StoryboardInstructionsandTemplateAtthecoordinators meetingyouwillhavetheopportunity toshareastoryboard thattellsthestoryofsomeofyourqualityimprovement workover thepastyear.Thegoalofthisstoryboard istosharewithothersyoureffort(s) incontinuous measureableimprovement. Yourstoryboardshould beorganizedintofourparts:1)whatyouaretrying toaccomplish (aim),2)howareyoumeasuring ifthestrategiesaremakingadifference (measures), 3)somechangesyou’ve testedthrough PDSAcyclestoreachimprovement (strategies),and4)lessons learned&nextsteps

Instructions

• Youraudiencewillbesmallgroups ofEHDIcoordinators &teams

• Pleasebring50-75copiesofyour storyboard, printedwithmultiple slidespersheet(bemindful ofhowpicturesandbackground print)

• Youhave12minutes totellyourstory.Keepitsimpleandstraightforward, yetbecreativeandhavefun!

• YourQIadvisorsareavailabletohelpyouprepareyourstoryboard

• Ifyouhavequestionsabout theWednesdaymeeting, pleaseemailAlysonWardatalyson.ward@usu.edu

StateOverview

• State:• QITeam:

– Teamleadcontactinformation:name&email– TeammembersandtheirroleswithinyourEHDI

program

ProjectAim• Describeone ofyourcurrentprojectaims• Anaimshouldanswerthequestion,“whatarewetryingto

accomplish?”Theaimshouldbewrittenasastatementoutliningthemeasurablegoalsandtimeframeofyoureffort“byhowmuch,bywhen”.

• Whydidyouchosethisaimasanareaofimprovement—whatgapdoesthisaimseektoaddress,howwereyouabletodeterminethisgap(e.g.,data,parentfeedback,processmapvulnerability)?

• WasthisaimpartofyourlatestHRSAproposal?• HowdoesthisaimrelatetooverallLTFUgoal/s?

Measurement• Listthemeasures youaretrackingtoknowifyouaremoving

towardyouraim• Youmayhavemultiple measures foroneaim(possibly

outcome,process,andbalancemeasures), please listthemall• Ifanyofyourmeasures arepercentages, includethenumerator

anddenominator• Includeanyoperationaldefinitions youhavedeveloped asyou

havecreatedyourmeasures (ex.whatdowordsliketimely andcompletedmean)

• Howareyoustoringandanalyzing yourdata?• Howoftenareyoureviewing data?• Areyoulookingatrawdata,percentages,runchartsetc.?

Pleaseprovideexamples.

Strategies• WhatchangesorstrategieshaveyoutestedthroughPDSA

cyclestohelpreachyouraim?• Didthesechangesorstrategiesleadtoimprovement?• Whatstrategieswerenotsuccessful?• Haveyouimplementedorspreadthesuccessfulstrategies?

LessonsLearned&NextStepsLessonslearned

• Whatadvicewouldyougivetootherstateswhowanttoworkonasimilaraim?

Nextsteps• Relatedtotheaiminthisstoryboard,whatstrategyareyou

consideringtestingnext?Howwillyouknowifthisstrategyleadstoimprovement?

• WhatdirectionwillyoubetakingyourQIworkduringthenextyear?Whataimswillyoubeworkingtoward?Howwillyoumeasurethoseaims?

Example#1

VermontEHDI

The Vermont Story

QI lead: Linda Hazard (coordinator)Linda.Hazard@partner.vermont.gov

QI Team:Stacy Jordan - Project CoordinatorJanet Fortune – Data AdministratorPatricia Thompson – Department AssistantDeborah Rooney – AudiologistSusan Kimmerly – Director 9 East NetworkCamilla Strauss – 9 East Network Parent Infant CoachSharon Henry – ParentRebecca Chalmers – ParentMeghan Guinnee – Quality Improvement Advisor

Reducing Lost to Follow-up….

Vermont Department of Health

Family

Hospitals

Midwives

Early Head Start

Audiologists

Providers

VTEHDI

Why Collaborate With Providers?

¨ Opportunity to decrease LTFU for screening and diagnosis.

¨ Opportunity to decrease number of missed infants and family declines.

¨ Opportunity to educate provider practices. ¤ Quarterly newsletters to provider offices.¤ Opportunity for providers to educate families.

Vermont Department of Health

ProjectAIM:VermontState

¨ ByApril2014,decreaselosttofollowup(LTFU/D)fordiagnosisbyatleast10%peryear.

Project Sub-AIMS: Primary Care Providers (PCPs)

¨ Increase the number of PCP practices to10 who provide OAE screening by 2013.

¨ Increase the knowledge of PCP providers regarding EHDI national 1-3-6 goals by 2013.

¨ Increase the number of missed infants by 5% who receive hearing screening for 2013, 2014, and 2015.

¨ Increase the number of infants who receive a re-screening by 5% for 2013, 2014 and 2015.

Vermont Department of Health

Project Sub-AIMS Cont’d: PCPs

¨ Increase the number of PCP practices to 90% using web based reporting of screening results by 2016.

¨ Increase the reporting of early childhood screenings for high risk infants (6 months of age to 5 years of age) by 60% by April of 2017.

¨ Increase the number of infants screened or re-screened by 10% in primary care practices by 2016 without OAE Screening units.

Vermont Department of Health

Choosing PCP Practices

It is in the numbers!¨We reviewed practices by looking at:

¤ Lost to follow-up by practice/provider¤ High-risk patients birth-5 years old¤ Location

Vermont Department of Health

Vermont Department of Health

Measurement

¨ CDC format LTFU/D

¤ Numerator: unresponsive, unable to contact, and unknown.

¤ Denominator: total not pass final screen.

¨ Non CDC format LTFU/D

¤ Numerator: unresponsive, unable to contact, unknown and missed.

¤ Denominator: total not pass final screen.

¨ LTFU/S and LTFU/D data monitored with run charts monthly for current birth year.¤ Missed and family decline monitored and tracked monthly.

¨ Qualitative Data Collection¤ Interviews

¤ Satisfaction Surveys

Measurement cont’d

¨ How we track data¤ Web based reporting via EHDI-IS

n 60 % of PCP offices reporting electronically.

¤ Weekly Reports via EHDI-ISn Rescreening, missed and referred for diagnostics

¤ Monthly Data Reports via EHDI-ISn CDC and non CDC format

¤ Quality Assurance reports via EHDI-IS¤ Qualitative Data¤ Phone calls and letters via Excel spreadsheets

Vermont Department of Health

LosttoFollow-UpRate(LTFU/D)forVT

Vermont Department of Health

0%

10%

20%

30%

40%

50%

60%

2009 2010 2011 2012 2013 2014

Perc

ent l

oss

to fo

llow

-up

Vermont Loss to Follow Up

% LTF/D Median

VT (LTFU/D) Quarterly 11/2013 to 10/2015

Vermont Department of Health

0%

5%

10%

15%

20%

25%

LTFU/D percent (CDC)

Measurement Continued

Vermont Department of Health

¨ Increase in PCP Practices Screening: Correlates to Decrease in LTFU/S and LTFU/D

What do PROVIDERS think?

Satisfaction Survey:¨Sent to 2 sites ¨Positive feedback ¨Want more information on babies they should be tracking

Vermont Department of Health

StrategiesTested

¨ Startedwith1primarycareprovideroffice(pilot)¤ Establish primary contact¤ Phone meeting¤ Initial training/meeting (in-person)¤ On-going support and technical assistance

¨ ThroughPDSAcycleswetestedthestrategiesof:¤ Primarycareprovidertraining¤ AvailabilityofOAEequipment¤ Webbasedreportingsystemtraining

Continued Testing and Scaling Up

¨ Added2additionalprimarycareprovideroffices.¤ Continuedtestingofsamestrategies

¨ Added2moreprimarycareprovideroffices.¤ Continuedtestingofsamestrategies

¨ Adoptedstrategiesasachangepackage¨ Scaledupprojecttoinclude11PCPpractices.¨ Allpracticescontinuetobeactive.

Vermont Department of Health

Lessons Learned and Next Steps

Lessons LearnedqWorking with PCP is an effective way

to reduce LTFU for screening and diagnosis.

qImportance of collaboration and buy in.

qChallenges for reimbursement of OAE screening.

Next Steps qSatisfaction survey to all practices.

qPrimary care provider report cards.

qHigh risk monitoring reports.

qPDSA cycles missed and declines.Vermont Department of Health

Reducing Lost to Follow-up….

Vermont Department of Health

Example#2

IdahoEHDI

_

IDAHO SOUND BEGINNINGSEARLY HEARING DETECTION AND INTERVENTION

IdahoQualityImprovement2015

IdahoDepartmentofHealthandWelfareInfantToddlerProgram

QILead:BrianShakespeare (coordinator)ShakespB@dhw.idaho.gov

QITeam:PamelaBlessinger – Health InformationSpecialistGregoryHenderson– DataManagerAndreaAmestoy– ParentOutreachCoordinatorErikaBlanchard– AudiologyTeamLeadDebbieBaerlocher – AudiologyTeamMemberHopeRamos– PelotonManager

PROJECTAIM

UNDERSTANDINGTHEREFERRALPROCESS

MEASUREMENT

MEASUREMENTcont’d

STRATEGIES

Inthefirstthreequarters,PilotHospital1sawa43%reductioninLTFratecomparedwiththesametimeperiodintheprioryear

QTR Refer NoDiagnosis LTFRateQ12014 5 1 20.00%Q22014 6 3 50.00%Q32014 6 3 50.00%Q12015 10 2 20.00%Q22015 9 3 33.33%Q32015 11 2 18.18%Pre-Intervention 17 7 41.18%Post-Intervention 30 7 23.33%Total 47 14 29.79%

RESULTS-HOSPITAL1

Inthefirstthreequarters,PilotHospital2sawa32%reductioninLTFratecomparedwiththesametimeperiodintheprioryear

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

0

5

10

15

20

25

30

35

40

Q12014 Q22014 Q32014 Q12015 Q22015 Q32015

ChartTitle

Refer NoDiagnosis LTFRate

QTR Refer NoDiagnosis LTFRateQ12014 22 5 22.73%Q22014 22 9 40.91%Q32014 34 6 17.65%Q12015 24 5 20.83%Q22015 21 3 14.29%Q32015 30 5 16.67%Pre-Intervention 78 20 25.64%Post-Intervention 75 13 17.33%Total 153 33 21.57%

RESULTS-HOSPITAL2

STRATEGIEScont’d

Inthefirsttwoquarters,PilotHospital3sawa38%reductioninLTFratecomparedwiththesametimeperiodintheprioryear

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

0

5

10

15

20

25

Q22014 Q32014 Q22015 Q32015

ChartTitle

Refer NoDiagnosis LTFRate

QTR Refer NoDiagnosis LTFRateQ22014 20 9 45.00%Q32014 14 7 50.00%Q22015 13 4 30.77%Q32015 11 3 27.27%Pre-Intervention 34 16 47.06%Post-Intervention 24 7 29.17%Total 58 23 39.66%

RESULTS-HOSPITAL3

Inthefirsttwoquarters,PilotHospital4sawa50%reductioninLTFratecomparedwiththesametimeperiodintheprioryear• Thischartlooks

erraticbecauseoftheverylowbirthcount

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

0

1

2

3

4

5

6

Q22014 Q32014 Q22015 Q32015

ChartTitle

Refer NoDiagnosis LTFRate

QTR Refer NoDiagnosis LTFRateQ22014 0 0 0.00%Q32014 5 2 40.00%Q22015 2 0 0.00%Q32015 3 1 33.33%Pre-Intervention 5 2 40.00%Post-Intervention 5 1 20.00%Total 10 3 30.00%

RESULTS-HOSPITAL4

LessonsLearned• InitiatingthePDSAwithachange

inscreeningstaffisadvantageous• Schedulinginthesameroomwith

theparent(s) isvitaltothefamilyattendingtheirappointment

• Followingupwithscreeningprogramsandaudiologyclinicsisimperative tothesuccessofthisstrategy

• Theinfrastructures inPilotHospitals3&4aremuchmorerepresentative ofhospitalsinIdaho

NextSteps• Spreadthestrategytomore

hospitalsacross thestate• Conquer theworld!

LESSONSLEARNEDANDNEXTSTEPS

Example#3

MinnesotaEHDI

Quality Improvement StoryboardMinnesota

QI Team:• Lead: Nicole Brown, EHDI Coordinator (Long-term Follow up) - Nicole.brown@state.mn.us• Kirsten Coverstone, EHDI Coordinator (Short-term follow up)• Melinda Marsolek, MDH Epidemiologist • Gina Oberg, PHN Hennepin County• Diane Graske, PHN Anoka County • Lona Daley, PHN Clay County• Mary Clausen, PHN Ramsey County• Rebecca Graham, PHN Wright County • Margaret Ratai, PHN St Louis County• Tony Ronco – NCHAM QI Advisor

AIM Statement• By December 31, 2015, we aim to decrease the number of children LTFU/D after not

passing their newborn hearing screening by improving the timeliness and resolution of “lost to follow-up” notifications sent to local public health (LPH).

• Specifically, we will:• Increase the percent of MDH Hearing Screening Notifications that are resolved from

34% to 50%.• Increase the number of MDH Hearing Screening Notifications that are resolved

within 1 month.

Why this aim? LPH are notified when MDH has exhausted all follow-up efforts. Only 34% of these cases sent to LPH are resolved.

How does it relate to overall LTFU goal/s?Reduce LTFU at diagnosis

0% 25% 50%

UnabletocontactfamilyPassedscreen:reportprovided

Familynotscheduling…Open

FamilynotlocatedDeclinedrescreening

DxwithCHLLivesoutofstate

Familynotrespondingafter…Passedscreen:reportnot…

FamilynotconcernedFamilyworkingwithPCP,but…

DeclinedLPHfollow-upNoFUdespitebestefforts…

Familyishomeless,unableto…

FollowupoutcomesforagenciesinvolvedintheLPHQIproject(includesallcasessentOct

2013-Sep2014)

NotResolved

Resolved

Measurement • Outcome measure:

• Numerator: # of MDH Hearing Screening Notifications that are resolved Denominator: # of MDH Hearing Screening Notifications sent

• Numerator: # of MDH Hearing Screening Notifications resolved within one month• Denominator: # of MDH Hearing Screening Notifications sent

• Reviewing data• Review percentages and plot data points on a run chart monthly• Run Charts Monthly

What Strategies Should We Test?We used a process map to help us figure out where to start, it lead to 2 improvement theoriesTheory 1: Improve parent education will reduce loss to follow-up

When talking with families:• Declined rescreening/diagnosis - 11% of the time. • Lack of education -32% of the time.

Theory 2: Improve contact information• Wrong number /disconnected phone number = 23% of the time. • Most successful in obtaining updated contact info from:

• MIIC (Minnesota’s immunization database)• Child’s PCP• WIC **

Improve Parent Education (based on Theory 1)• Strategy #1 - Standardization of educational materialsParent handout was developed and refined with input from LPH nurses and parents. Handout was printed and provided to LPH nurses doing follow-up.

Improve Contact Information (based on Theory 2)• Strategy #2 – Development of a checklist for LPHNurses tested a checklist developed based on successful approaches steps that the nurses found most successful. Testing included identifying the specific steps that are more successful in contacting families.

• Strategy #3 - Utilize Second Phone Number Collected at Discharge A second phone number is collected on the bloodspot card, however LPH EHDI Key Contacts have not had access to this second phone number.

Strategies

Strategy 3 in detail:Utilize Second Phone Number Collected at DischargeWhy was this strategy tested?Other states had success with this strategy.

What was the process for identifying the strategy?• LPH mapped current state, collected data on follow-up process, identified

cause using process map• Wrong number or disconnected phone number 23% of the time

What is the potential for the strategy to improve LTFU/D?Based on other state success, we considered we would have the same success. Also, when LPH staff was able to talk with families, they were most often successful in “closing case”.

PDSA #1• Plan- Contact families in Anoka and Hennepin Counties that we have

been unable to contact due to disconnected/wrong numbers and no response by using second phone numbers collected on the bloodspot card.

• Do- MDH provided 2nd phone number to LPH for cases with wrong/disconnected #. LPH attempted to contact families using these numbers.

• Study- 0 of 6 new phone numbers were helpful.

• Act- Abandon? Anoka county LPH nurse wanted to continue testing.

PDSA #2• Plan- Contact families in Anoka County with disconnected/wrong

numbers and no response by using second phone numbers collected on the bloodspot card.

• Do- MDH provided 2nd phone number to LPH for cases with wrong/disconnected #. LPH attempted to contact families using these numbers.

• Study- 0 of 3 additional new phone numbers were helpful.

• Act- Abandon.

A PS D

AP S

D

A P

S D D S P A

Lessons Learned/Moving Forward

Overall what have you learned from testing this strategy?• Why didn’t MN have the same results as other states with second contact? • Need to move beyond phone calls!

• 28% = voice message left & majority never returned call. • Utilization of other MCH Programs?

• 4 Midsize counties → 55% of cases resolved• 2 Largest counties → 22% of cases resolved

Moving Forward• Moving toward electronic reporting• Future tests once MN Screen (OZ) has been implemented• Need to contact families beyond phone calls – focus on metro counties

o Texting families