1. Developmental Screening at Rangel 2008-2009 Quality Improvement Project Chief of Service May 20, 2009 2008-2009 Quality Improvement Project Chief of Service May 20, 2009

2. Team Members Attendings –Evelyn Berger-Jenkins –Hetty Cunningham –Dan Cohen –Andrew Mutnick –Tawana Winkfield-Royster Residents –Hari Narayan –Rebecca Friedman –Nadia Saldanha –Caryn Kerman –Jessica Durst –Kate Avitabile –Bhawna Arya –Clem Bottino –Amna Afzal Attendings –Evelyn Berger-Jenkins –Hetty Cunningham –Dan Cohen –Andrew Mutnick –Tawana Winkfield-Royster Residents –Hari Narayan –Rebecca Friedman –Nadia Saldanha –Caryn Kerman –Jessica Durst –Kate Avitabile –Bhawna Arya –Clem Bottino –Amna Afzal Nurses –Yolanda Mora-Irizarry –Jamella Tangara Medical Assistants –Wendy Acosta –Kenia… Nurses –Yolanda Mora-Irizarry –Jamella Tangara Medical Assistants –Wendy Acosta –Kenia…

3. (Original) Aim Statement In order to improve care at the Charles Rangel Clinic, we plan to ensure effective and proper developmental screening of 95% of children from newborn to 5 years of life, utilizing the Denver II screening tool at the 9, 18 and 30 month well child visit and during any other visit in which parental concerns are identified via questionnaire or practitioner concerns arise based on observation. 95% of the patients who screen positive for developmental delays will be referred for further evaluation.

4. Baseline Measures Process Measures: –Percent of patients screened with non- validated tool (parental questionnaire) –Percent of patients with positive screens (parental concerns) who were evaluated with Denver II Process Measures: –Percent of patients screened with non- validated tool (parental questionnaire) –Percent of patients with positive screens (parental concerns) who were evaluated with Denver II

5. Pediatrics. 2006: 118:405-20. Clinical Relevance Early identification of developmental disorders is critical to well-being of children and their families Disorders can be caused by specific medical conditions and may indicate an increased risk of other medical complications Specific therapeutic interventions (Early Intervention) are available for a wide range of developmental disorders Early identification may affect medical treatment for the child and family planning for the parents Early identification of developmental disorders is critical to well-being of children and their families Disorders can be caused by specific medical conditions and may indicate an increased risk of other medical complications Specific therapeutic interventions (Early Intervention) are available for a wide range of developmental disorders Early identification may affect medical treatment for the child and family planning for the parents

6. Pediatrics. 2002; 110:184-6. Pediatrics. 2005; 116:174-9. Pediatrics. 2006; 118:405-20. Gaps in Care Despite 2001 AAP Policy Statement, few pediatricians use effective means to screen their patients for developmental problems. Only 23% of surveyed PMDs reported using a standardized screening instrument (Denver II) 2006 AAP Policy Statement made specific screening recommendations and presented an algorithm for addressing developmental concerns Despite 2001 AAP Policy Statement, few pediatricians use effective means to screen their patients for developmental problems. Only 23% of surveyed PMDs reported using a standardized screening instrument (Denver II) 2006 AAP Policy Statement made specific screening recommendations and presented an algorithm for addressing developmental concerns

7. AAP Screening Algorithm

8. Our Decision Tree

9. Adapted from PEDS screen and Bright Futures Guidelines Parental Questionnaire If your child is newborn – 9 months old : 1. Are you worried about how your child moves his/her head or arms/legs?YesNo 2. Are you worried about how your child uses his/her eyes or hands?YesNo 3. Are you worried about how your child communicates?Yes No 4. Are you worried about how your child interacts with you or others?YesNo If your child is 1 year old – 4 years old : 1. Are you worried about how your child moves and plays?YesNo 2. Are you worried about how your child uses his/her hands?Yes No 3. Are you worried about how your child communicates/talks?YesNo 4. Are you worried about how your child interacts with you or others?YesNo If you child is 5 years old – 12 years old: 1. Are you worried about your child’s behavior?YesNo 2. Are you worried about your child’s mood? Yes No 3. Are you worried about how your child is doing in school? Yes No 4. Are you worried about how your child is developing?Yes No If you child is older than 12 years: 1. Are you worried about your child’s behavior? YesNo 2. Are you worried about your child’s mood? Yes No 3. Are you worried about how your child is doing in school? Yes No 4. Are you worried about how your child is developing? YesNo If your child is newborn – 9 months old : 1. Are you worried about how your child moves his/her head or arms/legs?YesNo 2. Are you worried about how your child uses his/her eyes or hands?YesNo 3. Are you worried about how your child communicates?Yes No 4. Are you worried about how your child interacts with you or others?YesNo If your child is 1 year old – 4 years old : 1. Are you worried about how your child moves and plays?YesNo 2. Are you worried about how your child uses his/her hands?Yes No 3. Are you worried about how your child communicates/talks?YesNo 4. Are you worried about how your child interacts with you or others?YesNo If you child is 5 years old – 12 years old: 1. Are you worried about your child’s behavior?YesNo 2. Are you worried about your child’s mood? Yes No 3. Are you worried about how your child is doing in school? Yes No 4. Are you worried about how your child is developing?Yes No If you child is older than 12 years: 1. Are you worried about your child’s behavior? YesNo 2. Are you worried about your child’s mood? Yes No 3. Are you worried about how your child is doing in school? Yes No 4. Are you worried about how your child is developing? YesNo

10. New Aim Statement In order to improve care at the Charles Rangel Clinic, we plan to ensure effective and proper developmental screening of 95% of children from newborn to 5 years of life, utilizing the Denver II screening tool at the 9, 18 and 30 month well child visit and during any other visit in which parental concerns are identified via questionnaire or practitioner concerns arise based on observation.

11. PDSA Cycle #1 Resident trialed questionnaire in waiting room on 2 different afternoons –Screened 8 patients –Parents completed form –2/8 had concerns which were addressed by MD Resident trialed questionnaire in waiting room on 2 different afternoons –Screened 8 patients –Parents completed form –2/8 had concerns which were addressed by MD

12. PDSA Cycle #2 MAs distributed forms to parents who completed questionnaire On one Wednesday 64% eligible patients received forms –Of those, 14% answered incorrectly –29% (2/7) had developmental concerns 1 teenager 1 detailed developmental history but no Denver MAs distributed forms to parents who completed questionnaire On one Wednesday 64% eligible patients received forms –Of those, 14% answered incorrectly –29% (2/7) had developmental concerns 1 teenager 1 detailed developmental history but no Denver

13. PDSA Cycle #3 MAs read questionnaire to parents and documented response in vitals flow sheet under “Depression Screen” tab One afternoon flow sheets of patients of 2 different MDs were reviewed - no documentation of screens MAs read questionnaire to parents and documented response in vitals flow sheet under “Depression Screen” tab One afternoon flow sheets of patients of 2 different MDs were reviewed - no documentation of screens

14. Eclypsis Documentation Dr. Berger spoke with Dr. Robbins and the Eclypsis team –“Depression Screen” tab to be changed to “Screening Forms” tab to include any forms completed in the waiting room –Free text box in which MAs can document pertinent screening results –Will go live in July 2009 Dr. Berger spoke with Dr. Robbins and the Eclypsis team –“Depression Screen” tab to be changed to “Screening Forms” tab to include any forms completed in the waiting room –Free text box in which MAs can document pertinent screening results –Will go live in July 2009

15. PDSA Cycle #4 MAs read questionnaire to parents and documented response in vitals flow sheet Over 1.5 clinic days, 32% eligible patients received forms –18% (2/11) had developmental concerns addressed by MDs - but no clear documentation of Denver MAs read questionnaire to parents and documented response in vitals flow sheet Over 1.5 clinic days, 32% eligible patients received forms –18% (2/11) had developmental concerns addressed by MDs - but no clear documentation of Denver

16. PDSA Cycle #5 Reviewed results from cycle #4 with MAs –Could not identify reason for not screening all pts Laminated surveys in MAs lab and all exam rooms During one 10 day period only 8% eligible patients received forms –44% (4/9) of those had developmental concerns –All evaluated per MD notes - but no clear documentation of Denver) –None required intervention Reviewed results from cycle #4 with MAs –Could not identify reason for not screening all pts Laminated surveys in MAs lab and all exam rooms During one 10 day period only 8% eligible patients received forms –44% (4/9) of those had developmental concerns –All evaluated per MD notes - but no clear documentation of Denver) –None required intervention

17. Why such a decline? New clinic space New MAs working in Peds - did not receive tutorial from resident Fewer patients screened on days outpatient resident was not there to remind MAs/providers Flow of patients in the clinic –Forms in the MAs’ lab BUT… –Vitals taken in another room closer to the waiting room –Patients taken to exam rooms without entering lab New clinic space New MAs working in Peds - did not receive tutorial from resident Fewer patients screened on days outpatient resident was not there to remind MAs/providers Flow of patients in the clinic –Forms in the MAs’ lab BUT… –Vitals taken in another room closer to the waiting room –Patients taken to exam rooms without entering lab

18. Learning Points Important to do developmental screening since specific therapeutic interventions are available Difficult to do in a “population based” way Need to have systems in place to deal with positive screens We began to establish the infrastructure to perform proper developmental screening at Rangel Important to do developmental screening since specific therapeutic interventions are available Difficult to do in a “population based” way Need to have systems in place to deal with positive screens We began to establish the infrastructure to perform proper developmental screening at Rangel

19. Challenges and Next Steps Engaging all members of the staff Optimizing the physical space –Laminated questionnaire in the vitals room –Screening forms as “another vital sign” Incorporation into the waiting room screening form to utilize patient wait time Documentation of screen in Eclypsis flow sheet Purchase of more Denvers MD documentation of Denver completion Process by which PFAs can make referrals to EI Engaging all members of the staff Optimizing the physical space –Laminated questionnaire in the vitals room –Screening forms as “another vital sign” Incorporation into the waiting room screening form to utilize patient wait time Documentation of screen in Eclypsis flow sheet Purchase of more Denvers MD documentation of Denver completion Process by which PFAs can make referrals to EI