Revealing and Resolving Institutional Racism in the NICU

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Safety net newborn intensive care units (snNICUs) have been identified as contributors to the stark disparities in care and outcomes delivered to the 60,000 very low birth weight (VLBW; <1500g) infants born annually in the United States. Usual explanations for these findings highlight social risk and limited hospital resources as key drivers. However, in our population-based California cohort of NICUs, we find large variation in performance across safety net NICUs. For example, in a key national quality metric, any breast milk feeding at discharge, which exhibits the largest racial ethnic disparities, California snNICUs as a group perform worse that non-safety net NICUs. However, some snNICUs are among the state’s best performers (positive deviants), even after risk adjustment. There is a dearth of knowledge regarding the malleable organizational features differentiating quality of care across snNICUs. We propose to bridge this gap by gaining a deep understanding of network characteristics and their links to clinical care and outcomes. We will accomplish this by leveraging the unique population-based data resources and applied quality improvement expertise of the California Perinatal Quality Care Collaborative (CPQCC) to conduct a novel improvement collaborative among snNICUs to address performance and disparities in breast milk feeding rates at discharge for VLBW infants. This collaborative will serve to create an unprecedented peer learning network of snNICUs and serve as a vehicle for our team for a multimodal inquest to study the organizational features that either promote or degrade quality of care. We propose a large, population-scale study of snNICUs, with a large estimated sample of approximately 5,300 VLBW infants receiving care in 30 NICUs between 2024 to 2026. Specific aims: 1. Conduct a quality improvement collaborative of safety net NICUs, 2. Identify organizational features that may be associated with quality of care delivery, and 3. Associate safety net NICU organizational features with clinical outcomes. Our analyses will be guided by quality and implementation frameworks. Methods will include an Institute of Healthcare Improvement style quality improvement collaborative, quantitative validated surveys of safety culture and healthcare worker well-being, key informant interviews, and guided site visits. We will link organizational features with clinical quality of care and outcome metrics using epidemiological causal and observational modeling approaches. We have a long track record of impactful research funded by NIH using CPQCC data. We expect our research to have an immediate positive impact; internally, it is designed to build quality and safety capacity in snNICUs that can readily be extended to other aspects of care; externally, it will result in actionable information for policy makers, administrators and clinicians to improve perinatal care delivery and equity. The topic is timely, the sample (~90% of all CA snNICUs) is unique, the research team is accomplished, and the focus on an outcome of high importance to snNICUs, and to public health are significant strengths of this study.