1. Neonatal Abstinence Project Medical Guidelines Committee Kentucky NAS Workgroup Amy Snell

2. The First Law of Improvement “Every system is perfectly designed to achieve exactly the results it gets.”

3. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo Aim MeasuresChanges

4. PREPARATION for a QI PROJECT 1.Obtain buy-in from leadership: Nursing: Unit Nurse Manager, Nurse Administrator Medical: Physician Champion QI: Performance Improvement/Risk Management Staff NOTE: the NAS project could serve as a QI project for the pediatric medical staff committee, or for a nursing unit project for JCAHO 2.Select Team members (5-10) who will lead the development and implementation of this project, such as:  Staff Nurses  Pharmacologist  Risk Manager  Physician Champion  APRN, PA’s  Social Worker  Clerks  Students

5. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo AIM MEASURE IDEAS/ CHANGES

6. AIM 1. What Are We Trying to Accomplish? Aim:A written statement of the accomplishments expected from this improvement effort Key components: -A general description of aim – should answer, “what are we trying to accomplish?” - Some guidance for carrying out the work and rationale -Specific target population and time period -Measurable goals

7. AIM 1. What Are We Trying to Accomplish? AIM:By July 2015, The Kentucky Perinatal Quality Collaborative will improve the care of infants with Neonatal Abstinence Syndrome through standardizing NAS Scoring and medical guidelines for treatment of NAS infants. Our measurable goals are to: Decrease average LOS by 10% for NAS admissions Decrease the number of NAS infants referred for higher level of care Decrease the number of NAS infants requiring pharmacologic treatment

8. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo AIM MEASURE IDEAS

9. MEASURES 2. How will we know that a change is an improvement? BASELINE MEASURES (Hospital Level): Each hospital should try to establish: (a)Data: total number of neonatal admissions to your unit in 2013 (1/1/13 through 12/31/13) number of inborn, number of outborn number of admissions diagnosed with NAS [ICD-9 779.5] in 2013 number of inborn, number of outborn number receiving pharmacologic tx, their avg LOS number not receiving pharmacologic tx, their avg LOS (b)Policy (c)Staff Training/Education/Competencies

10. MEASURES 2. How will we know that a change is an improvement? BASELINE MEASURES (Hospital Level): Each hospital should try to establish: (a)Data (b)Policy -Does your hospital have a written policy on NAS - Does the policy include: Screening Scoring Non-pharmacologic tx Pharmacologic tx Discharge planning for infant and mother (c) Staff Training ( for 2013) - Did education/training on NAS include nursing staff? Medical staff? - Did nursing education/training on NAS include “how to score”? Inter-rater reliability? non-pharmacologic interventions?

11. MEASURES 2. How will we know that a change is an improvement? BASELINE MEASURES (Patient Level): Web-based project data site will be provided to collect De-Identified data on each NAS infant, most likely to be entered at the time the infant is discharged. Each hospital should keep a log (if desired) or record this data at discharge for NAS infants. These Patient Level Measures become the data collected in the “DO” phase of PDSA. First 2 months of collection (before trainings) will serve as baseline data. Relevant Mother’s Information: Maternal drug use: Methadone, buprenorphine, prescribed opioids, opioids not prescribed, heroin, benzodiazepines, polysubstance, cannot determine, other Mother in supervised drug treatment plan? YES: methadone, buprenorphine, other. Includes counseling? Drug testing? Parenting classes? NO: Mother referred to tx? Tx not available? Refused tx? Social Worker/Case manager involved? (document baby’s DOL referral made) DCBS referral made (document baby’s DOL referral made)

12. MEASURES 2. How will we know that a change is an improvement? BASELINE MEASURES (Patient Level): NAS Infant’s Information: Infant’s Birth Month and Year (not DOB) DOL admitted to your facility Gestational Age at birth (completed weeks) Inborn or Outborn Detected drug exposure in infant: Methadone, buprenorphine, prescribed opioids, opioids not prescribed, heroin, benzodiazepines, polysubstance, cannot determine, other Hour of life NAS Scoring began Non-Pharmacologic Interventions started? (hour of life) Interventions used: Swaddling; Gentle handling; Disturb only on cue; quiet/dim environment; Vertical Rocking; non-nutritive sucking; massage Infant transferred to another level of care? (day of life transferred); if YES, then Highest score before transfer Total LOS at your facility

13. MEASURES 2. How will we know that a change is an improvement? BASELINE MEASURES (Patient Level): NAS Infant’s Treatment Information: Pharmacologic Treatment started : (hour of life) Medication started Criteria for starting tx [>8x2; >12 x 1, etc] Additional medication required? (hour of life started) Which medication added? Initial wean begun? (hour of life) Re-escalation required? X1 X2 X3 or more All meds discontinued (Hour of life) Med # 1 – d/c at (hour of life) – Total Dose Med # 2 – d/c at (hour of life) – Total Dose Comment (text box) If no pharm tx, record: Highest score Duration of scoring Move to dischg screens

14. MEASURES 2. How will we know that a change is an improvement? BASELINE MEASURES (Patient Level): NAS Infant’s Discharge Information: Discharge month/year Discharge day of life Discharge Disposition (parent, kinship care, non-kinship foster care, adoption, other) DCBS involved in discharge arrangements? Safety plan completed? Caregiver instructed on Safe Sleep? Has appropriate infant bed? Caregiver instructed on Abusive Head Trauma prevention? Medical Home appointment for Infant arranged? Mother continuing in treatment? If NO, is DCBS aware? Comment (text box)

15. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo AIM MEASURES IDEAS

16. What Changes Can We Make That Will Result in Improvement? Tests of Change need 2 components: 1.Change concepts (ideas): ready for use or ready to adapt to your unique environment (i.e, tool for Finnegan training, Medical Guidelines for Pharmacologic tx) (**Use results from pre-work assessment to inform what you need to change) 2.PDSA test method

17. CHANGES 3. What change can we make that will result in improvement? CHANGES WE ARE TESTING: A) Improve consistency and inter-rater reliability for Finnegan Scoring B) Improve consistency and management of infants requiring pharmacologic therapy (medical guidelines)

18. The PDSA Cycle for Learning and Improvement Act What changes are to be made? Next cycle? Plan Assess the current situation (baseline) Questions and predictions (what should we do differently) Specifics of Plan (who, what, where, when) Plan for data collection Study Complete the analysis of the data Compare data to predictions Summarize what was learned Do Carry out the plan Document problems and unexpected observations Begin analysis of the data

19. PDSA: Break it Down/Simplify… Plan Figure out how you will implement, how you collect the data to monitor changes, and what results are you predicting to happen? Do “Just do it” (i.e. do the plan) Study What did you learn? Did your prediction hold? What assumptions need revision? Do you feel NAS babies are being better managed? Act What will you do with the knowledge you learned? Will you continue to use the guidelines? Will you continue education on NAS Scoring? How will you keep from slipping back to old ways? What are your next steps for continued improvement? What do you want to do next?

20. PROPOSED NAS PROJECT TIMELINE June 2014 – begin site enrollment July 1, 2014 – Open Red Cap site for web-based data collection (begin with NAS Babies DISCHARGED on or after July 1) Late Aug/Early Sept – Train the Trainer Oct. 1, 2015 – begin project period Monthly Conference calls – all sites – successes, barriers, lessons learned Monthly data reports from Red Cap January 2015 – Analysis and Review of project’s first Quarter Data monthly calls, reports April 2015 – Analysis and Review of first 2 quarters of data monthly or q 2 month calls/reports June 2015 – Team report out at KPA/KPQC face-to-face meeting - plan second year of project, next phase to roll out

21. Additional Changes to Test/Projects For Improving NAS Care (future projects) Maximizing Non-Pharmacologic Care and Practices Reducing Stigma and improving Compassionate Care Improving Transition to Community and Follow-up Care What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo

22. Use of the PDSA Cycles Multiple cycles Phased projects Evidence Best Practice Testable Ideas Changes that Result in Improvement AP SD A P S D AP SD D S P A Data Finnegan scoring Medical guidelines Non-Pharmacologic Interventions Decrease stigma; increase mom’s tx Improve Continuity And Transition to Community care

23. What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement ActPlan StudyDo Aim MeasuresChanges