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Preventive Services Improvement Project (PreSIP)

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Aims
 
  • Between February 2011 and October 2011, the Preventive Services Improvement Project (PreSIP) practice teams will aim to improve health supervision care for children age birth-3 so that:
    • Appropriate risk assessments are performed at 95% of well-child visits
    • 95% of mothers have received a maternal depression screening by the 9 month health supervision visit
    • 95% of patients have 1 completed standardized developmental screen at their 9 month health supervision visit; and 95% of patients have documentation of 1 completed standardized developmental screen at the 24 month health supervision visit.
    • 90% of patients with a positive developmental screen have a follow-up plan in chart
    • 95% of patients have documentation of a standardized autism-specific screen at the 24 month health supervision visit
    • 95% of patients with a positive autism screen have a follow-up plan in chart
    • 95% of patients receive an oral health risk assessment by the 9 month health supervision visit
    • 95% of patients without a dental home receive an oral health risk assessment at the 24 month health supervision visit
    • 95% of patients have documentation in chart that weight for length was measured and plotted on the percentile curves according to age and sex at their 9 month health supervision visit
    • 95% of patients have documentation in chart that BMI was plotted on the percentile curves according to age and sex at the 24 month health supervision visit
    • 85% of patients have documentation in the chart that parental strengths were discussed at the most recent visit
    • 95% of patients have documentation in the chart that parental concerns were actively elicited at the most recent visit
    • 95% of patients have documentation in the chart that at least 2 parental concerns were addressed at the most recent visit
    • 95% of patients have documentation in the chart that at least 3 of the Bright Futures priorities were discussed at the most recent visit
    • Between February 2011 and October 2011, the PreSIP practice teams will aim to improve office systems so that:
      • 100% of practices have a system in place to screen for maternal depression using a standardized depression screen for maternal depression
      • 100% of practices have a documented system in chart to assess preventive services and risk screenings (eg, a preventive services prompting sheet as seen below, other examples include a paper or electronic checklist or table to track preventive services for a patient over time)
      • 100% of practices have an easily accessible organized list of community resources for parents
      • 100% of practices have an identified staff person responsible for regularly updating the practice’s community resource information
      • 100% of practices have a system to identify and contact patients who are behind schedule for preventive services (ie, reminder/recall system)
      • 100% of practices use motivational interviewing and/or shared decision-making strategies with patients
      • 100% of practices have a system to track referrals (paper-based or electronic system)
      • 100% of practices have a system to identify patients with special health care needs
      • Between February 2011 and October 2011, the Preventive Services Improvement Project (PreSIP) practice teams will aim to test Bright Futures tools and resources during health supervision visits for children age birth-3 in order to improve care processes outlined above.
       
      Example Project Measures
       

      Measure Name & Description
      How Calculated
      Aim 1
      1) % patients with documentation in chart that parental concerns were actively elicited at most recent visit (Process)
      Target Population:
      All patients age 9 months and age 24 months in practice for health supervision care.
      Numerator:
      # patients age 9 months and age 24 months with documentation in chart that were asked about parental concerns.
      Denominator:
      All patients age 9 months and age 24 months in practice for health supervision care whose charts are reviewed.
      2) % patients with documentation in chart that at least two parental concerns were addressed at the most recent visit (Process)
      Target Population:
      All patients age 9 months and age 24 months  seen in practice for health supervision care.
      Numerator:
      # patients age 9 months and age 24 months  with documentation in chart that at least two parental concerns were addressed.
      Denominator:
      All patients age 9 months and age 24 months seen in practice for health supervision care  with a documented parental concern whose charts are reviewed.
      3) %  patients who have documentation in chart that age appropriate risk assessments were performed at the most recent visit (Process)
      Target Population:
      All patients age 9 months and 24 months in practice for health supervision care.
      Numerator:
      # patients age 9 months and 24 months with documentation in chart that age appropriate risk assessments were performed.
      Denominator:
      All patients age 9 months and age 24 months seen in practice for health supervision care whose charts are reviewed.
      4) % at-risk patients, as identified by risk assessment, with documentation in chart that risks were addressed at the most recent visit (Process)
      Target Population:
      All patients age 9 months and age 24 months seen in practice for health supervision care.
      Numerator:
      # patients age 9 months and age 24 months with documentation in chart that age appropriate risks were addressed.
      Denominator:
      All patients with documented risk, age 9 months and 24 months, seen in practice for health supervision care  whose charts are reviewed.
      5) % patients who have documentation in chart that at least three of the Bright Futures priorities were discussed at the most recent visit (Process)
      Target Population:
      All patients age 9 months and age 24 months seen in practice for health supervision care.
      Numerator:
      # patients age 9 months and age 24 months with documentation in chart that at least three Bright Futures priorities were discussed.
      Denominator:
      All patients age 9 months and age 24 months seen in practice for health supervision care whose charts are reviewed.
      6) % patients who have documentation in chart that parental strengths was discussed at the most recent visit (Process)
      Target Population:
      All patients age 9 months and age 24 months seen in practice for health supervision care.
      Numerator:
      # patients age 9 months and age 24 months with documentation in chart that parental strengths was discussed.
      Denominator:
      All patients age 9 months and age 24 months seen in practice for health supervision care whose charts are reviewed.
      7) % patients who have documentation in chart that weight for length was measured and plotted on the percentile curves according to age and sex (Process)
      Target Population:
      All patients seen in practice for the 9 month health supervision visit.
      Numerator:
      # patients with documentation in chart that weight for length was measured and plotted at the 9 month health supervision visit.
      Denominator:
      All patients seen in practice for 9 month health supervision visit whose charts are reviewed.
      8) % patients who have documentation of  1 completed standardized developmental screen at their 9 month health supervision visit  (Process)
      Target Population:
      All patients seen in practice for their 9 month health supervision visit.
      Numerator:
      # patients seen at their 9 month health supervision visit with documentation in chart of 1 completed standardized developmental screen.
      Denominator:
      All patients seen for their 9 month health supervision visit whose charts are reviewed.
      9) % patients with a positive developmental screen who have documentation of follow up plan in chart (Process)
      Target Population:
      All patients seen in practice for their 9 month health supervision visit.
      Numerator:
      # patients age 9 months with a positive developmental screen that have documentation in chart of a follow up plan.
      Denominator:
      All patients with a positive developmental screen, age 9 months, seen in practice for health supervision care whose charts are reviewed.
      10) % patients with documentation that oral health risk assessment was completed at 9 month visit  (Process)
      Target Population:
      All patients seen in practice for their 9 month health supervision visit.
      Numerator:
      # patients with documentation in chart of 1 oral health risk assessment at the 9 month health supervision visit.
      Denominator:
      All patients seen in practice for the 9 month health supervision visit whose charts are reviewed.
      11) %  patients who have documentation in chart that BMI was measured and plotted on the percentile curves according to age and sex (Process)
      Target Population:
      All patients seen in practice at the 24 month visit for health supervision care.
      Numerator:
      # patients with documentation in chart that BMI was measured and plotted at the 24 month health supervision visit.
      Denominator:
      All patients seen in practice for 24 month health supervision visit whose charts are reviewed.
      12) % patients with documentation of 1 completed standardized autism specific screenings at the 24 month visit (Process)
      Target Population:
      All patients seen in practice for 24 month health supervision visit.
      Numerator:
      # patients with documentation in chart of 1 autism specific screen at the 24 month visit.
      Denominator:
      All patients seen in practice for the 24 month health supervision visit whose charts are reviewed.
      13) % patients with a positive autism screen who have documentation of follow up plan in chart (Process)
      Target Population:
      All patients seen in practice for a 24 month health supervision visit.
      Numerator:
      # patients seen for a 24 month health supervision visit with a positive autism screen that have documentation in chart of a follow up plan.
      Denominator:
      All patients with a positive autism screen seen in practice for a 24 month health supervision visit whose charts are reviewed.
      14) % patients who have documentation of  1 completed standardized developmental screen at their 24 month health supervision visit (Process)
      Target Population:
      All patients seen in practice for their 24 month health supervision visit.
      Numerator:
      # patients seen at their 24 month health supervision visit with documentation in chart of 1 completed standardized developmental screen.
      Denominator:
      All patients seen for their 24 month health supervision visit whose charts are reviewed.
      15) % patients with a positive developmental screen who have documentation of follow up plan in chart (Process)
      Target Population:
      All patients seen in practice for their 24 month health supervision visit.
      Numerator:
      # patients seen for a 24 month health supervision visit with a positive developmental screen that have documentation in chart of a follow up plan.
      Denominator:
      All patients with a positive developmental screen seen in practice for 24 month health supervision visit whose charts are reviewed.
      16)  % patients without a dental home, that have documentation an oral health risk assessment was completed at the 24 month visit (Process)
      Target Population:
      All patients seen in practice for their 24 month health supervision visit.
      Numerator:
      # patients with documentation in chart that they  do not currently have a dental home and an oral health risk assessment occurred at the 24 month health supervision visit.
      Denominator:
      All patients seen in practice for the 24 month health supervision visit whose charts are reviewed.
      Aim 2
      1) % practices who have a system in place to screen for maternal depression (and at what ages) (Process)
      Target Population:
      All practices in the collaborative.
      Numerator:
      # practices with a system in place for maternal depression screening.
      Denominator:
      All practices completing the monthly progress report.
      2) % practices with a documented system (eg, preventive services prompting system) in chart to assess preventive services and risk screenings (Process)
      Target Population:
      All practices in collaborative.
      Numerator:
      # practices with preventive services prompting sheet.
      Denominator:
      All practices completing the practice inventory.
      3) % practices with an easily accessible organized list of community resources for parents (Process)
      Target Population:
      All practices in collaborative.
      Numerator:
      # practices with  community resources list.
      Denominator:
      All practices completing the practice inventory.
      4) % practices with an identified staff person responsible for regularly updating the practice’s community resource information  (Process)
      Target Population:
      All practices in collaborative.
      Numerator:
      # practices with an identified community resources staff person.
      Denominator:
      All practices completing the practice inventory.
      5) % practices with a system to identify and contact (ie, reminder/recall)  patients who are behind schedule for preventive services (Process)
      Target Population:
      All practices in collaborative.
      Numerator:
      # practices with an recall/reminder system.
      Denominator:
      All practices completing the practice inventory.
      6) % of practices that use motivational interviewing and/or shared-decision making strategies with patients (Process)
      Target Population:
      All practices in collaborative.
      Numerator:
      # practices that use motivational interviewing and/or shared-decision making strategies with patients.
      Denominator:
      All practices completing the practice inventory.
      7) % practices with a system to identify patients with special health care needs (Process)
      Target Population:
      All practices in collaborative.
      Numerator:
      # practices with a system to identify patients with special health care needs.
      Denominator:
      All practices completing the practice inventory.
      8) % practices with a system to track referrals using a paper-based or electronic system (EHR) (Process)
      Target Population:
      All practices in collaborative.
      Numerator:
      # practices with a system for tracking referrals.
      Denominator:
      All practices completing the practice inventory.
      Balancing Measure
      Time Spent (Balancing)
      Self report of time spent at the 9 month well child visit and at the 24 month well child visit (pre and post project).
       
      Teams
      Twenty-one clinical teams were selected from the AAP Quality Improvement Innovation Network as part of the Preventive Services Improvement Project (PreSIP). 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 Learning Session, including completion of a pre-survey (Inventory) and collection of simple baseline data.
      • Collecting and submitting at baseline and monthly (for a total of 10 months), simple data through chart reviews and reports.
      • Working with other members of the practice’s clinical team to improve care processes related to newborn screening processes.
      • Participating in 2 face-to-face Improvement Workshops (Learning Sessions).
      • Learning the Model for Improvement and implementing 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 improve preventive care processes.
      • Completing a post-survey and participate in focus groups at Learning Session 2.
      • If owned by a health care institution, seeking Institutional Review Board approval for participation.
      Project Design
      The Preventive Services Improvement Project used the Model for Improvement quality improvement methodology. 21 clinical teams participated in an adapted learning collaborative to improve their delivery of preventive services and determine "Can Bright Futures be implemented, birth to 3, in a busy clinical setting?" Testing occurred over 9 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 preventive care.
      • Learning Session 1: 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.
      • 9-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.
      • Learning Session 2: Clinical teams came together face-to-face at the end of the project to review preliminary project results, learn from the successes of other teams, discuss and plan for sustainability and spread, and participate in focus groups.
      Project Data Collection included:
      • Chart Review | Instructions for Chart Review
        • 10 charts of 9 month health supervision visits. Age range: 8-10 months
          Download Form
        • 10 charts of 24 month health supervision visits. Age range: 22-28 months Download Form
      • Practice Inventory Survey: 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 tested and report surprises and learnings each month. They also asked about maternal depression screening.
      • Focus Groups: Team members participated in focus groups at Learning Session 2 to provide greater detail and insights into the project and the improvements that were being made.
      • Learning Session Evaluation: A standard workshop evaluation was used to determine the effectiveness of each learning session. LS1 | LS2
      Resources for Clinical Teams:

      • Coding for Oral Health Services
      • Aim Statement Worksheet: This worksheet assists teams in developing a written, measurable, and time-sensitive description of the accomplishments the team expects to make from its improvement efforts.
      • Plan Test of Change Worksheet: This worksheet assists teams in developing and recording specific details about tests/PDSA cycles they plan and carry out during the Action Period.
      • Testing Change (PDSA) Worksheet: This worksheet assists teams to plan and record their Plan, Do, Study, Act cycles to monitor tests of change.
      Learning Session 1 Power Point Presentations:
      Learning Session 2 Power Point Presentations: 

       
      A special thanks to our PreSIP Project Team:
      • Paula Duncan , MD, FAAP
      • Marian Earls, MD, FAAP
      • William Stratbucker, MD, FAAP
       
      timeline 


       

      Results:

      This project was funded by the Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau, under a cooperative agreement to the American Academy of Pediatrics (# U04MC07853) and the Friends of Children Fund, a Charitable Fund of the American Academy of Pediatrics.
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