Strategies to Improve Quality of Care Delivery in Safety Net NICUs

Safety net newborn intensive care units (snNICUs) are challenged in their care and outcomes delivered very low birth weight (VLBW; <1500g) infants. In our population-based California cohort of NICUs, we find large variation in performance across snNICUs. For example, in a key national quality metric, any breast milk feeding at discharge, which exhibits the largest variation, California snNICUs as a group perform worse that non-safety net NICUs. However, some snNICUs are among the state’s best performers, even after adjustment for clinical risk. There is a dearth of knowledge regarding the malleable organizational features differentiating quality of care across snNICUs. We propose to bridge this gap by gaining a deep understanding of network characteristics and their links to clinical care and outcomes. We will accomplish this by leveraging the unique population-based data resources and applied quality improvement expertise of the California Perinatal Quality Care Collaborative (CPQCC) to conduct a novel improvement collaborative among snNICUs to address performance in breast milk feeding rates at discharge for VLBW infants. This collaborative will serve to create an unprecedented peer learning network of snNICUs and serve as a vehicle for our team for a multimodal inquest to study the organizational features that either support or hinder quality of care. We propose a large, population-scale study of snNICUs, with a large estimated sample of approximately 5,300 VLBW infants receiving care in 30 NICUs between 2024 to 2026. Specific aims: 1. Conduct a quality improvement collaborative of safety net NICUs, 2. Identify organizational features that may be associated with quality of care delivery, and 3. Associate safety net NICU organizational features with clinical outcomes. Our analyses will be guided by quality and implementation frameworks. Methods will include an Institute of Healthcare Improvement style quality improvement collaborative, quantitative validated surveys of safety culture and healthcare worker well-being, key informant interviews, and guided site visits. We will link organizational features with clinical quality of care and outcome metrics using epidemiological causal and observational modeling approaches. We have a long track record of impactful research funded by NIH using CPQCC data. We expect our research to have an immediate positive impact; internally, it is designed to build quality and safety capacity in snNICUs that can readily be extended to other aspects of care; externally, it will result in actionable information for policy makers, administrators and clinicians to improve perinatal care delivery. The topic is timely, the sample (~90% of all CA snNICUs) is unique, the research team is accomplished, and the focus on an outcome of high importance to snNICUs, and to public health are significant strengths of this study.