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Understanding Quality Improvement

Becoming a High Reliability NICU

All aspects of this project and this quality structure are interconnected. A big part of becoming what is known as a high reliability NICU is addressing the culture.In order for every front-line provider to deliver care according to the evidence-based protocols they need to understand the reasons why they should follow the processes and protocols. The ability to count on the front-line providers to be compliant with the protocols will depend on accountability and consistency. This accountability is the essential to developing a culture of high performance. The way I see it that the culture of a unit develops with a shared why and matures as there is consistent accountability and consistency in every provider’s behavior and compliance. It is up to the leadership and every provider to consistently champion and support this culture.

  • Culture/Vision

Quality and safety initiatives in healthcare often hide behind poorly defined terminology that seem intimidating, restrictive or controlling. However, establishing a strong quality infrastructure will increase clinical control, improve care, reduce errors and provide more freedom for the clinician to engage with patient care at the bedside. Integrating evidence-based medicine into the day-to-day clinical care of patients should be the minimum of expectation and individualized patient medical and personal needs can be addressed on top of evidence-based care. Medical management in the NICU is complex and standardizing clinical care based on evidence is daunting but possible. Reducing variation in care optimizes and elevates the quality of care and reduces the risk of medical errors. Every effort should be made to reduce the variation in care.

There is a focus on standardizing clinical management of defined diseases (such as RDS and hypoglycemia) but also focus on preventive management (reducing the risk of NEC, BPD and invasive infection).

This will give every NICU a blueprint of how to develop a strong evidence-based infrastructure and by doing this creating a process-oriented Architecture.


Most quality and safety experience and terminology has been derived from engineering, production and the aviation industry. Just imagine if there was no process at airports of checking in to get your boarding pass, checking your bags, going through TSA or boarding the plane. Also, no process for pilots to go through pre-flight check lists, check the fuel, getting the right luggage to the right plane, check in with the tower using understandable terminology and being guided to the right runway for takeoff. Imagine all the points where something could get missed and how chaotic and dangerous it would be to fly if the aviation industry did not function under strict protocols and processes. There are almost 10,000 planes in the air at any given time carrying over 1 million passengers. For each one of these 10,000 planes similar guidelines have been followed for each flight all over the world. Looking at a flight map of the world, with each one having multiple processesses, check lists and protocols you are looking at a process ecosystem.

  • Goals

Eliminate Quad IV all together because of stronger culture, shared vision and heightened awareness.


Eliminate Quad III: Probably the most destructive box in health care and leads to a lot of frustrations and unnecessary work.

Limit the time spent in Quad 1: Certain situations rightfully exist in quad 1 such as acute airway, intubation, called to resuscitation, arrythmias, chest tubes all basically events that define an ICU. However, units sometimes perceived as very chaotic frequently lack structure and tasks that should be automated are now making routine tasks become urgent such as not finding equipment, lack of order sets results in orders not being placed, delay in care and frequent and urgent requests to replace orders. In highly functional units protocols and processes will reduce the time clinicians spend in Quad I and when they do crisis resource management is practiced consistently which further mitigates the crisis mode and perception of crisis. Through competence (constant improvement projects, engaged team and simulation) the crisis period can be shortened through swift handling of the problem.


Increase time spent in quadrant II by

Standardizing care is one of many steps in streamlining the day-to-day NICU operations making it more efficient, lean and adding more value. Step back and see everything service that is provided in the NICU as a process.

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