Beware of Boxes.

Abstract

There have been 2 major approaches to improving the quality of care for infants with neonatal abstinence syndrome (NAS) over the last several years. The first takes the accepted model of care and improves it by creating more efficient processes and standardizing care.1,2 The second model, and the one we followed at Yale New Haven Children’s Hospital (YNHCH), makes more radical changes, implementing a new and different approach.3 As Shigeo Shingo, a godfathers of the Toyota Production System wrote, “Improvement usually means doing something we have never done before.”4 I am often asked how I was able to get people to accept such radical change, but the real challenge was opening myself up to these changes. Before we began our attempt to improve the care of infants with NAS at YNHCH, we had been following the standard of care. We managed infants in our NICU exposed to opioids using the modified Finnegan Tool to guide treatment. Nonpharmacologic interventions were the first-line treatment but were difficult to deliver in our barracks-style NICU. Parents could not room in, and we relied heavily on pharmacologic treatment. Over the course of 5 years at YNHCH, our team redesigned how we managed infants with NAS. We looked at why we were doing all the things we were doing and realized that there was little if any data to support it and, frankly, it did not make a whole lot of sense. The real reason for doing what we did today was simply because that was what we did …