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Practicing Safety: A Child Abuse and Neglect Prevention Improvement Project

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Aim
 
The Aim of the Practicing Safety project was to test the 3 Practicing Safety bundles (infant, toddler, parent) with 14 practicing pediatricians and their staff over 6 months to determine feasibility, as well as make improvements to the bundle set.  Guided by the AAP’s Practicing Safety Project Team, the clinical teams aimed to:
 
  • Improve assessment/screening and anticipatory guidance by pediatric physicians and staff with parents/caregivers on topics of crying, maternal depression, toilet training, and discipline.
  • Test use of the Practicing Safety tools for education by pediatric physicians and staff with parents/caregivers on topics of crying, maternal depression, toilet training, and discipline.
  • Test the usefulness of the Practicing Safety tools and ease of use of the tools; and determine strategies for use of the tools.
Numeric Goals
 
  • 100% of parents/caregivers receive assessment/screening regarding coping with crying at or by the 2 month well visit.
  • 100% of parents/caregivers receive anticipatory guidance regarding coping with crying at or by the 2 month well visit.
  • 100% of new mothers receive assessment/screening regarding maternal depression at or by the 2 month well visit.
  • 100% of new mothers receive anticipatory guidance regarding maternal depression at or by the 2 month well visit.
  • 100% of parents/caregivers receive assessment/screening regarding bonding/attachment at or by the 2 month visit.
  • 100% of parents/caregivers receive anticipatory guidance regarding bonding/attachment at or by the 2 month visit.
  • 100% of parents/caregivers receive assessment/screening regarding discipline at or by the 18 month well visit.
  • 100% of parents/caregivers receive anticipatory guidance regarding discipline at or by the 18 month well visit.
  • 100% of parents/caregivers receive assessment/screening regarding toilet training at or by the 18 month well visit.
  • 100% of parents/caregivers receive anticipatory guidance regarding toilet training at or by the 18 month well visit.
  • 100% of charts document the use of 1 or more tools for coping with crying at or by the 2 month well visit.
  • 100% of charts document the use of 1 or more tools for maternal depression at or by the 2 month well visit.
  • 100% of charts document the use of 1 or more tools for discipline at or by the 18 month well visit.
  • 100% of charts document the use of 1 or more tools for toilet training at or by the 18 month well visit.
Example Measures
 
Measure Name & Description
How Calculated
% of parents/caregivers receiving assessment/screening regarding coping with crying at or by the 2 month well visit.
(Process)
Target Population:
All 2 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart that parent/caregiver received assessment/screening regarding coping with crying at or by the 2 month well visit.
Denominator:
All 2 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of parents/caregivers receiving anticipatory guidance regarding coping with crying at or by the 2 month well visit. (Process)
 
 
Target Population:
All 2 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart that parent/caregiver received anticipatory guidance regarding coping with crying at or by the 2 month well visit.
Denominator:
All 2 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of new mothers receiving assessment/screening regarding maternal depression at or by the 2 month well visit.
(Process)
Target Population:
All 2 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart that mother received assessment/screening regarding maternal depression at or by the 2 month well visit.
Denominator:
All 2 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of new mothers receiving anticipatory guidance regarding maternal depression at or by the 2 month well visit.
(Process)
Target Population:
All 2 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart that mother received anticipatory guidance regarding maternal depression at or by the 2 month well visit.
Denominator:
All 2 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of parents/caregivers receiving assessment/screening regarding bonding/attachment at or by the 2 month well visit
(Process)
Target Population:
All 2 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart that parent/caregiver received assessment/screening regarding bonding/attachment at or by the 2 month well visit.
Denominator:
All 2 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of parents/caregivers receiving anticipatory guidance regarding bonding/attachment at or by the 2 month well visit
(Process)
Target Population:
All 2 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart that parent/caregiver received anticipatory guidance regarding bonding/attachment at or by the 2 month well visit.
Denominator:
All 2 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of parents/caregivers receiving assessment/screening regarding discipline at or by the 18 month well visit. (Process)
 
Target Population:
All 18 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart that parent/caregiver received assessment/screening regarding discipline at or by the 18 month well visit.
Denominator:
All 18 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of parents/caregivers receiving anticipatory guidance regarding discipline at or by the 18 month well visit.
(Process)
 
Target Population:
All 18 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart that parent/caregiver received anticipatory guidance regarding discipline at or by the 18 month well visit.
Denominator:
All 18 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of parents/caregivers receiving assessment/screening regarding toilet training at or by the 18 month well visit.
(Process)
 
Target Population:
All 18 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart that parent/caregiver received assessment/screening regarding toilet training at or by the 18 month well visit.
Denominator:
All 18 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of parents/caregivers receiving anticipatory guidance regarding toilet training at or by the 18 month well visit.
(Process)
 
Target Population:
All 18 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart that parent/caregiver received anticipatory guidance regarding toilet training at or by the 18 month well visit.
Denominator:
All 18 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of charts with documentation indicating use of 1 or more tools for coping with crying at or by the 2 month well visit.
(Process)
+ Specify:
-Use of “Welcome to the World of Parenting”       
-Use of “Guide for Parents: Swaddling 101.”
Target Population:
All 2 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart of use of 1 or more tools for coping with crying at or by the 2 month well visit.
# infants with documentation in chart of use of “Welcome to the World of Parenting” brochure at or by the 2 month well visit
# infants with documentation in chart of use of “Guide for Parents: Swaddling 101” brochure at or by the 2 month well visit
Denominator:
All 2 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of charts with documentation indicating use of 1 or more tools for maternal depression at or by the 2 month well visit. (Process)
+ Specify:
-Use of the Edinburgh Postnatal Depression
Scale (EPDS).
-Use of the “Postpartum Depression” brochure.    
Target Population:
All 2 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart of use of 1 or more tools for maternal depression at or by the 2 month well visit.
# of infants with documentation in chart of use of EPDS at or by the 2 month well visit
# of infants with documentation in chart of use of Postpartum Depression brochure at or by the 2 month well visit
Denominator:
All 2 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of charts with documentation indicating use of 1 or more tools for discipline at or by the 18 month well visit.
(Process)
+ Specify:
- Use of “Teaching Good Behavior – Tips on Discipline” brochure.
-Use of “Play is How Toddlers Learn” brochure.
Target Population:
All 18 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart of use of 1 or more tools for discipline at or by the 18 month well visit.
# infants with documentation in chart of use of “Teaching Good Behavior-Tips on Discipline” brochure at or by the 18 month well visit
# infants with documentation in chart of use of “Play is How Toddlers Learn” brochure at or by the 18 month well visit
Denominator:
All 18 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
% of charts with documentation indicating use of 1 or more tools for toilet training at or by the 18 month well visit.
(Process)
+ Specify:
-Use of “Toilet training” brochure.
Target Population:
All 18 month old infants seen in participating practice for well care visit.
Numerator:
# infants with documentation in chart of use of 1 or more tools for toilet training at or by the 18 month well visit.
# infants with documentation in chart of use of “Toilet training” brochure at or by the 18 month well visit.
Denominator:
All 18 month old infants seen in participating practice for well care visit whose charts are reviewed (10).
 
Practicing Safety Teams
 
14 clinical teams were selected from the Quality Improvement Innovation Network as part of the Practicing Safety improvement project. Each team consisted of a physician leader plus 2 other members of the practice (generally a nurse and an administrator). Click here to see a list of all of the clinical teams.
 
Clinical teams were responsible for:
 
    • Completing Prework activities prior to the Improvement Workshop, including review of the toolkit, completion of a pre-survey (Inventory) and collection of simple baseline data.
    • Collecting and submitting at baseline and monthly (for a total of 7 months), simple data through chart reviews and reports.
    • Working with other members of the practice’s clinical team to improve care processes related to maternal depression screening, counseling about crying, counseling about toilet training, and counseling about effective discipline.
    • Participating in 1 face-to-face Improvement Workshop.
    • Learning the Model for Improvement and implement Plan, Do, Study, Act (PDSA) cycles.
    • Sharing lessons learned and problem-solving with other participating practices through monthly conference calls and e-mail.
    • Using e-mail and the Internet on a regular basis for ongoing support, information, and communication among practice teams.
    • Testing innovations in care delivery to prevent child abuse and neglect.
    • Completing a post-survey (Inventory) and Tool Evaluation.
    • Participating in in-depth telephone interviews at the conclusion of the project.
    • If owned by a health care institution, seeking Institutional Review Board approval for participation.
Project Design
 
Practicing Safety used the Model for Improvement quality improvement methodology. 14 clinical teams participated in an adapted learning collaborative to use, modify, and test tools around coping with crying, maternal depression screening, effective discipline, and toilet training and provide feedback and suggestions for improvement of the tools. Testing occurred over 6 months using Plan, Do, Study, Act (PDSA) cycles. The overall design of the improvement project included:
 
  • Baseline assessments: Clinical teams assessed their current level of performance with respect to implementation of care processes related to anticipatory guidance and assessment/screening for coping with crying, maternal depression, discipline, and toilet training.
  • Learning Session: Clinical teams were oriented to the draft materials/tools, received results from baseline assessments, and were trained on the quality improvement methodology (Model for Improvement) for implementing process changes in a face-to-face session.
  • 6-month testing phase: Clinical teams developed a plan to improve care processes; utilized PDSA cycles to test tools, measures, and data collection instruments related to same; and reviewed monthly run charts.
  • Monthly conference calls: Clinical teams shared results of their tests with project faculty and other teams, questions were answered, and specific topics were discussed.
  • Post-Interviews: Clinical teams provided additional feedback regarding the tools through brief telephone interviews at the end of the project.
Project Data Collection included:
 
  • Chart Documentation Forms: Chart Documentation Forms were completed on ten infants with a 2-month old well child visit during the appropriate review month and ten toddlers with an 18-month old well child visit, all seen in the practice by the participating Practicing Safety clinical team members to document the use of the suggested anticipatory guidance, assessment/screenings and other tools.
  • Care Process Inventory: At pre- and post- , teams were asked to assess existing systems for providing care using this inventory.
  • Monthly Progress Reports: Monthly progress reports allowed clinical teams to describe specific changes and tools they have tested and rate their team's progress. They helped faculty to monitor progress and needs of practice teams.
  • Toolkit Evaluation Survey : At the end of the 6-month testing period, clinical teams provided feedback on draft tools using this evaluation survey.
  • Learning Session Evaluation: A standard workshop evaluation was used to determine the effectiveness of each learning session.
  • Post-Interviews: A basic interview script was used to obtain additional feedback from one representative from each of the clinical teams.
Resources for Clinical Teams
 
A special thanks to our Practicing Safety Project Team:
 
  • Diane Abatemarco, PhD, MSW
    Co-Principal Investigator
  • Ruth Gubernick, MPH
    Quality Improvement Advisor
  • Steven Kairys, MD, MPH, FAAP
    Co-Principal Investigator
  • John Stirling, MD, FAAP
    Project Faculty
 
 
timeline  
 
Toolkit
 
INFANT
MOTHER/CAREGIVER
TODDLER
Post Partum Depression Brochure
ENGLISH | SPANISH
Guide for Parents: Swaddling 101 (English), Contemporary Pediatrics, February 2004
Edinburgh Postnatal Depression Scale
ENGLISH
Coping with Crying Poster (no longer available)
Refresh. Renew. Recharge Poster
ENGLISH | SPANISH
Hug. Hold. Comfort. Cuddle Poster
ENGLISH | SPANISH
Have Your Read to Your Baby Today? Button
Reading. Routine. Relationships. Rewards Poster
ENGLISH | SPANISH
   
   
   
Potty Chart
ENGLISH | SPANISH
 
Project Results
 
Practicing Safety was in partnership with the AAP Section on Child Abuse and Neglect and funded by the AAP and the Doris Duke Charitable Foundation
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