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QI case study: Improving ROP screening in the NICU

Part one of a hypothetical case study illustrating how a NICU team begins to use Quality Improvement to identify problems with their ROP screening
Illustration showing ROP screening: nurse gently holds a wrapped up baby still whilst the ophtalmologist examines the baby's eyes using a hand magnifier and loupe

Each week we follow a hypothetical case study illustrating how a neonatal intensive care unit (NICU) team uses quality improvement (QI) and Plan-Do-Study-Act (PDSA) cycles to resolve problems with their ROP screening. The case shares many of the common challenges faced by NICUs around the world, especially in middle and low-income settings.

In this article we describe the early stage of the project where the QI team comes together to identify and analyse the issues with ROP screening in the NICU, and consider what action is needed.

QI case study: Improving ROP screening

A tertiary hospital in the capital city of middle-income country has a well-established and busy NICU which admits more than 100 neonates per month. The unit has:

  • 20 intensive care cots with incubators and life support systems, and
  • 15 step down cots where transition special care is provided for babies who no longer need intensive life support, such as ventilation.

The NICU staff are justifiably proud of their growing reputation and the ongoing improvement in their neonatal survival rates. However, the team also recognises the need to address concerns about managing comorbidities in the babies being cared for. Anecdotally, the ophthalmologist who visits the NICU on two fixed days per week to carry out ROP screening has raised a concern about the need to improve ROP screening uptake. She has particularly noted that babies are sometimes listed but do not come.

Starting the quality improvement initiative

To address the ophthalmologist’s concern about ROP screening, leadership staff at the NICU form a quality improvement (QI) team. The members represent each aspect of care provided to preterm babies:

  • Head of the NICU (neonatologist)
  • Head of neonatal nursing
  • Administrator
  • Two resident doctors
  • Two neonatal nurses from the intensive care and step down care units
  • Two parents.

The QI team’s first decision is to take a three stage approach to the project:

  1. A Situation analysis stage will collect information on how things currently work in the unit. This will help the team to identify and define problems with ROP screening.
  2. A Learning stage will use the Plan Do Study Act (PDSA) approach to test activities to improve ROP screening at the unit.
  3. A Post-intervention stage will help the team understand if the activities undertaken are beneficial and sustainable.

The QI leadership team selects a QI implementation team to test a selected intervention in the second learning stage. The implementation team meets once a week during the intervention to review the data they collect. This allows them to maintain focus on the QI initiative amongst all their other activities in the NICU.

Situation analysis stage

The QI team begin by asking two main questions to gain information on how ROP screening is currently working at the NICU.

  • What are the current ROP screening procedures?
  • How many babies are currently being screened for ROP at the NICU?

What are the current ROP screening procedures?

To answer this question, NICU neonatal nurse and neonatologist use process mapping to create flow charts which visualise:

  • The details of the protocol to identify babies for their first ROP screening and how it is being applied
  • The discharge and follow up screening procedures for preterm babies at high risk of ROP (fig 1).

Analysing the two flow charts highlights to the QI team that ensuring that ROP screening takes place, is not actively monitored in the NICU before babies are moved to the step down unit and then discharged.

Figure 1. Extract from the process flow chart on the discharge procedure for babies at high risk of ROP

Diagram illustrating the decisions and actions carried out in the neonatal clinic to move babies from NICU cots to step down cots to discharge and follow up (Click here to expand)

How many babies are currently being screened for ROP at the NICU?

The administrator collects the available data on the existing ROP screening rates, that is the percentage of babies who are screened out of the total list of babies that require screening. This indicates that only 33% of babies who are listed for screening actually get screened before being discharged.

Reflecting on the information collected so far, the QI team decides that it is important to gather more data on two key questions:

  • Are the neonatal nurses aware of the need for ROP screening?
  • How are parents being counselled about ROP at the NICU?

Are the neonatal nurses aware of the need for ROP screening?

To gain insight into neonatal nurses’ knowledge of ROP screening, the two neonatal nurses develop a simple, self-administered questionnaire with closed questions (which require a ‘yes’ or ‘no’ answer). The questionnaire has a maximum score of 10 marks with questions on:

  • the definition of ROP,
  • risk factors for ROP,
  • babies’ eligibility criteria for ROP screening,
  • criteria for a baby to be listed for first ROP screening and the importance of follow up.

Resident doctors in the NICU and step down units take charge of distributing the questionnaire which all 40 nurses complete. The QI team analyses the answers and finds that the median score is 4/10.

How are parents being counselled about ROP at the NICU?

The head of nursing and one of the resident doctors carry out a qualitative survey with parents of preterm babies on their understanding of ROP. They find that parents are not engaged actively or counselled and are often just told that there is another test to be done:

‘I was only told this test was to see if the eyes are working well’ (Parent)

Problem analysis

The QI team review and discuss all the information obtained using a fishbone analysis tool (see figure 2 and summary table below). They identify several areas which could be improved.

Figure 2. Fishbone analysis of the problem, ‘Only 33% of babies at risk are screened for ROP’

Illustration of the QI team's fishbone analysis as described in detail below (Click here to expand)

Summary table of the fishbone analysis

People Place Procedure Policy
Poor ROP knowledge amongst nurses. Location of ROP screening is away from NICU. Babies with undilated eyes not taken to screening. Guideline is unclear about the role of nurses.
Low parental awareness and acceptance. No referral at discharge for ROP screening. No active ROP counselling. There is a lack of ROP information for nurses and parents.
Babies on ventilators are not listed for screening.

To decide what to focus on in the learning stage of the project, the QI team prioritises the identified areas for improvement by importance, feasibility and cost of undertaking an intervention.

After further discussion, the QI team concludes that, to improve the ROP screening rate from 33%, that they will test two priority quality improvement activities:

  • Training the neonatal nurses on ROP
  • Increase the role of neonatal nurses in counselling parents about ROP in the NICU and step down units before discharge.


Now you have read the first part of the case study, what do you think are the strengths and weaknesses of the QI team’s proposal to carry out two interventions to improve the ROP screening rate? Should there be a different priority for action? Or would you change the overall intervention? Share your thoughts in the Comments.

We will return to this case study next week to share feedback on this activity before going on to explore what happens next as the QI team tests the proposed QI intervention in the project’s Learning stage using the PDSA cycles.

© London School of Hygiene & Tropical Medicine CC BY-NC-SA 4.0
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