Welcome! Neonatal Abstinence

Syndrome Project

November Action Period Call

Ohio Perinatal Quality Collaborative November 17, 2016

Welcome to the OPQC NAS November 2016 Action Period Call

Thank you for joining; please sign in the chat box with the names of all webinar participants and hospital affiliation.

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3

Time Topic Presenter12:00 pm Welcome & Agenda Review Susan Ford, MSN, RN

12:05 pm Data Overview Rick McClead, MD

12:15 pm Sustainability: do you have a plan??

Presenting your site’s participation in the OPQC NAS Collaborative Project

Susan Ford

12:40 pm Team Discussion All Teams

12:50 pm Next Steps Susan Ford

Agenda

REMEMBER:You can use *6to come off of GROUP MUTE

Key Driver DiagramProject Name: OPQC Neonatal NAS Leader: Walsh

SMART AIM

KEY DRIVERS INTERVENTIONS

By increasing identification of and

compassionate withdrawal treatment for full-term infants born with

Neonatal Abstinence Syndrome (NAS), we will

reduce length of stay by 1 day across participating sites by June 30, 2016.

Improve recognition and non-judgmental support for Narcotic

addicted women and infants

Connect with outpatient support and treatment program prior to

discharge

Standardize NAS Treatment Protocol

Optimize Non-Pharmacologic Rx Bundle

Initiate Rx If NAS score > 8 twice. Stabilization/ Escalation Phase Wean when stable for 48 hrs by 10%

daily.

Swaddling, low stimulation. Encourage kangaroo care Feed on demand- MBM if appropriate

or lactose free, 22 cal formula

All MD and RN staff to view “Nurture the Mother- Nurture the Child”

Monthly education on addiction care

Attain high reliability in NAS scoring by nursing staff

Partner with Families to Establish Safety Plan for Infant

• Fulltime RN staff at Level 2 and 3 to complete D’Apolito NAS scoring training video and achieve 90% reliability.

Establish agreement with outpatient program and/or Mental Health

Utilize Early Intervention Services

Collaborate with DHS/ CPS to ensure infant safety.

Prenatal Identification of MomImplement Optimal Med Rx Program

Engage families in Safety Planning. Partner with other stakeholders to influence policy and primary

prevention. Provide primary prevention materials to sites.

To reduce the number of moms and babies with narcotic exposure, and

reduce the need for treatment of NAS.

GLOBAL AIM

Sustainability

• IHI Getting Started Kit: Sustainability and Spread How-to Guide

• http://www.ihi.org/resources/Pages/Tools/HowtoGuideSustainabilitySpread.aspx

Creating a new system

Improvement

Hold GainsTest Implement

I. During testing

II. During implementation

III. After implementation

What is your team’s status?Are you ready to hold the gains?

What if your entire project team decided to retire by December 31, 2016?

Would the changes you’ve made continue to be used? What could make your organization revert to the old system?

Sliding back to the old systemOld System New System

• “We met our goals”• “We assumed the improvement would hold”• Other priorities took all resources away

(not on senior management’s radar screen)• Did not learn how to hold the gains• Infrastructure not in place

Keys to Holding the Gains

Communication

Infrastructure

Design effective ‘control’ system

Data

Communication

• Make clear to all stakeholders the Aim, successes, learnings, and benefits

• Document what you’ve done

• Keep in contact

Infrastructure• Address training and development of new skills

• Make changes to job descriptions, policies, and procedures

• Assign ownership for improvement and maintenance work of the new process

• Senior leaders held responsible for the efforts to sustain the change and remove inhibitors that might allow slippage back to the old system

• Standardize crucial steps in the new process

• Clarify individual responsibility/authority

• Design training for new employees

• Define some “simple rules” to guide the practice

• Build in Structures to “Foolproof” Change – In each of the intervention areas, the organization builds structures

(e.g., IT systems, packaged materials that support a given intervention) that make it difficult—if not impossible—for providers of care to revert to old ways of doing things.

– Speaks to our work with High Reliability!

Design an Effective “Control” System

Data• Use periodic self audits to verify practices

are being followed

1.) Ongoing Finnegan Scoring inter-rater reliability

2.) Review/audit of pharmacological bundle compliance (or non-pharmacological bundle compliance)

Are you ready to “Hold the Gains”?• Was your collaborative team successful?

• Is it your team’s intention to hold the gains?

• Is it an organizational priority?

• Is the leadership responsibility clear?

• Is the appropriate infrastructure in place?

• Do you plan to attend to measures?– Will there be ongoing measurement?– Will you ensure reliability by identifying

and understanding ‘failures’?

Follow up survey: IHI Breakthrough Series participants

• Question: Why do you believe you have maintained performance levels?

Top 3 responses:– Ongoing measurement

(keep reviewing your data!!)– Leadership involvement– Continued use of improvement methods

(continuous quality improvement)

IHI Survey of Successful Teams

Question % yesAre you still tracking your performance? 85%

Is there periodic reporting to leadership regarding performance?

88%

Were other residual benefits gained in the improvement process that took hold?

91%

Do you and your colleagues continue to use improvement methodology in your work?

91%

IHI Survey of Successful Teams

Question % yesDid the team begin to plan how to sustain its progress early on in the improvement process?

78%

Did you document the improvement process? 81%

Did you document the process of holding performance at your new level?

66%

Was a financial return on investment tied to the improvement that occurred?

16%

Has the team taken specific action in order to make the improvement process more permanent?

70%

Through collaborative use of improvement science methods, reduce preterm births & improve perinatal and preterm newborn outcomes in Ohio as quickly as possible.

Your Hospital Name here

Ohio Perinatal Quality Collaborative

Neonatal Abstinence Syndrome Project

Neonatal Abstinence Syndrome (NAS)• It is estimated that one infant is born exposed to maternal in-utero narcotic abuse

every hour in the United States. The NAS epidemic is steadily increasing, overwhelming social service systems and public payers.

• Treating newborns impacted by NAS was associated with nearly $100 million in healthcare expenses and almost 25,000 days in Ohio hospitals in 2013, according to data from the Ohio Hospital Association.

• The OPQC NAS initiative was begun to reduce variation in identification and treatment and to optimize the care of infants with NAS across Ohio.

• During the first phase of improvement work (2014-2015), 54 OPQC NAS site teams participated in adapting the Ohio Children’s Hospital Association (OCHA) care bundles, emphasizing compassionate care of infants and mothers, and standardizing both identification of affected infants and use of non-pharmacologic and pharmacologic care practices. In phase-2 of the project (2015-2016) OPQC teams participated in one of four formula groupings to better identify what works

best to improve non-pharmacologic support for infants with antenatal opiate exposure.

NAS Statewide Rate per 10k

14 19 21 25

3350

70

88

108121

134

0

20

40

60

80

100

120

140

160

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Rat

e pe

r 10,

000

Year

Source: Ohio Hospital Association

Promedica Toledo Children’s & ProMedica

Toledo - Normal Newborn

Miami Valley

Mercy Anderson

Aultman

Mt. Carmel EastOSU

UH Rainbow Babies & Children’s

Bethesda North Hospital

Nationwide Dublin Methodist

Akron Children’s Summa

Cincinnati Children’s

Hillcrest HospitalFairview Hospital

ClevelandClinic

Dayton Children’s

NationwideRiverside Methodist

Nationwide Grant

Nationwide Mt. Carmel St. Ann’s

UH Cincinnati

Good Samaritan Hospital

MetroHealth

Mt. Carmel WestNationwide Doctor’s

Akron Children’s

NationwideChildren’s

Mercy Children’s Hospital

Atrium Medical CenterFort Hamilton

Mercy Hospital Fairfield

Mercy Medical Center Canton

The Christ Hospital

St. Rita’sMedical Center

Southview Medical Center

Good Samaritan Hospital Dayton

Kettering

Mercy Health West

Southern Ohio Medical Center

Genesis Healthcare System

Marion General

Elyria Medical Center -UH

Mercy Regional Medical Center Lorain

ProMedica Bay Park

Lima Memorial Health System

Springfield RegionalMedical Center

Adena Regional

Medical Center

Soin Medical Center

Upper Valley Medical Center

Licking Memorial Health System

NAS Participating Sites

1/2014 start Level 3 and Level 2 teams

Akron Children’s St. Elizabeth

Health Center/Mahoning

Valley

Trumbull Memorial

4/2014 start Level 2 teams

Move circle over your hospital

Improve recognition and non-judgmental support for narcotic-addicted women and infants

Attitude Measures Survey:• To what extent are adverse life circumstances likely to be responsible for a person's

problematic drug use?

• To what extent is an individual personally responsible for their problematic drug use?

• To what extent do you feel angry towards people using drugs?

• To what extent do you feel disappointed towards people using drugs?

• To what extent do you feel sympathetic towards people using drugs?

• To what extent do you feel concerned towards people using drugs?

• To what extent do people who use drugs deserve the same level of medical care as people who don't use drugs?

Improve recognition and non-judgmental support for narcotic-addicted women and infants

Your Hospital Name

Optimize non-pharmacologic prescription bundle

Aggregate: 40% breast fed Your Hospital Name: %

• Add your site specific graph here.

• https://portal.opqc.net/NAS/SitePages/Home.aspx

Standardize NAS treatment protocol:% of infants that receive pharm tx

Aggregate: median 40.8% Your Hospital Name: %

• Add your site specific graph here.

• https://portal.opqc.net/NAS/SitePages/Home.aspx

Standardize NAS treatment protocol:length of treatment (LOT)

Aggregate: median 14.8 days Your Hospital Name: %

• Add your site specific graph here.

• https://portal.opqc.net/NAS/SitePages/Home.aspx

Standardize NAS treatment protocol:Length of Stay (LOS)

Aggregate: median 19.5 days Your Hospital Name

• Add your site specific graph here.

• https://portal.opqc.net/NAS/SitePages/Home.aspx

Connect with outpatient support and treatment program prior to discharge

Highlight your work/outreach to regional outpatient support agency. This was included in the January 2105 Learning Session Storyboard.

Your Site NamePDSA Ramp

Hunches Theories

Ideas

Changes That Result in

Improvement

A PS D

A PS D

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

Detail your team’s PDSAs

Next Steps

• Please continue to submit all NAS Data using the current Data Collection Form for all babies (non pharm & pharm tx) thru December 31, 2106.

• There will be a new Data Collection Form for NAS Sustain Phase (starts 1/1/17). This will be reviewed on December’s Action Period Calls.

• December Action Period Calls: – Tuesday, December 13th from 3pm -4pm– Thursday, December 15th from 12N-1pm

The OPQC NAS Project is funded by The Ohio

Department of Medicaid