implementation and case-study results of potentially...

SUPPLEMENT ARTICLE

Implementation and Case-Study Results ofPotentially Better Practices to Improve the DischargeProcess in the Neonatal Intensive Care UnitMarla M. Mills, RN, CNPa, Debra C. Sims, RNCb, Jack Jacob, MDc

aNeonatal Intensive Care Unit, University of Minnesota Children’s Hospital, Fairview, Minneapolis, Minnesota; bNeonatal Intensive Care Unit and cAlaska Neonatology/Pediatrix Medical Group, The Children’s Hospital at Providence, Anchorage, Alaska

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT

OBJECTIVE. The objective of this study was to implement potentially better practicesfor discharge planning in the NICU.

METHODS.Each participating hospital completed a self-assessment tool on dischargeplanning and a staff satisfaction survey. Parent satisfaction data were obtainedfrom an Internet-based survey. Many projects regarding discharge planning werecompleted at each participating center. A major emphasis was the development oftransition points to span discharge planning over the entire hospitalization. Resultsof compliance with tasks or processes that were identified by the transition pointsand results of staff and parent satisfaction surveys were monitored over time.

RESULTS. The implementation of the transition points at each center demonstrated animprovement in the completion of discharge tasks within the recommended timeframe. Combined results of all centers demonstrated a moderate improvement incompliance with transition points from baseline to final measurement in thefollowing areas: unit orientation (56%–81%), identification of a parent feedingplan (74%–92%), completion of cardiopulmonary resuscitation training (55%–72%), and car seat education (42%–63%). Staff survey results showed improve-ment from baseline to final measurement in the following areas: staff satisfactionwith the discharge process (32%–50%), clear documentation of the discharge plan(26%–40%), and clarity of team members’ roles in the discharge process (24%–44%). A resource kit on discharge planning was developed for staff and includeda section with parent education material. An Internet-based parent satisfactionsurvey was implemented successfully.

CONCLUSIONS.All centers that participated in the collaborative made significantstrides in the discharge planning process. Overall, parent satisfaction with dis-charge planning was high, and improvements were noted in staff satisfaction andavailability of resource material.

www.pediatrics.org/cgi/doi/10.1542/peds.2006-0913I

doi:10.1542/peds.2006-0913I

KeyWordsdischarge planning, potentially betterpractice, neonatal intensive care

AbbreviationsVON—Vermont Oxford NetworkPBP—potentially better practicePDSA—plan-do-study-actNPLH—No Place Like HomeEI—early intervention

Accepted for publication Jul 18, 2006

Address correspondence to Marla Mills, RNCNP, University of Minnesota Children’sHospital, Fairview, 2450 Riverside Ave,Minneapolis, MN 55455. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005;Online, 1098-4275). Copyright © 2006 by theAmerican Academy of Pediatrics

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THE TRANSITION FROM hospital to home for families ofan infant who has been in the NICU can be chal-

lenging. Comprehensive discharge planning can have apositive effect on the family’s transition to home. Anuncoordinated discharge can result in families’ beingunprepared to go home. The 6 hospitals in the VermontOxford Discharge Planning Collaborative (named the NoPlace Like Home group [NPLH]) had an overall aim tocreate a successful discharge planning process that spansthe NICU stay to the next level of care and a goal toembed discharge planning into all aspects of patient careand communication. The centers participating in thiscollaborative include Mission St Joseph’s Hospital, Ash-ville, NC; Rockford Memorial Hospital, Rockford, IL; StJohn’s Hospital and Medical Center, Detroit, MI; TheChildren’s Hospital at Providence, Anchorage, AK; Uni-versity of Minnesota Children’s Hospital, Fairview, Min-neapolis, MN; and Yakima Valley Memorial Hospital,Yakama, WA.

The group developed and implemented 5 potentiallybetter practices (PBPs) in the area of discharge planning.The practices were developed through expert advice,literature review, internal benchmarking, discussion,and group agreement. Implementation of practices oc-curred through a variety of projects that affect all aspectsof care in the NICU. Some of these projects took place atall participating centers, and some projects were centerspecific.

The following PBPs were focused on for dischargeplanning:

1. Create an easy-to-use, easy-to-access discharge plan-ning tool kit.

2. Restructure interdisciplinary oral and written com-munication tools and processes to reflect a “plan forthe day, the stay, and the way” to discharge.

3. Maximize the impact and use of caregiver educationaltools, and update materials and delivery systems forcaregiver education.

4. Use various continuous quality improvement toolsand processes to ensure parent/caregiver and staffsatisfaction.

5. Analyze and enhance interactions with and transfersinto the community (M. Hill, RN, MS, CMAC, un-published data, September 2002).

METHODSAfter achievement of consensus on the PBPs for dis-charge planning, the focus of the group turned to theimplementation of these PBPs. The results of the self-assessment and staff survey identified areas on whichthe collaborative and individual centers could focus toimprove the discharge process, and common needs wereidentified. All centers worked on staff satisfaction, par-

ent satisfaction, transition point tools, and parent edu-cation.

Individual centers worked on additional projects inthe areas that often provided ideas for improvements inother centers. Implementation of the PBPs for dischargeplanning affected documentation, interdisciplinary com-munication, parent education, timing of care provided,and family involvement in care. Many projects werecompleted as rapid-cycle projects based on the plan-do-study-act (PDSA) format.1 Most of the centers imple-mented areas of discharge planning in small, sequencedsteps. Semiannual meetings, monthly conference calls,and a listserv allowed the group to work on multipleprojects and review individual center projects. Throughsharing of ideas and progress, other centers gained newinsights on current projects and ideas for new projects.Some common indicators were agreed on to measureprogress in the areas of staff satisfaction, parent satisfac-tion, and compliance with transition points. Each centerdetermined its own format and implementation for rap-id-cycle projects on the basis of its own needs. Resultsfrom each center were shared with staff, and new rapid-cycle projects developed. Combined results from all cen-ters were tabulated to measure the progress of the col-laborative in the areas of parent satisfaction, staffsatisfaction, and transition points. Results were pre-sented as percentages, in a format that was consistentwith “simple, practical measurement” for rapid-cycleprojects.1

RESULTS

PBB 1: Create an Easy-to-Use Easy-to-Access DischargePlanning Tool KitAll units identified the need to coordinate dischargeteaching and planning so that it occurs throughout thehospitalization and does not overwhelm parents andstaff at the end of the hospital stay. The group was ableto identify and agree on several key transition pointsthat are reflective of the patient’s physiologic statusthroughout the hospitalization. Each center imple-mented the transition points in a way that worked bestin their unit. Centers developed a transition point tool toincorporate the points into their plan of care and docu-mentation.

The goal was to spread tasks in the discharge processover the hospitalization and eliminate the last day rush.Each participating hospital monitored the discharge pro-cess before implementation of the transition points andreassessed practice at 3- and 9-month intervals. A sum-mary of the compliance for completion of discharge taskswithin the transition point time frame is provided inTable 1 (all centers’ data combined) with ranges noted. Agoal of 85% compliance for completion of transitionpoints within the appropriate time frame was deter-mined. A moderate improvement was noted in compli-

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ance with transition points from the beginning of theproject to final measurement in the areas of unit orien-tation (56%–81%), identification of a feeding plan byparents (74%–92%), completion of cardiopulmonary re-suscitation training (55%–72%), and car seat education(42%–63%).

The implementation of the transition points at eachcenter was different. Mission Hospitals emphasizedteamwork and embedding discharge teaching into everyaspect of care. They chose not to change any forms butemphasized oral and written communication among alldisciplines. University of Minnesota Children’s Hospital,Fairview, developed a new discharge kardex with a goalto provide documentation in 1 location that is accessibleto all team members. Children’s Hospital at Providencedeveloped a transition point checklist that was used as areminder at the bedside for disciplines to complete.Through the “study” phase of multiple PDSA cycles,Children’s Hospital at Providence incorporated thechecklist as a permanent record into the education por-tion of the unit care plan. Yakima Valley Memorial Hos-pital revised a 2-page document that is used by all thedisciplines that are involved in the care of the infant andthe family and that incorporated the transition pointformat. After several revisions, staff used the form moreconsistently, duplication of documentation has de-creased, and satisfaction with the overall discharge pro-cess has improved. Rockford Memorial Hospital chose toimplement the transition point checklist with the goalsto have it become a permanent chart record and incor-porate the checklist into the interdisciplinary plan of careand education record. Documentation has improvedsteadily, and staff rely on the checklist as a communica-tion tool.

Each center identified other opportunities for im-provement. For example, University of Minnesota Chil-

dren’s Hospital, Fairview, developed a parent letter thatlists their responsibilities under each of the major tran-sition points. Yakima Valley Memorial Hospital hasworked further on modifying the parent letter for use intheir unit. University of Minnesota Children’s Hospital,Fairview, identified feeding management close to dis-charge as problematic and developed cue-based feedingguidelines to promote the infant’s ability to self-regulatehis or her oral intake and advance feedings on the basisof readiness cues. In cue-based feedings, infants are fedorally when readiness cues are present but fed by gavageas needed to maintain an adequate intake. The initialproject involved healthy, bottle-feeding preterm infantsbut has since expanded to include breastfeeding infants,infants with chronic health problems, and term infants.

Another challenging area that was identified by Uni-versity of Minnesota Children’s Hospital, Fairview, washow discharges late in the day resulted in increasedstaffing needs, limited additional admissions, and familyfrustration with a late discharge. A discharge time of11:00 AM was established so that families and staff couldplan and be ready to leave in a timely manner. Having aset discharge time allows for the cleaning of rooms,assignment revisions for the next shift, and acceptingnew admissions. The earlier discharge allows families toarrive home and settle in during the day. The percentageof discharges that occur before 11:00 AM has increasedfrom 30% to 73%.

PBP 2: Restructure Interdisciplinary Oral andWrittenCommunication and Processes to Reflect Plans for the Day, theStay, and theWay to DischargeMultiple formats are used to report and record the pa-tient’s progress and to plan care during the hospitaliza-tion, including daily or twice-daily medical rounds;nursing shift report; and various forms of interdiscipli-

TABLE 1 Compliance With Transition Points: Information for All Centers

Transition Point Baseline, % January 2004, % July 2004, %

By 1 wk after admissionUnit orientation 56 (22–85) 72 (46–92) 81 (73–95)Psychosocial assessment 72 (42–100) 77 (69–100) 83 (58–100)Metabolic screening 95a (88–100) 93a (81–100) 95a (90–100)Parent feeding plan identified 74 (50–100) 84 (57–100) 92a (85–100)

During level II care but at least 72 h from dischargeCPR training 55 (33–75) 70 (48–89) 72 (42–82)Hearing screening 71 (39–94) 70 (35–96) 79 (41–90)Back to Sleep education 60 (40–94) 60 (27–100) 67 (55–100)Primary doctor identified 92a (84–100) 86a (68–100) 82 (64–92)Car seat education and testing 42 (4–94) 51 (42–96) 63 (35–100)

Within 1–3 d before dischargeDischarge medication education/prescriptions 59 (38–91) 70 (39–100) 59 (25–100)Follow-up appointments 63 (29–91) 67 (39–100) 59 (45–95)Immunization education 88a (75–94) 83 (50–100) 90a (89–100)Home feeding plan 86a (70–100) 83 (65–100) 81 (61–100)Parent satisfaction survey 50 (41–60) 29 (23–36) 46 (29–56)

CPR indicates cardiopulmonary resuscitation. Ranges are from all centers.a Goal of 85% compliance was met.


nary rounds with documentation occurring on papercharts, computerized formats, and checklists. Each unithas its own system for verbal reporting and writtendocumentation.

Discharge planning can and should be incorporatedinto daily medical rounds, nursing reports, and writtendocumentation. However, this type of system may resultin fragmentation of documentation because dischargeplanning may not consistently be part of the focus of thedaily plan. Parent involvement in rounds or care confer-ences also is different for each hospital. Scheduled inter-disciplinary rounds have been identified in the literatureas helpful in discharge planning.2

Mission Hospitals revamped multidisciplinary roundsto meet better the needs of the team members. Theresults of a survey of team members who participated inrounds demonstrated that the members wanted to focuson infants who would be discharged within 1 week andadhere to a time limit of �1 hour per session. The teamleader reviews the following for each infant who is an-ticipated to be within 1 week of discharge: projected dayof discharge, home equipment and medication, homehealth needs, home feeding plan, screening needs (eg,car seat trial; hearing, developmental, or feeding assess-ment), identification of a pediatrician, and necessaryfollow-up. The change in format seems to have had apositive impact on the completion of discharge tasks atthe appropriate transition points and length of stay.

Children’s Hospital at Providence had a long-standingtradition of weekly walk-about interdisciplinary grandrounds that were disruptive for the unit and ineffectivefor many members. A work group met and determinedthat rounds should provide a clear clinical picture, in-volve all team members, coordinate discharge with thebest possible outcome for the infant and the family, andsupport transition to home and community.

The process and format were changed so that multi-disciplinary rounds now occur outside the unit, in aconference room, and are structured to review patientswho are at a transition point of 50% oral feedings andpatients with significant medical, social, or ethical issues.Staff nurses are present when their patient is on the list,and the case is presented briefly and includes a round-table presentation from all disciplines, with discussiontime limited to 10 minutes, and notes or plans are re-corded on the medical chart. The change has been pos-itive for most members. Measurements occur periodi-cally to sustain the gain and ensure that the changeremains positive.

PBP 3: Maximize the Impact and Use of Caregiver EducationToolsParent education is 1 of the critical components of dis-charge planning. Providing parents with the knowledge,skills, and resources to care for their infant after dis-charge remains 1 of the cornerstones of discharge plan-

ning. Discharge teaching must be individualized to meetthe learning needs and styles of different families.3 Dis-charge teaching includes both general and very special-ized teaching. The NPLH group developed written ma-terial for teaching several topics.

A list of parent education topics was developed anddivided among the group with each center responsiblefor development or revision of its assigned topics. Os-chner and Ross Laboratories developed an NICU InfantBook for use by parents and nurses.4,5 Many of the topicsincluded in this book have been revised with permission.The updated material was available to all participatingcenters by the listserv and in a resource kit that wasdistributed at a Vermont Oxford Network (VON) collab-orative meeting (VON, NPLH resource kit [unpublisheddata], October 2003). Because many families have In-ternet access during the hospitalization of their infant,6 alist of Internet resources for families was developed.

Rockford Memorial Hospital uses several pamphletsand instruction sheets as parent education tools. Thenurses noted that they were collecting and distributingthe same materials for every family and suggested thatall materials be combined into a folder for distributionshortly after admission. Several PDSA cycles were com-pleted, and welcome folders were developed for parents.Additional evaluation showed that parents were over-whelmed with the amount of information that theyreceived at admission. The next PDSA will divide theinformation into 2 folders: (1) pamphlets, brochures,and instructional sheets that are useful in the early phaseof orientation to NICU and (2) parent instruction sheetsto prepare for caring for their infant at home.

PBP 4: Use Various Continuous Quality Improvement Toolsand Processes to Ensure Parent and Staff SatisfactionMany quality improvement processes were used in theimplementation of the PBPs to ensure quality care andmeasure the impact of each project. Multiple rapid-cycleprojects were completed to analyze the impact of eachchange with frequent monitoring to ensure lastingchanges. Staff communication was central to the suc-cessful implementation of the PBPs. Some of the meth-ods used included posters, discussion at staff meetings,e-mail, and personal contact.

Initial staff input was obtained at all participatingcenters by a staff survey on discharge planning. Thesurvey used was adapted from a survey that was devel-oped by St John Hospital and Medical Center and con-sisted of 21 questions and an open-ended question ask-ing how discharge planning could be improved. Areasthat were included in the survey were satisfaction withthe overall process, the plan, documentation, perceptionof whether families were prepared for discharge, timeli-ness of such things as prescriptions and medicationteaching, home equipment and the cardiopulmonaryresuscitation education, timeliness of circumcision, and


whether there was a clear understanding of roles in-volved in the process and any suggestions for improve-ment.

Each center used the results of the surveys to identifyareas of focus for discharge planning within each hospi-tal and across the collaborative when results from all ofthe participating centers were combined. Five key ques-tions from the original survey were included in a repeatsurvey that was administered several months after thestart of the collaborative and again close to the end of thecollaborative. The results of the modified survey from allparticipating centers are shown in Fig 1. Improvementwas noted in staff satisfaction with the discharge process(32%–50%), workload allows time for teaching (19%–38%), clearly documenting the discharge plan (26%–40%), and clarity of team members’ roles in the dis-charge process (24%–44%). Improvement was noted inall centers from baseline to the final measurement, ex-cept in the area of staff satisfaction with documentation.

A goal of the NPLH collaborative was to implement afamily satisfaction tool. The tool that was used for thisgoal was the Internet-based parent satisfaction surveyhowsyourbaby.com that was developed especially forthe NICU population.7 Many of the questions in thesurvey are oriented toward the discharge process. Sur-vey questions address general satisfaction with care, par-ents’ feelings about preparedness for discharge, abilityand confidence in feeding, familiarity with their infant,feeling like a parent, participation in care, and adequacyof information from staff about medical and care issues.The collaborative group also developed open-endedquestions that were oriented toward improving the dis-charge process. Some individual centers also developedcenter-specific open-ended questions.

At the beginning of this collaborative, 3 of the 6

participating centers were using the howsyourbaby.comsurvey, although none had made the use and comple-tion of the survey part of their unit’s culture. Much ofthe energy so far has been spent on overcoming barriersrelating to implementation of the tool rather than usingthe tool to guide practice. It is helpful to have the surveycompleted in the NICU before discharge to improve re-sponse rates.

One way to facilitate the process is to embed into thedischarge process the task of having parents completethe survey. The transition point checklist was helpful infacilitating this. At Children’s Hospital at Providence,bedside staff, charge nurses, and family care coordinatorslead parents to a desktop computer, sign them onto theWeb site, and have them complete the survey in privacyon the day of discharge. Using this process, the NICU hasbeen successful in having �80% of families fill out thesurvey.

Experience suggests that the following barriers arecommon and need to be addressed for implementationto be successful:

● Having hospital administrators understand the needfor a NICU-specific patient satisfaction tool was a sig-nificant barrier. Many centers and pediatric depart-ments were using hospital-wide tools such as the PressGaney survey,8,9 which may meet the needs of thehospital as a whole but have limited applicability forthe NICU population.

● Many NICUs are not oriented to having computersdispersed throughout the NICU. This was an initialbarrier to implementation. Computer and Internet ac-cess for staff and family also was a barrier that delayedimplementation for some. Computers and Internet

FIGURE 1Staff satisfaction survey results on discharge planning: percentage who agree or strongly agree.


use needs to be incorporated into the NICU to opti-mize implementation.

● Computer phobia among nursing staff with reluctanceto be involved also may be a problem. Training a coregroup of staff on all shifts who can serve as at-the-timefacilitators for the remainder of the staff is a successfulstrategy.

● The survey generates a large amount of data that canbe difficult to present concisely. It is helpful to havededicated staff that can interpret and organize thepresentation of data for staff and leadership. This iscrucial if the information is to be used for staff feed-back and quality improvement efforts that are basedon results.

Centers that are more advanced in the use of this toolare at a point of using the data to change practice.Feedback from open-ended questions has been espe-cially valuable in revealing opportunities for improve-ment. Examples of these include a program for smokingcessation for identified families at a time when they aremost likely to be amenable to behavioral intervention,10

addressing the issue of consistent caregivers, parentalparticipation in multidisciplinary rounds, and develop-ing a cue-based feeding program to decrease parent frus-tration with feeding management near discharge. Sur-vey responses for all centers in the collaborative forpreparedness for discharge, feeding confidence, andteaching on car seats and sleeping are shown in Fig 2.Parent readiness for discharge was high at the beginningand throughout the collaborative. Parents’ receiving justthe right amount of information regarding car seat trialsand safe sleep demonstrated some variability throughoutthe collaborative.

University of Minnesota Children’s Hospital, Fair-

view, identified clarity of role responsibility in the dis-charge process as 1 area that needed improvement. Ini-tially, staff with responsibility in the discharge processwere interviewed to determine specific discharge tasks.The discharge tasks were listed, and agreement wasreached to clarify which person/role had primary orshared responsibility for task completion. The final roleresponsibility list was shared with all team members bye-mail and poster. A significant improvement, from 46%to 82%, was noted on the staff survey: Staff agreed withthe statement, “Each discipline’s role in the dischargeprocess is clear.”

PBP 5: Analyze and Enhance Interactions With and TransfersInto the CommunityThe ultimate goal of the NPLH group is the discharge ofinfants to their family and community. Once families arehome, parents need support and resources within theircommunity. Many children who are discharged from theNICU have no or few special needs related to theirneonatal course. However, some children who are dis-charged from the NICU will have or be at risk for healthand educational problems for many years.11 These needsare met best in the community setting through medicaland educational services that are available to families.The NPLH group as a collaborative did not focus exten-sively on posthospital experience of families, but eachcenter evaluated its status in this area. Many centerscompleted individual projects with a focus on commu-nity resources, providers, and feedback from familiesonce home from the hospital.

Children’s Hospital at Providence initiated the imple-mentation of follow-up telephone calls after dischargefrom the NICU. Questions developed included (1) Howprepared were you to take your infant home? (2) On a

FIGURE 2Parent satisfaction survey results, all centers combined.


scale of 1 to 10, on what 1 thing did we rate a 10? (3)What do we need to improve on most? (4) Have youseen your infant’s physician yet? (5) Has your infantbeen readmitted to the hospital or required any emer-gency care? Follow-up calls are made within 1 month ofdischarge.

The second week at home is believed to be the idealcontact time and is a long-term goal of this project.Challenges to date include time and personnel resourcesto complete the calls, disconnected numbers, and fami-lies not at home at the time of the calls. Feedback showsthat families are very willing to talk about their dischargeexperience, and almost all stated that their dischargewent smoothly. Limited implementation and inability tocontact all families as a result of challenges mentionedprevent drawing conclusions from any results to date.

Children’s Hospital at Providence conducted a surveythat requested feedback from pediatricians who assumecare of NICU graduates. They inquired whether familieswere adequately prepared in the care of their infant andwhether there were gaps in preparation of the familyand their actual needs once in the community. Gener-ally, pediatricians believed that NICU graduate familieswere savvy in the care of their infants and that educationand management of the care of their infant seemedsufficient. Areas of improvement included more consis-tent information from the NICU during the hospital stayand a better understanding of nutrition goals and man-agement initiated in the NICU.

Hoping to ease the often difficult and cumbersomeprocess that families may experience as they move fromtertiary care to community services, Mission Hospitalsparticipated with community providers in the 17 coun-ties of Western North Carolina to form a partnership thataddressed the referral process for early intervention (EI)-eligible families. Grant monies were obtained throughDuke Endowment to provide a full-time developmentalspecialist in the NICU. Part of that role includes educat-ing families about EI, making the referral to the com-munity provider, and arranging for the families to meetthe community provider before discharge from theNICU. This increased contact with families, as well as theadditional information about EI services, provides asmoother transition to home and care in the community.The partnership reports that there has been an increase infamilies who retain EI services after discharge.

A matrix of the implementation of the PBPs for dis-charge planning at each participating center is shown inFig 3. Each center completed the matrix early in thecollaborative and then periodically updated the matrixto monitor progress.

DISCUSSIONThe use of transition points helps provide a frameworkfor discharge planning. Transition points help keep allteam members on the same page. The concept of tran-

sition points provided enough structure for dischargeplanning to be useful yet offered enough flexibility thateach center implemented the transition points to suittheir own process. The focus of monitoring the transitionpoints was completion of the tasks within the recom-mended time frame. Centers in the collaborative used avariety of tools to implement the transition points. Theresult of the chart audit at each center helped to deter-mine future areas for additional work. The data fromindividual centers showed improvement in many areas,although in many cases, they did not reach the compli-ance goal of 85%.

Written and verbal communication with parents andamong all team members is crucial to facilitating asmooth discharge. One method that is recommended inthe literature and that also was implemented in somecenters and was in place before the collaborative is theuse of interdisciplinary rounds. Interdisciplinary roundsprovide input from all team members and families andprovide a format for the creation of effective long-rangeplanning.

Family education in preparation for discharge is builtinto the concept of the transition points, with familieslearning key pieces throughout the hospitalizationrather than the day of discharge. A variety of writteninformation can supplement the verbal and caregivingexperiences as families prepare to go home. The collab-orative completed many handouts for parents and de-veloped a list of Internet sites to aid in teaching.

The implementation of a parent satisfaction tool(howsyourbaby.com), based on work from the previousVON collaborative,7 was available for all centers andpresented a challenge for some centers. This was truedespite the common use of other patient satisfactiontools by these hospitals. The Internet access issue was asignificant barrier that delayed implementation for sev-eral centers. Research, however, indicates that this for-mat is much more amenable to honest responses thanother formats.12

The tool itself has some advantages compared withother, general patient satisfaction tools in that it is In-ternet based, is completed before discharge, and can beembedded into the discharge workflow for staff. This isimportant because many patient surveys that are mailedafter discharge have poor response rates, and results maybe difficult to interpret without having a complete pic-ture of parental views.13–15

The tool also has items that are specific to the NICUpopulation relating to social service support, how wellparents got to know their infant, how often they got tohold and participate in the care for their infant, ade-quacy of teaching for patient-specific problems, howoften they fed their infant, success at breastfeeding atdischarge, and questions about household smoking andabuse. An important feature is the ability to ask open-ended questions to identify issues that are important for


parents but not considered a priority by providers. Thefinding of problems and frustration on the issue of feed-ing toward the end of the hospital stay is a case in point.

A significant amount of time was required to imple-ment the howsyourbaby.com tool. Therefore, the groupdid little work using the information from the tool to

FIGURE 3PBP implementation matrix.


improve processes in the NICU. This is the next step formany centers and underscores the perseverance andtime commitment that it takes to implement this PBP.Nevertheless, the survey is rich in specific content that isamenable to interventions toward improving care andteaching.

One of the challenges for this project was to translatethe large amount of data from the survey into informa-tion that could be presented concisely to staff and man-agement. This was accomplished, and several centers areinvolved in providing graphic feedback information tostaff on a quarterly basis. In addition, centers that aremore advanced in the use of this tool have the need toaccess their own data and manipulate it for quality im-provement purposes. These issues are being addressed.

The collaborative identified several limitations of thesurvey that may need additional development in thefuture. A common problem with patient satisfaction in-struments is that ratings are misleadingly high.16 Thisalso was seen in our survey. Although this may speak forthe care provided, many factors that are unrelated tocare might result in overwhelmingly positive responsesin patient satisfaction surveys.16

It is important to recognize that the field of parentsatisfaction research is in its infancy,17 and additionaldevelopment of tools needs to occur. Another factor thatmay require modification of the tool in the future is theneed to concentrate on other aspects of neonatal carethat have an impact on parent satisfaction. These areidentified as predelivery care, delivery and stabilizationcare, transport and admission, critical and stable phasesof care, and follow-up care.17 This may necessitate sur-veying parents at different times during the NICU stayand also at some period after discharge.

Finally, centers with more experience with the toolhave identified the need for additional information onthe issue of parent satisfaction, such as whether thereare differences in satisfaction between fathers and moth-ers, between patients with short versus long stays orbetween infants with complicated medical courses andthose with self-limited problems, and between teen fam-ilies versus older ones. These questions underscore theneed for satisfaction tools to have the flexibility tochange as the science of measuring parent satisfactionadvances.

The second aspect to this PBP was improving staffsatisfaction with the discharge process. There is reason toconsider patient and staff satisfaction together. Evidenceshows that there is a strong correlation between patientsatisfaction and staff satisfaction, indicating a conver-gence of these 2 measures.18,19 Intuitively, a rushed dis-charge in which parent teaching and preparation aredone at the last minute is a major frustration for nursingstaff and families. The exploratory group demonstratedsignificant improvement in satisfaction with the dis-charge process, clarity of roles, and the discharge plan.

There was not as much improvement noted in the areaof documentation, but with the implementation of thetransition points, ongoing revisions and improvement indocumentation continued through much of the explor-atory group work.

Much of work of this collaborative focused on thein-hospital experience as families prepare for home. Theimmediate time period as infants make the transitionfrom hospital to home and support for families withintheir community remain very important. Individual cen-ters worked on this in follow-up telephone calls andreferrals to EI services. The impact of discharge planningon the posthospital experience remains a rich opportu-nity for additional work in the NICU population.

CONCLUSIONSThe NPLH group focused on multiple facets of dischargeplanning in the implementation of the PBPs. Throughmultiple rapid-cycle projects, changes were made in careplanning, documentation, and parent teaching material.Evaluation of the changes made was measured in patientoutcomes and parent and staff satisfaction.

The resulting recommendations needed to provideenough structure to be helpful in discharge planning buthave enough flexibility that each unit could adapt andimplement the recommendations in a way that best fittheir unit. Each center in the collaborative focused onslightly different PBPs. All NICUs in the exploratorygroup demonstrated significant improvement in dis-charge planning and continue their work in this area.

ACKNOWLEDGMENTSThe NPLH group thanks team members at each partici-pating center for work with families in discharge plan-ning and valuable help with this project: Children’s Hos-pital at Providence; Mission Hospitals; RockfordMemorial Hospital; St John Hospital and Medical Center,Detroit; University of Minnesota Children’s Hospital,Fairview; and Yakima Valley Memorial Hospital. A spe-cial thank you to Maria Hill, RN, MS, CMAC, for clinicalexpertise and Nancy Leahy-Jacklow for facilitation ofthis exploratory group. We thank Anne Rameriz, RN,CNS, Pat Fett, RN, CNS, Carol Van de Rostyne, RN,ANP-C, and Beth Engelhardt, MD, for contributions tothis article.

REFERENCES1. Horbar JD, Plesek PE, Leahy K. NIC/Q 2000: establishing habits

for improvement in neonatal intensive care units. Pediatrics.2003;111(4). Available at: www.pediatrics.org/cgi/content/full/111/4/SE1/e397

2. Halm MA, Gagner S, Goering M, Sabo J, Smith M, ZaccagniniM. Interdisciplinary rounds. Clin Nurse Spec. 2003;17:133–142

3. Bruccoliere T. How to make patient teaching stick. RN. 2000;63:34–38

4. Parker L, Richardson C. Oschner and Ross Laboratories NICU


BabyBook, Parent Edition. New Orleans, LA: Alton OschnerMedical Foundation; 1993

5. Parker L, Richardson C. Oschner and Ross Laboratories NICUBabyBook, Nurses’ Edition. New Orleans, LA: Alton OschnerMedical Foundation; 1993

6. Dhillon AS, Albersheim SG, Alsaad S, Pargass NS, Zupancic JA.Internet use and perceptions of information reliability by par-ents in a neonatal intensive care unit. J Perinatol. 2003;23:420–424

7. Saunders RP, Abraham MR, Crosby MJ, Thomas K, EdwardsWH. Evaluation and development of potentially better prac-tices for improving family-centered care in neonatal intensivecare units. Pediatrics. 2003;111(4). Available at: www.pediatrics.org/cgi/content/full/111/4/SE1/e437

8. Press I, Ganey RF. The mailout questionnaire as the practicalmethod of choice in patient satisfaction monitoring. J HealthCare Mark. 1989;9:67–68

9. Press Ganey. Available at: www.pressganey.com. AccessedSeptember 18, 2006

10. Saks NP, Hartigan P, Howard N, et al. Collaboration to imple-ment smoking cessation guidelines during the childbirth con-tinuum. Jt Comm J Qual Improv. 2001;27:664–672

11. Hack M, Klein N, Taylor HG. Long-term developmental out-comes of low birth weight infants. Future Child. 1995;5:176–196

12. Rhodes KV, Lauderdale DS, He T, Howes DS, Levinson W.“Between me and the computer”: increased detection on inti-mate partner violence using a computer questionnaire. AnnEmerg Med. 2002;40:493–495

13. Bourroughs TE, Waterman BM, Cira JC, Desikan R, ClaiborneDunnagan W. Patient satisfaction measurement strategies: acomparison of phone and mail methods. Jt Comm J Qual Improv.2001;27:349–361

14. Fowler FJ Jr, Gallagher PM, Stringfellow VL, Zaslavsky AM,Thompson JW, Cleary PD. Using telephone interviews to re-duce nonresponse bias to mail surveys of health plan members.Med Care. 2002;40:109–200

15. Kim J, Lonner JH, Nelson CL, Lotke PA. Response bias: effecton outcomes evaluation by mail surveys after total knee ar-throplasty. J Bone Joint Surg Am. 2004;86-A:15–21

16. Mitchell-DiCenso A, Guyatt G, Paes B, et al. A new measure ofparent satisfaction with medical care provided in the neonatalintensive care unit. J Clin Epidemiol. 1996;49:313–318

17. Conner JM, Nelson EC. Neonatal intensive care: satisfaction mea-sured from a parent’s perspective. Pediatrics. 1999;103:336–349

18. Vahey DC, Aiken LH, Slone DM, Clarke SP, Vargas D. Nurseburnout and patient satisfaction. Med Care. 2004;42(suppl):II57–II66

19. Leiter MP, Harvic P, Frizzell C. The correspondence of patientsatisfaction and nurse burnout. Soc Sci Med. 1998;47:1161–1167


DOI: 10.1542/peds.2006-0913I2006;118;S124Pediatrics

Marla M. Mills, Debra C. Sims and Jack JacobImprove the Discharge Process in the Neonatal Intensive Care Unit

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DOI: 10.1542/peds.2006-0913I2006;118;S124Pediatrics

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Implementation and Case-Study Results of Potentially Better Practices to

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