8/13/2021

Go Team: Reducing Team Activation Time

for Emergent NICU Transports
Allison Barberio, MHSA, CPHQ – Director of Quality, Inova Pediatric Service Line
Jennifer Alexander, MD – Neonatologist, NICU Transport Director

Privileged and Confidential: Copyright © National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

We have no Conflict of Interest to disclose.

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

1
 8/13/2021

Healthcare Quality Competency Framework

Workforce Report page 8

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

Learning Outcomes
● Translate a complex process into a process map to readily identify primary barriers
● Develop skills to foster collaboration with external contractors.
● Create method for consistent communication and feedback loop with a large clinical team impacted by change.

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

2
 8/13/2021

Inova L.J. Murphy Children’s Hospital

● 226-bed Children’s Hospital serving ● NICU Transport Team: Neonatal Nurse Practitioner, Transport Nurse, Transport
Northern Virginia Respiratory Therapist
● Level 1 Adult and Pediatric Trauma ● Ambulance Driver and Medic
Center ● Specially equipped ambulance rigs with specifications
● 108-bed Level IV Neonatal ● Over 100 NICU transports a year
Intensive Care Unit ● Partner with external ambulance company to support clinical team
● Very Low Birth Weight Infants–
Small Baby Unit in Development
● NICU Patient Days:
○ 2019: 31,707
○ 2020: 27,407

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

Model for Improvement

● Project Aim
○ To decrease median minutes to team departure for emergent NICU transports to 30 minutes or less
○ To achieve ≥80% reliability in NICU team departure within 30 minutes for emergent NICU transports by 6 months post-implementation

● Measures of Success
○ Outcome: Percentage of Emergent NICU Transports departure within 30 minutes of time of acceptance
○ Outcome: Reduction in median minutes to departure
○ Process: Percentage of transports utilizing 2-tier blast page process
○ Balancing: Safety Events involving lack of necessary equipment or appropriate personnel

● Changes for Improvement

○ Standardize Time Zero and Departure Time with external contractor for clarity and expectation setting
○ Creation of 2-tier blast page process to communicate time-sensitive transport information to a large multi-disciplinary team
○ Prioritize efficient communication for patient safety with pre-briefing huddle prior to departure
○ Establish a consistent meeting location closer to the NICU and eliminate non-value added team member movement

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

3
 8/13/2021

Team Formation
● Identifying Clinical, Technical, Operational and Executive Sponsors
○ Clinical Leaders: Neonatologist, NNP, Transport RN, Respiratory Therapy
○ Technical Experts: Call Center Leader, Ambulance Data Analyst, Paging Technology Analyst
○ Operational: NICU leadership, Ambulance Company Operation Leader
○ Executive Sponsor: Service Line Operational Director
○ Facilitator: Quality Consultant

● Key Takeaway for Identifying Team Members

○ Look back to past iterations for missing voices
○ Be upfront about expectation for decision-making capabilities of team members
○ Clarity on time commitment expectation
○ Meet & Greet

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

Setting Aims
● Utilize Project Charter to prevent scope creep

● Focus on one or two Aims for Improvement that are achievable within defined timeline
○ For our project, we chose Timely and Efficient Care. The reduction in administrative tasks required prior to team activation and adoption of common language used
by both NICU team and Ambulance Team are key interventions to reduce waste and effort.

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

4
 8/13/2021

Establishing Measures
● Collect all relevant data sources
○ Map sources to complete a more holistic picture, especially when involving an external contractor
○ De-fluff the data – focus only on what is most important and don’t get lost in everything available
○ Clearly define which data points are important to different team members; i.e. Ambulance company focuses on call intake to rig dispatch

● Outcomes
○ Defining Time Zero: Creation of a new variable to denote time zero for action. Time of Acceptance is the time the attending neonatologist completes intake
conversation with referral physician and activates both NICU transport and ambulance dispatch simultaneously.
○ Median Minutes to Departure for Emergent Transport
○ Percentage of Emergent Transports departing in <30 minutes from time of acceptance

● Process
○ Percentage of Transports utilizing 2-tier blast page process

● Balancing
○ Safety Events involving lack of equipment or appropriate personnel as identified in post-transport debrief

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

Root Cause Analysis to Select Changes

● Voice of the Customer
● Observation to Process Map
● Data Story
Role Feedback on Current Process
Voice of the Customer
NICU Charge RN Phone tree is stressful due to changing transport
team members and time to connect; team may
be in middle of procedure and unable to answer
Transport RN Team has difficulty finding out who the
ambulance crew is and where to meet them
when the arrive
Transport RT/ RT Leadership We have to backfill coverage for inpatients and
need our leaders to know that transport is going
out asap for assistance
Ambulance Company/Dispatch Crew We need more guidance from the physicians on
the urgency of assignment based on patient need
due to limited resources. STEMI Activation
Process works well for IFMC team.
Referring Neonatologists The process for getting a patient accepted and
knowing the team is on the way is not smooth.
We are calling for assistance for a critically ill
patient and need to know the team’s status to
communicate with parents.
Privileged and Confidential: Copyright ©National Association for Healthcare Quality
Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

10

5
 8/13/2021

Root Cause Analysis to Select Changes

1 2

5 7

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

11

Create a Data Story

● Map the data along the process map built from observation and team member input
○ Determine the largest areas of opportunity based on impact to overall performance

● Initial data analysis to probe where to ask further questions

○ Time to ambulance crew assignment - primary bottleneck #1
■ Ambulance company operators noted lack of clarity on criticality of call and how to triage assignment. Transports may be critical or more routine
based on patient population, therefore operators need clarity from neonatologists on call triage for assignment.

○ Internal Clinical Team Communication – primary bottleneck #2

■ Neonatologists relying on charge RN to communicate out to transport team members within unit of upcoming transport required 7 phone calls.
Each call lasting a few minutes, this greatly delayed team activation. It also left out team members who would be receiving handoff from
transport team members departing on transport.

○ Connecting dispatched ambulance crew to clinical team for pick-up – primary bottleneck #3
■ Clinical team calling dispatch center for crew information to coordinate rendezvous location and time with additional 2 phone calls. Team had no
way to contact ambulance crew directly which led to delays.

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

12

6
 8/13/2021

Selecting Changes
Blast Page #1 (sent by One-Call):
1. Phone tag to referring hospitals to encourage One Call use to • Referral hospital
• Time of acceptance
initiate transfer – September 2020 • Emergent or urgent
2. Implement 2-tier blast page process – September 2020 • Diagnosis
3. Secure pager for One Call team for immediate page success
validation – January 2020 Transport team meets in NICU at transporters
4. Page content standardization – ongoing Blast Page #2:
5. Adopt PTS transport language (emergent/urgent) and clinical • PTS crew contact information
guidance for neonatologist on selecting transport type – August • ETA
2020 • My transfer acceptance time is _____.
6. Implement internal pre-briefing huddle to review equipment • This is an emergent transfer for ____ that
readiness and patient details – September 2020 (Balancing needs to leave within 30 minutes.
• This is an urgent transfer for ___ that
measure: safety events) needs to leave within 60 minutes.
7. Create standard meeting location for pickup/drop-off for PTS/NICU
teams closer to NICU – August 2020

Door 81 at Women & Children’s Entrance

(Panera)
Privileged andConfidential: Copyright ©National Association for Healthcare Quality
Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

13

New Process

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

14

7
 8/13/2021

Outcomes
Emergent Transport - Median Minutes to Departure
Lower is
80 better
74
70
Blast Page
70
Go Live
64 64
60 61

54
50
45 45
40
36

30 30 30

24
20 20 20 21
19
17

10
5 6 5
4 4 4 4 3 3 3 4 4
2 1 1 2 1
0
20-Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 21-Jan Feb Mar Apr May June
Total Emergent Transports Median Minutes to Dispatch Goal

In the pre-intervention period (Jan - Aug; n=26), emergent transport median minutes to
departure was 57 min.
Privileged andConfidential: Copyright ©National Association for Healthcare Quality In the post-intervention period (Sept - June 2021; n=25) emergent transport median
Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason. minutes to departure was 22 minutes. Average minutes 27 min.

15

Outcomes
Percentage of Emergent Transports Depature within 30
minutes
35 80%

73%
70%
30

60%
25

50%
Number of Emergent Transports

20

40%

15
30%

10 23%
20%

5
10%

0 0%
Post Implementation (Sept 2020 -
Pre-Implementation (Jan - Aug 2020)
June 2021)
Emergent within 30 min 6 22
Total Emergent Transports 26 30
% of Emergent Transports Departure within 30
23% 73%
minutes
Privileged and Confidential: Copyright ©National Association for Healthcare Quality
Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

16

8
 8/13/2021

Process

% of Transports Blast Page Process Used

100% PDSA Cycle 1: Consistent Utilization of 2-
tier blast page with audit
90% PDSA Cycle 2: Page content script for
clarity
80%

70%

60%

50%

40%

30%

20%

10%

0%
Sept Oct Nov Dec Jan Feb Mar Apr May June

% of Transports Blast Page Process Used

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

17

Balancing
● Patient and Team Member Safety is at the core of every process. Time-based improvement efforts lend themselves to an increased risk of
human error due to situational pressure.
● Balancing Measure: Number of Safety Events due to lack of equipment or appropriate personnel

● Performance: There was one reported incident of a missing piece of respiratory equipment from the Go Bag. Go Bags are prepared respiratory
and nursing transport bags checked daily (similar to MSET cart) for ease.

● Intervention: Pre-briefing prior to transport allows clinical team to gather and discuss any specialty equipment needed for particular patient

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

18

9
 8/13/2021

Key Takeaways
● Think outside the box! The 2-tier blast page activation is a process utilized by the Adult STEMI team and was brought forward
as a solution by the dispatch center team.
● Simple wins gain the team’s trust
● Be willing to change course if something isn’t working as imagined. Sometimes great ideas don’t fix the problem presented.
● Celebrate the wins and let the team take ownership – NICU clinical team created internal QI working group to address more
opportunities including handoff from referring facilities and condition-specific transport (IVH reduction)
● Engaging the contractor as a key member of the patient care process.

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

19

Special Thanks

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

20

10
 8/13/2021

Contact Information

Allison.Barberio@inova.org
JAlexander@fnapc.com

Privileged and Confidential: Copyright ©National Association for Healthcare Quality

Recipients should not distribute in whole or part and no portion of these materials may be reused for any reason.

21

11