382 - Institutional Culture at the Limit of Viability: a multi-center mixed methods study

Publication Number: 4374.382

Shannon Adams-Hartung, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Jessica T. Fry, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States; Natalia Henner, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States

Background: Significant inter-center variation in perinatal management exists in the 22-to-24-week gestational age range. Subsequently, there is significant inter-center variation in outcomes for infants born at these gestational ages. There are many factors that could contribute to this discrepancy. "Institutional culture," defined as "the beliefs, norms, attitudes, and assumptions that are learned over time, shared by [an] organization's members, and operate usually at a subconscious level," may be one of them (Figure 1).

Objective: To characterize how medical teams across perinatal centers depict their local institutional culture regarding the antenatal, delivery, and postnatal management of periviable pregnancies.

Design/Methods: Based on pilot qualitative research performed by our team, we developed a novel survey tool to measure institutional culture related to periviability management. A first draft of the survey was designed with the support of Lurie's Smith Child Health Catalyst team. This initial tool was refined through cognitive interviews and consensus meetings with a multidisciplinary team of experts from multiple institutions specifically chosen to support this work, including a parent partner. A revised version of the survey was then administered to obstetric and neonatal staff for pilot testing at two geographically disparate intuitions. Pilot testing responses were reviewed to determine instrument validity before a finalized survey was declared ready for widespread distribution.

Results: Survey tool refinement occurred over a period of several months with multiple rounds of iteration. Pilot testing yielded 20 responses from both obstetric and neonatal providers with a wide range of clinical experience. The survey received positive feedback, and results were appropriately varied. General observations from select portions of the survey can be found in Tables 1 and 2. Initial results are limited but indicate participant-identified moral distress and a culture of pessimism around the care of periviable pregnancies, as well as a perceived importance of interdisciplinary counseling and collaboration.

Conclusion(s): Our novel survey instrument is now suitable for widespread distribution. Our team has made connections with individuals at multiple centers who will partner with us to facilitate data collection. Survey data will be analyzed at an institutional level to quantitatively characterize local culture. This project will culminate in the correlation of local culture data with local outcomes data including maternal and neonatal morbidity/mortality, to assess for patterns and associations.

Figure 1
Conceptual model

Table 1
Important components of periviable management

Table 2
Perceived institutional competence