SAFE AND HEALTHY BEGINNINGS (SHB)
2007-2008

SHB Aim | SHB Example Measures | SHB Teams | Project Design | Project Data Collection | Resources for Clinical Teams | SHB Expert Group | Project Timeline | Toolkit

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

22 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:

• Chart Review: Monthly chart reviews were conducted by clinical teams over the 5-month period for 10-20 consecutive newborn infants in the newborn nursery and at the first visit to the pediatric practice. Run charts were created for each clinical team each month.
  • Newborn Nursery Chart Review Tool
  • Newborn Nursery Chart Review Instructions
  • Primary Care Practice Chart Review Tool
  • Primary Care Practice Chart Review Instructions
• Systems Toolkit Evaluation Form: At the midpoint and endpoint of the 5-month testing period, clinical teams provided feedback on draft tools using this evaluation form.
• Care Process Inventory: During months 1, 3, and 5 of testing, teams were asked to assess existing systems for providing newborn care using this inventory.
  • Newborn Nursery Inventory
  • Primary Care Inventory
• Monthly Progress Reports: Monthly progress reports allowed clinical teams to describe specific changes and tools they have tested and rate their team's progress. They helped faculty to monitor progress and needs of practice teams.
  • Newborn Nursery Monthly Progress Report
  • Primary Care Monthly Progress Report
• Learning Session Evaluations: Standard workshop evaluations were used to determine the effectiveness of each learning session.
  • Learning Session 1 Form
  • Learning Session 2 Form

Resources for Clinical Teams

• Safe and Healthy Beginnings: A Resource Toolkit for Hospitals and Physicians' Offices (Coming Soon!)
• Aim Statement Worksheet: This worksheet assists teams in developing an aim statement for their project.
  Improvement Planning Worksheet: This worksheet helps teams refine their aim statement, identify measures relevant to their aim, clarify who is part of the improvement team, generate ideas for change, prioritize and schedule tests of change, and plan their first PDSA cycle in detail.
• Testing Schedule Form: This form is a template teams can use to develop a schedule and track changes made.
• PDSA Cycle Worksheet: This worksheet assists teams to plan and record their Plan, Do, Study, Act cycles to monitor tests of change.
• Learning Session 1 Power Point Presentations:
  • Model for Improvement
  • Hyperbilirubinemia Guidelines
  • Gaps and Successes: Breastfeeding 1
  • Gaps and Successes: Breastfeeding 2
  • Care Coordination
• Learning Session 2 Power Point Presentations:
  • Team Highlights - Loyola University Medical Center Newborn Nursery
• Team Highlights - Saint Elizabeth Regional Health Nursery (Lafayette Home Hospital-Greater Lafayette Health Services)
• Team Highlights - New York Presbyterian Well Baby Nursery
• Team Highlights - Lyndon B. Johnson Hospital Pediatric Clinic and Well Baby Nursery
• Team Highlights - Utah Valley Pediatrics
• Hyperbilirubinemia
• Breastfeeding Issues Associated with Hyperbilirubinemia
• Accelerating Improvement
  
  
• AAP Hyperbilirubinemia Guidelines: This link takes you directly to the clinical practice guideline, “Management of Hyperbilirubinemia in the Newborn Infant 35 or More Weeks of Gestation.”
• AAP Breastfeeding Web site: This Web site provides information and resources about breastfeeding, including several AAP breastfeeding initiatives.
• Center for Health Care Quality at Cincinnati Children’s Hospital Medical Center: This Web site provides resources for health care providers to make the highest-quality care a reality for children, adolescents and their families.
• Safe and Healthy Beginnings Power Point Presentation Slides: These slides, presented by Carole Lannon and Ann Stark at the conclusion of the SHB project, review the project design and preliminary results. MP3 Recording of Presentation
• The Joint Commission Speak Up Initiative: This national campaign urges patients to take a role in preventing health care errors by becoming active, involved and informed participants on the health care team. The program features brochures, posters and buttons on a variety of patient safety topics.

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

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 Cincinnati Children's Hospital Medical Center and funded by the AAP, McNeil Consumer Healthcare, and the Centers for Research and Education in Therapeutics (CERTS)