Quality Rounds
Baby Monitors
Minnesota is borrowing a page from Vermont on how to improve the quality of pediatric care.
By Scott D. Smith
Vermont overtook Minnesota as the healthiest state in 2007 in the annual listing America’s Health Rankings. Now, Minnesota’s pediatricians are trying to win back some ground by emulating a quality-improvement initiative known as the Vermont Child Health Improvement Program (VCHIP).
VCHIP is a collaboration involving the University of Vermont College of Medicine, the Vermont Department of Health, and the Vermont Chapter of the American Academy of Pediatrics. Unlike the majority of quality-improvement efforts, which are aimed at improving the care of adults, VCHIP helps physicians use quality-improvement methods to provide better care to their young patients.
Since VCHIP was launched in 2000, the state has made measurable progress. For example, a number of the state’s pediatric practices now use a structured developmental screening process during well-child visits as opposed to a less-formal one, and most clinics have improved their immunization practices. About a dozen hospitals are doing a better job of counseling new parents about sleep position, car seat fit, and exposure to tobacco smoke. More school-aged children with asthma now have care plans on file and available to school nurses, and more adolescents are screened for risky behaviors such as substance abuse and protective factors such as having friends or participating in sports.
The first VCHIP project, the Vermont Preventive Services Initiative, focused on preventive care for children younger than 5 years of age. The 31 clinics that participated decided which things they wished to improve. For example, they may have wanted to increase the percentage of 2-year-olds who were up to date on their immunizations, screened for anemia or tuberculosis, or assessed for second-hand tobacco smoke or lead exposure, or they may have focused on increasing the percentage of 4-year-olds who got vision screenings and referrals for dental care.
Participating practices formed quality-improvement teams consisting of a physician, a nurse, and an administrative support person. VCHIP staff conducted chart reviews to help the clinics gather baseline data about how well they were doing in these areas. Pediatricians and nurses from the program visited each clinic at least once to help the team set goals and identify ways to change their practices in order to meet those goals. A project director from VCHIP conducted monthly conference calls with the participating clinics and tracked their progress.
In the end, all of the practices that participated saw improvements on one or more measure, according to an article about the initiative published in the October 2006 issue of Pediatrics.
Since then, VCHIP has conducted quality-improvement projects that have focused on prenatal care, tracking child development, caring for opiate-exposed newborns, and improving mental health care for children. According to Judith Shaw, VCHIP executive director, 85 percent of the state’s pediatric practices have participated in at least one VCHIP project.
Why VCHIP Works
Shaw says clinics are willing to participate in VCHIP projects because the program offers them so much assistance. She knows from her years working as a pediatric nurse in a primary care setting that providers often cringe when they hear about quality improvement because it often involves a series of mandates and no help implementing them. “I worked in primary care for 12 years, and it was really busy. We’d get a new form from the Department of Health, and it would just go in a pile,” she says.
Unlike a consulting firm, VCHIP does not address clinics’ individual problems but instead invites them to participate in projects it establishes. VCHIP’s staff of 25 provides clinics with assistance such as auditing charts, researching best practices, and suggesting changes in the way they deliver care. VCHIP also can bring to bear the resources of the University of Vermont, Vermont’s Department of Health and Medicaid program, and the state’s pediatricians and family physicians to tackle problems that arise.
Shaw and her staff seek funding from federal grants and local and national foundations in addition to that which they receive from Vermont’s Medicaid program to help cover the costs associated with quality-improvement projects. And they share policy recommendations with Vermont’s Medicaid officials based on the results of a project.
Vermont pediatricians consider VCHIP the go-to place for quality improvement. Joseph Hagan, M.D., who practices in Burlington, says his practice, which includes two pediatricians and two pediatric nurse practitioners, has done several VCHIP projects that have led to improvements in the way they do lead, anemia, and developmental screenings; the group is also doing a better job of tracking patients’ vaccination status and plotting body mass index. “The VCHIP system is there to help you look at what you are doing and ask ‘How can I do it better?’ and ‘How can I make that improvement part of our practice?’” Hagan says.
VCHIP has succeeded, he says, because it has won the trust of pediatricians in the state, a feat that third-party payers that have tried to implement quality-improvement projects have been unable to accomplish. “Often in a relationship with Medicaid, they may have a way of doing things that is like, ‘We’re the government, and you have to do it this way,’ and that does not give most practitioners a warm and fuzzy feeling.”
Hagan says that having VCHIP staff to call on makes it easier to take part in its projects. “There needs to be dedicated time and support so practices can succeed.”
Minnesota’s Fledging Program
Finding the money to hire staff is a hurdle that Minnesota has yet to clear in its effort to emulate Vermont’s program. The Minnesota chapter of the American Academy of Pediatrics has taken the lead on establishing the Minnesota Child Health Improvement Partnership (MnCHIP). Thus far, the chapter has formed an advisory committee, which includes parents, representatives from UCare, provider organizations, the Minnesota Department of Health, the Minnesota Department of Human Services, and others.
MnCHIP received a grant from the Commonwealth Fund in 2007 to conduct its first project. The state’s departments of Health and Human Services contributed staff time. That first project, which is nearing completion, involves nine clinics that are trying to improve their child development screening rates. Gordon Harvieux, M.D., a pediatrician at the Duluth Clinic, which participated in the project, says MnCHIP is helping his clinic comply with 2006 American Academy of Pediatrics (AAP) guidelines calling for pediatricians to conduct standardized developmental screenings at 9, 18, and 24 or 30 months of age.
He says the nine pediatricians in his practice simply had been asking parents about whether their child was hitting certain milestones. However, studies have shown that such casual surveillance can miss problems. The AAP recommends use of a standardized screening tool in addition to asking parents questions. For this project, clinics could use one of more than a dozen screening tools listed on the Department of Health’s website.
Harvieux says his team, which included himself, a nurse, and an administrative support person, chose to have parents complete the Ages and Stages Questionnaire. MnCHIP representatives helped them incorporate it into clinic visits.
Harvieux started changing the way he does developmental screenings in August of 2008; the other physicians in his practice have since adopted the new method. He says concern that the new screening approach would be too time-consuming and yield too little benefit has been unfounded. “We are detecting issues much earlier, specifically with speech and language development,” he says.
According to Meredith Martinez, a policy specialist for the Minnesota Department of Human Services who staffed the project, preliminary data indicate that the practices that took part boosted their developmental screening rates from 55 percent to 89 percent. Martinez says that as the project draws to a close, the MnCHIP advisory committee is discussing ways to use the results to motivate other clinics and physicians to adopt the screening technique.
Anne Edwards, M.D., president of the Minnesota chapter of the AAP, says she hopes they can leverage the success of the developmental screening project in order to secure funding for other projects. She would ultimately like to see MnCHIP become as well-respected among pediatricians here as VCHIP is in Vermont. “I hope MnCHIP ends up being the place people come regarding quality improvement projects for children’s health,” she says.
In order for that to happen, Minnesota needs to put in place a few more pieces of the puzzle. One of those is finding an academic partner. The other is finding the funds to at least hire a program director. Shaw says having a dedicated staff member is a must. “They need someone who goes to bed every night worrying about improving children’s health,” she says. MM
Scott Smith is a staff writer for the Minnesota Medical Association.