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Using a composite morbidity score and cultural survey to explore characteristics of high proficiency neonatal intensive care units
  1. Joseph W Kaempf1,
  2. Lian Wang1,
  3. Michael Dunn2
  1. 1Women and Children’s Services, Department of Neonatology, Providence Health System, St. Vincent Medical Center, Medical Data and Research Center, Portland, Oregon, USA
  2. 2Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
  1. Correspondence to Dr Joseph W Kaempf, Women and Children’s Services, Department of Neonatology. Providence Health System, St. Vincent Medical Center, Medical Data and Research Center, Portland, OR 97225, USA; joseph.kaempf{at}


Background Continuous quality improvement (CQI) collaboration has not eliminated the morbidity variability seen among neonatal intensive care units (NICUs). Factors other than inconstant application of potentially better practices (PBPs) might explain divergent proficiency.

Objective Measure a composite morbidity score and determine whether cultural, environmental and cognitive factors distinguish high proficiency from lower proficiency NICUs.

Design/methods Retrospective analysis using a risk-adjusted composite morbidity score (Benefit Metric) and cultural survey focusing on very low birth weight (VLBW) infants from 39 NICUs, years 2000–2014. The Benefit Metric and yearly variance from the group mean was rank-ordered by NICU. A comprehensive survey was completed by each NICU exploring whether morbidity variance correlated with CQI methodology, cultural, environmental and/or cognitive characteristics.

Results 58 272 VLBW infants were included, mean (SD) age 28.2 (3.0) weeks, birth weight 1031 (301) g. The 39 NICU groups’ Benefit Metric improved 40%, from 80 in 2000 to 112 in 2014 (P<0.001). 14 NICUs had composite morbidity scores significantly better than the group, 16 did not differ and 9 scored below the group mean. The 14 highest performing NICUs were characterised by more effective team work, superior morale, greater problem-solving expectations of providers, enhanced learning opportunities, knowledge of CQI fundamentals and more generous staffing.

Conclusion Cultural, environmental and cognitive characteristics vary among NICUs perhaps more than traditional CQI methodology and PBPs, possibly explaining the inconstancy of VLBW infant morbidity reduction efforts. High proficiency NICUs foster spirited team work and camaraderie, sustained learning opportunities and support of favourable staffing that allows problem solving and widespread involvement in CQI activities.

  • composite morbidity score
  • continued quality improvement
  • very low birth weight infants
  • potentially better practices

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  • Contributors JWK and LW had full access to the data and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: all authors. Acquisition, analysis and/or interpretation of the data: JWK and LW. Drafting of the manuscript: JWK. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: JWK and LW. Obtained funding: JWK. Administrative, technical or material support: JWK. Study supervision: JWK.

  • Funding This investigation was supported by the Providence Health and Services Foundation and Northwest Newborn Specialists PC.

  • Disclaimer The Vermont Oxford Network played no role in the design, analysis, interpretation, or reporting of this research. The views, conclusions, and opinions expressed are solely those of the authors and do not represent the Vermont Oxford Network.

  • Competing interests None declared.

  • Ethics approval The institutional review board at each participating hospital approved this investigation.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Collaborators This investigation was conducted in collaboration with multidisciplinary NICU teams from the following institutions: Asante Rogue Regional Medical Center, Medford, OR, Baylor All Saints Medical Center, Fort Worth, TX, Capital Health Medical Center, Pennington, NJ, Children’s Hospital of San Antonio, San Antonio, TX, Community Medical Center, Missoula, MT, East Tennessee Children’s Hospital, Knoxville, TN, Helen DeVos Children’s Hospital, Grand Rapids, MI, Kadlec Regional Medical Center, Richland, WA, Kapiolani Medical Center, Honolulu, HI, Legacy Randall Children’s Hospital, Portland, OR, Legacy Salmon Creek Hospital, Vancouver, WA, Lucille Packard Children’s Hospital Stanford, Palo Alto, CA, Maricopa Integrated Health System, Phoenix, AZ, Meriter Hospital, Madison, WI, Methodist Children’s Hospital of San Antonio, San Antonio, TX, Miami Valley Hospital, Dayton, OH, Minneapolis Children’s Hospital, Minneapolis, MN, North Central Baptist Hospital, San Antonio, TX, Northside Hospital, Atlanta, GA, Oregon Health Sciences University, Portland, OR, PeaceHealth Sacred Heart Hospital, Eugene, OR, Providence Alaska Medical Center, Anchorage, AK, Providence Little Company of Mary Medical Center, Torrance, CA, Providence Sacred Heart Medical Center and Children’s Hospital, Spokane, WA, Providence St. Joseph Medical Center, Burbank, CA, Providence St. Vincent Medical Center, Portland, OR, Providence Tarzana Medical Center, Los Angeles, CA, St.Barnabas Hospital, Livingston, NJ, St. Charles Medical Center, Bend, OR, St. Luke’s Hospital, Boise, ID, St. Paul Children’s Hospital, St. Paul, MN, St. Vincent Healthcare, Billings, MT, Salem Hospital, Salem, OR, Sharp Mary Birch Hospital for Women and Newborns, San Diego, CA, Swedish Medical Center, Seattle, WA, Sunnybrook Health Sciences Center, Toronto, CA, University of Michigan Hospital and Health Center, Ann Arbor, MI, University of Washington Medical Center, Seattle WA, Winnie Palmer Hospital for Women and Babies, Orlando, FL.

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