Newborn Screen Positive Infant ACTion Learning Collaborative Learning Session II

1. Newborn Screen Positive Infant ACTion Learning CollaborativeLearning Session II Kim Giuliano, MD and Anna Winfield, MD Cleveland Clinic Children’s Hospital February 12, 2011

2. 11 primary care pediatric offices in Cleveland, OH and surrounding suburbs • 2 pilot sites for QuINN Newborn Screen Positive Infant ACTion Project : • Main Campus • 7 pediatricians, 3 RNs, 3 MAs • Westown Office • 2 staff pediatricians, 2 float pediatricians, 1 RN, remainder staff MAs • Both offices are teaching sites for residents and medical students

3. Team Members Kim Giuliano, MD Anna Winfield, MD Mo VanGunten, RN Kristen Kolarik, MA

4. Aim Statement – All Newborns • By November 2010, Cleveland Clinic Children’s Hospital’s (CCCH) Main Campus and Westown offices will improve newborn screening processes by implementing AAP’s recommendations. • In 2011, sustainable improvement measures will be spread to additional CCCH General Pediatric Offices. • Specific Aims: • 100% of infants receive assessment at first visit for completion of newborn screening. • 100% of charts are flagged for patients who are not screened. • 100% of newborn screening results are received before the 2- to 4-week visit. • 100% of in-range newborn screening results are documented in the infant’s chart and sharedwith parents.

5. Aim Statement – Abnormal NBS • By November 2010, CCCH’s Main Campus and Westown offices will improve the processes for managing out-of-range newborn screening results by implementing AAP’s recommendations. • In 2011, sustainable improvement measures will be spread to additional CCCH General Pediatric Offices. • Specific Aims: • 100% of parents of infants with an out-of-range newborn screening result receive condition-specific information and support. • 100% of infants with an out-of-range screening result receive confirmatory testing and/or definitive consultation with subspecialists. • 100% of false out-of-range newborn screening results are documented in the infant’s chart and discussed with parents. • 100% of children given a diagnosis of a significant medical condition are identified as a child with special health care needs and are provided a medical home.

6. Changes Implemented • Reliable Systems of Care • NBS Office Policy Statement • Tracking systems (log sheet at Westown, binder at Main Campus) • EMR templates edited for newborn, 2-4 week visit, 2 month visit • Registry for abnormal NBS and CSHCN

8. Changes Implemented • Community-based Care • Referral line for metabolic specialists • Contacted Ohio Department of Health – arranged contact person for missing NBS reports • Contacted nursery hospitalists to facilitate discharge communication and education re: NBS

9. Changes Implemented • Active Well-informed Patients • Newborn packets given at first office visit • Hospitalist outreach to ensure same pamphlet is given at all CCCH sites

10. Cycles of Improvement • EMR templates #1 • PLAN • “Dot phrase” created to insert into already existing templates to document NBS completion and sharing of results with parents. Way to test the documentation phrase without changing the template for all providers in the office. • DO • Dr. Giuliano and Dr. Winfield used for 1 week • Forgot to use for one newborn • STUDY • Good way to document but relies on provider to remember • ACT • Change template for all providers

11. Cycles of Improvement • EMR templates #2 • PLAN • Change template for all providers at both offices • DO • All providers informed • Some providers continued using old templates • STUDY • Easy to document but correct template needs to be used • ACT • Removed old templates from provider’s “favorites” list • Sent email communication to all residents and providers that do not have regular face-to-face contact

12. Cycles of Improvement • EMR templates #3 • PLAN • All providers using same template • DO • All providers made the change • STUDY • Improvement noted in run charts for documentation of NBS completion and sharing of results with parents • ACT • Adopt as final plan for Westown and Main Campus

15. Cycles of Improvement • EMR templates #4 • PLAN: • Designing system wide “SmartSets” that will include our current templates (currently in progress)

16. Cycles of Improvement • Log Sheets #1 • PLAN • Log sheet created for documentation of NBS results/status for each newborn seen in practice • DO • Dr. Giuliano and Dr. Winfield used for 1 week • STUDY • Complete and easy to view documentation • 100% of newborns seen in pilot week had complete sheets • ACT • Institute use of log sheet for ALL newborns

17. LOG SHEET

18. Cycles of Improvement • Log Sheets #2 • PLAN • Utilize log sheet for all newborns seen by all providers • DO • Office staff and providers instructed in use • Did not have opportunity to educate all providers face to face • STUDY • Main Campus office consistently used log sheets • Westown office did not consistently create log sheets • Lack of “paper chart” resulted in loss of information • <25% of newborns seen at Westown by other providers had complete log sheets • ACT • Brainstorm alternate means of documentation for Westown • Adopt but continue to study at Main Campus

19. Cycles of Improvement • Log Sheets #3 • PLAN • Reformulated log sheet from one document per patient to centralized recording site • DO • Educate one medical assistant in use of centralized log sheet • Dr. Winfield responsible for tracking data weekly • STUDY • More consistent use of tracking data • Easy to review • ACT • Utilize centralized log sheet for all newborns seen at Westown practice

21. Results Residents and new MDs started Old templates removed from “favorites”, email to providers EMR template changed

22. Results Westown changed to one tracking sheet Tracking binders

23. Results at 1mo visit(Approaching 100% at 2 mo visit) Old templates removed from “favorites”, email to providers EMR template changed

24. Results ACT sheets used for unusual metabolic conditions only Educated providers about ACT sheets & abnormal newborn screening guide made

25. What You Have Learned • Lessons Learned • Team work is essential in the office • Partnership with other organizations is valuable • Communication is key • What works for one site may not work for another • Important to track measures at appropriate time interval and for areas that are truly in need of change • Challenges and setbacks • Hard to make large changes in a big institution • Dr. Winfield cut back hours around same time new physicians started in her office • Dr. Giuliano and Dr. Winfield at different physical locations

26. General Lessons Learned • What contributed to your progress so far • Teamwork • EMR templates • Tracking processes • Anticipated issues • Some sites may not identify NBS as an area in need of improvement • Some sites may not feel they have the time to invest in similar project • Getting IT to help change the EMR Health Maintenance Alert • Hospitalists communication