NAS QI Initiative Monthly Outcome Measures

SMART AIM 1

By October 2020, 85% of all Kansas birth centers enrolled in VON NAS Universal Training Program will have achieved “Center of Excellence” designation.

Progress Toward VON Completion

These figures represent participating centers’ progress in completing the VON NAS Universal Training Program modules.

SMART AIM 2

By October 2020, less than 50% of infants at risk for NAS will be directly admitted to the NICU.

Direct Admission to the NICU

These figures represent the percentage of infants at risk for NAS directly admitted to the NICU where the numerator is admission to the NICU because of risk and the denominator is inborn infants identified as meeting the KPQC definition of “at risk for NAS” plus infants transferred in because of risk status.

SMART AIM 3

By October 2020, the number of infants at risk for NAS who require pharmacological treatment will decrease by 25%.

At-risk Infants Treated Pharmacologically

These figures represent the percentage of infants treated pharmacologically where the numerator is pharmacologic treatment and the denominator is inborn infants identified as meeting the KPQC definition of “at risk for NAS” plus infants transferred in because of risk status.

SMART AIM 4

By October 2020, the LOS of Kansas infants with NAS treated pharmacologically will decreased by 2 days.

Average Length of Stay for Infants Treated Pharmacologically

These figures represent the average length of stay of all infants treated across centers.

NAS QI Initiative Quarterly Process Measures

Implementation Stage

These figures represent the number of participating birth centers at each implementation stage for each of the following practices:

Identification
Evaluation
Treatment
Discharge

1. Standardized protocol for maternal substance abuse screening
2. Standardized protocol for infant drug screen screening

3. Standardized education program for NAS scoring utilizing one specific tool

4. Standardized protocol directed at avoiding separation of infant and mother outlining
    evaluation and non-pharmacologic treatment of the substance exposed infant
5. Standardized education for families to engage in non-pharmacologic intervention
6. Provide Vermont Oxford Network NAS Universal Education virtual classroom access to the
    interdisciplinary team and all involved in creating a culture of compassion and healing for
    the mother and infant.
7. Standardized protocol outlining criteria for breastfeeding, which promotes and supports
    breastfeeding in eligible mothers
8. Standardized protocol for pharmacologic treatment of NAS

9. Standardized process to ensure safe discharge
10. Standardized process for measuring and reporting NAS rates, data collection and
    outcome measures.