1. Reach Out and Read WHFHC, 181 st Clinic Quality Improvement Project 2009-2010 Academic Year

2. WH ROR TEAM  Minna Saslaw  Melanie Gissen  Steve Caddle  Adriana Matiz  Laura Robbins  Marina Catallozzi  Dodi Meyer  Melissa Glassman  Mary McCord  Anne Armstrong-Coben  MA s  Emelin Martinez  Martha Bolivar  Dulce Barrios  Emily Kott  Caroline Chang  Ben Landis  Kristen Williams  Robyn Matloff  Nefthi Sandeep  Dina Ferdman  Ted Macnow  Amy Ost  Faith Dorsey  Crystal Sparling  Sarah Szlam  Neva Howard  Kim Noble

3. Project Background Reach Out and Read (ROR) is a primary care-based model that was established in 1989 to promote early literacy for children ages 6 months to 5 years. In the U.S., 2 out of 3 children read below their grade level and 90 million adults lack adequate ability to read. The goals of the program are to provide children with age- appropriate books at their well child visits as well as emphasize the importance of reading aloud as an activity shared between parent and child. Studies have shown that parents exposed to the ROR model are more likely to read aloud to their children and that these children score significantly higher on standardized language exams. Currently, nationwide participation has increased to over 4,500 sites, providing more than 6 million books to 3.8 million children.

4. Project Background In the exam room, doctors and nurses trained in the developmental strategies of early literacy encourage parents to read aloud to their young children, and offer age-appropriate tips The pediatric primary care provider gives every child between the ages of 6 months and 5 years a new, developmentally appropriate children’s book to take home and keep In the waiting room, displays, information, and gently-used books create a literacy-rich environment. Where possible, volunteer readers entertain the children, modeling for the parents the pleasures – and techniques – of reading aloud.

5. Project Background  A provider poll of ~70 faculty/residents at our 4 clinic sites  Most providers (80%) at least “mostly familiar” with ROR model  Majority (90%) “often” give age-appropriate books  Only 50% “often” give anticipatory guidance  Only 12% “always” give anticipatory guidance  Cited reasons for failing to provide AG  Lack of time  Forgetting

6. AIM Statement: Increase provider adherence to the ROR model. Increasing provider knowledge on the goals and benefits of the program Increasing the number of effective encounters between provider and patient/guardian regarding reading aloud to children at an early age.

7. Project Goals  100% of providers will receive education on the goals of the national ROR model and training on how to implement them during their patient encounters.  90% of patients, ages 6 mo-5yrs, will receive a developmentally-appropriate book at the well child visit.  50% of families of patients ages 6 mo-5 years will receive effective counseling at the well child visit on the importance of reading aloud to their child and how this experience can positively impact their child's language and development.  50% of patients charts will have consistent documentation of ROR counseling and book distribution at well-child visits.

8. WH ROR Book Distribution  MA s take turns stocking books in exam rooms  Each MA is supposed to check that their exam rooms are fully stocked daily  Every 1-2 months, the MA s call the ROR coordinator to reorder

9. Total WCC 6m - 5y seen in one-week review Book given (%) Patient Ed (%) Plan (%)AG (%)Pt. ed + plan (%) Attendings N=6 5941 (69)38 (92)15 (36)212 (29) Residents N=6 3125 (81)22 (88)14 (56)010 (40) Documentation of book giving at well-child visits in EHR Measurements, Phase I Completed October 2009

10. Home Phone Calls: The Survey Measurements, Phase II Completed November 2009 How old is your child? ____ Did your child get a book during your visit today? Yes No Did the doctor explain why they were giving you the book? Yes No If YES, please mark the reasons that they mentioned __ Importance of spending time with family __ Hearing parent voice and sitting with parent __ Improving language skills __ Learning to read __ Learning animals, shapes, numbers, colors, etc __ Other: (please list)_____________________________ Did the doctor explain how to use the book? Yes No If YES, please mark methods explained to you __ Reading aloud or having child read to you __ Using pictures/words for teaching __ Making reading a part of a nightly routine __ Other: (please list) _____________________________

11. Home Phone Calls: Data Summary Measurements, Phase II Completed November 2009 Well Child Care Calls Answered (N=14) Received Book (N=11) Yes115 No36

12. Home Phone Calls: Feedback and Response Measurements, Phase II Completed November 2009 Phone recipient not parent who brought in child to the visit so unsure whether they received the book Parental Anxiety: “Why is the doctor calling my home/my work? Is something wrong with my child?” Inability to best answer survey questions over the phone: “I know how to read to my child. I do it all the time.”

13. Waiting Room Surveys  Due to barriers obtaining data via home phone calls, the decision was made to use surveys in the waiting room  Over one week, surveys were handed to each parent of the targeted-age child after finishing the clinic visit  Surveys were handed out by a third party to prevent bias Measurements, Phase III Completed December 2009

14. Waiting Room Survey Results Block 6Block 8Block 9Block 10 Book given85 88 Explained why? 705982 Explained how? 65717782 Note: Survey not done in Block 7 in order to educate providers about ROR Longitudinal Analysis of Progress

15. Interventions  Block 7 - provider ROR education  Block 8 - anticipatory guidance handouts  Block 9 - acronym expanders  Block 10 & 11 - book stocking charts

16. ANTICIPATORY GUIDANCE HANDOUT

17. ACRONYM EXPANDER PHOTO

18. BOOK STOCKING PHOTOS

19. Waiting Room Survey Results Longitudinal Analysis of Progress

20. Where Do We Go From Here?  Stocking strategies  Chart system  Divider system  Anticipatory guidance bookmarks

21. Anticipatory guidance bookmarks  Designed along with national ROR office  Translated into Spanish by Emelin Martinez, Martha Bolivar, and Dulce Barrios  Backtranslated by Adriana Matiz  National ROR office to fund the printing  Eclipsys also to have specific AG  In the meantime  Paper handouts in exam rooms with bookmark text  Acronym expanders in Eclipsys

22. Stamper Project – Survey USE OF THE STAMPER: 25% Always 33% Most of the Time 8% Sometimes 33% Never ELEMENTS USED MOST: 66% Consult Notes 22% Correspondence 11% EI/Disability Evaluations 33% Use them all equally SATISFIED WITH LOOK OF THE STAMP: 66% Yes 16% Maybe 16% No (reasons included lines are not evenly justified, too large, too complicated) HAS IT BEEN EFFECTIVE: 40% Yes 40% Maybe 20% No HOW OFTEN SCANNED INTO PROPER LOCATION: 9% Always 27% Usually 63% Unsure WOULD IT BE HELPFUL IN OTHER CLINICS: 73% Yes 27% No PARTICIPANT S: 6 Attendings 2 PGY-1s 3 PGY-2s 3 PGY-3s

23. Stamper Project - Study  Tracked all documents to be scanned on 4 separate days  11 of 30 (37%) documents to be scanned were stamped  Of the 11 stamped documents:  3 (27%) made it to the correct folder with the correct title  5 (45%) made it to the correct folder but had no title  1 (9%) made it to the wrong folder and had no title  1 document was not scanned because the same consult note had been scanned into eclipsys 1 month previously