Child Abuse and Neglect Risk Assessment: Quality Improvement in a Primary Care Setting.

OBJECTIVES: Practicing Safety is an American Academy of Pediatrics toolkit to help practices address child abuse and neglect (CAN) risk by increasing screening and providing resources. The objectives in an urban practice serving low-income children were to 1) standardize CAN risk assessment and developmental screening, and 2) improve resource provision. METHODS: A quality improvement initiative to standardize CAN risk assessment, using materials adapted from Practicing Safety, was conducted through the use of SmartTools in an electronic health record. The Edinburgh Postnatal Depression Scale and Parents Evaluation of Developmental Status were used to assess maternal depression and child development, respectively. Charts were reviewed in waves-pre-, immediate post-, and early post-implementation (waves 1 to 3); monthly for 6 months (waves 4 to 9); and quarterly for 12 months (waves 10 to 13)-to assess screening and resource provision for 6 domains: infant crying, maternal depression, development, discipline, temper tantrums, and toilet training. RESULTS: A total of 581 charts were reviewed (92, 95, and 94 for waves 1 to 3, respectively; 30 each for waves 4 to 13). Screening for infant crying, maternal depression, development, and discipline rose from 0% pre-implementation to over 50% post-implementation. Screening for temper tantrums and toilet training rose from 6% to 72% and from 36% to 82%, respectively. For all measures, resource provision improved over time, and all improvements were maintained for 1.5 years post-implementation. CONCLUSIONS: Incorporating an adapted version of Practicing Safety into an electronic health record is a practical and effective approach to improving CAN risk assessment and resource provision. This quality improvement initiative is an example of a practice-wide improvement that resulted in clinical practice change.

Practicing safety: a quality improvement intervention to test tools to enhance pediatric psychosocial care for children 0-3 years.

BACKGROUND: Child maltreatment is a significant public health issue in the United States. Yet, fewer than half of pediatricians discuss behavioral, developmental, or parenting issues with parents. OBJECTIVE: This paper describes the testing of bundles of tools and processes, part of a larger intervention, Practicing Safety, targeted at changing physician and staff behavior to identify families at risk for child maltreatment, provide anticipatory guidance, refer to community resources, and follow-up and track at-risk families. The intervention was implemented with 14 pediatric primary care practices throughout the United States; the study was completed in 2011. METHODS: A within-subjects repeated measures pre-post follow-up design was used to evaluate the intervention. Baseline and repeated measurements of pediatric practices' processes were collected using qualitative and quantitative methods. In total, 14 core improvement teams from across the country tested three bundles of tools (maternal, infant, toddler) within a quality improvement framework over seven months. RESULTS: Quantitative results showed statistically significant adoption of tools and processes and enhancement of practice behaviors and office environmental supports. The increase in tool use was immediate and was sustained for six months after implementation. Qualitative data provided insight as to how meaningful the intervention was to the core improvement teams, especially with more complicated behaviors (eg, engaging social workers or community agencies for referrals). Barriers included lack of community resources. Findings showed unanticipated outcomes such as helping practices to become medical homes. CONCLUSION: Lessons learned included that practices appreciate and can adopt brief interventions that have meaningful and useful tools and process to enhance psychosocial care for children 0-3 and that do not place a burden on pediatric practice. An innovative, quality improvement strategy, intuitive to pediatricians, with a brief intervention may help prevent child maltreatment.

A Quality Improvement Collaborative to Improve Pediatric Primary Care Genetic Services.

OBJECTIVE: To investigate if a national pediatric primary care quality improvement collaborative (QIC) could improve and sustain adherence with process measures related to diagnosis and management of children with genetic disorders. METHODS: Thirteen practices in 11 states from the American Academy of Pediatrics' Quality Improvement Innovation Networks participated in a 6-month QIC that included regular educational opportunities, access to genetic professionals, and performance feedback. The QIC identified 11 aims related to improving diagnosis and management of children with genetic disorders. The practices evaluated adherence by reviewing patient records at baseline, monthly for 6 months (active improvement period), and then once 6 months after the QIC's conclusion to check for sustainability. Random intercept binomial regression models with practice level random intercepts were used to compare adherence over time for each aim. RESULTS: During the active improvement period, statistically significant improvements in adherence were observed for 4 of the 7 aims achieving minimal data submission levels. For example, adherence improved for family histories created/maintained at health supervision visits documenting all components of the family history (6% vs 60%, P < .001), and for patients with specific genetic disorders who received recommended care (58% vs 85%, P < .001). All 4 of these aims also demonstrated statistically significant improvements during the sustainability period. CONCLUSIONS: A national QIC reveals promise in improving and sustaining adherence with process measures related to the diagnosis and management of genetic disorders. Future research should focus on patient outcome measures and the optimal number of aims to pursue in QICs.

Context Matters: Practitioner Perspectives on Immunization Delivery Quality Improvement Efforts.

Uneven adherence to immunization guidelines might leave some communities vulnerable to outbreaks of vaccine-preventable diseases. To examine factors related to implementation of immunization delivery best practices, we analyzed responses to monthly surveys and debriefing interviews from 16 diverse pediatric practices engaged in a year-long virtual learning collaborative. The collaborative provided a toolkit, online learning sessions, performance feedback, and conference calls with a quality improvement coach. Participants used iterative plan-do-study-act cycles to implement self-selected changes in immunization practices. Descriptive statistics were applied to quantitative data; qualitative data were analyzed using a framework approach. Impediments to implementing guidelines included difficulties with electronic record systems, rigid management structures, competing priorities, and parental resistance. Facilitators included linkage with regional immunization registries, positive social interactions, and performance feedback. Findings suggest that improving immunization delivery requires not only awareness of recommendations and training in improvement methods but also efforts to ameliorate contextual factors that impede immunization delivery.

Association between medical home characteristics and staff professional experiences in pediatric practices.

BACKGROUND: The patient-centered medical home (PCMH) model has been touted as a potential way to improve primary care. As more PCMH projects are undertaken it is critical to understand professional experiences as staff are key in implementing and maintaining the necessary changes. A paucity of information on staff experiences is available, and our study aims to fill that critical gap in the literature. METHODS: Eligible pediatric practices were invited to participate in the Florida Pediatric Medical Home Demonstration Project out which 20 practices were selected. Eligibility criteria included a minimum of 100 children with special health care needs and participation in Medicaid, a Medicaid health plan, or Florida KidCare. Survey data were collected from staff working in these 20 pediatric practices across Florida. Ware's seven-point scale assessed satisfaction and burnout was measured using the six-point Maslach scale. The Medical Home Index measured the practice's medical home characteristics. Descriptive and multivariate analyses were conducted. In total, 170 staff members completed the survey and the response rate was 42.6%. RESULTS: Staff members reported high job satisfaction (mean 5.54; SD 1.26) and average burnout. Multivariate analyses suggest that care coordination is positively associated (b = 0.75) and community outreach is negatively associated (b = -0.18) with job satisfaction. Quality improvement and organizational capacity are positively associated with increased staff burnout (OR = 1.37, 5.89, respectively). Chronic condition and data management are associated with lower burnout (OR = 0.05 and 0.20, respectively). Across all models adaptive reserve, or the ability to make and sustain change, is associated with higher job satisfaction and lower staff burnout. CONCLUSIONS: Staff experiences in the transition to becoming a PCMH are important. Although our study is cross-sectional, it provides some insight about how medical home, staff and practice characteristics are associated with job satisfaction and burnout. Many PCMH initiatives include facilitation and it should assist staff on how to adapt to change. Unless staff needs are addressed a PCMH may be threatened by fatigue, burnout, and low morale.

Assessing patient experiences in the pediatric patient-centered medical home: a comparison of two instruments.

The Patient-Centered Medical Home (PCMH) is a model of care that has been promoted as a way to transform a broken primary care system in the US. However, in order to convince more practices to make the transformation and to properly reimburse practices who are PCMHs, valid and reliable data are needed. Data that capture patient experiences in a PCMH is valuable, but which instrument should be used remains unclear. Our study aims to compare the validity and reliability of two national PCMH instruments. Telephone surveys were conducted with children who receive care from 20 pediatric practices across Florida (n = 990). All of the children are eligible for Medicaid or the Children's Health Insurance Program. Analyses were conducted to compare the Consumer Assessment of Health Plan Survey-Patient-Centered Medical Home (CAHPS-PCMH) and the National Survey of Children with Special Health Care Needs (NS-CSHCN) medical home domain. Respondents were mainly White non-Hispanic, female, under 35 years old, and from a two-parent household. The NS-CSHCN outperformed the CAHPS-PCMH in regard to scale reliability (Cronbach's alpha coefficients all ≥0.81 vs. 0.56-0.85, respectively). In regard to item-domain convergence and discriminant validity the CAHPS-PCMH fared better than the NS-CSHCN (range of convergence 0.66-0.93 vs. 0.32-1.00). The CAHPS-PCMH did not correspond to the scale structure in construct validity testing. Neither instrument performed well in the known-groups validity tests. No clear best instrument was determined. Further revision and calibration may be needed to accurately assess patient experiences in the PCMH.

Improving newborn screening follow-up in pediatric practices: quality improvement innovation network.

OBJECTIVE: To implement a 6-month quality improvement project in 15 primary care pediatric practices to improve short-term newborn screening (NBS) follow-up. METHODS: At the start of the project, each practice completed a survey to evaluate office systems related to NBS and completed a chart audit. Practice teams were provided information about NBS and trained in quality-improvement methods, and then implemented changes to improve care. Monthly chart audits over a 6-month period were completed to assess change. RESULTS: At baseline, almost half of practices completed assessment of infants for NBS; after 6 months, 80% of practices completed assessment of all infants. Only 2 practices documented all in-range results and shared them with parents at baseline; by completion, 10 of 15 practices documented and shared in-range results for ≥ 70% of infants. Use of the American College of Medical Genetics ACTion sheets, a decision support tool, increased from 1 of 15 practices at baseline to 7 of 15 at completion. CONCLUSIONS: Practices were successful in improving NBS processes, including assessment, documentation, and communication with families. Providers perceived no increase in provider time at first visit, 2- to 4-week visit, or during first contact with the family of an infant with an out-of-range result after implementation of improved processes. Primary care practices increased their use of decision support tools after the project.

Using genograms to understand pediatric practices' readiness for change to prevent abuse and neglect.

A novel use of genograms in primary care practice is to identify processes and relationships among physicians and staff prior to implementing practice change. The authors hypothesized that the genogram would inform researchers and practice staff, participating in a child maltreatment prevention study, how practice members function in a practice. They describe the use of genograms and show how the genogram results are associated with intervention uptake. Researchers constructed genograms, collected baseline surveys, and conducted postintervention interviews with physicians. Data were analyzed to determine processes associated with intervention uptake. While survey results supported the relationships and conflicts observed in the genograms, the genogram provided more multilevel information that reflected practices' abilities to implement change. By providing a snapshot of the relationship and organizational dynamics within a practice, genograms can assess culture for practice change. Genograms describe organizational dynamics and are useful tools to use prior to initiating new programs.

Expanding the pediatrician's black bag: a psychosocial care improvement model to address the "new morbidities".

BACKGROUND: Behavioral, developmental, and psychosocial problems ("new morbidities") significantly affect the well-being of children ages 0-3 years. Practices generally fail to deliver consistent anticipatory guidance or counseling to parents. A multifaceted intervention was designed to increase the capacity of three very different practice types to adopt and implement Practicing Safety, a child abuse and neglect prevention program. METHODS: Using a feasibility intervention study, a combination of organizational change approaches, including complexity science principles--self-organization, emergence, and co-evolution--were tested. The multimethod assessment process (MAP) was employed to understand the unique characteristics of each practice that could impede or promote innovation. Findings guided a facilitated, team-based change intervention, the Reflective Adaptive Process (RAP) to restructure psychosocial care. FINDINGS: Each practice demonstrated fundamental changes in decision making, developmental assessment, and parent education processes. Practicing Safety tools were adopted and incorporated into daily routines. RAP team members exhibited new patterns of communication and relationships that supported organizationwide preventive service innovations. DISCUSSION: The MAP and RAP interventions enabled study practices to integrate novel methods for prevention of child abuse and neglect into daily routines.

Using a registry to improve immunization delivery.

The NJIPSP was successful in encouraging a group of small urban practices to adopt the use of immunization registry and to transform immunization delivery from a mechanistic well-child service to a visible, monitored process of care. The project represents a unique combination of technology, public-private collaboration, and well-established quality improvement techniques. The change process involved the whole office as a team in adopting new immunization delivery roles and services. The greatest barrier to acceptance of the registry was (and continues to be) the need for manual data entry as the primary source of data collection, rather than electronic data transfer from other systems. The manual entry of data was labor intensive for participating practices and affected data measurement. Despite this barrier, however, the majority of practices substantially improved the quality of their immunization delivery practices in multiple areas. The rapid movement of primary care practices toward some form of electronic record may reduce this barrier and increase the percentage of practices willing to use a community registry. Practices that engaged collectively in the change process gained momentum from the group effort. Equally important was the public health partnership that helped identify and reduce improvement obstacles. Sustainability of practice-based immunization changes will rely, in part, on the registry's ease of use and the continued visibility of public health at the practice level. Active practice level collaboration by public health adds great value to change efforts. We believe that the best possible immunization delivery relies on both technology (registries and the EMR) and effective office systems. Projects like the NJIPSP are models for systems that integrate technology, practice change, and quality improvement, and their success has the potential to foster the spread of this approach to other primary care practices (especially in New Jersey). The NJIPSP combination of office-based change approaches and an active partnership and hands on involvement with public health has the potential to support the delivery of consistently excellent immunization delivery.

Key elements for successful integrated health information systems: lessons from the States.

The Genetic Services Branch, Maternal and Child Health Bureau of the Health Services and Resources Administration has provided funding to state health departments to integrate their newborn dried blood-spot screening programs with other early child health information systems since 1999. In 2001, All Kids Count conducted site visits to these grantees to identify and describe best practices in planning, developing, and implementing their integration projects. The site visits were organized around 9 key elements considered critical to the success of an information systems integration project: leadership, project governance, project management, stakeholder involvement, organizational and technical strategy, technical support and coordination, financial support and management, policy support and evaluation. Best practices for each of the key elements and 5 lessons learned were documented in Integration of Newborn Screening and Genetic Service Systems with Other Maternal & Child Health Systems: A Sourcebook for Planning and Development. The lessons learned are overarching conclusions that agencies should consider when planning and implementing integrated information systems. This article briefly describes the key elements, their best practices as implemented by states, and the lessons learned.