Neonatal Intensive Care Quality Improvement Research Articles

NICU bedside caregivers sustain process improvement and decrease incidence of bronchopulmonary dysplasia in infants < 30 weeks gestation.

The objective of this study was to investigate whether a respiratory care bundle, implemented through participation in the Vermont Oxford Network-sponsored Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2005) and primarily dependent on bedside caregivers, resulted in sustained decrease in the incidence of bronchopulmonary dysplasia (BPD) in infants < 30 wk gestation. A retrospective cohort study was conducted. Infants inborn between 23 wk and 29 wk + 6 d of gestation were included. Patients with congenital heart disease, significant congenital or lung anomalies, or death before intubation were excluded. Four time periods (T1-T4) were identified: T1: September 1, 2002 to August 31, 2004; T2: September 1, 2004 to August 31, 2006; T3: September 1, 2006 to August 31, 2008; T4: September 1, 2008 to August 31, 2010. A total of 1,050 infants were included in the study. BPD decreased significantly in T3 post-implementation of the respiratory bundle compared with T1 (29.9% vs 51.2%, respectively; adjusted odds ratio [aOR] = 0.06 [95% CI 0.03-0.13], P = < .001). The decrease was not sustained into T4. There was a significant increase in the rate of BPD-free survival to discharge in T3 compared with T1 (53.1% vs 47%; aOR = 1.68 [95% CI 1.11-2.56], P = .01) that was also not sustained. The rate of infants requiring O2 at 28 d of life decreased significantly in T3 versus T1 (40.3% vs 69.9%, respectively; aOR = 0.12 [95% CI 0.07-0.20], P = < .001). Increases in the rate of surfactant administration by 1 h of life and rate of caffeine use were observed in T4 versus T1, respectively. There was a significant decrease in median ventilator days and a significant increase in the median number of noninvasive CPAP days throughout the study period. In this study, implementation of a respiratory bundle managed primarily by nurses and respiratory therapists was successful in increasing the use of less invasive respiratory support in a consistent manner among very low birthweight infants at a single institution. However, this study and others have failed to show sustained improvement in the incidence of BPD despite sustained process change.

Evidence-Based Quality Improvement in Neonatal and Perinatal Medicine: The Neonatal Intensive Care Quality Improvement Collaborative Experience

This supplement is a collection of original articles written by participants in the Vermont Oxford Network (VON) Neonatal Intensive Care Quality Improvement Collaborative 2002 (NIC/Q 2002). It is the third in a planned series of supplements that began in January 1999 with the electronic supplement in Pediatrics titled “Evidenced-Based Quality Improvement in Neonatal and Perinatal Medicine”1 and continued in April 2003 with “Evidenced-Based Quality Improvement in Neonatal and Perinatal Medicine: The NIC/Q 2000 Experience.”2 The premise of this series is that the quality of practices in clinical, organizational, and operational care for newborn infants and their families can be improved dramatically using the 4 key habits for improvement3: (1) systems thinking; (2) a habit for change; (3) evidenced-based clinical science; and (4) multicenter, multidisciplinary collaborative learning. This current collection represents the work of the NIC/Q 2002 Evidenced-Based Quality Improvement Collaborative in Neonatology. The articles in this collection provide a detailed description of a multiinstitutional improvement collaborative. They should be of interest to health care providers as they pertain both to the NICU setting specifically and to collaborative quality improvement in general. The collaborative, sponsored by the VON, comprised multidisciplinary teams from NICUs in the United States and Canada. The 46 centers in the NIC/Q 2002 collaborative were selected on the basis of willingness to make the personal and financial commitment to join the project with an annual fee, as well as funding travel expenses for the teams. Each center was responsible for determining whether local Institutional Review Board approval was necessary for participation. The 46 centers and their key personnel are listed in Appendix 1. They include many sites from the NIC/Q and NIC/Q 2000 collaboratives. These teams worked together from March 2000 through October 2003 with the guidance of expert faculty and staff (Appendix 2) … Address correspondence to Jeffrey D. Horbar, MD, Vermont Oxford Network, 33 Kilburn St, Burlington, VT 05401. E-mail: horbar{at}vtoxford.org

Management of High-Order Multiple Births: Application of Lessons Learned Because of Participation in Vermont Oxford Network Collaboratives

The delivery and care of sextuplets is complex. Potentially better practices that were developed as part of the Vermont Oxford Network improvement collaboratives were used to prepare for a sextuplet delivery at Akron Children's Hospital. The team used potentially better practices that were learned from the Neonatal Intensive Care Quality Improvement Collaborative 2002 using multidisciplinary teams. There was extensive media coverage of the delivery. The goal was to use nearly all potentially better practices that focused on the goals of reducing nosocomial infection, reducing chronic lung disease, reducing radiograph use, reducing length of stay, reducing blood gas use, promoting nutrition, reducing intraventricular hemorrhage, and enriching family-centered care. The center aimed to use these 97 potentially better practices. Of the 97 possible potential better practices as set by the Neonatal Intensive Care Quality Improvement Collaborative 2002, 96 (99%) were used. This is a blueprint that any center that is faced with high-order multiple births could use as a reference point to begin planning. The team created a benchmark to achieve in every birth of very low birth weight infants and not just a special situation of high-order multiple births.

Evaluation and Development of Potentially Better Practices to Improve Pain Management of Neonates

Despite increased knowledge, improved options, and regulatory mandates, pain management of neonates remains inadequate, promoted by the ineffective translation of research data into clinical practice. The Neonatal Intensive Care Quality Improvement Collaborative 2002 was created to provide participating NICUs the tools necessary to translate research, related to prevention and treatment of neonatal pain, into practice. The objective for this study was to use proven quality improvement methods to develop a process to improve neonatal pain management collaboratively. Twelve members of the Neonatal Intensive Care Quality Improvement Collaborative 2002 formed an exploratory group to improve neonatal pain management. The exploratory group established group and site-specific goals and outcome measures for this project. Group members crafted a list of potentially better practices on the basis of the available literature, encouraged implementation of the potentially better practices at individual sites, developed a database for sharing information, and measured baseline outcomes. The goal "improve the assessment and management of infants experiencing pain in the NICU" was established. In addition, each site within the group identified local goals for improvement in neonatal pain management. Data from 7 categories of neonates (N = 277) were collected within 48 hours of NICU admission to establish baseline data for clinical practices. Ten potentially better practices were developed for prioritized pain conditions, and 61 potentially better practices were newly implemented at the 12 participating sites. Various methods were used for pain assessment at the participating centers. At baseline, heel sticks were used more frequently than peripheral intravenous insertions or venipunctures, with substantial variability in the number of avoidable procedures between centers. Pain was assessed in only 17% of procedures, and analgesic interventions were performed in 19% of the procedures at baseline. Collaborative use of quality improvement methods resulted in the creation of self-directed, efficient, and effective processes to improve neonatal pain management. Group establishment of potentially better practices, collective and site-specific goals, and extensive baseline data resulted in accelerated implementation of clinical practices that would not likely occur outside a collaborative setting.

Evaluation and Development of Potentially Better Practices for Staffing in Neonatal Intensive Care Units

Five NICUs that participate in the Vermont Oxford Network's Neonatal Intensive Care Quality Improvement Collaborative 2002 attempted to identify potentially better practices that would have a directly impact on nurse recruitment and retention. The group identified nurse recruitment and retention as an important initiative for many hospitals that face a nursing shortage. The group analyzed information from hospital demographics, literature reviews, process analysis questionnaires, and site visits. The literature review, process analysis questionnaire, and benchmarking with magnet hospitals identified 5 drivers for retention and recruitment. The drivers evolved into 5 potentially better practices that cover orientation, recognition and rewards, work environment, nurse/physician collaboration, and nursing autonomy. The magnet hospitals, which are known to have the highest retention rate and the lowest turnover rate, have many of these potentially better practices in place. The 5 practices described herein have the potential to decrease nursing turnover in NICUs.

Evaluation and Development of Potentially Better Practices for Perinatal and Neonatal Communication and Collaboration

The obstetric and neonatal exploratory focus group of the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative 2002 set out to improve collaboration, communication, and coordination between maternal and neonatal caregivers in 3 areas: the pregnancy at 22 to 26 weeks, measurement of maternal outcomes that are linked with neonatal outcomes, and team performance during high-risk delivery. Antepartum and intrapartum maternal attributes and interventions also were considered important measurements to identify practice variations and their relationship to neonatal outcomes for ongoing obstetric and neonatal collaboration. Potentially better practices were developed on the basis of evidence in the literature, expert opinion, and internal analysis at the participating perinatal centers. The potentially better practices include development of local guidelines at each center for the care and counseling of pregnant women who are at risk for delivering at the margin of viability; communication strategies for obstetric and neonatology providers relating to high-risk pregnancy treatment plans; team communication and performance at high-risk deliveries; design of organizational structures and processes that facilitate obstetric and neonatal collaboration; and development of perinatal data to evaluate effects of perinatal practices on maternal, fetal, and neonatal outcomes. As a result of the project, participating centers developed local guidelines for pregnancies between 22 and 26 weeks, created a cross-center maternal database that currently is being linked to neonatal outcomes, and completed a pilot study on video simulation of neonatal-perinatal team communication. Increased understanding of practice variation in the management of care for infants who are at the margins of viability, locally developed guidelines, and a focus on improved team communication during delivery can be accomplished with a multicenter collaborative approach.

Reduction of Bronchopulmonary Dysplasia After Participation in the Breathsavers Group of the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative

The objective of this study was to compare the primary and secondary outcomes of very low birth weight infants before and after participation in the Breathsavers Group of the Vermont Oxford Network-sponsored Neonatal Intensive Care Quality Collaborative. Hospitals that participated in the Breathsavers Group contributed clinical data on the outcomes of their very low birth weight infants to the Vermont Oxford Network using standardized clinical definitions, data forms, and inclusion criteria. Outcomes from the last year of the collaborative, 2003, were compared with those from the baseline year, 2001. Models for treatment practices and outcomes measures were adjusted for within-hospital correlation (clustering) and standard risk factors that were present at birth. Bronchopulmonary dysplasia dropped significantly in 2003 compared with the baseline year. Survival improved but not significantly. In addition, severe retinopathy of prematurity, severe intraventricular hemorrhage, and supplemental oxygen at discharge dropped significantly. The use of conventional ventilation at any time during the initial hospitalization, postnatal steroids, and time to first dose of surfactant all decreased significantly. The use of nasal continuous positive airway pressure at any time during hospitalization increased. The use of high-frequency ventilation, delivery room intubation, and surfactant at any time during hospitalization did not change. The Breathsavers Group improved both clinical care processes and clinical outcomes during the Neonatal Intensive Care Quality Collaborative.

Evaluation and Development of Potentially Better Practices to Improve the Discharge Process in the Neonatal Intensive Care Unit

Our goal was to identify potentially better practices that create a successful discharge planning process that spans the entire newborn intensive care stay to the next level of care by embedding the discharge planning into all aspects of patient care and communication. Potentially better practices were developed through recommendations from a content expert and a literature review. Internal benchmarking, self-assessment tools, monthly conference calls, the Neonatal Intensive Care Quality Improvement Collaborative 2002 listserv, parent feedback, and semiannual conferences were used to finalize recommendations and implement practices. Potentially better practices included (1) create an easy-to-use/easy-to-access discharge planning tool kit, (2) restructure written and oral communication tools and processes to reflect plans for the day, the stay, and the way to discharge, (3) maximize the impact and use of caregiver educational tools, and update materials and delivery systems for caregiver education, (4) use continuous quality improvement tools and processes to ensure parent/caregiver and staff satisfaction, and (5) analyze and enhance transfers into and interactions with the community. The potentially better practices are recommendations that are designed to integrate organizational, clinical, and operational processes to ensure optimal discharge planning from admission through follow-up in the community.

Implementation and Case-Study Results of Potentially Better Practices to Improve Pain Management of Neonates

Collaborative quality improvement techniques were used to facilitate local quality improvement in the management of pain in infants. Several case studies are presented to highlight this process. Twelve NICUs in the Neonatal Intensive Care Quality Improvement Collaborative 2002 focused on improving neonatal pain management and sedation practices. These centers developed and implemented evidence-based potentially better practices for pain management and sedation in neonates. The group introduced changes through plan-do-study-act cycles and tracked performance measures throughout the process. Strategies for implementing potentially better practices varied between centers on the basis of local characteristics. Individual centers identified barriers to implementation, developed tools for improvement, and shared their experience with the collaborative. Baseline data from the 12 sites revealed substantial opportunities for improved pain management, and local potentially better practice implementation resulted in measurable improvements in pain management at participating centers. The use of collaborative quality improvement techniques enhanced local quality improvement efforts and resulted in effective implementation of potentially better practices at participating centers.

Marginal Increase in Cost and Excess Length of Stay Associated With Nosocomial Bloodstream Infections in Surviving Very Low Birth Weight Infants

Nosocomial bloodstream infections (NBIs) are associated with serious morbidity and prolonged length of stay (LOS) in very low birth weight (VLBW) infants. However, the marginal costs and excess LOS associated with these infections have never been measured in different birth weight (BW) categories after adjustment for many of the potentially confounding demographic variables, comorbidities, and treatments. The objective of this study was to measure the marginal cost and excess LOS caused by NBIs in surviving VLBW infants in different BW categories. This retrospective study examined data previously collected as part of the Neonatal Intensive Care Quality Improvement Collaborative 2000 and the Vermont Oxford Network clinical outcomes database. Univariate analyses and multiple regression were used to examine the effect of NBIs on hospital costs and LOS. Seventeen neonatal intensive care units that participated in the Neonatal Intensive Care Quality Improvement Collaborative 2000 submitted both clinical and financial data on their VLBW infants who were born from January 1, 1998, to December 31, 1999. This study included data from both university and community hospitals. NBIs occurred in 19.7% of 2809 patients included in this study. NBI was associated with significantly increased treatment costs for infants with BW 751 to 1500 g. The marginal costs of NBIs, as estimated by multiple regression, varied from 5875 dollars for VLBW infants with a BW of 401 to 750 g to 12,80 dollars for those with BW of 751 to 1000 g. LOS was significantly increased in all BW categories. The excess LOS estimated by multiple regression varied from 4 days in VLBW infants with a BW of 1001 to 1251 g to 7 days in those with a BW of 751 to 1000 g. NBIs are associated with increased hospital treatment costs and LOS but by varying amounts depending on the BW. Preventing a single NBI could reduce the treatment costs of a VLBW infant by at least several thousand dollars. These savings are a greater percentage of the total treatment costs in VLBW infants with BW 1001 to 1500 g than in smaller infants.

Evaluation and Development of Potentially Better Practices to Prevent Chronic Lung Disease and Reduce Lung Injury in Neonates

Despite increased knowledge and improving technology, chronic lung disease (CLD) rates in extremely low birth weight infants have remained constant for 20 years. One reason for this is an ineffective translation of research-proven improvements into practice. The Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/Q 2000) was created to provide participating nurseries the tools necessary to effect change. The objective of this study was to develop and implement a process that uses quality improvement techniques to collaboratively improve CLD rates. Nine member hospitals of the NIC/Q 2000 collaborative formed a focus group aiming to decrease CLD rates. The focus group established goals and outcome measures, created a list of potentially better practices (PBPs) based on available literature, benchmarked and performed site visits, encouraged individual site implementation of PBPs, developed a database, and measured outcomes. The goal "decrease CLD rates in extremely low birth weight infants" was established. Nine PBPs were identified, and 57 PBPs were implemented by the 9 participating sites. Twelve site visits were conducted, and a 435-patient database of infants with a mean birth weight of 789 g was established. Collaborative use of quality improvement techniques resulted in creation of a logical, efficient, and effective process to improve CLD rates. Group creation of PBPs, based on literature review and reinforced with site visits, internal data analysis, and improved individual site outcomes, resulted in accelerated and effective change, unlikely to occur if attempted outside of the collaborative.

Implementing Potentially Better Practices to Reduce Lung Injury in Neonates

Adherence to basic quality improvement principles enhances the implementation of potentially better practices (PBPs) and requires extensive planning and education. Even after PBPs have been identified and acknowledged as desirable, effective implementation of these practices does not occur easily. The objective of this study was to identify and assess implementation strategies that facilitate quality improvements in the respiratory care of extremely low birth weight infants. The 9 members of the Neonatal Intensive Care Quality Improvement Collaborative Year 2000 Reducing Lung Injury focus group identified 9 PBPs in a evidence-based manner to decrease chronic lung disease in extremely low birth weight newborns. Each site implemented several or all PBPs based on a site-specific selection process. Each site was asked to submit 1 or more examples of experiences that highlighted effective implementation strategies. This article reports these examples and emphasizes the principles on which they are based. The 9 participating institutions implemented a total of 57 PBPs (range: 1-9; median: 5). Including previous implementation, the 9 participating institutions implemented a total of 70 of a possible 81 PBPs before or during the study period (range: 5-9; median: 8). We report 7 approaches that facilitated PBP implementation: information availability, feedback, perseverance, collaboration, imitation, recognition of implementation complexity, and tracking of process indicators. Quality improvement efforts are enhanced by identifying and then implementing PBPs. In our experience, implementation of these PBPs can be difficult. Implementation strategies, such as those identified in this article, can improve the chances that quality improvement efforts will be effective.

NIC/Q 2000: Establishing Habits for Improvement in Neonatal Intensive Care Units

The Vermont Oxford Network is a group of health professionals who are committed to improving the quality and safety of medical care for newborn infants and their families. Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/Q 2000) was the second in a series of multiorganization improvement collaboratives organized and administered by the Vermont Oxford Network. The objective of this collaborative was to make measurable improvements in the quality and safety of neonatal intensive care, develop new tools and resources for improvement specific to the neonatal intensive care unit setting, evaluate improvement progress, and disseminate the learning. The 34 centers that participated in NIC/Q 2000 learned and applied 4 key habits for improvement: the habit for change, the habit for evidence-based practice, the habit for systems thinking, and the habit for collaborative learning. A plan-do-study-act method of rapid-cycle improvement was an integral part of the habit for change. Multidisciplinary teams from the participating centers worked closely together in face-to-face meetings, conference calls, and dedicated e-mail listservs under the guidance of trained facilitators and expert faculty. Focus groups formed around specific improvement topics used critical appraisal of the published literature, detailed process analysis, benchmarking, and round-robin site visits to identify potentially better practices (PBPs). The focus groups developed a total of 51 PBPs. Each focus group has developed a "resource kit" summarizing its work. Many of these PBPs have been tested and implemented at the participating centers using rapid-cycle improvement. The PBPs and descriptions of individual center PDSA cycles are available to participants on NICQ.org, the dedicated Internet site for the collaborative. Collaborative quality improvement based on the 4 key habits can assist multidisciplinary neonatal intensive care unit teams in identifying, testing, and successfully implementing change.

Development of Potentially Better Practices for the Neonatal Intensive Care Unit as a Culture of Collaboration: Communication, Accountability, Respect, and Empowerment

The Vermont Oxford Network (VON) CARE Group was formed in response to the need to create organizational cultures supportive of change and quality improvement. The CARE Group consisted of team members from 4 participating neonatal intensive care units (NICUs). All CARE Group members chose to work on multidisciplinary teamwork for the duration of the Neonatal Intensive Care Quality Improvement Collaborative Year 2000. A questionnaire was developed by the CARE Group and administered to the 4 focus group NICUs. The survey focused on 6 domains of the organization: unit coordination, working in the NICU, leadership, management of disagreements, authority, and unit culture. Benchmarking visits were completed to supplement the information found in the survey and the literature. Seven potentially better practices (PBPs) were developed on the basis of the surveys, benchmark visits, and literature reviews. The PBPs include 1) a clear, shared NICU purpose, goals, and values; 2) effective communication among and between teams and team members; 3) leaders lead by example; 4) nurture a collaborative NICU environment with trust and respect; 5) live principled standards of conduct and standards of excellence; 6) nurture competent and committed teams and team members; and 7) commit to effective and positive conflict management. The CARE Group successfully used quality improvement methods and collaboration to delineate principles and practices of multidisciplinary teamwork.

Using Economic Information in a Quality Improvement Collaborative

This article provides an overview of neonatal intensive care unit treatment costs for hospitals that participated in the Neonatal Intensive Care Quality Improvement Collaborative Year 2000 (NIC/Q 2000) quality improvement collaborative and discusses how economic information can be used in quality improvement efforts. Detailed information on neonatal intensive care unit treatment costs is presented for 29 hospitals that participated in the NIC/Q 2000 collaborative. The sample consists of 6797 very low birth weight infants (1500 g or less at birth) with admission dates between January 1, 1997, and December 31, 1998. Information on median treatment cost per infant, ancillary costs, accommodation costs, length of stay, and cost per day is presented. In addition, ancillary costs are further disaggregated into those for respiratory therapy, laboratory, radiology, pharmacy, and all other ancillary services. The role of level of care and other factors that influence treatment costs are then explored.

Implementing Potentially Better Practices to Improve Neonatal Outcomes After Reducing Postnatal Dexamethasone Use in Infants Born Between 501 and 1250 Grams

The purpose of this article is to describe how a neonatal intensive care unit (NICU) was able to reduce substantially the use of postnatal dexamethasone in infants born between 501 and 1250 g while at the same time implementing a group of potentially better practices (PBPs) in an attempt to decrease the incidence and severity of chronic lung disease (CLD). This study was both a retrospective chart review and an ongoing multicenter evidence-based investigation associated with the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative (NIC/Q 2000). The NICU specifically made the reduction of CLD and dexamethasone use a priority and thus formulated a list of PBPs that could improve clinical outcomes across 3 time periods: era 1, standard NICU care that antedated the quality improvement project; era 2, gradual implementation of the PBPs; and era 3, full implementation of the PBPs. All infants who had a birth weight between 501 and 1250 g and were admitted to the NICU during the 3 study eras were included (era 1, n = 134; era 2, n = 73; era 3, n = 83). As part of the NIC/Q 2000 process, the NICU implemented 3 primary PBPs to improve clinical outcomes related to pulmonary disease: 1) gentle, low tidal volume resuscitation and ventilation, permissive hypercarbia, increased use of nasal continuous positive airway pressure; 2) decreased use of postnatal dexamethasone; and 3) vitamin A administration. The total dexamethasone use, the incidence of CLD, and the mortality rate were the primary outcomes of interest. Secondary outcomes included the severity of CLD, total ventilator and nasal continuous positive airway pressure days, grades 3 and 4 intracranial hemorrhage, periventricular leukomalacia, stages 3 and 4 retinopathy of prematurity, necrotizing enterocolitis, pneumothorax, length of stay, late-onset sepsis, and pneumonia. The percentage of infants who received dexamethasone during their NICU admission decreased from 49% in era 1 to 22% in era 3. Of those who received dexamethasone, the median number of days of exposure dropped from 23.0 in era 1 to 6.5 in era 3. The median total NICU exposure to dexamethasone in infants who received at least 1 dose declined from 3.5 mg/kg in era 1 to 0.9 mg/kg in era 3. The overall amount of dexamethasone administered per total patient population decreased 85% from era 1 to era 3. CLD was seen in 22% of infants in era 1 and 28% in era 3, a nonsignificant increase. The severity of CLD did not significantly change across the 3 eras, neither did the mortality rate. We observed a significant reduction in the use of mechanical ventilation as well as a decline in the incidence of late-onset sepsis and pneumonia, with no other significant change in morbidities or length of stay. Postnatal dexamethasone use in premature infants born between 501 and 1250 g can be sharply curtailed without a significant worsening in a broad range of clinical outcomes. Although a modest, nonsignificant trend was observed toward a greater number of infants needing supplemental oxygen at 36 weeks' postmenstrual age, the severity of CLD did not increase, the mortality rate did not rise, length of stay did not increase, and other benefits such as decreased use of mechanical ventilation and fewer episodes of nosocomial infection were documented.

In Search of Excellence—The Neonatal Intensive Care Quality Improvement Collaborative

As part of its effort to improve the quality of care in the neonatal intensive care unit at Baylor University Medical Center (BUMC), the unit has participated in the Vermont Oxford Network. This network tracks outcomes and pools data, allowing comparisons and benchmarking. A group of 34 nurseries from the Vermont Oxford Network has collaborated in an innovative quality improvement initiative. This article describes this initiative, called the Neonatal Intensive Care Quality Collaborative 2000 project, and its impact on the neonatal service at BUMC. The project promotes the practice of 4 key habits: the habit for change, the habit for understanding the processes of care, the habit for collaborative learning, and the habit for using evidence-based practices of care.