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- 1. Implementation of the Standard of Care to Address Childhood Overweight and Obesity in Primary Care QUALITY IMPROVEMENT PLAN: By: Kimberly A. Deppe, MSN, ARNP-C, DNP student Northern Kentucky University
- 2. Learning Objectives: AT THE END OF THIS PRESENTATION: •The student will develop an understanding of the need to identify overweight and obese children •The student will analyze the quality improvement project value in supporting the adoption of the evidence-based guideline for the provision of care to overweight and obese children in primary care •The student will be able to articulate areas of the plan causing questions and suggest changes to facilitate continual quality improvement in care.
- 3. Introduction tudent uality plan elevant informtion from DNP project ow is the quality plan needed
- 4. The Multidisciplinary Team ho is a shareholder • Healthcare organization • Healthcare provider • Patient • Insurer • General community • Student
- 5. Multidisciplinary Team (cont.): • What are the shareholder responsibilities • Healthcare organization • Healthcare provider • Patient • Insurer • General community • Student
- 6. The Quality Model: he PDCA Cycle for Improvement Plan- o-
- 7. The PDCA Cycle for Learning and Improvement Act • What changes are to be made? • Next cycle? Plan • Objective • Questions and predictions (why) • Plan to carry out the cycle (who, what, where, when) • Plan for data collection Check • Complete the analysis of the data •Compare data to predictions •Summarize what was learned Do • Carry out the plan • Document problems and unexpected observations • Begin analysis of the data From: Associates in Process Improvement
- 8. Repeated Use of the PDCA Cycle Hunches Theories Ideas Changes That Result in Improvement A P C D A PC D A P C D D C P A Small Scale Testing Follow-up Tests Test new conditions Implementation of Change What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement Learning and Im provem ent Evidence & Data From: Associates in Process Improvement
- 9. Multiple PDCA Cycle Ramps Testing and adaptation A P C D A P C D A P C D D C P A A P C D A P C D A P C D D C P A A P C D A P C D A P C D D C P A A P C D A P C D A P C D D C P A Adopt guideline Group visits Non-MD roles in visit flow Registry Change Concepts From Associates in Process Improvement
- 10. Quality Planning bjectives: • Apply evidence based guidelines as evidenced by the : • Documentation of BMI • Use of correct ICD 9 • Use of a specific care plan
- 11. Childhood Overweight and Obesity: Measuring Quality of Care Process Outcome Recognition of elevated BMI Counseling on diet and exercise Periodic follow-up Assessing symptom progress BMI <85th percentile NORMAL BMI
- 12. Children with Overweight and Obesity: Challenges to Measuring Quality of Care Process Outcome Correct diagnosis Periodic follow-up Assessing symptom progress Initiation of care plan Improved BMI and symptom resolution
- 13. Quality Planning ata collection •Chart reviews •BMI measurement •ICD-9 or 10 code for diagnosis •CPT code for treatment •Provider demographics
- 14. Quality Planning (cont.): etrospective Review •External Validity •Selection Biases in Quasi-experimental design
- 18. References AHRQ. (2013). Provider training on adolescent weight management promotes body mass index Documentation and referrals to health/fitness classes, but at rates below health system goals. AHRQ Health Care Innovations Exchange. Retrieved from http://www.innovations.ahrq.gov/popup.aspx?id=2980&type=3&isUpdated=False&isArchive American Heart Association. (2013). Overweight and obesity. Statistical Fact Sheet 2013 Update. Retrieved from http://www.heart.org/idc/groups/heartpublic/@wcm/@sop/@smd/documents/downloadable/ucm _319588.pdf American Public Health Association. (2013). Tackling childhood Obesity: Vision and Guiding Principles. Retrieved from http://www.apha.org/programs/resources/obesity/tacklingobesity.htm Centers for Disease Control and Prevention. (2013). Overweight and Obesity. Retrieved from http://www.cdc.gov/obesity/stateprograms/programGoal.html Center for Healthy Weight and Nutrition. (2013). Primary care pocket guide to pediatric obesity management. Nationwide Children’s Organization. Retrieved from http://pediatrics.aappublications.org/content/vol120/Supplement_4/index.shtml CMA Foundation (2008). Child & Adolescent Obesity ProviderToolkit. Retrieved from http://www.thecmafoundation.org/projects/ObesityGeneralPDFs/ChildToolkit_Revised%20April%202008.pdf Dimitroff, L. (2011). Comparing and contrasting nursing research, evidence-based practice, and quality improvement: A differential diagnosis. Capital District Nursing Research Allicance. Retrieved from http://www.capitaldistrictnursingresearchalliance.com/images/Microsoft_Lynda_D_PPComparing_and_contrasting.pdf Expert Committee, & Barlow, S. E. (2007). Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity. Pediatrics. 120, S164-S192.
- 19. Goldstein, H. (2013). Become a child health advocate for obesity prevention in California. Medscape Family Medicine Education. Retrieved from http://www.medscape.org/viewarticle/806855?src=wnl_cme_revw Harris, J. L., Roussel, L., Walters, S. E., & Dearman, C. (2011). Project Planning and Management: A Guide for CNLs, DNPs, and Nurse Executives. Sudbury, MA: Jones & Bartlett Learning. Hirsch, L., & Gandolf, S. (2013). SWOT: The high-level self-exam that boosts your bottom line. Retrieved from http://www.healthcaresuccess.com/articles/swot.html Health Service Executive. (2012). Training Programme For Public Health Nurses And Doctors In Childhealth. Screening, Surveillance, And Health Promotion. Retrieved from http://lenus.ie/hse/handle/10147/110557 Iowa Department of Public Health. (2013). Iowans Fit for Life: Active and Eating Smart. Retrieved from http://www.state.ia.us/iowansfitforlife/docs/Chapter_2_Goals_Objective_and_Strategiesk.pdf Kaufman, F. (2013). A focus on childhood obesity in California. Medscape Family Medicine Education. Retrieved from http://www.medscape.org/viewarticle/806794_transcript_3 New York State Department of Health. (2013). Strategic Plan for Overweight and Obesity Prevention. Retrieved from http://www.health.ny.gov/prevention/obesity/strategic_plan/goals.htm Reporting of quality indicators and improvement in hospital performance: The P. Re.Val.E. regional outcome evaluation program. Health Research and Educational Trust. doi: 10.1111/j.1475-6773.2012.01014.x
Editor's Notes
- INTRODUCE SELF; QUALITY PLAN: to promote the assurance of quality healthcare provision to overweight and obese children. RELEVANT INFO: Purpose The incidence of childhood obesity is growing in the United States. There are an estimated 12 million obese children in the United States and an estimated 23 million overweight children in the United States. Childhood overweight and obesity leads to co-morbidities of diabetes, insulin resistance, renal failure, fatty liver, hypertension, cardiovascular disease and other chronic illnesses. These co-morbidities and their incidence is a great strain on our public health dollar. 52 percent of healthcare practitioners assess BMI in children older than 2 years of age. A national survey of pediatricians found the following: sixty percent feel somewhat prepared to counsel patients on overweight and 38 percent feel counseling is effective; sixty-two percent were unfamiliar with billing codes for weight management services; fifty-six percent thought reimbursement was insufficient; and sixty-seven percent thought time available to counsel was not adequate. (AHRQ, 2013) Further, the assessment of weight status (overweight, obese, normal or underweight) is a directive in the new Healthcare Reform legislation. Each healthcare practitioner is to assess weight status, diagnose overweight or obesity and provide interventions. It is believed, if healthcare practitioners have reference tools, they will strive to provide quality care and meet the standards set forth in Healthcare Reform. NEED FOR QUALITY PLAN: Because the majority of healthcare providers do not address overweight and obesity, and with an emphasis on disease prevention, a quality improvement plan is needed. INSTITUTIONAL FIT: This plan fits into the strategic plan for the associated hospital. The goal of the associated hospital for ambulatory services is identified on their website as ,,,” to provide the highest quality of care to improve the functional level of each patient…” The identification of high quality relates to the use of evidence-based practice. If practitioners are meeting the identified variables previously described, then they are using evidence-based practice and meeting the departmental goal. For the healthcare practitioner, the unspoken desire is to provide quality care. If benchmarks are met, this is met for the practitioner.
- Healthcare organization-- IRB, QA staff, outpatient service manager Healthcare provider—ARNPs, DOs, PAs, MDs in primary care-family px, peds Patient—those attending clinic visits Insurer– third party payers General community the greater community where patients reside
- Healthcare organization : QA departments will be to assist in the gathering of data from EHR. The IRB staff will assist in reviewing the plan and assuring patient’s are protected from harm. The heads of the ambulatory care departments will assist with arranging the in-services and providing support for the plan with their office staff Healthcare provider attend the inservices and put the information into practice Patient patient and their families will be to actively participate in treatment and follow through with care. Parents will need to aid children in following through with 5-2-1-0 interventions. In most cases, this will mean that parents have to make changes as well Insurer : recognize diagnosis and pay for services General community : develop places for families to be able to exercise and play STUDENT : initiation of the QI plan, keeping the plan in motion, providing the in-services and providing practitioner resources. Further, the student will gather the data from chart audits and conduct the analysis of the data. The outcome of audits will be summarized for each practitioner involved, thus, providing feedback on performance to help with reinforcement of follow-through.
- P lan---objectives and processes are created (Pretest) D o---the plan is implemented (educational initiative) C heck---processes are evaluated and monitored; (Post-test) A ct---the processes are modified for improvement (analysis of data)
- More review of concept – go through each portion of the cycle and explain using an example from one of the teams, if possible. If you have time and want to reinforce in a fun way, consider comparing to these other models: 4Ps: Plan, Plan, Plan, Panic (at the end of the six months) -The Nike Model: “Just DO It” -The Research Model: Plan-Do-Study-Publish
- So here’s a visual image for you to dream about… Remember the three fundamental questions for improvement… Using the PDCA cycle of improvement allows us to answer the third question - “What changes can we make that will result in improvement?” Here’s how: the hunches and theories and ideas we have will first be tested on a small-scale using the Plan-Do-Study-Act cycle. Then we will run follow-up tests and continue to learn from the data. We’ll continue to test under a wide range of conditions, collecting data along the way until we learn what changes do in fact result in improvement. Then we can confidently implement those changes.
- In reality, making changes in your practice won’t likely be as simple as focusing on one PDCA cycle at a time. This slide shows a more realistic picture, with multiple PDCA cycles running simultaneously to bring about improvement in a number of areas, such as adopting evidence-based guidelines , using group visits or establishing a patient registry . Focusing your efforts on testing small-scale changes for short periods of time will make it easier to keep your momentum in multiple PDCA cycles .
- Primary care practitioners and pediatric care practitioners will do routine documentation of BMI with each child being weighed and measured at every visit and the BMI will be interpreted accurately, using CDC weight charts and the percentage as evidenced from use of electronic healthcare records and correct ICD-9 and ICD-10 diagnostic codes. Healthcare practitioners will document in the patient record counseling , specific to age of the child, provided every office visit that includes 5-2-1-0 messaging (to eat 5 servings of fruits and vegetables, no more than 2 hours on screen time, 1hour of physical activity or active play; and to consume little or no sugar-sweetened beverages, as evidenced in documentation contained in the EHR “Plan”. Each health supervision visit for a child will include counseling about overweight and obesity prevention with the 5-2-1-0 message with evidence of handouts being offered to families that reinforce the recommendations as evidenced in the “Plan” of the EHR. Healthcare practitioners will apply evidence-based establish procedures for the diagnosis of childhood overweight and obesity and will apply evidence-based care for children who are overweight and obese through a treatment plan that includes comprehensive review of the family history, child’s blood pressure for all children older than 3 years who are overweight and obese, child’s cholesterol level, and assess the health risks from this information as evidenced by thorough completion of the health history, family history, and social history portion of the EHR. Healthcare practitioners will establish and use a procedure to “flag” charts of overweight and obese children to alert all providers to the need to monitor growth, risk factors and social/emotional issues at every office visit as evidenced by the use of “flagging of the chart feature” in the HER. Healthcare practitioners will demonstrate adherence to the quality improvement plan based in Chart audits resulting in an improvement in performance after the in-service as compared to audits completed prior to the in-service on childhood overweight and obesity identification, assessment and treatment.
- The best measures for quality of care are clinical outcomes. When those are difficult to measure accurately, process measures that have a proven association with outcome measures are used. Process measures include elements of diagnosis, treatment, and management. For obesity, the processes recognition of elevated BMI, counseling on diet and exercise, and frequent follow up are linked to improved clinical outcome of lowered BMI.
- For adhd, process measures may include—correct diagnosis, stimulant and behavior management, periodic follow-up and assessing symptom progress with the outcome measure being improved attendiveness and hyperactivity To basic?
- Chart reviews will be done electronically, through capture of patient information from reports designed specifically for the study. Patients will not be identified by name. All selection criteria and data can be collected in a spreadsheet. For chart data to be included, the first selection criteria is that of age of patient, the second selection criteria for data capture is BMI, the third is BMI graph percentage being 85-94% for OW and 95 and over for OB; the next criteria is the ICD-9 codes from the visit; and lastly will be the CPT codes and provider identification and credentials. The same data will be collected after the educational intervention. These measures will evaluate objectives 1. For objectives 2, 3, 4, and 5, data elements in the EHR will be evaluated through electronic audit to determine there is information contained in the data fields. The evaluation will be because information is recorded or not recorded. Objective 6 is evaluated by collecting the same information prior to the implementation of the plan and at one-, two-, and three-month intervals after the in-service education.
- Through a retrospective review, the testing effect on validity will be controlled. For purposes of this design, the pretest information will be gathered on or after the experiment has started. The archival proxy for the pretest will be information from patient records related to age, BMI, CDC child BMI graphing, ICD-9 coding for overweight or obesity, and CPT coding for referrals, counseling or testing related to diagnosis of OW or OB that occurred prior to the educational event and is previously recorded in the patient record. External validity relates to the ability to generalize the research conclusion to other studies. Therefore, the researcher desires to make sure the population is well represented by the sample. Threats to external validity include: (a) selection biases; (b) constructs, methods and confounding; (c) the 'real world' versus the 'experimental world'; and (d) history effects and maturation. Selection biases are controlled by randomly assigning to groups. In a quasi-experimental design, the random assignment does not occur. Thus, there is selection bias. To decrease the selection bias, the sample can be stratified. Stratification of the sample will ensure that there are a representative proportion of males and females, people of different ages, and so forth. Other characteristics of the population you were studying such as educational level, occupation will also be considered as the population is stratified.
- Benchmarks will be utilized as set by the HHS and used as a part of meaningful use in the Healthcare Reform procedure. The meaningful use measure is set at 85% to indicate minimal acceptable quality care. The student will utilize the same measure on each of the objectives. . New information related to identification, assessment and intervention for overweight and obese children will be provided to practitioners as it becomes available in the form of newsletters or memos to be determined by the practitioner’s desires, the ambulatory department manager’s ideas and the student’s invitation to do so. Initially, the first time for evaluation is one month post-education. This will occur in September, as the education will occur in August. Following the first month, the next evaluation will be completed at a two-month interval and then repeated at a three-month interval. The second report will occur after data is received at the two-month interval, followed with a report after the three-month data receipt. The findings will be reported to the QA staff, ambulatory care manager and the practitioner levels. This plan fits into the strategic plan for the associated hospital. The goal of the associated hospital for ambulatory services is identified on their website as ,,,” to provide the highest quality of care to improve the functional level of each patient…” The identification of high quality relates to the use of evidence-based practice. If practitioners are meeting the identified variables previously described, then they are using evidence-based practice and meeting the departmental goal. For the healthcare practitioner, the unspoken desire is to provide quality care. If benchmarks are met, this is met for the practitioner. The student goal of completing the capstone project will also be met at the end of measurement of data and analysis of the project completion.
- METHODS: written and oral communicaton; quick user guides TIMING: ongoing and as new information is received. Quarterly with electronic data collected for meaningful use reporting
- , this quality improvement plan is designed to promote the assurance of quality healthcare provision to overweight and obese children. Further, the study promotes practitioner attention to identification, assessment and intervention for overweight and obese children, which promotes addressing the public health epidemic. When intervening with overweight and obese children, it is believed co-morbidities resulting in chronic adverse health states can be avoided. Through this avoidance, it is believed healthcare dollars are saved.