1. Establish Medical Assistant Protocols for Comprehensive Age Appropriate Well-Child Screenings (PA26) Richel Z. Avery, MD Assistant Professor/Clinical Ronda Lantz, RN, FNP Clinical Instructor Department of Family and Community Medicine The University of Texas Health Science Center in San Antonio December 5, 2015

2. Disclosures Dr. Avery and Mrs. Lantz have no relevant financial relationships with commercial interests to disclose. They have completed and submitted disclosures as STFM requires.

3. Session Objectives 1.Discuss how a QI project on medical assistant protocols for comprehensive age appropriate well-child screenings standardized patient care in one clinic. 2.Discuss the generalizability of the QI project to standardized comprehensive age appropriate well-child screenings in your clinic. 3

4. Clinical Context University of Texas (UT) Medicine Primary Care Clinic (PCC): FM, IM/Geri providers FM: 7 providers (4 full-time/3 part-time)  4 providers see children  1,800 visits/month; 8% of visits are children We completed the UT System’s Clinical Safety and Effectiveness QI Course that included a project  Our project focused on Well-Child Visits

5. Problem/Conclusion An analysis of our well-child visit documentation showed inconsistent quality due to:  lack of standardized procedures, and  use of different resources by individual providers Conclusion: Our clinic needed to standardized well child visits to align with our strategic goals: Improve patient safety & meet the standard of care 5

6. Literature Review Four factors influenced standardized visit contents among Pediatricians: 1.Residency or fellowship training 2.Information in Bright Futures guidelines 3.Discussions with physicians in their community 4.Incentives from health plans 1.Committee on Psychosocial Aspects of Child and Family Health. (2001) The new morbidity revisited: A renewed commitment of the psychosocial aspects of pediatric care. Pediatrics, 108(5): 1227-1230. 2.Norlin C, Crawford M, Bell C, Sheng X, Stein M. Delivery of Well-Child Care: A Look Inside the Door. Academic Pediatrics, 2011; 11(1): 18-26.

7. Background The AAP’s and Bright Futures’ guidelines for Preventive Pediatric Health: Emphasize continuity of care and comprehensive health supervision The Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) service: Medicaid's preventive child (birth - 20 YO) health service (medical, dental, and case management)  In Texas, EPDST is known as Texas Health Steps: Includes preventive care components, or Early and Periodic Screening (EPS), of the total EPSDT service (see blue handout) 7

8. Project Milestones 2013 Create Team November 2013 Write QI AIM StatementDecember 2013 Gather Baseline DataOctober 2013 to March 2014 2014 Stage 1 Conduct Weekly Team Meetings/Brainstorm SessionsJanuary 2014 Develop Workflow and Fishbone DiagramFebruary 2014 Implement Intervention 1: FlipcardsMarch 2014 Analyze DataApril-June 2014 2015 Stage 2 Re-Assess Project Results June 2015 Implement Intervention 2: Sharpee Cards July 2015 Analyze Data August -Sept 2015

9. Methods Identify problems Analyze clinic workflow (see pink handout) Conduct Fishbone analyses (see green handout) Create Pareto diagram and control charts of background data

11. Intervention 1 Apr.-May 2014) Flip cards MA training, visual aids Intervention 2 Aug.-Sept. 2015 Sharpee Cards MA Training New Clinic Workflow Methods

12. Interventions Focused on our MAs: Versatile, they perform both administrative and clinical functions  Goal: Enabling providers to conduct more efficient visits by improving clinical efficiency and optimizing patient flow Emphasized MA training to improve their knowledge & skills so they can complete tasks conforming to the clinic’s standards 12

13. Well Child Visit Workflow Intake Room In Provider Orders Discharge Documentation (See white handout)

14. Measures of Analysis 1.Vital Signs 2.Vision Screen 3.Hearing Screen 4.TB Screen 5.Lead Screen 14

15. Data-Gathering Periods Pre-intervention Data (Baseline)  October 2013 and March 2014 Post-intervention 1 Data  April and May 2014 Post-intervention 2 Data  August and Sept 2015 15

16. There was improvement of 2 0 points from baseline after t he Intervention 1 and

17. Percentage of Screening Measures Completed by Month Baseline

18. Vital Signs Baseline Post- 1 Post- 2

19. Hearing Screenings Baseline Post- 1 Post- 2

20. Vision Screenings Baseline Post- 1 Post- 2

21. TB Screenings Baseline Post- 1 Post- 2

22. Lead Screens Baseline Post- 1 Post- 2

23. Project Outcomes Stage 1: Improvement of chart completeness: 81% Stage 2: Improvement of chart completeness: 98% All 5 screening measures showed improvement

24. Limitations 1.Lack of uniformity in visit types when patients are scheduled 2.Pedi Wellness template in the EMR is incomplete 3.Need for more IT support 4. Restructuring of the organization/change in leadership

25. Project’s Take-Home Points 1.Enhanced uniformity of clinic flow processes 2.Improved efficiency of staff with periodic training 3.Set a standard for Higher quality of care that meets the state health department requirements 4.Proved nurse leadership helps maintain competency among the MA 5.Demonstrated that some QI projects require more than one stage

26. Questions for Discussion What challenges with Well Child Visits occur in your clinic? What tool(s) help you standardize Well Child Visits? How do you use MAs in your clinic?

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