Evaluating the Processes of Neonatal Intensive Care: Thinking Upstream to Improve Downstream Outcomes

Evaluating the Processes of Neonatal Intensive Care......Page 1
Evaluating the Processes of Neonatal Intensive Care......Page 3
Contents......Page 5
Preface......Page 7
References......Page 9
Work standards......Page 11
Probing the variation among providers; “drilling down” in our work......Page 12
What is quality?......Page 13
How we will approach quality improvement?......Page 14
Lessons from Japan about quality and cost......Page 15
A view of the work of the NICU......Page 17
The plan of this book......Page 18
References......Page 19
Thinking about interrelationships......Page 23
Systems......Page 24
System aims......Page 25
How do we know we are meeting our aims?......Page 26
Work as a system......Page 27
Interrelationships within a system......Page 28
System boundaries and system perspectives......Page 29
Key ideas about systems from Senge’s rules of the “fifth discipline”......Page 30
References......Page 32
Processes: general understanding......Page 33
Process mapping......Page 34
Analyzing a process map......Page 36
Customers......Page 37
Customer knowledge......Page 38
Matching the service with the customer need......Page 39
Suppliers......Page 40
Vision: seeing the bigger picture......Page 41
References......Page 42
A process for identifying and treating acute pneumothorax......Page 43
Further suggestions by NICU staff for improvement......Page 45
If process ownership is not assigned, there may be no real process......Page 46
Mudaand some assumptions about efficiency and waste......Page 48
Ideas for where to begin looking for mudain the NICU......Page 49
Ideas for reducing muda......Page 50
References......Page 53
A Bayesian search for muda in diagnostic testing......Page 54
Maybe this way is more intuitive......Page 57
To evaluate the results of a diagnostic test we need specific disease knowledge......Page 59
Overtreating: a plea for locally determined test characteristics......Page 60
The receiver operating characteristic (ROC) curve: diagnostic tests and categorical discrimination......Page 61
References......Page 63
How needless complexity compounds to undermine process reliability......Page 64
Reference......Page 66
Reiterative tests of change: the PDCA cycle......Page 67
Cause and effect diagram: formulating a “differential diagnosis” for an outcome......Page 69
Pareto charting......Page 72
The run chart: preserving the time dimension......Page 75
References......Page 76
Toward an operational definition of “outcomes research”......Page 81
What do we want to measure? Well, what question are we asking?......Page 83
The clinical value compass and NICU outcomes......Page 84
Tips for creating variables to measure......Page 86
Investigative perspective and outcome interpretation......Page 88
Measuring variables: how?......Page 89
Understanding relationships among variables and comparing data from different NICUs (systems)......Page 91
References......Page 93
Filtering data: appropriate responses v tampering......Page 94
Decision rules for filtering data: what are we assuming?......Page 95
Control charting......Page 96
Control charting informs process improvement work......Page 97
Characterizing the variation......Page 98
A clinical example: patient temperature measurement values......Page 99
Berwick’s temperatures: XmR method......Page 100
Signal detection rules......Page 102
References......Page 104
What does a telephone manufacturing plant have in common with a hospital? (after Berwick1)......Page 105
SPC to help understand NICU data: an example......Page 106
Creating a control chart without using a computer......Page 109
Evaluating control limits......Page 111
Analytic statistics, enumerative statistics, and comparing results among NICUs......Page 112
Recapping......Page 113
References......Page 114
A benchmarking story......Page 117
The limitations of local knowledge......Page 118
Benchmarking does improve health care outcomes......Page 120
Benchmarking for improving our work and meeting our patients’ expectations......Page 121
John Wennberg’s key questions for health care......Page 122
References......Page 123
An instrument panel display: what and why......Page 125
To prepare an instrument panel display......Page 126
An example of a first-iteration display......Page 128
Relating the checklist for guiding instrument panel creation with the illustrative display......Page 129
Accuracy and completeness......Page 131
References......Page 134
People underlie improvement work......Page 135
Motivating people at work......Page 136
Tying it all together......Page 137
Implementing change......Page 138
Personalities and innovation......Page 139
Tactics for engaging people with an innovation......Page 141
Conceptual drift: re-invention......Page 142
Leadership......Page 143
References......Page 145
Where have we arrived?......Page 146
Systems thinking......Page 147
Where to go from here?......Page 148
References......Page 150
Appendix......Page 151
Appendix: A checklist for thinking about NICU outcomes research......Page 153
Reference......Page 155
Index......Page 156