office based prevention of child abuse and neglect: lessons learned from the practicing safety quiin...
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Office Based Prevention of Child Abuse and Neglect: Lessons Learned from the
Practicing Safety QuIIN Project
Diane Abatemarco, PhD, MSW, CO-PI
Ruth Gubernick, MPH, QI Advisor
Steve Kairys, MD, MPH, FAAP, Co-PI
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Call Objectives
At the end of this conference call, participants will be able to:
Identify which Practicing Safety (PS) tools were reported to be the most useful in each of the 3 bundles
Recall at least 2 qualitative themes uncovered by post in-depth interviews
Analyze the office supports and systems that enable successful adoption of interventions
List at least 2 lessons learned from the QuIIN PS project Test 1 or more tools with your own practice team to
improve assessment/screening and anticipatory guidance for 1 or more of the PS focused topics
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Practicing Safety: The Need
In 2006, an estimated 906,000 children were found to be victims of child abuse and neglect in the United States and Puerto Rico*
64.1% were victims of neglect 16.0% were physically abused Children under the age of 4 continue to have the highest rate of
victimization Over one-quarter (30%) of the 906,000 victims were under the age of 4 Nearly 80% (79.4%) of perpetrators of child maltreatment were parents.
Pediatricians are in a unique position to address topics that can prevent child abuse and neglect
Pediatricians can see a child a total of 13 times for well child visits before age 4
Literature documents the high value that parents place on the education and advice shared with them by their pediatrician
*Source: U.S. Department of Health and Human Services, Administration on Children, Youth and Families. Child Maltreatment 2006. Washington, DC: U.S. Government Printing Office, 2008
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Practicing Safety Project Aims
Improve assessment/screening and anticipatory guidance by pediatric physicians and staff with parents/caregivers on topics of crying, maternal depression, toilet training, and discipline (to 100% by November 2009).
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.
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Practicing Safety Project Methods
Modified Learning Collaborative with 14 teams (lead physician plus 2 others from practice)
Model for Improvement; Plan, Do, Study, Act; small tests of change Prework period (April 2009)
Baseline chart review Pre-Inventory Survey
Learning Session 1(May 2009) Action Period (June-November 2009)
Monthly Chart Review/Chart Documentation Forms 10 charts of patients at the 2-month visit (infant and mother/caregiver
bundles) 10 charts of patients at the 18-month visit (toddler bundle)
Monthly Progress Reports Monthly Team Calls Review of Run Charts to guide improvements (posted to a Project Workspace
Web site) Follow-up (November 2009)
Post-Inventory Survey Post Toolkit Evaluation Survey Post-Telephone Interviews
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Tuscaloosa, ALUniversity Medical
Center
Dayton, OHChildren’s
Health Clinic
Houston, TXLyndon B. Johnson
Pediatric Clinic
Grand Rapids, MIHelen DeVos
Children’s Hospital General Pediatrics
Greenville, SCCenter for Pediatric Medicine
Brooklyn, NYMaimonides Infants and Children’s Hospital-
Newkirk Family Health Center
Flushing, NYFlushing Hospital
Medical Center
New Haven, CTHospital of Saint Raphael Pediatric
Primary Care Center
West Reading, PAAll About Children Pediatric Partners
PC
Longview, WA
Child and Adolescent
Clinic
Bluefield, WVDr Frazer’s Office
Brewton, ALLower Alabama
Pediatrics
Thank you to the 14 Practicing Safety Teams!
Charlotte, NCCMC-Myers Park
Pediatrics
Midlothian, VAPediatric &
Adolescent Health Partners
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Practicing Safety Toolkit
3 Bundles Infant: coping with crying Mother/Caregiver: maternal depression,
bonding/attachment Toddler: effective discipline, toilet training
Each bundle includes a practice guide as well as tools for each topic
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Infant Bundle
Infant Bundle: Coping with Crying
Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance.
Green light: Assessment/Screening
Anticipatory Guidance
-Example: How often does your baby cry and how do you handle it?-Provide anticipatory guidance-Welcome to the World of Parenting brochure-Guide for parents: Swaddling 101-Crying poster
Yellow light: Parent concerns -Example: Who can you call to help when you need a break?-Provide anticipatory guidance-Refer to family strengthening organization
Red light: Possible safety concerns for infant
Referral to Child Protective Services for evaluation and care management
Introduce at 2 weeks to 4 weeks; Reinforce at 2 months**Tools are identified by purple font
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Mother/Caregiver Bundle
Mother/Caregiver Bundle: Maternal Depression/Bonding/Attachment
Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance.
Green light:
Assessment/Screening
Anticipatory Guidance
-Edinburgh Postnatal Depression Scale (EPDS)-Example: Is the mom’s partner available for support?-Example: What do you enjoy doing with your baby?-Provide anticipatory guidance-Postpartum Depression Brochure-Refresh. Renew. Recharge Poster-Have you Read to Your Baby today button
Yellow light:
At risk for depression/<9* but have concerns/early signs
Referral to support system, including PCP, OB, Behavioral health agency, home visiting program
Red light:
Depression/≥9* or ≥1 on Q#10*/potential risk to self and/or infant
Referral to Child Protective Services and/or Behavioral Health agency
*Refers to the EPDSIntroduce at 2 weeks to 4 weeks; Reinforce at 2 and 3 months
**Tools are identified by purple font
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Toddler Bundle: Discipline
Toddler Bundle: Discipline
Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance.
Green light: Assessment/Screening
Anticipatory Guidance
-Example: What makes you lose it with your baby/child? How do you handle it?-How were you disciplined as a child?-Provide anticipatory guidance-Teaching Good Behavior-Tips on Discipline-Play is How Toddlers Learn-Reading. Routine. Relationships. Rewards poster
Yellow light: Evidence help is needed/parental frustration/unrealistic expectations
-Example: How do you handle temper tantrums?-Provide anticipatory guidance-Temper Tantrum brochure-Refer to family strengthening organization
Red light: Possible safety concerns for child
Referral to Child Protective Services for evaluation and care management
Introduce at 6 months; Reinforce at 12, 15, 18, 24, 36 months**Tools are identified by purple font
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Toddler Bundle: Toilet Training
Toddler Bundle: Toilet Training
Practice Guide: includes care management plan, assessment/screening questions, anticipatory guidance.
Green light: Assessment/Screening
Anticipatory Guidance
-Example: Have you thouhgt about or started toilet training? How is it going?-Provide anticipatory guidance-AAP Toilet Training brochure
Yellow light: Evidence help is needed/parental frustration/unrealistic expectations
-Provide anticipatory guidance-Potty Chart-Bedwetting Brochure-Refer to family strengthening organization
Red light: Possible safety concerns for child
Referral to Child Protective Services for evaluation and care management
Introduce at 18 months; Reinforce at 2 and 3 years**Tools are identified by purple font
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Practicing Safety Results: Assessment/Screening and
Anticipatory Guidance
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Infant
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Mother/Caregiver
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Toddler: Discipline
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Toddler: Toilet Training
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Practicing Safety Results: Usefulness of Tools
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Average Respondent Ratings of “Practicing Safety Tool Evaluation: Infant Bundle”
Swaddling 101 World of ParentingCoping with
CryingHug, Hold, Comfort,
Cuddle
Information/ Content
Appropriate Information 3.9 4.6 4.3 4.2
Adequately Comprehensive/ Thorough 4.0 4.4 4.3 4.1
Aids in Patient Care 3.9 4.5 4.3 4.2
Cultural Sensitivity
Literacy Level is Appropriate 3.5 3.9 4.5 4.4
Culturally Appropriate 3.8 4.2 4.4 4.4
Free of Bias 4.5 4.5 4.6 4.6
Usefulness
Readability 3.5 4.1 4.6 4.5
Relevant Information 3.9 4.2 4.4 4.4
Purpose is Clear 3.9 4.3 4.4 4.4
Effective 3.9 4.2 4.3 4.3
Total (average) 3.9 4.3 4.4 4.3
Key:1 = Poor5 = Excellent
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Average Respondent Ratings of “Practicing Safety Tool Evaluation: Mother/Caregiver Bundle”
Post Partum Depression Refresh, Renew, Recharge
Edinburgh Postnatal Scale Read to Baby Button
Information/ Content
Appropriate Information 4.5 4.1 4.4 3.4
Adequately Comprehensive/ Thorough 4.3 4.1 4.2 3.4
Aids in Patient Care 4.5 4.1 4.5 3.4
Cultural Sensitivity
Literacy Level is Appropriate 3.7 4.2 3.6 4.3
Culturally Appropriate 4.1 4.4 4.1 4.2
Free of Bias 4.5 4.6 4.3 4.6
Usefulness
Readability 4.1 4.2 3.9 4.1
Relevant Information 4.2 4.2 4.2 4.2
Purpose is Clear 4.6 4.2 4.4 4.3
Effective 4.1 4.1 4.4 3.9
Total (average) 4.3 4.2 4.2 4.0
Key:1 = Poor5 = Excellent
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Average Respondent Ratings of “Practicing Safety Tool Evaluation: Toddler Bundle”
Toilet Training
Potty Chart
Bed-Wetting
Teaching Good
BehaviorTemper Tantrum
Playing is Learning
Reading, Routine, etc.
Information/ Content
Appropriate Information 4.7 4.6 4.2 4.8 4.9 4.7 4.5
Adequately Comprehen-sive/ Thorough 4.6 4.3 4.2 4.7 4.7 4.6 4.5
Aids in Patient Care 4.7 4.5 4.1 4.7 4.8 4.5 4.4
Cultural Sensitivity
Literacy Level Appropriate 4.1 4.6 4.3 4.3 4.2 4.4 4.3
Culturally Appropriate 4.4 4.5 4.4 4.5 4.6 4.6 4.3
Free of Bias 4.7 4.7 4.6 4.8 4.8 4.7 4.5
Usefulness
Readability 4.5 4.7 4.1 4.6 4.6 4.6 4.5
Relevant Information 4.7 4.5 4.1 4.7 4.8 4.8 4.4
Purpose is Clear 4.8 4.8 4.3 4.8 4.8 4.8 4.6
Effective 4.5 4.6 4.0 4.6 4.7 4.6 4.2
Total (average) 4.6 4.6 4.2 4.6 4.7 4.6 4.4Key:1 = Poor5 = Excellent
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Practicing Safety Results: Office Systems Inventory
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POLICIES Our practice has policy/ policies in place to support the following (check all that apply):
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
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..
Form
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Givin
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Givin
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Form
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Givin
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Givin
g all
paren
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Docu
men
ting
plans
f..
Pre-inventory Post-inventory
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DOCUMENTATION SYSTEMS Our practice has a system in place to (check all that apply):
0.0%20.0%40.0%60.0%80.0%
100.0%
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ide as
sess
me...
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ent p
rese
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Pre-inventory Post-inventory
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Average Time spent at 2- and 18-month well child visits from pre to post intervention
Pre-test Average(n=13 practices)
Post-test Average(n=13 practices)
Change in minutes (average)
On average, howmuch time is spent ata 2-month well childvisit (in minutes)
19.2 minutes 20.6 minutes +1.4 minutes
On average, how much time is spent ata 18-month well childvisit (in minutes)
21.7 minutes 22.3 minutes +0.6 minutes
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Practicing Safety Results: Qualitative Themes
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Qualitative Themes
Consistent use of PS toolkit Systemization of risk Changes to chart documentation Community resource linkages Initiation of meetings Improved medical education Implementation of QI methodology Increased awareness Challenges Unanticipated positive outcomes
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Practicing Safety Lessons Learned
Practices need guidance in order to incorporate practice-based protocols that address child abuse and neglect prevention as part of well-child care
Pediatricians, once supported and mentored, are excited to offer families more concrete and systematic guidance in these areas
Practicing Safety can inform more successful implementation of enhanced care and assists practices in establishing a medical home
Parents are receptive to guidance on these topics and believe these issues are of significant concern
Practicing Safety provided an opportunity for enhanced clinical education for physicians, nurses, residents, etc
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Practicing Safety Lessons Learned (con’t.)
Practices tailored tools to fit their patient population. Some practices incorporated tools for more than the project
prescribed well-child visit based on age. Some practices collapsed the suggested “green” and “yellow”
assessment questions and anticipatory guidance and used both levels routinely as primary prevention topics at well-visits for all of their families with children in the targeted age ranges
Some practices found a need for multi-lingual, low literacy and more graphic materials for parents
Just participating in PS raised awareness of child abuse and neglect issues for all roles in the pediatric office
Chart documentation is key to determining improvements in care
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Practicing Safety Lessons Learned (con’t.)
It is important to have an engaged practice champion to succeed & leadership support, teams enhance practice change
Some practices found it challenging to promote the bigger picture of their work to the rest of the practice physicians and staff – the importance of testing and measuring prior to full-on implementation
Administrative and clinical priorities compete with making change (H1N1, EMR implementation, staff turnover)
Coding and reimbursement remain a challenge The project motivated practices to link with community. Lastly, practices would like more info on diffusion.
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Any PS Teams on the Call?
Share your experiences and lessons learned!
What is your proudest accomplishment? What lesson do you find important for others
interested in making change?
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Additional Resources
Practicing Safety QuIIN Web Page: http://www.aap.org/qualityimprovement/quiin/PracticingSafety.html
Project Staff Jill Healy, QuIIN Project Manager [email protected] Tammy Hurley, Manager, Child Abuse and Neglect
Prevention Activities [email protected]
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Thank you!
Questions