Improving commitment to family-centered care in the NICU: a multicenter collaborative quality improvement project

Introduction

In 1993, Helen Harrison, a NICU (Neonatal Intensive Care Unit) Parent, collaborated with Drs. Jerold Lucey and William Silverman to create ten principles of family-centered neonatal care [1]. This collaborative effort including family voices laid the groundwork for the basis that families play integral roles in NICUs. Family-Centered Care (FCC) in the NICU is a key factor in improving infant health and family mental health outcomes as well as in empowering family participation in their infant’s care [2]. Disparities in neonatal health outcomes across racial and ethnic lines persist and may be exacerbated by a lack of family involvement or inclusion in the NICU [3].

NICU families should be empowered and supported by clinicians as they care for their infant(s); therefore, it’s important to train healthcare professionals to adopt family-centered approaches. True adoption of FCC culture in healthcare involves not only incorporating family-centered practices clinically at the bedside but also involving family partners (former NICU families) in quality improvement (QI) work, facilitating communications with all inpatient families, and developing FCC guidelines and policies. By integrating family partners, units can ensure the longevity and sustainability of FCC culture.

Problem descriptions

While principles of FCC have been identified and guidelines for implementing FCC in the NICU have been developed [4, 5], many NICUs face significant challenges with incorporating FCC practices and models into their existing workflows, and the uptake of FCC by NICUs has not been widespread or rapid. A national survey of the AAP (American Academy of Pediatrics) TECaN (Trainees and Early Career Neonatologists) interest group showed that 65% (31/48) of respondents did not have committees overseeing FCC activities in their NICUs and family partners were not a routine part of their QI work. Multiple barriers to implementation exist, including but not limited to existing NICU culture, NICU staff time constraints, parents who cannot be present in the NICU, lack of dedicated financial resources, and leadership buy-in [6, 7].

By prioritizing and integrating the lived experiences and insights of former NICU families formally through constructs such as committees, we can collectively overcome many of these barriers and create a culture of FCC. These family partner-inclusive committees are an integral step in creating a culture of FCC and promoting the importance of family-centeredness in all aspects of neonatal care, from written policies to bedside care to QI initiatives. We embarked on a QI collaborative model, aiming to enhance FCC practices by assisting centers in forming an FCC committee and Family Partnership Council (FPC) in their units. Drawing from a previous study, our focus was on creating local committees to oversee FCC activities with the belief that a strong local team and FCC champions would improve FCC practices in participating units [8]. During this process, we also explored barriers in forming FCC committees and FPCs.

Methods

Setting

This QI effort was facilitated by the FCC Taskforce, an international, multicenter collaborative solely focused on FCC in the NICU [9]. The FCC Taskforce recruited participants and provided the infrastructure for collaborative small groups. Although the FCC Taskforce now represents 1950 members in 65 countries, in the recruitment phase of this initiative, the FCC Taskforce had 50 members from only the US and Israel. Units recruited to the QI initiative were asked to participate in one of five small groups, with the primary goal of establishing a FCC Committee and/or FPC in order to promote FCC practices locally. Each small group consisted of 4–6 centers matched by AAP NICU Levels (III & IV) and led by two neonatologists and 1–2 family partners. Both neonatologist leaders and family leads of the small groups were members of the Executive Council of the FCC Taskforce. All of these individuals demonstrated a commitment to FCC in their own units and to promoting FCC as a standard of care in neonatology. These five small groups met monthly to share challenges in implementing FCC and brainstormed ideas around overcoming barriers to creating an FCC committee and/or FPC in their centers.

Additionally, we created a schedule of bimonthly webinars starting in May of 2022. By organizing these free educational webinars to promote FCC practices, share implementation strategies, and highlight former NICU parent insights, we provided resources for NICUs to adopt an FCC model. The ultimate goal of the FCC Taskforce is to promote a variety of FCC initiatives and to track FCC quality improvement metrics. However, we recognize that different units are in different phases of development of FCC constructs, and some of the participating units were just beginning to integrate the concepts of FCC into their workflows. We feel that one of the most basic and necessary frameworks to be successful in FCC is the existence of a committee dedicated to promoting FCC culture. As a result, we chose to start with this as a unified goal for participating units and selected the time period of January-December 2023 based on unit recruitment and small group formation.

Design

At the beginning of the project, centers were surveyed about their characteristics and existence of a FCC committee and FPC in their units, as well as the barriers and challenges they faced in forming FCC committees and FPCs. An FCC committee was defined as a multidisciplinary team of health care professionals that meets regularly and aims to empower family participation in the NICU. They were considered active if they had at least quarterly meetings and somewhat active if they met less than four times annually. FPC was defined as a hospital-wide or NICU-specific group of clinicians and family partners committed to ensuring high quality of care and patient experiences. Specifically, FPCs included engaged members of several former NICU families collaborating with clinicians at different levels. If they met at least twice a year, they were considered active and if they met only once a year, somewhat active.

Each center’s passionate FCC champion (physicians, nurses), a key leader in the implementation of FCC, voluntarily completed a survey three times throughout the project from January 2023 to December 2023 to capture baseline, mid-year, and end-of-year data.

Specific aims

Our SMART (Specific, Measurable, Achievable, Relevant, Time-bound) aims were as follows:

1.

To increase the percentage of NICUs with an active NICU-specific FCC Committee from a baseline of 18% in January 2023 to 28% (absolute increase of 10%) by December 2023, and
2.

To increase the percentage of NICUs with an active FPC from a baseline of 18% in January 2023 to 28% (absolute increase of 10%) by December 2023.

Interventions

We tested the efficacy of a small group mentoring model and targeted webinar curriculum to increase the percentage of NICUs with committees overseeing FCC activities.

Small group mentoring model

We shared a key driver diagram with an aim to establish a NICU-specific FCC committee and FPC (Fig. 1a) in all centers within the small groups. Key drivers included 1) obtaining leadership commitment/buy-in, 2) increasing staff education, 3) reducing barriers to family participation, and 4) reducing barriers to staff participation. Small group leaders shared their local center change ideas and used the mentoring model to overcome barriers to improve FCC practices. Small group members also described that having reflection sessions with their mentors where they could express their ideas and concerns about FCC helped them to get a better understanding of FCC. Within small group discussions, each center was encouraged to make modifications to fit their own institution’s likely key drivers in order to achieve change which gave them flexibility and, most of all, involvement in the staff’s implementation of FCC, including them from the first idea until the actual implementation, which gave them autonomy.

We also discussed the various iterative Plan Do Study Act (PDSA) cycles each center planned to pursue and process measures they should follow to increase FCC activities. These were specific to each center’s QI initiatives, and we were able to highlight many similar barriers among centers and share challenges and successes.

Educational webinar

Other interventions focused on education to change unit culture through free bimonthly webinars. The webinar curriculum equally represented medical expert and family perspectives on FCC, with each webinar including family partners as speakers. Equal representation of healthcare professionals and family partners was and is a top priority for the FCC Taskforce, modeling for our membership how to successfully integrate family partners as collaborators by including them as webinar speakers, small group leaders, executive council members, and in Taskforce leadership.

The FCC Taskforce selected topics for webinar presentations that addressed many of the barriers identified in our process mapping and our small group discussions. These included (but were not limited to):

The NICU dad perspective and associated disparities in FCC
How to implement a Family Partnership Council
Examples of practical ways to implement FCC
How to engage families in QI work at both the local and national level

Each webinar encouraged open discussion with robust, insightful, judgment-free conversations during these live events. Creating a psychologically safe virtual environment for family and healthcare partners to share their challenges, worries, and solutions around FCC practices was critical to effective learning for all participants. The Taskforce made intentional efforts to break down hierarchical barriers in FCC implementation by elevating the perspectives of often marginalized communities such as people of color, non-birthing parents, and women by following “All in Meeting” Guideline (https://necsociety.org/2019/07/12/nec-societys-10-step-guide-for-an-all-in-meeting/).

Statistical analysis

We used Pareto charts for process mapping, Statistical Process Control charts to evaluate special cause variation, and chi-square for group comparison. The Stanford University IRB reviewed this protocol (IRB-74207) and classified our study as a QI project. This manuscript was created using revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guidelines [10].

Results

Context survey

Thirty-four NICUs across the US and Israel were recruited for the study. Nine dropped out by mid-year. Twenty-two NICUs completed the survey at all 3 timepoints. Supplementary Table 1 shows the demographics of the 22 participating NICUs.

Process mapping

Based on responses from each center’s FCC champion to our initial survey, we constructed Pareto charts (Fig. 2a, b) to identify the most common barriers to forming an FCC committee, FPC and to providing FCC. For FCC implementation, the top barrier was lack of staff time, followed by resistance to NICU culture change, lack of family presence, lack of a family-friendly NICU environment, and lack of leadership buy-in. For FPC, nearly a quarter of participating units reported every barrier listed on our survey was a challenge for their local institution – these barriers included families unable to join meetings, difficulties with recruiting families, financial factors, lack of staff time, lack of leadership buy-in, and uncertainty about how to set up an FPC.

Outcome measures

Six of 22 participating centers (Fig. 3a, green) could not commit to forming an FCC committee in their local unit. All others successfully established either active or somewhat active FCC committees. Active FCC committees increased from baseline 18% to 23% midpoint to 59% at the end of the project (Fig. 3a) and active FPCs stayed the same 18% at baseline and midpoint and increased to 45% at the end (Fig. 3b). The demographics (Supplementary Table 2) between centers who successfully formed an FCC committee [11] versus centers who did not successfully form [6] were similar except centers that those that successfully formed FCC committees were more likely to have an FCC champion who recruited staff to join the FCC Taskforce (11 vs 1, p = 0.02).

Process measures

The FCC Taskforce collaborated with many organizations and created an FCC Taskforce Marketing and Communications committee to put together the bi-monthly webinar series. Educational webinars were shared widely with Taskforce members and their colleagues through partner organization mailing listservs and on several social media platforms. Viewers included multidisciplinary members of the healthcare team – nurse leaders, therapists, social workers – and leaders of quality improvement, advocacy, and educational organizations with a NICU-specific focus. Taskforce members and non-members alike could view and share past webinar recordings for free on www.fcctaskforce.org, and seek out topics that specifically address their needs in improving FCC practices in their local NICUs. As a process measure, we tracked webinar views per month from May 2022 to July 2024. We showed improvement in bimonthly webinar views with special cause variation was demonstrated by a shift above the center line starting in January 2023, indicating a non-random, significant change in webinar views after creation of the website and the creation of a marketing and communications committee. Specifically, we noted an increase in webinar views from an average of 28 views per webinar to an average of 182 views per webinar, representing a 546% increase. This signal change was sustained through our most recent data collection in July 2024 (see XmR SPC chart, Fig. 4).

Strategies from three individual units

While we had 22 units participate in the small group collaborative, we cannot present the detailed work of each of these units in this manuscript. As a result, we have selected three case examples of participating units to demonstrate the breadth of work and unique experience at three different types of sites; namely a community level III NICU, an academic level IV NICU, and international level III NICU.

Family-centered care committee formation in El Camino Health, community level III NICU, Mountain View, CA

El Camino Health is a 22-bed level III NICU in a community hospital staffed by academic neonatologists in Silicon Valley, California. Initial brainstorming sessions were held at the administrative level between the nursing director, nursing manager, NICU medical director, and several attending neonatologists. We (MB, DS, and team) identified stakeholders to support beginning the FCC committee and subsequently sustaining this program. Stakeholders included the patient experience department, senior hospital administration team, nurses, physicians, and our former families whose babies had been cared for in the NICU. We created a key driver diagram (Fig. 1b) addressing change ideas.

Staff recruitment & engagement

Because staff play a crucial role in delivering FCC, we started recruiting staff based on their exceptional care at the bedside. Being part of an FCC committee would help them move up the clinical ladder, and this information was used for buy-in. Participating staff also received administrative time support for their work. Given busy work schedules, instead of creating a large FCC committee with poor staff participation and a resulting inability to hear everyone’s voice, we created smaller subcommittees that were given autonomy in establishing and sustaining programs and motivating bedside staff FCC champions. We showed improvement in staff engagement in the first PDSA cycle. Each subcommittee regularly shared their progress or concerns with the FCC chair (MB), which was communicated to NICU leadership.

Staff education

The FCC leadership team created an orientation checklist that included all FCC activities and educated all clinicians, including new hires, travel nurses, and trainees, during their orientation and yearly professional development days. After educational FCC activities, the FCC chair created fun raffle prizes for those who shared their “lessons learned,”’which are published in an FCC newsletter shared widely with the entire Maternal Child Health Department at the hospital.

Leadership commitment

FCC chair (MB) and NICU medical director (DS), played a pivotal role in outlining the FCC program and its benefits to senior administration. During the initial stages of forming our FCC committee, the patient experience team provided NICU-specific parent satisfaction scores for various categories. Both hospital administration and healthcare professionals agreed to aim to enhance the scores in some categories through QI projects targeting FCC over the next few years. Hospital leadership committed to compensating nursing and physician time for these QI projects.

Former NICU families recruitment

We have been hosting our “NICU Reunion” annually for graduates and use this event to secure contact information for those interested in giving back. Healthcare professionals on our unit utilized those contacts to organize our Family Advisory Committee (FAC), which allowed former NICU parents to share their expectations, needs, and experiences with our providers. The FAC has provided us with clear tasks to undertake toward improving FCC, which have been instrumental in improving our parent satisfaction scores. Throughout the journey, former NICU families were able to actively partner with clinicians to join FCC subcommittees and provide invaluable insights, so we changed the name of this group to Family Partnership Council (FPC) in 2022 to better reflect the active role of this group.

Family Partnership Council formation, Ann & Robert H. Lurie Children’s Hospital, level IV NICU, Chicago, IL

Lurie Children’s Hospital is an urban, university-based level IV 64-bed referral NICU in Chicago; all infants are outborn and referred in for subspecialty care. Our hospital had an active hospital-wide Family Advisory Board, consisting of several former patients’ families but we wanted to develop a NICU-specific one and to engage parents as partners, beyond an advisory role. To begin, we (KM and team) met with hospital leadership for guidance in developing our NICU-specific team. We sought mentorship from peer institutions with established parent partners. To gain families’ perspectives, we conducted a needs assessment regarding the strengths and gaps of FCC in our NICU. 82% of parents stated they would value a program that engaged NICU alumni parents in providing parent support and a stakeholder perspective to various aspects of NICU care. With this information, we approached leadership and individuals in key disciplines (e.g., nursing, social work, child life services, case management, therapists, psychologists) that enthusiastically supported the mission of creating a council to oversee FCC activities and helped us develop it. We agreed the primary focus of the FPC was to initiate projects driven by parents and supported by staff. The secondary focus was to provide an advisory board of parent stakeholders for their perspective on research, QI, and clinical NICU projects and programs.

Family recruitment

Once our FPC framework was established, we recruited families of diverse backgrounds and clinical experiences to attempt to capture broad, representative perspectives. We asked for a one-year commitment and approached families who were at least one year out from their NICU discharge so that they could have space to focus on their child at home, heal from the NICU journey, and reflect on how their NICU experience impacted the next year of their child’s health and life. We established monthly meetings via videoconferencing (for parental convenience and because we began during the COVID-19 pandemic) at a weeknight time chosen by parents. Meetings have a strong staff presence, typically higher than parent attendance, though staff primarily listen throughout the meeting to parent discussions.

QI projects

With a strong focus on empowering parents to lead, the initial meetings centered on listening to parents’ experiences and ideas. Key themes for improvement ideas arose and we applied QI methodology (PICK (Possible, Implement, Challenge and Kill) chart) to prioritize project development. Family partners have led 6 projects, such as a comprehensive Journey to Home guide for children with medical complexities, with 2 more initiatives underway. They have provided important stakeholder input on 12 guest projects, such as a post-operative pain parent survey for a local QI project. We have hosted events for family partners to show our appreciation for their time and expertise and build community among NICU families. In three years, 23 family partners and 24 healthcare partners have committed over 700 hours of volunteer work to support project development. Within the FPC, 92% of NICU staff and family partners acknowledge the contributions parents make to systems-wide initiatives.

Family-centered care committee formation in Tel Aviv Medical Center, Tel Aviv, Israel

Tel Aviv Medical Center’s NICU is a 44-bed level III NICU located in the heart of Tel Aviv, Israel, and affiliated with Tel Aviv University. Our NICU joined one of the FCC Taskforce’s small groups and benefitted from ongoing mentorship and camaraderie. We (RM and team) focused on all primary drivers for establishing an FCC Committee (Fig. 1a) and modified change ideas according to our needs. The ongoing progress by our FCC Committee has led us to approach and recruit former NICU families as family partners, and we plan to have our first FPC meeting in 2025. Our initial discussions regarding implementing FCC elements in our NICU were informal and involved just a few team members of different disciplines (physician, nurse, social worker, and psychologist).

Our first attempt at establishing monthly FCC meetings was met with pushback from nursing team management. As a workaround, we started adding FCC agenda items to existing monthly meetings held with our occupational and physical therapists. Over time, we recruited other team members to attend these meetings (including nurses, residents, dietitians, fellows, and physicians), and eventually solidified an FCC committee that meets monthly. During these monthly meetings, we identified a few areas where we could focus our efforts to increase FCC in our NICU: 1) providing FCC education to our staff, 2) changing local work habits, and 3) pursuing family-driven projects.

Providing FCC education to staff

To increase awareness about FCC, we emphasized the basic principles of FCC with staff, including asking about skin-to-skin care during rounds, involving parents during shift change, and discussing reduction of pokes. We initiated monthly simulations led by our psychosocial team, where our physicians and nurses could practice FCC clinical care and communication. Moreover, our participation in Taskforce small group QI project introduced our FCC team leaders to approaches for coping with existing challenges and strengthened their belief that change is possible and important enough to invest in.

Changing local work habits

After receiving buy-in from certain staff, including some nursing team leaders, we began making changes by incorporating them into local daily routines. We have updated treatment protocols (e.g. skin-to-skin, blood test frequencies, etc.), recruited new neonatologists passionate about developmental care and FCC, and targeted practices that are easy to change and have a significant impact (e.g. enforcing quiet times and limiting light exposures). Changing these local habits further exposed the team to FCC practices and increased their confidence and motivation in pursuing this work.

Pursuing family-driven projects

During this Taskforce collaborative work, we held sessions with former NICU parents so that our team could better appreciate the lived experience of parents and reflect on the care they provide to families. Two families approached us with projects they had in mind to improve care, communication, and parental stress in the NICU. We were open to these ideas and started working together to fulfill these projects, which further led to our formal partnership with families in the establishment of our FPC.

Discussion

Our multicenter QI collaborative work led by family partners and healthcare professionals has successfully increased FCC committees and FPCs at hospitals in the US and Israel. Regardless of the center’s size or the number of physicians or trainees in the group, we have made significant strides in increasing the number of units with an FCC committee and FPCs in one year. Sixteen NICUs successfully formed FCC committees, and 13 of the FCC committees met 4 times a year (defined as active). Fifteen centers formed FPCs and 10 of the FPCs met twice yearly (defined as active). Based on the Framework for Family Involvement in Quality Improvement, a majority of centers in our study achieved level 2 family involvement by forming an FPC [12]. We found the small group model boosted accountability among centers and mentors were able to provide education about FCC and FPC.

Several organizations, including the AAP and World Health Organization, support FCC in their neonatal care recommendations, which is a promising development that may empower NICU clinicians to collaborate with families to adopt an FCC model of care [13, 14]. Studies have shown significant benefits of FCC for infants, which include improved overall well-being, enhanced parent-infant attachment, shorter hospital stays, and reduced readmission rates [11, 15, 16]. Parents also benefit from an FCC approach. Studies have shown FCC in the NICU reduces parental stress, increases parent confidence post-discharge, and supports parent-infant bonding [15, 17, 18]. The FCC delivery model contributes to more meaningful work, improved job satisfaction, and feelings of accomplishment among nurses [19, 20]. Although healthcare professionals may be aware of the benefits of FCC, forming an FCC committee with vested healthcare professionals and implementing FCC practices present challenges.

The process of delivering FCC has been shown to be influenced by factors across six categories: equitable relationships, the bond of trust, knowledge sharing, empowerment in the workplace, environment and culture, and regulations [7]. We identified lack of staff time as the top barrier to forming an FCC committee, a common theme identified in previous studies [6, 21]. In our first example, the team at El Camino community NICU addressed their lack of staff engagement by revamping the committee structure by forming subcommittees, providing flexibility for staff to work independently, and autonomy in owning subcommittees’ projects. A recent US study recommended addressing staffing and workflow challenges by developing a dedicated family support role, considering teaching duties when making staff assignments, employing primary care nursing, and boosting the availability of interdisciplinary team support such as social work, child life, and lactation consultation [22].

We identified resistance to culture change as another significant barrier to forming an FCC committee and providing FCC in the NICU. In bimonthly educational webinars, we shared scientific evidence and families’ lived experiences so that participating centers could better understand the importance of FCC. Small group leaders advised participants to share the webinar recordings with their center’s team, encouraging FCC as the standard of care. In our first example, the El Camino team recognized staff who went above and beyond in delivering FCC practices and consistently provided staff and trainees education by incorporating it into their orientation and yearly training. These efforts created an opportunity for staff to mentor and guide the families in the NICU, and staff invited families to return to the NICU to collaborate with healthcare professionals post-discharge. In the third example, the Tel Aviv Medical Center team had challenges obtaining nursing leadership support in forming an FCC committee. As a workaround, they began by adding an FCC agenda to existing meetings with occupational and physical therapists. Through grassroots efforts, where they educated and recruited staff from other departments over time, they eventually established a formal FCC committee.

Creating an FPC with family partners is crucial to building trust with families and learning what is important to them. In our study, fewer centers were successfully able to develop active FPCs because we learned NICU staff had difficulty recruiting family partners. Some centers were successful in forming an active FPC because they had previously established family partnerships prior to the pandemic. While family involvement lapsed during the pandemic, those centers were able to re-establish an active FPC as a result of participation in this QI study. In the first example we shared above, the El Camino community NICU weaved the FPC into the FCC committee by adding family partners to different subcommittees, including their NICU leadership team, which sustained the work even during the pandemic. In the second example, the Lurie Children’s Hospital participants focused on building a strong FPC by gathering NICU alumni perspectives in the form of a needs assessment and then approaching the NICU leadership team with the results. In the third example, the Tel Aviv Medical Center team invited family partners to shared their feedback and prioritized family-driven projects, which helped them to establish family partnership council.

Framework for Family Involvement in Quality Improvement shows there are multiple ways that families can collaborate with healthcare professionals, with the highest-level being level 5 where families co lead a QI project [12]. In our study, family partners co-led small groups, provided mentoring, and were featured speakers during every educational webinar. We achieved Level 5 family partner engagement, thereby underscoring the importance of their role in our collaborative work and enhancing the benefits of the FCC model.

Limitations

There are a few limitations and challenges to our study. We only tracked outcome measures at three points during the study period. We chose the formation of an FCC Committee and/or FPC as our primary outcome measure, which required a time commitment and an organized recruitment process from participating NICUs; 6 centers could not achieve this goal within the one-year timeframe. Since participation in the FCC Taskforce is entirely voluntary, we have in some ways self-selected participants who already embrace FCC and are passionate about its implementation. That being said, the creation of an FCC committee and/or FPC requires support from the entire institution and so the accomplishment of this primary outcome measure in our participating units cannot be solely relegated to the initiative participants already being passionate about FCC. We do strongly believe that by achieving a critical mass of NICUs with FCC committees and/or FPCs, we will make headway in advancing FCC practices even in institutions that do not already readily embrace it as a facet of quality care. Regarding our process measure, we were able to track total webinar views longitudinally. However, we could not assess the number of QI participants who viewed the webinars, though we discussed the webinars during our small group meetings and asked members to share upcoming webinar events and webinar recordings with their unit’s staff.

Because this project involved participants in different time zones across the U.S. and Israel, it was difficult for all participants to join every small group meeting. Full participation in small group meetings and webinars was also limited due to participants’ work schedules. When we began the QI collaborative, we were able to recruit 34 centers; by mid-year we lost 9 centers, and by the end of the year we were down to 22 centers. Our best guess is that the 9 centers were unable to participate due to the time commitment involved with this work and the competing obligations of most clinicians, especially since FCC is not yet considered a gold standard of care in the NICU.

Next Steps: Every participating center in this QI project is dedicated to FCC; however, each center has different areas of need and desires for focus. As a result, the FCC Taskforce is facilitating free monthly office hours to build on this collaborative work and alter the small group structure to be topic-focused. The topic-focused small groups will allow for more meaningful participation and individualized help for centers interested in advancing their FCC practices. While we recruited clinicians passionate about FCC to be part of this initial QI cohort, we hope to continue this work to include those who are not yet as focused on FCC. The FCC Taskforce has an ambitious over-arching aim to become a benchmarking institution for NICU FCC quality improvement. This manuscript describes our initial multi-site QI initiative which had a necessarily narrower focus to start, namely to encourage the development of FCC committees and FPCs. The work of the FCC Taskforce continues as we strive to measure and implement additional FCC practices and to reach even more NICUs across the globe.

Conclusion

By facilitating accountability in FCC implementation through a small group collaborative mentoring model, and sharing evidence-based FCC practices paired with critical family perspectives during webinars, this QI project created a forward movement to close the healthcare gap in delivering FCC as standard of care in the NICU setting.