Quality Corner: March 2016

March 10, 2016 by

Shining a Light on Quality

When an error occurs during the course of a patient’s hospitalization, it takes courage to disclose to the family the problems that arose, however, we do this as part of our desire to build trust and lasting relationships with the families that we treat (and it’s the right thing to do!). Although there were many who voiced concerns that full disclosure will lead to an increase in malpractice suits and litigation, there is ample evidence that the opposite has occurred.

Much like disclosure, transparency – “the free, uninhibited flow of information that is open to the scrutiny of others” – of quality data has led to many positive impacts while the potential harm of sharing data has had much less of an impact than initially feared. The National Patient Safety Foundation has determined that there are four domains of transparency:

  • Between clinicians and patients (error disclosure)
  • Among clinicians themselves (peer review, Be Safe reporting)
  • Among healthcare organizations (regional or national collaboratives)
  • Between healthcare organizations and the public (public reporting of data)

The Medical Center has recently started publicly reporting data, initially focusing on transplant programs. The Department of Pediatrics has also begun to be a part of this project to provide patients with reliable information that is in a form that is useful and easily read. Working with the Marketing Department, the NICU recently published outcomes data on the website. Disclosing information on infection rates, respiratory complications, intraventricular hemorrhage and other issues from 2012 – 2015 allows families to visually see where we are doing well and where we need to continue to focus quality improvement efforts.

Additionally, two other Children’s Hospital programs have publically shared data. Our Congenital Heart Disease program has voluntarily released data from the Society of Thoracic Surgeons database on operative mortality. The Division of Respiratory Medicine’s Cystic Fibrosis program shares data through the Cystic Fibrosis Foundation. (Disclaimer – must register with the CFF which is free.)

Feel free to peruse this data and share your insights. What outcomes would you like to see from your doctor and health care system? What outcomes would you like to tout from your clinic or program?

Ref: The National Patient Safety Foundation’s Lucian Leape Institute. Shining a Light: Safer Health Care Through Transparency. Executive Summary. 2015. Accessed here.


Special congratulations to the Pediatric Sepsis Alert and the Neonatal Admission Temperature teams. They recently presented their quality improvement efforts at the statewide Virginia Patient Safety Summit at the beginning of February. Their abstracts were also selected to be presented at the upcoming Pediatric Academic Society’s Annual meeting in Baltimore at the end of April. Also accepted to the PAS meeting in April is an abstract describing the work on unplanned extubations in the NICU. Congratulations to all involved!

Sepsis Alert Team:

  • Janine Smith BSN, RN
  • Zachary Coffman MD
  • Cheryl Hubbard RN
  • Emily Chen, PharmD
  • Lynn McDaniel, MD

Admission Temperature in the NICU team:

  • Matthew Harer MD
  • Brooke Vergales MD
  • Ashley Early MSN, RN
  • Taylor Cady BSN, RN
  • Christian Chisholm MD
  • Jonathan Swanson MD, MSc

Unplanned Extubation Team:

  • Georgetta Gentry BSN, RN
  • Tamara Wheeler RRT
  • Janet Glass RRT
  • Janine Smith BSN, RN
  • Tim Hicks BS RRT
  • Debra Owens MSN, RN NNP-BC
  • Jonathan Swanson MD, MSc

Filed Under: Features