Patient Safety and Quality Improvement

Patient Safety and Quality Improvement. The facility must have a documented and approved Neonatal PI Plan. The Chief Executive Officer, Chief Medical Officer (or Chief of Staff), and Chief Nursing Officer must implement a culture of safety for the facility and ensure adequate resources are allocated to support a concurrent, data-driven Neonatal PI Plan. 1. The facility will have a system for identification and review of significant events that could indicate threats to patient safety, with a goal of learning from identified events and mitigating future risk of recurrence, including: a. A list of specific triggers or safety indicators that warrant a record review, with the goal of identifying significant safety events such as errors, adverse events, near misses, complications, and mortalities; b. A process for systematic multidisciplinary review of selected cases or safety events, using acceptable failure mode and effect analysis tools with a goal of identifying interventions to improve systems and reduce future safety risks; and c. A process for monitoring the implementation of identified interventions. 2. The facility will have a dashboard or equivalent that is used to summarize and track quality indicators relevant to newborn care, including: a. A list of selected quality measures relevant to the facility with a process for obtaining data needed for each selected neonatal quality measure; b. A platform to display performance on the selected quality measures, including a process for updating data with a frequency that allows for appropriate identification of performance concerns; c. Benchmarking of performance, when possible, with internal or external benchmarks; and d. A multidisciplinary forum for review of the dashboard or equivalent. 3. The facility will have a structured approach to quality improvement (QI) that seeks to improve care quality and outcomes. Quality outcomes include care that is safe, efficient, effective, timely, equitable, and patient centered. Approaches will include: a. A clear process for determining current QI initiatives, with a goal that the unit is engaged in at least 1 to 2 such initiatives at any given time; b. Identification of a multidisciplinary QI team for each initiative, with a designated team lead; c. Use of structured improvement methods or framework to guide improvement efforts; and d. A multidisciplinary quality committee that meets regularly to identify and review QI initiatives. 4. The facility will maximize efforts to standardize and improve care through the use of guidelines and policies that align with research-driven and evidence-based best practices, including: a. A process for identifying topics for guideline or policy development; b. A process for developing guidelines and policies that incorporate evidence- based recommendations; c. A platform for making guidelines and policies readily available to clinical providers; and d. A process for periodic review of guidelines and policies to guarantee they remain updated, and evidence based. 5. The facility will have multidisciplinary involvement in quality and safety activities, including: a. Involvement of all disciplines represented in the neonatal quality and safety activities as appropriate and as described above; and b. For level IV facilities, involvement of subspecialty services with significant presence in the neonatal unit. 6. The neonatal-specific unit will coordinate with hospital quality and safety activities, including: a. Structured collaboration with the obstetrics and pediatric surgery departments, if applicable, to identify and implement opportunities for shared quality and safety efforts; b. Participation in hospital-level quality and safety activities to confirm alignment of neonatal quality goals with hospital priorities; c. Alignment with hospital activities and reporting of quality measures to national organizations; and d. Participation in efforts to guarantee everyday readiness for external assessments by regulatory organizations. 7. The facility will participate in larger communities of perinatal safety and quality, including: a. Collaboration between transferring and receiving hospitals to examine and improve population-level quality and safety through structured activities such as transport review and sharing of clinical protocols; and b. For level III and IV facilities, participation in regional, state, or national databases that allows benchmarking of performance. 1. The Neonatal Medical Director (NMD) must have the authority to make referrals for peer review, receive feedback from the peer review process, and ensure neonatal physician representation in the peer review process for neonatal cases. 2. The facility must have documented evidence of neonatal PI summary reports reviewed and reported by Perinatal Multidisciplinary Committee that monitor and ensure the provision of services or procedures through telehealth and telemedicine, if utilized, is in accordance with the standards of care applicable to the provision of the same service or procedure in an in-person setting. 3. The facility must have documented evidence of neonatal PI summary reports to support that aggregate neonatal data are consistently reviewed to identify developing trends, opportunities for improvement, and necessary corrective actions. Summary reports must be provided through the Perinatal Multidisciplinary Committee, available for site surveyors, and submitted to the Department as requested.