Academic Pediatrics

30. THE BENEFITS OF A TRULY INDIVIDUALIZED CURRICULUM Publication date: August 2019 Source: Academic Pediatrics, Volume 19, Issue 6 Author(s): Punit N. Jhaveri, Pooja B. Jhaveri, Brandon M. Smith Background In response to the 2013 ACMGE Program Requirements that mandated “a minimum of six educational units of an individualized curriculum determined by the learning needs and career plans of each resident and... developed through the guidance of a faculty mentor,” many pediatric programs developed career-based tracks. Because tracks have the potential to introduce unnecessary and potentially harmful rigidity, our program aimed for each resident to develop a truly individualized schedule. Objective Allow each resident in our program to develop a unique individualized schedule through faculty guidance. Methods A new position, the Director of Individualized Education (DIE) was created with 0.05 FTE departmental support, which translates to approximately 100 hours of protected time, or approximately 2.5 hours per resident in a program of approximately 40 total residents. A new resident block schedule was created that is broadly divided into three categories: A) Required rotations (94 weeks) include those mandated by ACGME requirements plus other rotations required by the program. B) Selectives (12 weeks in the third year) are chosen from a limited menu based on hospital staffing needs. C) Electives (38 weeks, available as 2- or 4-week experiences) are structured to meet ACGME requirements for “key subspecialties,” “additional educational units,” and the “individualized curriculum,” following the “double counting” rules from prior ACGME FAQs. For the 32 such weeks that occur in the PGY2 and PGY3 years, rotations are chosen after a meeting between the resident and the DIE. A flowsheet for each resident is reviewed annually by the DIE and semi-annually by the Program Director or an Associate Program Director to ensure compliance with ACGME requirements. Results 54 residents have completed our program under the current scheduling system, and no two residents have had identical schedules. On the ACGME annual survey of PGY3 residents from 2016 to 2018: 1) 97.4% of our residents (vs. 86.6% nationally) chose Agree or Strongly Agree for the question, “In my training program, a portion of my training is based on my learning needs related to my career plans.” 2) 94.8% of our residents (vs. 92.9% nationally) chose Agree or Strongly Agree for the question, “My training program provides a faculty mentor or advisor to help develop learning activities to meet my learning needs related to my career plans.” Outcomes A relatively small investment (0.05 FTE for the DIE) has been sufficient to allow each resident to receive proper mentoring in the context of thoughtful discussions about both career goals and current strengths/weaknesses. The DIE has also had time to invest in building relationships with divisions and departments throughout our childrens hospital and academic medical center, resulting in many new and innovative rotations, including GI pathology, transport (prehospital) medicine, maternal-fetal-medicine, complex primary care, and many others. Ultimately, we have been able to provide each resident with a unique schedule and a high level of satisfaction with the individualized curriculum.

109. IF YOU CALL IT, WILL THEY COME?: USING QUALITY IMPROVEMENT METHODOLOGY TO IMPROVE RESIDENT CODE TEAM LEADERSHIP SKILLS Publication date: August 2019 Source: Academic Pediatrics, Volume 19, Issue 6 Author(s): Amanda J. Rogers Background Management of an acutely ill or decompensating child is pivotal to a pediatric resident's training. Pediatric physicians should be prepared to recognize and respond to pediatric emergencies. Starting in 2014, senior residents in our program were designated as the code team leader on even days. Subsequent data demonstrate that residents rarely led codes on even days. We therefore developed a quality improvement initiative to improve resident code team leadership skills. Aim Statement Our primary aim was to increase the percent of even day codes led by a resident to 50% by May 2018. Interventions A needs assessment survey was conducted to identify barriers to resident code team leadership. A fishbone diagram developed to categorize barriers to target. Plan Do Study Act cycles were conducted to implement and test various interventions including a simulation-based workshop on code team leadership, data sharing about code events, and just-in-time resources addressing common questions. Measures Outcome measures included the percentage of even day codes led by resident. Process measures included resident self-confidence in their code team leaders. Balancing Measures included the percent of even day codes with subsequent negative events. Results Baseline data demonstrated no even day codes led by residents. Special cause variation was seen following interventions of simulation-based education and just-in-time training with 40% of codes led by senior residents. Improvements were sustained throughout the academic year. Conclusions and Next Steps Using quality improvement methodology we were able to successfully increase the number of codes led by senior residents without increased negative outcomes. Future interventions will aim at sustaining improvement into a new academic year.

107. PATHWAYS INITIATIVE TO IMPROVE TRANSITION CARE IN A MED-PEDS RESIDENCY PROGRAM Publication date: August 2019 Source: Academic Pediatrics, Volume 19, Issue 6 Author(s): Robert Sanchez, Erin Hickey, Jessica Gold, George Weyer, Nabil Abou Baker, Rita Rossi-Foulkes Background Approximately 750,000 adolescents with special health care needs graduate to adulthood annually, often with their health suffering. Less than half receive the services needed for a successful transition. In Illinois the Division of Specialized Care for Children Family Survey revealed that only 18.2% of youth ages 14-21 received transition services. A recent review demonstrated that almost two thirds of HCT evaluation studies had statistically significant positive outcomes. Another study demonstrated that providing HCT services resulted in a 28% reduction in per member per month total cost driven by reductions in hospitalization and ED visits. Aim Statement 1. Increase HCT services for youth and young adults with special health care needs (YASHCN) in a Med-Peds residency practice (10% per year). 2. Increase HCT consultations for YASHCN (10% per year). 3. Improve HCT knowledge, attitudes and practices among Med-Peds residents. (improve annually). 4. Provide Med-Peds residents with a longitudinal QI project aligned with ACGME requirements. Interventions PATHways is a residency-based HCT consultative service founded to improve health for YASHCN and provide HCT education to residents. PATHways’ QI initiatives are modeled after Gottransition's Six Core Elements. A HCT policy was disseminated. EMR tools were developed to assess HCT skills and create portable health summaries. A registry of over 200 YASHCN aged 14-26 in the practice was created. Formal HCT education was provided to residents through HCT consultations. Measures 1. Baseline and annual follow up HCT knowledge, attitude, and practices survey of residents 2. Baseline and annual follow up audits of patients in the HCT registry addressing key elements (readiness assessment, HCT planning, creation of portable health summaries) 3. Tracking of consultations: Requesting services, diagnoses, HCT services provided. Results 33 consultations were provided over 18 months and were received from 9 different services with Pediatrics comprising 70%. Autonomy planning and completion of portable healthcare summaries comprised the majority of consults (80%). Consultations also aided in guardianship (43%), insurance and income support planning (67%), and identifying adult providers (20%). Residents surveys demonstrated increased HCT knowledge. Residents correctly identified the ages to introduce HCT, begin HCT planning, and prepare for transfer (scores increased by 8%, 21%, and 8%, respectively). They were able to identify specific tools for HCT including the clinic's policy and registry. After one year, 42% of residents stated that they addressed HCT readiness often in their practice, increased from 18%, and no residents reported not ever addressing HCT, improved from 38%. Residents reported providing more frequent guidance on education, insurance planning, registering for adult services, guardianship assessment, and identifying adult providers. Residents reported feeling more empowered and engaged in caring for YASCHN. Baseline and follow up chart audits demonstrated that readiness assessment improved from 10 to 50%, transition planning improved from 20 to 60% and creation of portable health summaries improved from 5 to 45%. Conclusions and Next Steps The PATHways initiative is a feasible way to improve HCT for YASHCN and resident HCT knowledge, attitudes and practices. Next Steps: 1. Utilize the EMR's new feature, Slicer Dicer for transition registry management and chart audits. 2. Mailers and EMR messages will be sent to all patients in the transition registry directing them to schedule a HCT appointment. 3. Continue to raise awareness about the PATHways consultation services.

106. IMPROVING THE FREQUENCY AND QUALITY OF FEEDBACK RECEIVED BY RESIDENTS THROUGH EDUCATION, REMINDERS, AND INCENTIVES Publication date: August 2019 Source: Academic Pediatrics, Volume 19, Issue 6 Author(s): Anne Kimball, Jasmine Weiss, Omar Elsayed-Ali, Gargi Mukherjee, Rachel Gillman, Susie Buchter, Rebecca Sanders, Melissa Adams, David Wolf Background Feedback is an essential and effective tool for resident learning and improvement. Our residency-wide quality improvement project is focused on feedback, after identifying this as an area for improvement on our annual ACGME survey. The Milestones Guidebook lists the five features of high quality feedback as timeliness, specificity, balance, reflection, and action plans. Our baseline data revealed that, on average, 55% of residents received weekly feedback, and the feedback was rated as 2.9 out of 5 on a Likert scale, with a 3 being moderately helpful. On assessment of quality measures, residents perceived their feedback as 69% timely, 75% specific, 42% balanced, 40% reflective, and 39% actionable. Aim Statement Our goal is to improve the verbal feedback for residents on all rotations by increasing the percentage of residents receiving weekly feedback by 30%, improving the average Likert score by 1, and improving each quality measure by 30%. Interventions We used the model for improvement, with resident-designed monthly PDSA cycles, led by the chief residents. PDSA cycle 1 focused on reminders. Biweekly emails were sent to all residents on setting expectations and asking for feedback, and one email was sent to faculty and fellows about the importance of weekly feedback. PDSA cycle 2 focused on education and incentives. Cards were provided to each resident with tips for receiving high quality feedback and a link to log the feedback, for which points were awarded towards the resident's “House Staff Cup” team. Measures Data are collected via weekly online surveys, which are disseminated through a QR code at grand rounds to provide protected time for survey response. Results We have shown improvement in every outcome measure, though not yet to our goal. The frequency of weekly feedback has improved from 55% to 65% after two PDSA cycles. The average Likert score has improved from 2.9 to 3.23. The five quality measures have improved by an average of 28% from baseline. Conclusions and Next Steps Our largest gains after two PDSA cycles have been in the quality measures, which were likely impacted by improved awareness of what constitutes high quality feedback. The frequency of feedback has improved, but not to our 30% goal. Additional cycles will be designed with input from residents with a goal of overcoming barriers such as time constraints and faculty culture. We hope to see improvements in the evaluation and feedback components on our ACGME survey this year.

105. ADVERSE CHILDHOOD EXPERIENCES SCREENING IN RESIDENT CONTINUITY CLINIC Publication date: August 2019 Source: Academic Pediatrics, Volume 19, Issue 6 Author(s): Courtney W. Brantley, Brian Lurie, Sydney Primis, Sara Horstmann Background Adverse Childhood Experiences (ACEs) are traumatic events that occur prior to age 18. Exposure to ACEs has been associated with negative health outcomes including developmental delay and mental health conditions. ACEs are common and there are ∼17,000 children in our county with exposure to 2+ ACEs. Studies show early resource utilization and promoting resilience can combat the effects of ACEs, however many individuals are not using resources. Aim Statement his project is aimed at improving screening and recognition of ACEs to allow for referrals to resources in order to decrease effects from ACEs. Our goal is to screen 75% of children ages 0-5 for ACEs during well visits. For those who screen positive (score of 4+), our goal is to refer to resources 75% of the time. The project also focuses on improving provider knowledge of ACEs with a goal of 75% of residents reporting feeling at least “somewhat comfortable” with ACEs screening. This project takes place at Myers Park Pediatrics in the Resident Continuity Clinic and involves children ages 0-5 years. The project was initiated in March 2018 and is ongoing. Interventions Visual prompts were placed on workstations to help registration staff and providers remember which visits the screening was scheduled to take place. Scoring instructions were placed on the form. After initial data showed many screens were left incomplete, scoring instructions were taken off the form to encourage more families to complete the form without fear of a SW consult which was originally listed on the form. Provider education including resilience screening and lectures were provided to increase knowledge about ACEs and allow providers to understand the importance of screening. A cover sheet was also placed on the screening form and was edited to provide families more information on why screening was being performed. Measures Outcome measures included % of children ages 0-5 that are screened for ACEs and % of children ages 0-5 with positive screens that are referred with the goal for both being 75%. Process measures included % of residents trained in ACEs screening, % of front desk staff trained in distributing ACEs forms, % of forms distributed to families, and % of forms completed by families. Balancing measures included 75% of front desk staff will report no change in work flow due to handing out screening and 75% of residents will report that ACEs screening is helping them learn about ACEs and how to manage them. Results The average % of screening for all patients in the targeted population was 57%. At times the percentage of screens was above the goal, however was not sustained. Results demonstrated random variation despite multiple interventions. Only 4 patients had ACEs scores of 4+, however all were referred to resources which was above our goal of 75%. Only 10% of residents initially reported feeling at least “somewhat comfortable” with ACEs screening, however after initiation of the project and further education, 85% of residents reported feeling at least “somewhat comfortable”, with a goal of 75%. Eighty-six percent of residents reported that they learned from ACEs screening. When assessing balancing measure, 88% of registration staff reported no change in overall work flow. Conclusions and Next Steps ACEs are common and can have many negative health outcomes. Early intervention with resources can promote resilience and prevent negative outcomes. We have been successful in implementing screening in a local clinic, but have not met sustainability. We have been able to educate providers and ensure that there is no negative impact on clinic work flow. We continue to make changes to improve screening and identification of those affected by ACEs to refer them to resources. We have also been chosen to participate in a Pediatric Integrated Care Collaborative which will provide improved education for our providers and more resources to our patients related to ACEs.

104. IDENTIFYING PATIENTS AT RISK OF CLINICAL DETERIORATION PRIOR TO PICU TRANSFER Publication date: August 2019 Source: Academic Pediatrics, Volume 19, Issue 6 Author(s): Hamza Nasir, Sara Ghannam, Sumeet Gill, Scott Studeny, Denrik Abrahan, Archana Ramgopal, Amanda Spicer, Jamie Fast, Arnaldo Zayas-Santiago, Katie Pestak, Nicholas Davalla, Amrit Gill Background Cleveland Clinic Children's incorporated the Situational Awareness (SA) model in 2013 to prevent and reduce patient unrecognized clinical deterioration (UCD). The model equips healthcare providers to identify patients at risk of deterioration via use of various criteria and intervene in a timely manner. From April 2018 through August 2018, only 14% of patients transferred to the PICU from the RNF were identified as SA. Our goal was to increase utilization of the SA model to identify patients at risk of clinical deterioration to at least 50% prior to PICU transfer. This project was sponsored by an ACGME initiative aimed at supporting innovation to transform the clinical learning environment where residents pursue their training. Aim Statement Increase the percentage of patients identified as Situational Awareness prior to transfer to PICU from 14% to 50% by November, 2018. Interventions Interventions were implemented over a period of 4 months: 1) incorporating assessment of patients SA status during morning rounds with the multidisciplinary team including Nursing, 2) SA discussion during resident afternoon sign-out and 3) adding SA status identification box into the resident electronic sign-out form. The processes were audited randomly to ensure interventions were being carried out. Measures Data were collected through a retrospective chart review surveying SA documentation of patients prior to PICU transfer from the RNF. Only patients under Pediatric resident-run services were included. Data were obtained from Cleveland Clinic Quality Data Registries and monitored bi-weekly. Results Following implementation of interventions, data show a median of 50% of patients being identified as SA prior to transfer to PICU. Based on observations and audits, those teams which included Nursing on morning rounds had better outcomes. Assessment of patients during morning rounds had the most profound impact whereas though resident sign-out interventions had a positive effect, they were not implemented to their full extent as seen on audit checks and required multiple education sessions. Conclusions and Next Steps Interventions were successful at increasing the utilization of the SA model. As noted by consecutive points above baseline median, this shift in the data signals a non-random pattern. We hope, adherence to SA model, can prevent UCD. There is still room for improvement and future interventions will focus on sustainability and use of technology to hardwire the process and promote adherence to routinely assessment of SA status.

103. IMPROVING SCREENING LAB COMPLIANCE IN AN URBAN PEDIATRIC PRACTICE Publication date: August 2019 Source: Academic Pediatrics, Volume 19, Issue 6 Author(s): Madhuri G. Dave, Kaitlin M. McKenna, Lauren E. Castaneda Background Screening laboratory evaluations are important components of pediatric primary care. Current AAP guidelines recommend hemoglobin and lead screening at 12 months as well as lipid screening between 9-11 years. Health disparities, including variable access to transportation, contribute to failure to complete recommended screening labs at an underserved urban pediatric clinic. Following urban clinic relocation from site 1 to site 2 and subsequent loss of on-site phlebotomy, the average lab completion rate declined significantly. Aim Statement Our primary aim is to increase the rate of screening lab completions in our urban pediatric population to 75% by December 2018. Interventions A multidisciplinary team completed a Quality Improvement study to evaluate barriers to completing screening labs. Standardized phone calls to families with incomplete labs were made and fishbone diagrams were created to categorize barriers. A process map was created to understand the steps required to complete screening labs. Interventions included: reminder phone calls, standardized instructions placed into After Visit Summary (directions to the lab location, lab hours and public transportation routes to the lab), initiation of access to onsite phlebotomy, and training of on site clinic staff in phlebotomy. Measures Outcome measures were the percent of patients with completed screening labs. Process measures included percentage of patients without complete labs who received follow-up phone calls. Balancing measures were allocation and cost of staff resources. Plan Do Study Act (PDSA) methodology was used to implement and test interventions. Statistical process control charts were used to analyze the impact of interventions. Results 473 charts were reviewed. Average screening lab completion at Site 1 was 79% with decline to baseline of 21% with move to clinic Site 2. Lab completion rates increased to mean of 42% with initial interventions in action period. Lab completion increased to 90% with special cause improvement after on site staff phlebotomy training. Cost analysis data pending. Conclusions and Next Steps Significant increase was noted in lab completion upon the addition of on-site lab phlebotomy at site 2. Initial interventions did not lead to increased compliance rates further highlighting the importance of accessibility in an urban population. Urban underserved clinics may consider addition of on-site phlebotomy to continue to close the gaps in health disparity.

102. CARPE DIEM MEDIUM: MAKING THE MOST IMPACT IN AN ACADEMIC HALF DAY Publication date: August 2019 Source: Academic Pediatrics, Volume 19, Issue 6 Author(s): Taylor Couch, Michelle Escala, Amy Hendrix, Michelle Condren, Keith Mather Background There are a variety of challenges to providing meaningful and relevant education to pediatric residents, including adapting to different adult learning styles, availability of lecturers, and balancing protection of educational times and coverage of patient care. In 2015, our program noticed a decline in our board pass rate to 25% for this graduating class, which lowered our three year pass rate for first time takers to 65% for 2013-15. Aim Statement Our educational goal is planned to improve in training exam (ITE) standard scores to national average and improve first-time-taker board pass rates to meet 3 year pass rate of at least 80% by 2019 and 100% by 2021. Interventions We used serial PDSA cycles with change processes during the academic afternoons from 2015 through 2019. In 2015-16, we initiated a standardized 18-month curriculum. In 2016-17, we revised curriculum focusing on American Board of Pediatrics (ABP) content specifications and providing residents with standardized pre-reading materials. In 2017-18, we adjusted the curriculum to 12-months and started to follow residents’ progress and assess knowledge gaps using an online pediatric question bank. This also helped us track residents considered “at risk” for board failure. Measures We trended ITE scores and first-time-taker ABP board pass rates to measure effectiveness in changes to half day processes. Results When tracking ITE scores, our intern class in 2015 had a score 9 points below national average, and in their third year closed gap to 3 points below. As for our intern class from 2016, they averaged a 16 point deficit, improved to a 4 point deficit in 2017, and surpassed national average by 2 points in 2018. In regards to first-time-taker board pass rates, we had rates of 40% (2/5 residents) for 2015, 83% (5/6) for 2016, 83% (5/6) for 2017, and 100% (7/7) for 2018. Our 3 year first-time board pass rate increased to 85% for 2016-18. Conclusions and Next Steps Academic half days do pose some challenges in regards to scheduling coverage and faculty lecturers; however, our utilization has been successful and well received by our residents. We have shown significant improvement in ITE scores and board pass rate with minor changes each year. Our next PDSA cycle now incorporates weekly board review for the third year residents and a longitudinal developmental/behavioral/psychiatric curriculum for first and second year residents.

101. RESIDENT-LED QI INITIATIVE TO IMPROVE ASSESSMENT AND CARE OF PATIENTS WITH EARLY CHILDHOOD CARIES Publication date: August 2019 Source: Academic Pediatrics, Volume 19, Issue 6 Author(s): Melanie Degliuomini, Angela Chan, Snezana Osorio, Erika Abramson, Robyn Rosenblum Background Early childhood caries (ECC), defined as one or more decayed, missing, or filled teeth in children under 6 years, is the most common, chronic, preventable condition in childhood. ECC affects 28% of US children 2-5 years of age, particularly children of lower socioeconomic status. The American Academy of Pediatric Dentistry (AAPD) and the AAP recommend that children establish a dental home by 12 months, but lack of standardized ECC assessments and dental referral processes are often barriers to optimal care. Aim Statement In this 12- month long resident-led QI project we aimed to improve the ECC risk assessment rate for children 6 months to 6 years to 70%, and to improve the dental referral rate to 90%. Interventions The Model of Improvement was used for this QI project from December 2017 to December 2018 at a community clinic affiliated with an academic center. An electronic Oral Risk Assessment Tool was created based on AAP guidelines. Residents performed 6 plan-do-study-act (PDSA) cycles utilizing 7 interventions derived from tertiary key drivers. Measures Process, outcome and balancing measures were collected via electronic medical record review (resident documentation of EEC screening, dental referrals and developmental screening respectively). Statistical control charts were utilized to display and analyze the data. API rules were applied to detect special cause variation. Results 281 patients were screened. Oral health risk assessment improved from 37.84% to 77.74%. Initially, 72.22% of screened patients were at high risk for caries (with >1 risk factor for ECC on risk assessment tool). Over time, this rate significantly decreased to 52.46% largely due to family education. On average, 47.66% of screened patients had a dental home. Residents reached outcome goal of 90% referral rate for those patients without a dental home. Developmental screening rate, as a balancing measure, remained at 100% compliance. Conclusions and Next Steps Implementation of this QI project showed our patient population was at high-risk for ECC, which had previously been unknown, and decreased with our interventions. Creation of an electronic screening tool facilitated screening. Family education and providing a referral list of community dentists were the most successful interventions. Next steps include creating an electronic dental referral system and partnering with community dentists to enhance ECC-related family and patient education.

100. HAVE YOU CHECKED YOUR INBOX TODAY? A QI PROJECT TO IMPROVE COMMUNICATION OF INBOX RESULTS Publication date: August 2019 Source: Academic Pediatrics, Volume 19, Issue 6 Author(s): Kristen Samaddar, Charity Adusei, Eric Duncan, Brittany Vaio, Jennifer Farabaugh Objective Prompt communication of results is critical for patient safety and satisfaction. In the ambulatory setting, residents are less likely than attending physicians to communicate results timely. In continuity clinic at Phoenix Children's, prescription requests, test results, and secure health messages are sent to provider electronic inboxes. In 2018, residents participated in a QI project to improve action on inbox content. A non-compliant inbox is defined as having any item not addressed within 7 days, with severely non-compliant as having more than 10 unaddressed items. Aim Statement To decrease inbox non-compliance for PCH continuity clinic residents to < 20% by December 2018. Interventions Key drivers were identified via resident survey. Interventions included reminder stickers on computers; 1-on-1 education for inbox set-up and management; targeted education for particular residents; clinic timeouts; reminders in chief weekly email; utilizing medical assistants (MAs) to communicate normal results. Measures Residents on the ambulatory rotation performed monthly audits of the continuity clinic residents’ inboxes (n = 60) before and after each of nine interventions. Rates of non-compliance, severe non-compliance, and absolute number of unaddressed items were tracked. Results Inbox non-compliance for residents decreased throughout 2018 from 51% in January to 17% by December. Severe non-compliance decreased from 17% to 3.3% over the same period. Not all inboxes were reviewed each month due to technology issues and supervisor availability, but the number of inboxes reviewed increased over time to include all by the end. Conclusions and Next Steps While difficult to determine which intervention had the biggest impact, a significant drop occurred by utilizing MAs to communicate normal results. A large spike in non-compliance occurred in August, correlating with a new academic year. The cumulative effect of frequent reminders and status updates most likely led to steady improvement. The ongoing investment of new residents in the interventions was important for energizing and sustaining change. Next steps are to identify resident champions for each day of continuity clinic and to improve the training of new residents.