# Quality Policy - NICU/PICU

| Document ID | POL-001 |
|-------------|---------|
| Title | Quality Policy - Neonatal and Pediatric Intensive Care |
| Revision | 1.0 |
| Effective Date | [DATE] |
| Author | [AUTHOR] |
| Approved By | [APPROVER] |

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## 1. Policy Statement

[ORGANIZATION NAME] is committed to providing the highest quality of critical care to neonates, infants, and children in our intensive care units. We are dedicated to:

- Delivering evidence-based, family-centered care that meets or exceeds national standards
- Maintaining a safe environment for our most vulnerable patients
- Supporting the developmental needs of critically ill neonates and children
- Ensuring all care practices comply with applicable regulatory requirements and professional guidelines
- Continually improving our Quality Management System to enhance patient outcomes and family satisfaction

## 2. Quality Objectives

Our NICU/PICU commits to:

1. **Patient Safety First**: Eliminating preventable harm through proactive safety practices and continuous monitoring
2. **Family-Centered Care**: Engaging families as essential partners in the care of their critically ill child
3. **Evidence-Based Practice**: Implementing the latest evidence-based guidelines for neonatal and pediatric critical care
4. **Developmental Care**: Minimizing stress and supporting neurodevelopmental outcomes for our youngest patients
5. **Regulatory Compliance**: Maintaining compliance with Joint Commission, AAP, CMS, and all applicable standards
6. **Continuous Improvement**: Using data-driven quality improvement initiatives to enhance outcomes
7. **Staff Competency**: Ensuring all staff maintain current competency in neonatal and pediatric resuscitation and critical care
8. **Infection Prevention**: Preventing healthcare-associated infections through rigorous adherence to protocols

## 3. Management Commitment

The NICU/PICU leadership demonstrates commitment to the QMS by:

- Ensuring the quality policy is appropriate for the unique needs of critically ill neonates and children
- Establishing measurable quality objectives aligned with national benchmarks (Vermont Oxford Network, NACHRI)
- Integrating QMS requirements into all clinical processes and protocols
- Promoting evidence-based practice and continuous quality improvement
- Ensuring adequate staffing, equipment, and resources for safe intensive care delivery
- Communicating the importance of quality and safety to all staff, families, and stakeholders
- Supporting family presence and participation in rounds and care decisions
- Engaging interdisciplinary teams in quality improvement initiatives
- Reviewing quality metrics and outcomes regularly

## 4. Scope

This policy applies to:
- All clinical staff working in NICU/PICU (physicians, nurse practitioners, nurses, respiratory therapists, pharmacists)
- Support staff involved in patient care (social work, child life, pastoral care)
- All processes and procedures within the NICU/PICU Quality Management System
- Family members as partners in care

## 5. Quality Metrics

We measure and monitor:
- Mortality rates (risk-adjusted)
- Healthcare-associated infection rates (CLABSI, VAE, CAUTI)
- Medication errors and near-misses
- Unplanned extubations and reintubations
- Skin breakdown and pressure injuries
- Family satisfaction scores
- Length of stay
- Readmission rates within 48 hours
- Breastfeeding/human milk feeding rates (NICU)
- Pain assessment and management compliance
- Code blue response times
- Developmental care practice adherence

## 6. Family-Centered Care Commitment

We recognize families as:
- Essential members of the healthcare team
- The constant in the child's life
- Having the right to participate in all decisions
- Needing support, information, and respect
- Partners in quality improvement efforts

## 7. Communication

This policy shall be:
- Communicated to all NICU/PICU staff during orientation and annually
- Available to families through unit information materials
- Reviewed annually for continuing suitability
- Updated to reflect current best practices and regulatory requirements

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## Revision History

| Rev | Date | Description | Author |
|-----|------|-------------|--------|
| 1.0 | [DATE] | Initial release | [AUTHOR] |