University of South Florida Learning Session 2 April 27-28, 2012

Disclosure 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.

Vision USF Pediatrics, as an academic pediatric practice, will continue to attain the highest standards of Patient-Centered Medical Homes for our patients, including Children with Special needs, through the implementation of a rigorous continuous improvement process

Goal Use the AAP Medical Home demonstration Project as a tool to asses our current Medical home and to identify the practice gaps. These tools will help us to implement quality improvement strategies and create a work team to enhance and, optimize utilization of our resources and improve how we deliver care to our patients.

USF PEDIATRICS  Located in Tampa, Florida  University Teaching Institution  Two clinics for patient care 17 DavisSouth Tampa Center

USF PEDIATRICS CORE TEAM Nikki Laura Dr. Pelaez Dr. Lilly

USF PEDIATRICS TEAM Mary Melanie Pediatric Residents

 Develops an interdisciplinary team to guide care in a continuous, accessible, comprehensive, and coordinated manner;  Takes responsibility for coordinating its patients’ health care across care settings and services over time, in consultation and collaboration with the patient and family;  Provides patients with ready access to care;  “Knows” its patients and provides care that is whole-person oriented and consistent with patients’ unique needs and preferences;  Partners with patients to make treatment decisions;  Encourages open communication between patients and the care team;  Supports patients and their caregivers in managing the patient’s health;  Fosters an environment of trust and respect; and Principles of Family-centered Care

Aim Statement #1 USF Pediatrics by March 2012 will aim to improve our Medical Home through an increase in parent involvement. Our team will focus on testing the suggested strategies and tools related to providing family-centered care Parent survey using a modify CAHPS questioner. (See follow up slide for results) Adjusted to address lack of survey response and need for statistical validation Patients will be surveyed in all of our clinics using a web survey or I pad. The survey will collect information about satisfaction and preferred way of communication (i.e. text, etc). The survey is culturally sensitive based upon our patient population (English and Spanish). Evaluation will entail analysis of survey results Note: The survey was designed with the help of our medical home residents and a medical student.

1. Which USF Pediatrics clinic have you visited most frequently in the last 12 months?

7. How often did the provider listen carefully to you?

8. How often did the provider know important information about your child's medical history?

9. How often did the provider explain things in a way that made it easy for you to understand?

10. How often did the provider spend enough time with your child?

18. In the last 12 months, how often were the nurses at your child's clinic as helpful as you thought th...

19. In the last 12 months, when you called your child the clinic to get an appointment for a sick visit...

Use Modified CAHPS survey PLAN Survey was created in 2 versions: 1) all clinics 2) By Provider DO  Cycle #1 the survey was distributed by the providers in clinic using the I pad  Cycle #2 The survey was distributed by all team areas( front desk, Nursing, residents, and providers). Using IP address-for web/IPAD/mobile phone versions, flyers, I pads, desktops and printed copies STUDY  Cycle #1 Only 17 surveys were collected in 1 month  Cycle #2 111 surveys were collected in 2 weeks  We learned that obtaining completed surveys is very difficult  Parents like to cooperate if given adequate guidance. Positive response from parents when initially approached and personalized and when discussed at Team Meetings with Parents  Use a system that interprets the data for you to improve efficiency of handling large numbers of surveys

Use Modified CAHPS survey  ACT  Compare our survey results to CAHPS  Statistical assistance with determining numbers to recruit for population based – suggestion for AAP  Future plans are to change how patients are recruited for surveys. ONLINE ON WEBSITE PURSUE ING PATIENTS SURVEY ON FACEBOOK DEVELOP OUR OWN APPLICATION

USF Pediatrics by April 2012 will aim to improve our Medical Home through an increase Parent participation with the development and Implementation of a Family Advisory Council. Our team will focus on testing the suggested strategies and tools related to providing Family- centered care. Recruitment of parents and attendance at the meeting 90 % of the time The council will meet 4 times a year, we are hoping for 15 diverse families from all 3 Practice sites in conjunction with representation of general pediatricians, specialists, hospitalists, social workers and nursing staff. We will use the modified CAHPS survey as explanation of areas of improvement in the practice and starting point for the discussion. Evaluation of the council will consist of a survey related to satisfaction, perceptions of council function/success, process measures related to attendance and participation. Aim Statement #2

Parents Advisory Council PLAN Create a Parent Advisory council.The council will meet 4 times a year, consist of 15 diverse families from all 3 Practice sites in conjunction with representation of general pediatricians, specialists, hospitalists, social workers and nursing staff. DO  Active recruitment for 1 month. Provider driven  Developed Steering Committee – General Pediatricians, Specialists, CMS Assistant Medical Director, Social Work, 2 Parents, plan for nurse  Held first meeting, with stipend provided to families: Only 8 families were recruited ( 2 not able to attend) 5 providers( adolescent, 2 hospitalists, Gen Peds) 1 Nurse 1 teen 1 Patient

Parents Advisory Council STUDY  The results were positive – we started from 0 and got 8 families, 2 patients and got positive feedback from participants related to continued participation and assisting us with recruitment  It is difficult to recruit patients and families  Need to recruit from a broader base because people tend to no show to meetings/patients are sick and can’t always attend ACT  Modify the recruitment PAC suggested: not to limit recruitment to the doctors, open invitations to parent groups, advertise in the clinic front desk, bathrooms and patient rooms. Web communication and face book  Start a Parents Blog  Develop USF Pediatric Application for Parent Information  Continue to pursue using one way as means to communicate with families

Reflection  We learned most: 1.How to work as a team. Physicians/Nurses cannot do this alone, need parents and practice support 2.Pre Planning is crucial for efficient processes 3.Sustainability is difficult if the core team does not work together 4.Patients and Parents like to be involved and appreciate that we want to hear their opinions 5.Ongoing Communication is essential to our improvement process for the Medical Home 6.AAP support is crucial for practices that would like to implement a Medical Home

Reflection  We learned least : 1.Still need to work on higher level practice support 2.Still need to refine how we use and analyze our patient surveys to improve statistical validation and to get at other questions: Specific provider info, clinical guidelines evaluation etc

Reflection  One assumption we had when we started that turned out not to be valid was: We would not be able increase our number of completed surveys Families would not want to participate on the Parent Council (Previous failure)  One assumption we had when we started that held true was: Though our Medical Home has been established for some time, improvements are still needed and can be accomplished with planning and teamwork The act of attempting quality improvement strategies helps us to focus on problem identification and problem solving

Advice we would like to pass along to other teams in our C4K Collaborative about creating change in this focus area 1.Parent (and staff) participation in improvement activities brings answers you may not expect or you can’t find. Parents can tell you things that you have not seen about community, local ER’s, resources and what other parents may perceive about your practice. 2.Communication, communication, communication 3.Setting clear expectations and holding participants accountable for project activities is necessary 4.Create Incentives for participants - residents staff and parents (educational materials, comp days, money if you have it...) We know this is good advice because: 1.When we included staff our survey numbers increased dramatically 2.Because our parents told us at our meeting and on our surveys 3.When we were clear and repetitive in our communication with everyone, compliance was improved. 4.When we offered incentives in combination with education of staff/residents and parents, this increased participation.

We are wondering if next we should…  AAP Provide individualized feedback and support related to areas of weakness/need for practices Provide support for online patient surveys and statistical analysis for practices that don’t have access to these supports  USF Pediatrics Practice Develop our web parent access for outreach (Blog, parent education) Develop USF Pediatrics Application for distribution of patient information (more private than face book) – specific for our patients (Patient Health communication – like My Chart in EPIC)