i have no relevant financial relationships with the manufacturers of any commercial products and/or...
TRANSCRIPT
I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an
unapproved/investigative use of a commercial product/device in their presentation.
Newborn Screen Positive Infant ACTion Learning Collaborative
Learning Session IIKim Giuliano, MD and Anna Winfield, MD
Cleveland Clinic Children’s HospitalFebruary 12, 2011
11 primary care pediatric offices in Cleveland, OH and surrounding suburbs
2 pilot sites for QuINN Newborn Screen Positive Infant ACTion Project : Main Campus
7 pediatricians, 3 RNs, 3 MAs Westown Office
2 staff pediatricians, 2 float pediatricians, 1 RN, remainder staff MAs
Both offices are teaching sites for residents and medical students
Team Members
Kim Giuliano, MD Anna Winfield, MD
Mo VanGunten, RN Kristen Kolarik, MA
Aim Statement – All Newborns
By November 2010, Cleveland Clinic Children’s Hospital’s (CCCH) Main Campus and Westown offices will improve newborn screening processes by implementing AAP’s recommendations.
In 2011, sustainable improvement measures will be spread to additional CCCH General Pediatric Offices.
Specific Aims: 100% of infants receive assessment at first visit for
completion of newborn screening. 100% of charts are flagged for patients who are not screened. 100% of newborn screening results are received before the 2-
to 4-week visit. 100% of in-range newborn screening results are documented
in the infant’s chart and shared with parents.
Aim Statement – Abnormal NBS
By November 2010, CCCH’s Main Campus and Westown offices will improve the processes for managing out-of-range newborn screening results by implementing AAP’s recommendations.
In 2011, sustainable improvement measures will be spread to additional CCCH General Pediatric Offices.
Specific Aims: 100% of parents of infants with an out-of-range newborn screening
result receive condition-specific information and support. 100% of infants with an out-of-range screening result receive
confirmatory testing and/or definitive consultation with subspecialists. 100% of false out-of-range newborn screening results are documented
in the infant’s chart and discussed with parents. 100% of children given a diagnosis of a significant medical condition are
identified as a child with special health care needs and are provided a medical home.
Changes Implemented
Reliable Systems of Care NBS Office Policy Statement Tracking systems (log sheet at Westown,
binder at Main Campus) EMR templates edited for newborn, 2-4
week visit, 2 month visit Registry for abnormal NBS and CSHCN
Changes Implemented
Community-based Care Referral line for metabolic specialists Contacted Ohio Department of Health – arranged
contact person for missing NBS reports Contacted nursery hospitalists to facilitate
discharge communication and education re: NBS
Changes Implemented
Active Well-informed Patients Newborn packets given at first office visit Hospitalist outreach to ensure same pamphlet is
given at all CCCH sites
Cycles of Improvement
EMR templates #1 PLAN
“Dot phrase” created to insert into already existing templates to document NBS completion and sharing of results with parents. Way to test the documentation phrase without changing the template for all providers in the office.
DO Dr. Giuliano and Dr. Winfield used for 1 week Forgot to use for one newborn
STUDY Good way to document but relies on provider to remember
ACT Change template for all providers
Cycles of Improvement
EMR templates #2 PLAN
Change template for all providers at both offices DO
All providers informed Some providers continued using old templates
STUDY Easy to document but correct template needs to be used
ACT Removed old templates from provider’s “favorites” list Sent email communication to all residents and providers
that do not have regular face-to-face contact
Cycles of Improvement
EMR templates #3 PLAN
All providers using same template DO
All providers made the change STUDY
Improvement noted in run charts for documentation of NBS completion and sharing of results with parents
ACT Adopt as final plan for Westown and Main Campus
Cycles of Improvement
EMR templates #4 PLAN:
Designing system wide “SmartSets” that will include our current templates (currently in progress)
Cycles of Improvement
Log Sheets #1 PLAN
Log sheet created for documentation of NBS results/status for each newborn seen in practice
DO Dr. Giuliano and Dr. Winfield used for 1 week
STUDY Complete and easy to view documentation 100% of newborns seen in pilot week had complete
sheets ACT
Institute use of log sheet for ALL newborns
LOG SHEET
Cycles of Improvement
Log Sheets #2 PLAN
Utilize log sheet for all newborns seen by all providers DO
Office staff and providers instructed in use Did not have opportunity to educate all providers face to face
STUDY Main Campus office consistently used log sheets Westown office did not consistently create log sheets Lack of “paper chart” resulted in loss of information <25% of newborns seen at Westown by other providers had
complete log sheets ACT
Brainstorm alternate means of documentation for Westown Adopt but continue to study at Main Campus
Cycles of Improvement
Log Sheets #3 PLAN
Reformulated log sheet from one document per patient to centralized recording site
DO Educate one medical assistant in use of centralized log sheet Dr. Winfield responsible for tracking data weekly
STUDY More consistent use of tracking data Easy to review
ACT Utilize centralized log sheet for all newborns seen at Westown
practice
Results
% Infants Receiving Assessment at First Visit for Completion of Newborn Screening
0%
20%
40%
60%
80%
100%
Apr June July Aug Sept Oct Nov
% A
ch
iev
ed
% Achieved Goal Aggregate
EMR template changed
Residents and new MDs started
Old templates removed from “favorites”, email to providers
Results
% of Newborn Screening Results Received Before 2- to 4-week Visit
0%
20%
40%
60%
80%
100%
Apr June July Aug Sept Oct Nov
% A
ch
iev
ed
% Achieved Goal Aggregate
Tracking binders
Westown changed to one tracking sheet
Results at 1mo visit(Approaching 100% at 2 mo visit)
% of In-range Newborn Screening Results Documented in Chart and Shared with Parents
0%
20%
40%
60%
80%
100%
Apr June July Aug Sept Oct Nov
% A
ch
iev
ed
% Achieved Goal Aggregate
EMR template changed
Old templates removed from “favorites”, email to providers
Results
% of Providers Who Reviewed the ACT sheet(s) for Infant(s) w/ an Out-of-range NBS Result
0%
20%
40%
60%
80%
100%
Apr June July Aug Sept Oct Nov
% A
ch
iev
ed
% Achieved Goal Aggregate
Educated providers about ACT sheets & abnormal newborn screening guide made
ACT sheets used for unusual metabolic conditions only
What You Have Learned
Lessons Learned Team work is essential in the office Partnership with other organizations is valuable Communication is key What works for one site may not work for another Important to track measures at appropriate time interval and
for areas that are truly in need of change Challenges and setbacks
Hard to make large changes in a big institution Dr. Winfield cut back hours around same time new physicians
started in her office Dr. Giuliano and Dr. Winfield at different physical locations
General Lessons Learned
What contributed to your progress so far Teamwork EMR templates Tracking processes
Anticipated issues Some sites may not identify NBS as an area in
need of improvement Some sites may not feel they have the time to
invest in similar project Getting IT to help change the EMR Health
Maintenance Alert Hospitalists communication