Developing a Sustainable Quality Improvement Program in an Academic Center: The Experience of an Adolescent Unit.

Introduction: Successful quality improvement (QI) efforts use a comprehensive, institutional QI framework and professional development, but literature describing implementing QI frameworks in Adolescent Medicine practices is sparse. We aimed to implement and increase the number of formally structured QI projects (primary aim) and the number of projects achieving a centerline (CL) shift (secondary aim) in our hospital's Adolescent Medicine Clinic. Methods: We used formal QI methodology to improve health outcomes by increasing the number of faculty with formalized QI education, creating interdisciplinary QI teams, and improving staff motivation. QI education was mandatory for Adolescent Medicine fellows and pediatric residents and encouraged for faculty and staff. The Divisional QI leadership team attended monthly meetings to review key driver diagrams, run and control charts, and receive intervention updates. All providers and staff received monthly updates, and the Hospital Quality and Safety Committee received biannual updates. We used run charts to share progress with primary and secondary aims. Results: Since Q3 2014, the Adolescent Medicine team consistently achieved the primary aim of having 5 active projects in process, with 9 projects from Q1 2018-Q4 2020. For the secondary aim, a target of 50% of active QI projects attaining a sustained centerline shift was achieved in Q2 2018 and maintained in 16 of 20 quarters since. Conclusions: Clinicians can use QI methodology to improve health outcomes while facilitating professional development. For this initiative to succeed, institutional leadership must provide an infrastructure prioritizing meaningful QI involvement.

Quality Tool School: Improving the Delivery of Quality Improvement Education in a Children's Hospital.

Background: In 2013, Nationwide Children's Hospital's (NCH) Quality Tool School (QTS) was created as an initial Quality Improvement educational series, composed of three separate classes, totaling 5.5 hours of hands-on QI training. QTS complemented the NCH 40-hour Quality Improvement Essentials course. Methods: Over 10 years, the series went through three phases of aims: Phase 1: develop and implement three core courses (Project Tools, Excel, and Control Charts); Phase 2: have participants complete the entire series of all three classes; Phase 3: have participants who complete the entire series of all three classes demonstrate the application of learning through involvement in a quality improvement project. Results: Since initiation, QTS has provided an educational entry point for 1428 NCH employees to participate in QI projects and teams. QTS has shown statistically significant improvement in 2 of the 3 principal aims. The Phase 1 metric of average monthly one-class participation completion percentage showed a statistically significant centerline shift from 9 to 16 students in October 2018. The Phase 3 metric Percentage of QTS participants completing the QTS series of classes and then participating in a QI team began in 2016 with a baseline of 42%. A centerline shift from 42% to 63% occurred in Q4 2018. Conclusions: QTS can provide QI education to healthcare system employees using limited resources. Organizations that strategically integrate a culture of QI into core beliefs can realize substantial improvement gains.

Increasing access to psychological services within pediatric rheumatology care.

BACKGROUND: Given the impact of psychological factors on rheumatic disease, pediatric psychologists serve a vital role in promoting quality of life and managing common problems among youth with rheumatic disease. The aim of this project was to increase access to psychological services among youth with rheumatic disease at a children's hospital. METHODS: A quality improvement (QI) team identified key drivers and interventions aimed to increase access to psychological services for youth with rheumatic disease. Data was collected for a 6-month baseline period and 4-year intervention period. We applied the Plan-Do-Study Act method of QI and the American Society for Quality criteria to adjust the center line and control limits. RESULTS: There were two statistically significant center line shifts in the number of patients seen by psychology and one statistically significant shift in referrals to psychology over time with applied stepwise interventions. Patients seen by a psychologist increased by 3,173% from a baseline average of 1.8 to 59.9 patients seen per month (p < 0.03). Psychology referrals increased by 48% from a baseline average of 9.85 to 14.58 referrals per month over the intervention period (p < .01). CONCLUSIONS: Youth with rheumatic disease received increased access to mental health treatment when psychological services were imbedded within rheumatology care. Psychology referrals also increased significantly, suggesting that psychology integration within a medical clinic can increase identification of needs. Results suggest that psychology integration into rheumatology care may increase access to mental health treatment and identification of psychological needs in this at-risk population.

Implementing Evidence-Based, Electronic, Substance-Use Screening in a Primary Care Clinic.

PURPOSE: Substance use is common among adolescents, and among those with substance use disorders; use often persists into middle age, underlying the importance of early detection and treatment. The goal of this quality improvement project was to increase the electronic substance use screening rate of adolescents presenting for preventative health visits from 0% to 50% between March 2021 and September 2021. METHODS: This is an ongoing quality improvement project. Participants included patients ≥12 who presented to the Adolescent Medicine Clinic for preventative health visits. We incorporated the Screening to Brief Intervention into the existing Car, Relax, Alone, Forget, Friends, Trouble tool within the electronic health record. We completed a Plan-Do-Study-Act cycle by reviewing every patient's chart who did not receive screening and identified that a common reason for missed screening was designating the visit as "establishing care" rather than preventative health visit. We modified our eligible patient criteria to include all adolescents presenting to establish primary care. RESULTS: We achieved a statistically significant center-line shift with a p value (<.001) from approximately 0% at baseline to a new baseline of 85% from June 2021 to June 2022. After broadening our eligibility criteria, our electronic screening rate improved from 78% in November 2021, to 83% in December 2021. DISCUSSION: Electronic health record integration of the Screening to Brief Intervention/Car, Relax, Alone, Forget, Friends, Trouble is an effective method to systematically and electronically screen adolescents for SUD at preventative health visits. Integration using similar approaches may benefit other institutions interested in providing standardized SUD screening.

Preventing Teen Pregnancies on Teratogenic Drugs by Quality Improvement and Behavioral Economics.

BACKGROUND: Adolescents with chronic disease engage in sexual activity similar to their healthy peers, with generally low utilization of contraception. Adolescents with rheumatic diseases prescribed teratogenic medications may be at risk for unplanned pregnancy. METHODS: Using structured quality improvement (QI) methods with behavior economic (BE) principles, a multidisciplinary team aimed to implement pregnancy prevention processes for females on high-risk medications. We leveraged BE-inspired interventions including improved accessibility of consents, utilizing distinctly colored consent forms, real-time reminders, peer comparison, and audit and feedback. Our primary aim was to increase the number of days between pregnancies for postmenarcheal females followed in rheumatology clinics who were taking teratogenic medications. Phase 1 focused on annual consenting of female adolescents prescribed teratogenic drugs. Phase 2 emphasized sexual history screening and pregnancy prevention planning at every clinic visit for females ≥12 years on teratogenic medications. RESULTS: We increased the days between pregnancies for female adolescents prescribed teratogenic medications from 52 days to >900 days by using QI methodology with BE strategies. In phase 1, annual consents for postmenarcheal patients on teratogenic medications improved from 0% in 2017 to 95% in 2021. In phase 2, sexual history screening and pregnancy prevention planning at every clinic visit improved from 2% in 2019 to over 78% in 2021. CONCLUSIONS: A multiphase, multidisciplinary QI project with integration of behavior economic strategies can improve patient and caregiver counseling to prevent unplanned pregnancies for adolescents on teratogenic medications.

Timely Access to Mental Health Services for Patients with Pain.

Efficient access to pediatric mental health services is a growing concern as the number of patients increases and outpaces efforts to expand services. This study outlines interventions implemented using quality improvement (QI) science and methodology to demonstrate how a clinic embedded in a large children's hospital can improve access to the first appointment for a population seeking pain management services. METHODS: A process improvement project started with a QI team, whose members designed interventions to change scheduling practices. Initial changes involved decreased time between calls to families, and efforts to streamline notifications among clinicians. Additional interventions included a close examination of waitlist assignment based on appropriateness and assessing patient interest in treatment. RESULTS: Within 3 months of implementation, a significant decline in wait time occurred for patients seeking services for pain management, from 106 to 48 days. This change remained stable for 6 months. In light of a sharp increase in referrals and wait time during the study period, efforts to engage additional clinicians in managing referrals resulted in wait time to stabilize at an average of 63 days to the first appointment. This change remained for 10 months. Scheduling changes did not negatively affect other providers. CONCLUSIONS: This study demonstrates the application of QI science to improve patient access to mental health care. Future directions will focus on enhancing the use of the electronic health record, along with previsit family engagement.

Decreasing Radiograph Errors in Pediatric Sports Medicine Clinic.

BACKGROUND: Radiographs are frequently ordered for general musculoskeletal complaints in the outpatient setting. However, incorrect laterality, incorrect location, or unnecessary radiographs have been reported as errors in our clinics. This quality improvement (QI) project aimed to reduce incorrect duplicate radiographs in outpatient pediatric sports medicine clinic. The overall global goal was to stop unnecessary radiation exposure in our pediatric patients. METHODS: Using QI methodology, we evaluated the current clinic flow, the process of ordering radiographs, and the completion of radiographs at the main sports medicine outpatient clinic. Staff communication, staff education, and patient participation were identified as the prominent gaps in our clinic process. We implemented interventions using progressive biweekly Plan-Do-Study-Act (PDSA) cycles to promote change and to reduce our radiographic errors. RESULTS: Retrospective baseline data demonstrated baseline errors of 9% (10/106) in the main outpatient clinic. After 6 months of PDSA cycles, we found no duplicate errors. Highly successful interventions included radiograph screening survey for families, staff education, and improved staff communication. The project was expanded to a second outpatient clinic with baseline errors of 6% (4/64). After 2 months of PDSA cycles, no duplicate errors were found. CONCLUSION: Our goal was to reduce incorrect duplicate radiographs in outpatient sports medicine clinic and limit unnecessary radiation exposure in our pediatric patients. A reduction in duplicate errors at 2 clinics occurred using the Institute for Healthcare Improvement model to facilitate change. Effective communication between physicians, clinical athletic trainers, radiology technologists, patients, and families drove the success of this quality improvement initiative.