From the Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas.

Whitfield describes their work as “a search for methods and processes of care that minimize or eliminate both long- and short-term complications of neonatal intensive care.” Utilizing a systematic approach to improvement, taught by Paul Plesk, the Vermont Oxford NICQ 2000 team has embraced 4 key habits, which are detailed in the manuscript. To evaluate their project, we should look for evidence that adoption of these key habits results in significant reductions in morbidity or mortality.

Previous Vermont Oxford Network improvement work reported significant impact heterogeneity. Several centers noted degradation instead of improvement in the target outcomes. Impact heterogeneity suggests that unit culture might play an important role. Unit-based culture can be described in terms of several characteristics. The association of unit characteristics and their relationship with outcomes and other measures of quality should be tested. It appears that the NICQ 2000 project embraced, without testing, 4 key habits.

To respond to this project design, the following might be considered if teaching these 4 key habits does not result in universal benefit.

THE HABIT FOR CHANGE

“The key to more effective care is the willingness of staff to accept new ideas.” There is an implied link between this habit and the group, developmental, hierarchical, and rational cultural characteristics. It is presumed that specific patterns of these characteristics are linked to tolerance of rapid change. The NICQ 2000 project teams should be challenged to identify which patterns of cultural characteristics are associated with improvements in outcomes, not just rapid change. NICUs have an unfortunate past of rapidly adopting what seems to work. NICUs are not department stores where rapid alterations in interactions between client and clerk can at its worst result in dissatisfaction. Negative long-term impacts of interventions that appear to have short-term benefits are common in NICUs. Do we want a willingness to change, or do we want a willingness to test new ideas in a structured way? The unit characteristics of these 2 cultures may be very different.

THE HABIT OF UNDERSTANDING THE PROCESSES OF CARE

While this is identified in the key habits, it was not employed in the first phase of NICQ. The NICQ 2000 team should emphasize this aspect and document its value. Items published by the last team were labeled potentially better practices, not processes. Potentially better practices direct what is done, not how it is done. It can take years to detail all of the multiple layers of processes and subordinate processes in any one unit. Nursing policy and procedure books, which are inches thick, speak to an NICU's complexity. Opportunities for improvement may be generated and introduced from the review of process descriptions. However, external deadlines for reporting the reams of detailed process analysis are distracting. Collaboration may delay understanding of how variation in local process impacts quality.

Benchmarking, as used by NICQ, assumes that a high-performing center can be observed and questioned about its practices and that these discussions can be linked to the outcome measure. On the contrary, it might be the artist, not the brush. Careful attention to detail, with consistent processes in a low-chaos environment, may overcome the lack of the newest “techno-intervention.” The challenge to the NICQ 2000 team is to demonstrate the value (by measurable improvements in target outcomes) of not just reviewing and writing but sharing the detailed process analysis information and implementing elements associated with improvements.

THE HABIT OF COLLABORATIVE LEARNING

The authors describe this activity well. In the previously published NICQ work, some of the potentially better practices came from critical analysis of the literature. Some came from observation and discussions with high-performing units. In the end, potentially better practices required a consensus of the participants. However, the implementation of potentially better practices was not reported in detail. The NICQ 2000 team should measure the improvements made in the target outcome and their relationship to the implemented potentially better practices.

THE HABIT OF USING EVIDENCE-BASED MEDICINE

An advocate of critical appraisal, I can only ask why the editors of major journals continue to accept underpowered, poorly designed studies, which cannot pass a critical appraisal. The NICQ 2000 team could make a dramatic impact by challenging the editorial board of Pediatrics (the current editor of that journal attends each of their meetings) to mandate a critical appraisal from all authors when they submit manuscripts for publication.

Dr. Whitfield's challenge is to gather and deliver to the Baylor NICU every element of outstanding practice. Collaboration in NICQ may spark motivation and develop a network for new ideas. Adopting a list of consensus-derived potentially better practices or trying to teach new cultural habits may not be an effective approach, but this project will soon tell us that answer. I have no doubt that the Baylor NICU's journey starts with, and depends upon, the commitment, concern, and dedication of the physicians and staff. I respect and applaud their efforts, as this report displays hard work and dedication. We should anxiously await their impact report.