Quality improvement (QI) and evidence-based medicine (EBM) activities ideally generate value (benefit/cost). Physicians and hospitals vary in ability to demonstrate efficiency despite common methodology available to all. Based upon our 60-some years of combined QI and EBM experience, we suggest reasoned consideration of meta-cognition—thinking about thinking. How do we observe, analyze, intuit, then share observations and learning with collaborative networks? The Greek word aletheia denotes disclosure of the essence of an object or event as its genuine nature, “unhidden, revealed, unconcealed”. Aletheia is authenticity, not a claim or opinion, not an argument or hypothesis, nor an intervention-based assertion. QI and EBM have crucial features obscured by the lure and distraction of technology, economic conflicts, and inherent self-interests. We offer 20 QI and EBM observations in the spirit of aletheia. Enhancing the well-being of children is the foundation of a civilized society, a journey needful of shared QI understanding.
Access optionsAccess options
Subscribe to Journal
Get full journal access for 1 year
only $20.67 per issue
All prices are NET prices.
VAT will be added later in the checkout.
Rent or Buy article
Get time limited or full article access on ReadCube.
All prices are NET prices.
Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Braithwaite J. Changing how we think about healthcare improvement. BMJ. 2018. https://doi.org/10.1136/bmj.k2014.
Barnes J. Early Greek philosophy. London, England: Penguin Books; 1987.
Altenbernd Johnson P. On Heidegger. Belmont, CA: Wadsworth/Thomson Learning; 2000.
Cleary T. The essential Tao. New York, NY: Harper-Collins Publishers; 1991.
Kaplan A. The new world of philosophy. New York, NY: Vintage Books Random House; 1961.
Kugelman A, Inbar-Sanado E, Shinwell ES, Makhoul IR, Leshem M, Zangen S, et al. Iatrogenesis in neonatal intensive care units: observational and interventional, prospective, multicenter study. Pediatrics. 2008;122:550–5.
Tottman AC, Alsweiler JM, Bloomfield FH, Harding JE. Presence and pattern of scarring in children born very preterm. Arch Dis Child Fetal Neonatal Ed. 2018;103:F277–F279.
Poets CF, Lorenz L. Prevention of bronchopulmonary dysplasia in extremely low gestational age neonates: current evidence. Arch Dis Child Fetal Neonatal Ed. 2018. https://doi.org/10.1136/archdischild-2017-314264.
Cooper L, Morrill A, Russell RB, Gooding JS, Miller L, Berns SD. Close to me: enhancing kangaroo practice for NICU staff and parents. Adv Neonatal Care. 2014;14:410–23.
Kaempf JW, Suresh G. Antenatal corticosteroids for the late preterm infant and agnotology. J Perinatol. 2017;37:1265–7.
Alderliesten T, Lemmers P, van Haastert MA, de Vries LS, Bonestroo HJC, Baerts W, et al. Hypotension in preterm infants: low blood pressure alone does not affect neurodevelopmental outcome. J Pediatr. 2014;164:986–91.
SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network. N Engl J Med. 2010;362:1959–69.
Kaempf JW, Kaempf AJ, Wu Y, Stawarz M, Niemeyer J, Grunkemeier G. Hyperglycemia, insulin and slower growth velocity may increase the risk of retinopathy of prematurity. J Perinatol. 2011;31:251–7.
Katheria AC, Lakshminrusimha S, Rabe H, McAdams R, Mercer JS. Placental transfusion: a review. J Perinatol. 2017;37:105–11.
Nightingale Electronic Reporting System. Burlington, VT: Vermont Oxford Network. Accessed November 1, 2018.
Beal J, Silverman B, Bellant J, Young TE, Klontz K. Late onset necrotizing enterocolitis in infants following use of xantham gum-containing thickening agent. J Pediatr. 2012;161:354–6.
Zimmerman KO, Smith PB, Benjamin DK, Laughon M, Clark R, Traubeet C, et al. Sedation, analgesia, and paralysis during mechanical ventilation of premature infants. J Pediatr. 2017;180:99–104.e1.
Sackett DL, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice & teach EBM. Edinburgh, Scotland: Churchill Livingstone, Harcourt Brace and Company; 1998.
Kaempf JW, Dirksen K. Extremely premature birth, informed written consent, and the Greek ideal of sophrosyne. J Perinatol. 2018;38:306–10.
Celenza JF, Zayack D, Buus-Frank ME, Horbar JD. Family involvement in quality improvement: from bedside advocate to system advisor. Clin Perinatol. 2017;44:553–66.
Savel RH, Goldstein EB, Gropper MA. Critical care checklists, the Keystone Project, and the Office for Human Research Protections: a case for streamlining the approval process in quality improvement research. Crit Care Med. 2009;37:725–8.
Dutta S, Singh B, Chessell L, Wilson J, Janes M, McDonald K, et al. Guidelines for feeding very low birth weight infants. Nutrients. 2015;7:423–42.
Toussaint JS, Berry LL. The promise of Lean in health care. Mayo Clin Proc. 2013;88:74–82.
Kaempf JW, Wang L, Dunn M. Using a composite morbidity score and cultural survey to explore characteristics of high proficiency neonatal intensive care units. Arch Dis Child Fetal Neonatal Ed. 2018. https://doi.org/10.1136/archdischild-2017-313715.
Grossman MR, Berkwitt AK, Osborn RR, Xu Y, Esserman DA, Shapiro ED, et al. An initiative to improve the quality of care of infants with neonatal abstinence syndrome. Pediatrics. 2017;139:e20163360.
Aly H, Mohamed MA, Wung JT. Surfactant and continuous positive airway pressure for the prevention of chronic lung disease: history, reality, and new challenges. Semin Fetal Neon Med. 2017;22:348–53.
Schulman J, Dimand RJ, Lee HC, Duenas GV, Bennett MV, Gould JB. Neonatal intensive care unit antibiotic use. Pediatrics. 2015. https://doi.org/10.1542/peds.2014-3409.
Berwick DM. Disseminating innovations in health care. JAMA. 2003;289:1969–75.
Algaze CA, Shin AY, Nather C, Elgin, Krisa H, Ramamoorthy C, et al. Applying lessons from an inaugural clinical pathway to establish a clinical effectiveness program. Pediatr Qual Saf. 2018;3:e115.
Cheong JLY, Anderson PJ, Burnett AC, Roberts G, Davis N, Hickey H, et al. Changing neurodevelopment at 8 years in children born extremely preterm since the 1990s. Pediatrics. 2017;139:e20164086.
Twilhaar ES, Wade RM, de Kieviet JF, van Goudoever JB, van Elburg RM, Oosterlaan J. Cognitive outcomes of children born extremely or very preterm since the 1990s and associated risk factors: a meta-analysis and meta-regression. JAMA Pediatrics. https://doi.org/10.1001/jamapediatrics.2017.5323.
Adams-Chapman I, Heyne RJ, DeMauro SB, Duncan AF, Hintz SR, Pappas A, et al. Neurodevelopmental impairment among extremely preterm infants in the Neonatal Research Network. Pediatrics. 2018;141:e20173091.
Cummings JC. Committee on Fetus and Newborn. Clinical Report—Antenatal counseling regarding resuscitation and intensive care before 25 weeks of gestation. Pediatrics. 2015;136:588–95.
Raju TNK, Mercer BM, Joseph GF. Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-FetalMedicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. J Perinatol. 2014;34:333–42.
Mafi JN, Parchman M. Low-value care: an intractable global problem with no quick fix. BMJ Qual Saf. 2018;27:333–6.
Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham CX, et al. Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. JAMA Int Med. 2017;177:195–205.
Annas GJ. Reframing the debate on healthcare reform by replacing our metaphors. N Engl J Med. 1995;332:744–7.
Gooding JS, Cooper LG, Blaine AI, Franck LS, Howse JL, Berns SD. Family support and family-centered care in the neonatal intensive care unit: origins, advances, impact. Sem Perinatol. 2011;35:20–28.
Ayanian JZ, Markel H. Donabedian’s lasting framework for health care quality. New Engl J Med. 2016;375:205–7.
Georgieff M. The role of nutrition in neonatal nutrition. American Academy of Pediatrics District VIII Conference plenary presentation. Seattle WA, 2017.
Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of adverse childhood experiences from the 2011–4 behavioral risk factor surveillance system in 23 states. JAMA Pediatr. 2018. https://doi.org/10.1001/jamapediatrics.2018.2537.
Harrison W, Goodman D. Epidemiologic trends in neonatal intensive care. JAMA Pediatr. 2015;169:855–62.
Edwards EE, Horbar JD. Variation in use by NICU types in the United States. Pediatrics. 2018. https://doi.org/10.1542/peds.2018-1457.
Stowell C, Robicsek A. Endless forms most beautiful: evolving toward higher value care. NEJM Catalyst. 2018. https://catalyst.nejm.org/evolving-high-value-care-value-oriented-architcture/.
Berwick DM. Politics and healthcare. JAMA. 2018;320:1437–8.
Le Guin UK. Lao Tzu Tao Te Ching—A book about the way and the power of the way. Boulder, CO: Shambhala Publications, Inc; 1997.
Wittgenstein LW. Tractatus logico-philosophicus. New York, NY: Harcourt Brace and Company; 1922.
Krutch JW. The modern temper. New York, NY: Harcourt Brace and Company; 1956.
Muller HJ. The uses of the past. New York, NY: Oxford University Press; 1952.
Dr. Kaempf conceptualized the essay and drafted the initial manuscript. Dr. Suresh added insights, more references, and participated in the subsequent formulation. Both authors reviewed and approved the final revision.
This collaborative quality improvement report was supported by the Providence St. Joseph Health System and Providence Foundation, Women and Children’s Services, Portland, OR.