QI Resources – NICU QI Tools

NICU lactation Quality Improvement (QI) is a framework used to systematically improve lactation care and infant health outcomes through evidence-based best practices.

Mother kissing baby on the hand

Model for Quality Improvement 

QI involves continuous efforts to reduce process variation and improve the outcomes of these processes for patients.

Establishing a QI team

Sustainable Quality Improvement/ practice change requires commitment and effort from multiple disciplines within the hospital. The establishment of a core team is a critical first step.

It should be noted:

  • It is not necessary to have every position filled before starting
  • Healthcare professionals can cover multiple responsibilities
  • The hospital’s QI department/ team (if there is one) should be engaged early on

Setting aims

Goal setting is critical to ensure complete alignment – making sure everyone is working towards a common goal. It is also essential in being able to measure and communicate impact – an essential part of sustainable change and motivation.

The QI team needs to align in setting realistic and achievable SMART goals:

  • Specific
  • Measurable
  • Achievable
  • Realistic
  • Time-bound

Identifying the needs

Often the first step to achieving a goal is to map out possible causes as to why the goal is not currently being achieved.

This can be mapped out by:

This involves accompanying the mother through her care experience, for example, from a routine prenatal check, delivery of her baby, her journey to the maternity ward and the neonatal unit. It is useful to consult with the mother and family members to discuss their experiences. This aspect of QI has the greatest impact on staff and is most influential in implementing practice change.

Process Mapping:
This provides a visual plan of what happens to the mother and infant at each stage. It enables the QI team to identify which steps are of critical importance and who / what department is responsible to implement the care process.

Identifying drivers and selecting changes

Cause and effect analysis helps the working group to consider the root causes of problems and the effect these have. This can help identify the main challenges and the most important areas to focus on for improvement.

Driver (fishbone) diagrams1 are used to identify the main influences or 'drivers' to the mother and infant patient experience and help to identify what aspect of care needs to be influenced in order to improve outcomes.

A driver diagram is a framework that helps to set aims, identify the main areas to focus on (drivers), with a schedule of interventions that need to be set in order to achieve the outlined goals.

Driver fishbone diagram

Testing the changes

Plan Do Study Act model

An important part of the model for improvement is the Plan, Do, Study, Act (PDSA) cycle2,3 – a tried and tested method that helps plan a chosen intervention, test it on a small scale and then review it before deciding how to proceed. It comprises four steps.

  • Step 1: Plan – planning the practice change to be put in place and predicting what will happen through the cycle. Detailed work here includes deciding what data will be collected, who will do what, when and where the change will be implemented.
  • Step 2: Do – collecting baseline data, implementing the practice change, measuring and collecting data as planned.
  • Step 3: Study – analysing before-and-after data to determine if the implemented plan resulted in an improvement or not and to what degree and to see what can be learned.
  • Step 4: Act – returning to the start, if it is ready, how to roll out the change and if not, planning how to amend the next cycle. Asking if the change should be adopted, adapted or abandoned, and continue to audit regularly.

With this method confidence grows quickly, gaps are identified and rectified early. Regular reporting to all departments supports working together and focus on making a difference to patient outcomes. The learning from one cycle should guide the cycles that follow.4


1 Ishikawa K. Introduction to Quality Control. London, UK: Chapman and Hall; 1991. 435 p.

2 Deming Edwards W. Out of the crisis. Cambridge MA: MIT Center for Advanced Engineering Study; 1986. xiii, 507 p.

3 Deming Edwards W. The new economics for industry, government, education. Cambridge MA: Massachusetts Institute of Technology; 1993. 240 p.

4 Christoff P. Running PDSA cycles. Curr Probl Pediatr Adolesc Health Care. 2018; 48(8):198–201.