PAS: Process initiative helped improve risk screening in adolescents

SAN DIEGO – Initiation of a process improvement initiative helped to increase health risk screening during adolescent visits, results from a single-center study showed.

It also revealed challenges inherent in teaching residents about adolescent primary care.

“Adolescence is a peak period for risk-taking behaviors and the development of chronic physical and mental health conditions, which is why many professional organizations recommend that teenagers and young adults receive an annual preventive visit to receive counseling and screening around some of these issues,” lead study author Dr. Maya Kumar said at the annual meeting of the Pediatric Academic Societies. “Unfortunately there’s a growing body of evidence to suggest that most adolescents and young adults are not receiving this recommended preventive care.”

With the introduction of the Affordable Care Act, she continued, “we anticipated that more and more low-income youth would be starting to come to us once they were eligible to sign up for insurance and start receiving primary care. That led us to start asking ourselves the question: Do we have an adequate, comprehensive screening process in place to protect these vulnerable youth?”

At the Children’s Hospital Los Angeles Teen Health Center, where Dr. Kumar served as a fellow in adolescent medicine until 2014, the researchers set out to improve annual documented screening rates within 9 months to 90% or greater for each of four process measures chosen based on the American Academy of Pediatrics’ Bright Futures guidelines: health risk behaviors, sexually transmitted infections/HIV laboratory screening, tuberculosis risk assessment, and vaccine review. The Teen Health Center operates three types of clinics: one staffed by attending physicians, one staffed by fellows, and one staffed by residents. The office staff for all clinics includes one registered nurse, two medical assistants, and four administrative support staff.

“We do have an EMR [electronic medical record] although it does have limitations,” said Dr. Kumar. “If we want to give screening questionnaires to our patients, we have to do it on paper, and then the provider has to manually review it separately from the EMR. There is no way to tell from the EMR the last time the patient came in for a preventive visit. The only way you as a provider can know [that] is to manually comb through every visit they’ve had and look to see what was done.

“We also don’t have an automated system to notify patients when it’s time for their next annual preventive visit, and many of our patients don’t have their parents involved, so they’re unlikely to remember on their own, and we don’t have a consistent way to contact them and remind them.”

The baseline period was July 1 through Aug. 31, 2013, while the intervention period was Sept. 1, 2013, through March 31, 2014. At baseline, “we had a lot of room for improvement,” said Dr. Kumar, who is now an attending physician in adolescent medicine at the University of California, San Diego. “We were underscreening our sexually active youth. We were not looking for TB risk factors, and while we were doing well screening for some risk behaviors such as tobacco exposure, we were not doing so well with other behaviors like whether they wore a bicycle helmet or a seat belt.”

During the 9-month intervention period, the researchers conducted three tests of change based on Deming’s Plan-Do-Study-Act (PDSA) cycles, in which the interventions were developed from discussions in weekly faculty fellow meetings, monthly office business meetings, and discussions with rotating trainees. After each of the PDSA cycles, at least 20 charts from the practice were reviewed to track progress in the 30 days following the intervention.

“We identified a number of factors we felt were contributing to inadequate baseline screening rates, [including] office staff workload,” Dr. Kumar said. “Having only one nurse and two medical assistants to staff multiple clinics running at the same time made it impossible for them to participate in the screening process at baseline; we didn’t have a way to schedule an annual well visit; we did not have a formal TB risk assessment tool; we were stuck using paper questionnaires; and we got feedback from residents who told us when they started the rotation that they were unfamiliar with what was involved in adolescent primary care, because so few of them had been exposed to adolescents during their pediatric residencies.”

The researchers approached the clinic’s IT department to ask if changes to the EMR could be made, including a recall system for annual physicals and provider alerts for the last time a patient had preventive screening. “We were told that was not possible at that time,” Dr. Kumar said. “So we had to focus on key drivers that were within our control.”

The first PDSA cycle focused on cuing the providers to ensure that they were reviewing the paper questionnaire about adolescent health screening. “We asked our medical assistants to insert the paper questionnaire sideways into the patient folders to give the providers a visual cue to stop and review the documents during the visit,” she said. The second PDSA cycle consisted of the introduction of a TB risk assessment form and a well-adolescent visit “cheat sheet” that was distributed to pediatric residents in electronic and hard copy forms, while the third PDSA targeted residents more heavily by giving them a 1-hour lecture about adolescent primary care, and sending an e-mail reminder to rotating residents about necessary screening.

In general, there was an increase for all of the process measures from baseline to the end of the study period, but a certain amount of attrition occurred between PDSA cycles 2 and 3. For example, the TB assessment was 19% at baseline, 27% after PDSA cycle 1, 85% after PDSA cycle 2, and 50% after PDSA cycle 3; screening for sexual activity was 81% at baseline, 91% after PDSA cycle 1, 100% after cycle 2, and 95% after cycle 3; while vaccine review was 57% at baseline, 72% after PDSA cycle 1, 100% after cycle 2, and 80% after cycle 3.

“We managed to improve our screening rates overall for almost all of the measures we were looking at,” Dr. Kumar said. “There was a lot of buy-in and support behind this project from the patients, providers, administrators, and office staff. Considering that we were not allowed to make changes to our EMR, we got a lot of bang for our buck.”

The attrition in many of the process measures by PDSA cycle 3 “highlights the fundamental need we have for systemic solutions rather than relying on individuals to change their behavior,” Dr. Kumar said. “The residents responded positively to the interventions that were targeted towards them. Many indicated that their understanding of adolescent preventive care improved. But they also said it was a lot to learn in a 1-month rotation. The only way we’re going to create sustainable change is to focus on system-based solutions.”

She said that staff at Children’s Hospital Los Angeles Teen Health Center are “working to use these results as leverage to expand EMR functionality to include a recall system for annual physicals; to create provider alerts to inform the provider when the patients are due for their next annual screening; and electronic versions of the questionnaires that the patients can complete and have downloaded directly to the EMR,” she said. “We also recognize the importance of improving longitudinal teaching around adolescent health throughout pediatric residency programs, and not just during a 1-month rotation.”

Dr. Kumar reported having no relevant financial conflicts.

[email protected]


On Twitter @dougbrunk

SAN DIEGO – Initiation of a process improvement initiative helped to increase health risk screening during adolescent visits, results from a single-center study showed.

It also revealed challenges inherent in teaching residents about adolescent primary care.

“Adolescence is a peak period for risk-taking behaviors and the development of chronic physical and mental health conditions, which is why many professional organizations recommend that teenagers and young adults receive an annual preventive visit to receive counseling and screening around some of these issues,” lead study author Dr. Maya Kumar said at the annual meeting of the Pediatric Academic Societies. “Unfortunately there’s a growing body of evidence to suggest that most adolescents and young adults are not receiving this recommended preventive care.”

With the introduction of the Affordable Care Act, she continued, “we anticipated that more and more low-income youth would be starting to come to us once they were eligible to sign up for insurance and start receiving primary care. That led us to start asking ourselves the question: Do we have an adequate, comprehensive screening process in place to protect these vulnerable youth?”

At the Children’s Hospital Los Angeles Teen Health Center, where Dr. Kumar served as a fellow in adolescent medicine until 2014, the researchers set out to improve annual documented screening rates within 9 months to 90% or greater for each of four process measures chosen based on the American Academy of Pediatrics’ Bright Futures guidelines: health risk behaviors, sexually transmitted infections/HIV laboratory screening, tuberculosis risk assessment, and vaccine review. The Teen Health Center operates three types of clinics: one staffed by attending physicians, one staffed by fellows, and one staffed by residents. The office staff for all clinics includes one registered nurse, two medical assistants, and four administrative support staff.

“We do have an EMR [electronic medical record] although it does have limitations,” said Dr. Kumar. “If we want to give screening questionnaires to our patients, we have to do it on paper, and then the provider has to manually review it separately from the EMR. There is no way to tell from the EMR the last time the patient came in for a preventive visit. The only way you as a provider can know [that] is to manually comb through every visit they’ve had and look to see what was done.

“We also don’t have an automated system to notify patients when it’s time for their next annual preventive visit, and many of our patients don’t have their parents involved, so they’re unlikely to remember on their own, and we don’t have a consistent way to contact them and remind them.”

The baseline period was July 1 through Aug. 31, 2013, while the intervention period was Sept. 1, 2013, through March 31, 2014. At baseline, “we had a lot of room for improvement,” said Dr. Kumar, who is now an attending physician in adolescent medicine at the University of California, San Diego. “We were underscreening our sexually active youth. We were not looking for TB risk factors, and while we were doing well screening for some risk behaviors such as tobacco exposure, we were not doing so well with other behaviors like whether they wore a bicycle helmet or a seat belt.”

During the 9-month intervention period, the researchers conducted three tests of change based on Deming’s Plan-Do-Study-Act (PDSA) cycles, in which the interventions were developed from discussions in weekly faculty fellow meetings, monthly office business meetings, and discussions with rotating trainees. After each of the PDSA cycles, at least 20 charts from the practice were reviewed to track progress in the 30 days following the intervention.

“We identified a number of factors we felt were contributing to inadequate baseline screening rates, [including] office staff workload,” Dr. Kumar said. “Having only one nurse and two medical assistants to staff multiple clinics running at the same time made it impossible for them to participate in the screening process at baseline; we didn’t have a way to schedule an annual well visit; we did not have a formal TB risk assessment tool; we were stuck using paper questionnaires; and we got feedback from residents who told us when they started the rotation that they were unfamiliar with what was involved in adolescent primary care, because so few of them had been exposed to adolescents during their pediatric residencies.”

The researchers approached the clinic’s IT department to ask if changes to the EMR could be made, including a recall system for annual physicals and provider alerts for the last time a patient had preventive screening. “We were told that was not possible at that time,” Dr. Kumar said. “So we had to focus on key drivers that were within our control.”

The first PDSA cycle focused on cuing the providers to ensure that they were reviewing the paper questionnaire about adolescent health screening. “We asked our medical assistants to insert the paper questionnaire sideways into the patient folders to give the providers a visual cue to stop and review the documents during the visit,” she said. The second PDSA cycle consisted of the introduction of a TB risk assessment form and a well-adolescent visit “cheat sheet” that was distributed to pediatric residents in electronic and hard copy forms, while the third PDSA targeted residents more heavily by giving them a 1-hour lecture about adolescent primary care, and sending an e-mail reminder to rotating residents about necessary screening.

In general, there was an increase for all of the process measures from baseline to the end of the study period, but a certain amount of attrition occurred between PDSA cycles 2 and 3. For example, the TB assessment was 19% at baseline, 27% after PDSA cycle 1, 85% after PDSA cycle 2, and 50% after PDSA cycle 3; screening for sexual activity was 81% at baseline, 91% after PDSA cycle 1, 100% after cycle 2, and 95% after cycle 3; while vaccine review was 57% at baseline, 72% after PDSA cycle 1, 100% after cycle 2, and 80% after cycle 3.

“We managed to improve our screening rates overall for almost all of the measures we were looking at,” Dr. Kumar said. “There was a lot of buy-in and support behind this project from the patients, providers, administrators, and office staff. Considering that we were not allowed to make changes to our EMR, we got a lot of bang for our buck.”

The attrition in many of the process measures by PDSA cycle 3 “highlights the fundamental need we have for systemic solutions rather than relying on individuals to change their behavior,” Dr. Kumar said. “The residents responded positively to the interventions that were targeted towards them. Many indicated that their understanding of adolescent preventive care improved. But they also said it was a lot to learn in a 1-month rotation. The only way we’re going to create sustainable change is to focus on system-based solutions.”

She said that staff at Children’s Hospital Los Angeles Teen Health Center are “working to use these results as leverage to expand EMR functionality to include a recall system for annual physicals; to create provider alerts to inform the provider when the patients are due for their next annual screening; and electronic versions of the questionnaires that the patients can complete and have downloaded directly to the EMR,” she said. “We also recognize the importance of improving longitudinal teaching around adolescent health throughout pediatric residency programs, and not just during a 1-month rotation.”

Dr. Kumar reported having no relevant financial conflicts.

[email protected]


On Twitter @dougbrunk

SAN DIEGO – Initiation of a process improvement initiative helped to increase health risk screening during adolescent visits, results from a single-center study showed.

It also revealed challenges inherent in teaching residents about adolescent primary care.

“Adolescence is a peak period for risk-taking behaviors and the development of chronic physical and mental health conditions, which is why many professional organizations recommend that teenagers and young adults receive an annual preventive visit to receive counseling and screening around some of these issues,” lead study author Dr. Maya Kumar said at the annual meeting of the Pediatric Academic Societies. “Unfortunately there’s a growing body of evidence to suggest that most adolescents and young adults are not receiving this recommended preventive care.”

With the introduction of the Affordable Care Act, she continued, “we anticipated that more and more low-income youth would be starting to come to us once they were eligible to sign up for insurance and start receiving primary care. That led us to start asking ourselves the question: Do we have an adequate, comprehensive screening process in place to protect these vulnerable youth?”

At the Children’s Hospital Los Angeles Teen Health Center, where Dr. Kumar served as a fellow in adolescent medicine until 2014, the researchers set out to improve annual documented screening rates within 9 months to 90% or greater for each of four process measures chosen based on the American Academy of Pediatrics’ Bright Futures guidelines: health risk behaviors, sexually transmitted infections/HIV laboratory screening, tuberculosis risk assessment, and vaccine review. The Teen Health Center operates three types of clinics: one staffed by attending physicians, one staffed by fellows, and one staffed by residents. The office staff for all clinics includes one registered nurse, two medical assistants, and four administrative support staff.

“We do have an EMR [electronic medical record] although it does have limitations,” said Dr. Kumar. “If we want to give screening questionnaires to our patients, we have to do it on paper, and then the provider has to manually review it separately from the EMR. There is no way to tell from the EMR the last time the patient came in for a preventive visit. The only way you as a provider can know [that] is to manually comb through every visit they’ve had and look to see what was done.

“We also don’t have an automated system to notify patients when it’s time for their next annual preventive visit, and many of our patients don’t have their parents involved, so they’re unlikely to remember on their own, and we don’t have a consistent way to contact them and remind them.”

The baseline period was July 1 through Aug. 31, 2013, while the intervention period was Sept. 1, 2013, through March 31, 2014. At baseline, “we had a lot of room for improvement,” said Dr. Kumar, who is now an attending physician in adolescent medicine at the University of California, San Diego. “We were underscreening our sexually active youth. We were not looking for TB risk factors, and while we were doing well screening for some risk behaviors such as tobacco exposure, we were not doing so well with other behaviors like whether they wore a bicycle helmet or a seat belt.”

During the 9-month intervention period, the researchers conducted three tests of change based on Deming’s Plan-Do-Study-Act (PDSA) cycles, in which the interventions were developed from discussions in weekly faculty fellow meetings, monthly office business meetings, and discussions with rotating trainees. After each of the PDSA cycles, at least 20 charts from the practice were reviewed to track progress in the 30 days following the intervention.

“We identified a number of factors we felt were contributing to inadequate baseline screening rates, [including] office staff workload,” Dr. Kumar said. “Having only one nurse and two medical assistants to staff multiple clinics running at the same time made it impossible for them to participate in the screening process at baseline; we didn’t have a way to schedule an annual well visit; we did not have a formal TB risk assessment tool; we were stuck using paper questionnaires; and we got feedback from residents who told us when they started the rotation that they were unfamiliar with what was involved in adolescent primary care, because so few of them had been exposed to adolescents during their pediatric residencies.”

The researchers approached the clinic’s IT department to ask if changes to the EMR could be made, including a recall system for annual physicals and provider alerts for the last time a patient had preventive screening. “We were told that was not possible at that time,” Dr. Kumar said. “So we had to focus on key drivers that were within our control.”

The first PDSA cycle focused on cuing the providers to ensure that they were reviewing the paper questionnaire about adolescent health screening. “We asked our medical assistants to insert the paper questionnaire sideways into the patient folders to give the providers a visual cue to stop and review the documents during the visit,” she said. The second PDSA cycle consisted of the introduction of a TB risk assessment form and a well-adolescent visit “cheat sheet” that was distributed to pediatric residents in electronic and hard copy forms, while the third PDSA targeted residents more heavily by giving them a 1-hour lecture about adolescent primary care, and sending an e-mail reminder to rotating residents about necessary screening.

In general, there was an increase for all of the process measures from baseline to the end of the study period, but a certain amount of attrition occurred between PDSA cycles 2 and 3. For example, the TB assessment was 19% at baseline, 27% after PDSA cycle 1, 85% after PDSA cycle 2, and 50% after PDSA cycle 3; screening for sexual activity was 81% at baseline, 91% after PDSA cycle 1, 100% after cycle 2, and 95% after cycle 3; while vaccine review was 57% at baseline, 72% after PDSA cycle 1, 100% after cycle 2, and 80% after cycle 3.

“We managed to improve our screening rates overall for almost all of the measures we were looking at,” Dr. Kumar said. “There was a lot of buy-in and support behind this project from the patients, providers, administrators, and office staff. Considering that we were not allowed to make changes to our EMR, we got a lot of bang for our buck.”

The attrition in many of the process measures by PDSA cycle 3 “highlights the fundamental need we have for systemic solutions rather than relying on individuals to change their behavior,” Dr. Kumar said. “The residents responded positively to the interventions that were targeted towards them. Many indicated that their understanding of adolescent preventive care improved. But they also said it was a lot to learn in a 1-month rotation. The only way we’re going to create sustainable change is to focus on system-based solutions.”

She said that staff at Children’s Hospital Los Angeles Teen Health Center are “working to use these results as leverage to expand EMR functionality to include a recall system for annual physicals; to create provider alerts to inform the provider when the patients are due for their next annual screening; and electronic versions of the questionnaires that the patients can complete and have downloaded directly to the EMR,” she said. “We also recognize the importance of improving longitudinal teaching around adolescent health throughout pediatric residency programs, and not just during a 1-month rotation.”

Dr. Kumar reported having no relevant financial conflicts.

[email protected]


On Twitter @dougbrunk