evidence-based approach to improving care.

While Levine created the program to fit its available resources and needs, it's easily adapted to individual locations. Through the use of hands-on projects, QI coaches and data analysts, program evaluation and individual coaching, the hospital saw an increase in resident confidence levels for QI knowledge and skills, and 100 percent of 2015 graduates had leadership roles in QI projects.

Laura Noonan, M.D., director of the Center for Advancing Pediatric Excellence at Levine, says that the most rewarding parts of this program are the number of children that these projects are impacting and the knowledge that residents are gaining in problem solving. "Instead of impacting one child's life at a time, these projects are involving hundreds of children's lives at a time and getting them the care they need," Noonan says. "It will be a while before we see significant outcomes change, but we are now improving care in a reliable, consistent manner."

The most challenging part, Noonan says, was fitting more into an already full curriculum. "Their jobs change every month from working with healthy newborns to ill and dying patients," she says. "That pushes us to think creatively about learning and education, but it acts as a barrier."

7 changes for improvement

Here are strategies Levine Children's Hospital tested in improving its resident training program.

IHI modules assignments. This portion of the curriculum, which utilizes free online courses for professional continuing education created by the Institute for Healthcare Improvement (IHI) is reviewed annually for needed changes.

Assigned readings.  The hospital saw low compliance with assigned reading among residents and, after adjusting the amount of reading and its content, changed the name from "required" to "recommended" readings.

Faculty QI mentors. The traditional resident/faculty mentorship was deemed ineffective, so the program moved to utilizing the QI coach and data analyst for all of the mentoring.

Personal improvement projects (PIP). The first year, students gain experiential learning through a PIP, a hands-on introduction to QI, and a reflective practice project, a chart audit exercise where residents analyze their performance. Residents say this is one of the strongest elements in the program.

Resident leadership role. The program began with a physician champion but that proved overwhelming. Now, the program allows residents to take ownership of a small piece of a larger project.

Individualized coaching. QI coach and data analyst meetings encourage self evaluation during the program.

Scenario testing. Residents are scored on implementing their QI knowledge in a realistic pediatric scenario, standardized by experts. This was adapted for pediatrics from the adult-based Quality Improvement Knowledge Application Tool (QIKAT).

Distinctive achievement: standardizing care for NICU patients

Necrotizing enterocolitis (NEC) is a disease characterized by damage to the intestines of premature babies. The cause is not known. While analyzing its outcomes compared to other hospitals, staff members at Cincinnati Children's Hospital Medical Center's NICU noticed they had increasing rates of NEC. They began a project with the goal of decreasing the number of very low birth weight infants (VLBW) diagnosed with NEC by standardizing care with four key drivers. The effort took place in three hospitals and has now expanded to two others in the region.

The team reached its goal of reducing NEC from 0.18 (cases per 100 VLBW patient days) to 0.07 in 2014 and achieved a decrease to 0.03 in June 2015. "Earlier last year, I was giving a talk on NEC to the residents and they said, ‘Oh, we're so glad you talked about this because we have never seen a case,'" says Amy Nathan, M.D., project lead, medical director, Neonatology and Pulmonary Biology."I got a huge smile on my face—it's the dream to totally eliminate it. That hasn't happened yet. It may not happen in my lifetime but, to see a resident go through a month or two in the NICU and never see a case was a great feeling."

4 key drivers for improved feeding

Cincinnati Children's Hospital Medical Center uses these strategies to reduce the number of VLBW infants diagnosed with NEC.

Standardize feeding practices. With a standardized feeding protocol, the rates of NEC decrease, regardless of variations. "It's easy to get hung up on how we should feed small babies, but the small details are not as important as long as you're consistent," Nathan says.

Use human milk. Nathan says the literature shows human milk as the strongest link to preventing NEC. The team began using donor milk rather than formula for the babies whose mothers could not provide milk. This was the biggest expense associated with the project.

Maintain a healthy microbiome. Research has shown that bacteria may be one of the causes of NEC, as removing the intestines' natural bacteria allows "bad" bacteria to take root. One of the three NICUs piloting these drivers had a strong pharmaceutical connection and helped run the antibiotics portion of biome management.

Optimize intestinal perfusion. Lack of circulation to the intestines is the other hypothesized cause of NEC, so team members increased the amount of time before cutting the cord (allowing the baby to get more blood from the placenta) and changed some of the medication they used in an attempt to get more blood to the intestines.

Send questions or comments to magazine@childrenshospitals.org.