Taking Care of Patients, their Families and Each OtherThe Secret to a Successful NICU

Objectives: Discuss the implementation of best practices that

allow us to take care of patients, their families and each other; SFR environment Shared Governance Med Teams Training Leadership Rounding Bedside Shift Change Improved Breastfeeding Support

Discuss how implementing best practices has impacted the satisfaction of our NICU families and staff

About our NICU 80 bed SFR Two floors 3 multidisciplinary teams Staffing 1-3 babies/families: 1 nurse

Moved to new SFR NICU in

October

Implemented Shared

Governance

Focus Groups

Increased Accountability

Press Ganey Yearly Mean Trend

Med Teams

Training

Leadership Rounding

andPartnering with

Parents at bedside shift change

Improved Breast feeding Support

Mean 88.3

83.6

84.4

90.199.8

90.3

90.6

82

84

88

82

86

90

92

2008n=236

2009n=235

2010n=280

2011n=223

2012n=230

2013n=190

2014n=0

n = number of respondents

Old NICU

Create a family centered developmentally supportive environment

Goal for New NICU

Using Process to Drive Change Involvement of families in design Large involvement of staff in sub-

committees looking at process changes for the new NICU

Using simulation to work out the kinks Using scenarios to set expectations

Millennium Neonatology: A Building for the Future, Padbury, Taub, Bender 2010

Effect of SFR on infantOutcomes

Improved Parental Participation Increase number of parental visits Increased time spent doing infant’s care Increased time doing Kangaroo Care Increased number of opportunities to

feed infant

Millennium Neonatology: A Building for the Future, Padbury, Taub, Bender 2010

Effect on Parental Outcomes  Open Bay

(n = 151)Single Room

(n = 252)P< 

Parent SatisfactionPress Ganey NICU

Score

4.4 (0.7) 

4.9 (0.3) 

.001

Parent Stress Parent Stressor

Scale NICU

3.1 (0.8) 

2.8 (0.8) 

.001

Maternal Depression Beck Depression

Inventory

 

13.1 (9.3)

 

11.9 (8.7) ---- 

Millennium Neonatology: A Building for the Future, Padbury, Taub, Bender 2010

Parental Care

Millennium Neonatology: A Building for the Future, Padbury, Taub, Bender 2010

Benefits of Working with Shared Governance Empowers staff Bottom up vs. top down process of

implementation Buy-in because it is their project

Brainstorming with staff/Shared Governance Need to reframe the concept of family

centered care to creating partnerships with parents

Preferred providing tools for staff vs. scripting

Way to formalizing something we did already when parents came to the NICU

Focus Groups Purpose was to identify new or unknown

concerns of parents in the new SFR environment and gather suggestions for improvement from the perspective of the parent.

Two groups were formed; Newcomers < 2 weeks in the NICU Veterans 5 weeks to 6 months in the NICU

Results of the Focus Groups Opportunities included;

Supporting siblings at home and at hospital Sharing the information of the Primary RN Predicting timing of rounds Sharing the plan of care Easing the financial burden of eating at the

hospital Connecting with other parents Improving the orientation of new families

Accountability Setting expectations of staff and holding

staff accountable for their actions helps to value your best staff

Med Teams Training ObjectivesIdentify the essential elements and benefits

of teamwork

Recognize standards of service and effective communication within a team

Utilize and demonstrate teamwork, communication and service recovery strategies

p <0.01

p<0.01

Pre-Intervention 3 Months 12 Months Post-Intervention Post-Intervention

Perc

ent o

f Res

pond

ents

who

Agr

ee o

r Str

ongl

y Ag

ree

NICU: “Staff feel free to question the decisions or actions of those with more authority”

National Average

90th% Nationally

>MAX% Nationally

Med Teams Effectiveness

Leadership Rounding To connect with patients to make sure

that we are meeting their needs Provide service recovery when needed To identify/track areas requiring

improvement To connect with staff to make sure we

are meeting their needs To recognize employees for work well

done

Partnering with Parents at Bedside Shift Change“Improve the experience of care through mutually beneficial partnerships.”

Griffin, Bringing Change-of-Shift Report to the Bedside A Patient- and Family-Centered Approach, Journal of Perinatal Nursing, Vol 24, No 4, pp 348-353. 2010

Partnering with Parents supports the four core principles of Family Centered Care

“Partnering with parents is the respectful exchange of information where the nurse and the parent collaborate to develop a plan of care that encourages parent’s participation.”

Communication uses words and phrases that the patient

understands and meets their emotional needs.

Patients and families are part of the care team and participate at

the level the patient chooses.

Care for each patient is based on a customized interdisciplinary

shared care plan with patients educated, enabled and confident

to carry out their care plans.

Every care interaction is anchored in a

respectful partnership

anticipating and responding to

patient and family needs

Institute for Healthcare Improvement, Driver Diagram: Improving the Patient Experience of Inpatient Care, 90-Day Project Team (October 2008)

Partnering with Parents will improve our compliance with the new JCAHO patient safety goals of;

Improving the effectiveness of communication among caregivers

Encouraging patients’ active involvement in their own care as a patient safety strategy

The Joint Commission. National Patient Safety Goals. www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals. Accessed April 23, 2010

Partnering with Patients has been shown to improve patient care by; Decreasing adverse events and medication

errors Increasing the patient’s adherence to care

plan Decreasing re-admissions Decreasing the number of days on ventilator

Institute of Medicine. Crossing the Quality Chasm: A New Health System for the Twenty-first Century. Washington, DC: National Academies Press; 2001

What’s in it for me? Benefits for staff! 1. Having parents that are less anxious and

therefore less needy.2. Decreasing the risk of medication error

and adverse events by using parents as a double check.

3. Decrease risk of litigation.4. Having parents that are engaged in

reaching their care goal, a goal that has been mutually agreed upon.

5. Having parents help facilitate their own discharge process.

Partnering helps to meet our needs of NICU parents1. For accurate information and inclusion in

the infant’s care and decision making2. To be vigilant and to watch over and

protect the infant3. For contact with the infant4. To be positively perceived by the nursery

staff5. For individualized care6. For a therapeutic relationship with the

nursing staff

Cleavland, Parenting in the Neonatal Intensive Care Unit, JOGNN, Vol 37, Issue 6, pp 666-691, 2008

Seeing the process in action… on a field trip White boards helped to guide patient

participation in nursing rounds White boards were a great way to audit for

accountability Setting expectations was critical to success Auditing with friendly reminders helped to

get everyone on board Scripting…

Improved Breastfeeding SupportInstead of focusing on the volume of milk a mom pumps

and that a baby is gets at breast we need to focus on;

1. Giving mom the tools she needs to establish a robust milk supply.

2. Encouraging mom to practice milk transfer (movement of milk from breast into baby)

3. Bolstering maternal confidence

Pediatrics Vol. 107 No. 3 March 1, 2001 pp. 543 -548The timing and predictors of early termination of breastfeedingIO Ertem, N Votto, JM Leventhal

Six Steps to Successful Breastfeeding in the NICU

1. Establish and maintain a robust milk supply

2. Provide frequent Kangaroo Care

3. Provide Kangaroo Care while infant is tube fed

4. Allow infant to nuzzle or play at the breast during Kangaroo Care

5. Allow infant to begin to snack and breastfeed when ready

6. Prepare mom and baby for breastfeeding after discharge

Overcoming Challenges Consistency of the message “taking care

of babies, families and each other” Working with staff to craft the model Working to get buy-in from the medical

team Explaining why change is mission critical Making practice changes expectations

and holding staff accountable

“Family Centered Care is less a destination than a journey.” Implementing Potentially Better

Practices for Improving Family Centered Care in Neonatal intensive Care Units: Successes and Challenges Cisneros Moore et al, PEDIATRICS, Vol. 111,No. Supplement E1 April 2003, pp.e450-e460