Primary Care Quality Improvement Metrics and National Committee on Quality Assurance Medical Home Recognition for Children With Medical Complexity.

The Complex Care Center at Cincinnati Children's Hospital Medical Center developed and implemented a set of evidence-based clinical process measures of immunization delivery, preventive and chronic condition laboratory screening, and behavioral health medication surveillance for use in the primary care setting. METHODS: Improvement activities focused on 4 measures across 4 domains mandated by the National Committee on Quality Assurance for patient-centered medical home recognition. Interventions were implemented in phases from January 2017 to October 2018. The goal was the improvement in immunizations, preventive lead screening, vitamin D testing in chronic conditions, and behavioral health medication surveillance. Preventative lipid screening in the entire population and thyroid-stimulating hormone levels in patients with Down syndrome were also measured. RESULTS: The offering and the completion of an immunization bundle increased from a mean of 61.0% to a mean of 83.7% of patients. Eligible patients with documented lead surveillance increased from 61.2% to 96.5%. Patients with documented 25-hydroxy vitamin D levels increased from 72.2% to 87.8%. The percentage of patients metabolically monitored while taking an atypical antipsychotic continued at 92.0%. CONCLUSIONS: Using quality improvement education, data measurement/feedback, electronic medical record optimization/decision support, and care gap identification with planned care, the Complex Care Center demonstrated improved reliability in needed immunization delivery and laboratory screenings for a heterogeneous primary care population of children with medical complexity. As the numbers of children with medical complexity rise, so does the importance of reliable processes and relevant measures for quality in their unique care delivery systems.

Using Lean methodologies to streamline processing of requests for durable medical equipment and supplies for children with complex conditions.

BACKGROUND: An improvement team from the Complex Care Center at our large pediatric medical center participated in a 60-day initiative to use Lean methodologies to standardize their processes, eliminate waste and improve the timely and reliable provision of durable medical equipment and supplies. METHODS: The team used value stream mapping to identify processes needing improvement. Improvement activities addressed the initial processing of a request, provider signature on the form, returning the form to the sender, and uploading the completed documents to the electronic medical record. Data on lead time (time between receiving a request and sending the completed request to the Health Information Management department) and process time (amount of time the staff worked on the request) were collected via manual pre- and post-time studies. RESULTS: Following implementation of interventions, the median lead time for processing durable medical equipment and supply requests decreased from 50 days to 3 days (p < 0.0001). Median processing time decreased from 14min to 9min (p < 0.0001). The decrease in processing time realized annual cost savings of approximately $11,000. CONCLUSIONS: Collaborative leadership and multidisciplinary training in Lean methods allowed the CCC staff to incorporate common sense, standardize practices, and adapt their work environment to improve the timely and reliable provision of equipment and supplies that are essential for their patients. IMPLICATIONS: The application of Lean methodologies to processing requests for DME and supplies could also result in a natural spread to other paperwork and requests, thus avoiding delays and potential risk for clinical instability or deterioration.

Quality Improvement Strategies for Population Management of Children With Medical Complexity.

BACKGROUND AND OBJECTIVES: Children with medical complexity require the expertise of specialists and hospitals but may lack primary care to provide preventive, acute, and chronic care management. The Complex Care Center (CCC) at Cincinnati Children's Hospital Medical Center employed quality improvement methodologies in 3 initiatives to improve care for this fragile population. METHODS: Improvement activities focused on 3 main areas: population identification and stratification for care support, reliable delivery of preventive and chronic care, and planned care to identify and coordinate needed services. RESULTS: The percent of patients who attended a well-child care visit in the previous 13 months increased 91% and was sustained for the next year. The median monthly no-show rate remained unchanged. Within 10 months of implementing the interventions, >90% of CCC patients <7 years of age were receiving all recommended vaccines. Seventy-two percent of all CCC patients received their annual influenza vaccine. A sustained 98% to 100% of children with a complex chronic disease received previsit planning (PVP) for their well-child care and chronic condition management visits, whereas only 1 new patient did not receive PVP. CONCLUSIONS: Children with medical complexity require adaptations to typical primary care processes to support preventive health practices, chronic and acute care management, immunization, and collaborative care with their multiple specialists and support providers. We used quality improvement methodology to identify patients with the highest needs, reliably deliver appropriate preventive and chronic care, and implement PVP.

Identifying interprofessional global health competencies for 21st-century health professionals.

BACKGROUND: At the 2008 inaugural meeting of the Consortium of Universities for Global Health (CUGH), participants discussed the rapid expansion of global health programs and the lack of standardized competencies and curricula to guide these programs. In 2013, CUGH appointed a Global Health Competency Subcommittee and charged this subcommittee with identifying broad global health core competencies applicable across disciplines. OBJECTIVES: The purpose of this paper is to describe the Subcommittee's work and proposed list of interprofessional global health competencies. METHODS: After agreeing on a definition of global health to guide the Subcommittee's work, members conducted an extensive literature review to identify existing competencies in all fields relevant to global health. Subcommittee members initially identified 82 competencies in 12 separate domains, and proposed four different competency levels. The proposed competencies and domains were discussed during multiple conference calls, and subcommittee members voted to determine the final competencies to be included in two of the four proposed competency levels (global citizen and basic operational level - program oriented). FINDINGS: The final proposed list included a total of 13 competencies across 8 domains for the Global Citizen Level and 39 competencies across 11 domains for the Basic Operational Program-Oriented Level. CONCLUSIONS: There is a need for continued debate and dialog to validate the proposed set of competencies, and a need for further research to identify best strategies for incorporating these competencies into global health educational programs. Future research should focus on implementation and evaluation of these competencies across a range of educational programs, and further delineating the competencies needed across all four proposed competency levels.