1. Parental Strengths Kasey Scannell M.D., Jeana Bush M.D., Nicole McCoy M.D., Kanitra Clyburn RN Preventive Services Improvement Project Learning Session 2 November 11-12, 2011

2. 2 Disclosures I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.

3. Myers Park Pediatrics Organization: FPN Continuity Clinic General Pediatrics Provider Profile: Faculty Practice: 5 Mid-levels : 4 Residents: 34 Rotating faculty educators: 8 Nursing: 18 clinical staff  13 RNs Interpreters: 3 full time, 4 part time Registrar Staff: 11 1 st challenge: educating 51 providers

4. Myers Park Pediatrics  Insurance: 90% Medicaid  Language: 54% English, 45% Spanish, ~1% Other  # WCC: >1000 per month  Written and PowerNote hybrid 4

5. Quality  Residency program with a QI emphasis  Outpatient clinic with 6 projects ongoing  Every resident, most providers & many nurses are required to participate in QI annually 2 nd Challenge: Constant change!

6. Parental Strengths  Project Goal: 85% of patients have documentation in the chart that parental strengths were documented at the most recent visit  Myers Park Group Definition: emphasizing at least one thing the parent is doing well to promote the child’s health and well being

7. Examples  Positive health choices Breastfeeding Bottle weaning Healthy diet Proper oral health  Providing a safe environment Wearing bike helmet Safety proofing house Proper car seat placement  Positive parental decisions Reading to child Making WIC appointments Behavior management Recognition of developmental concerns Bringing to the WCC appointment

8. AIM statements  Myers Park: by April 2011, at 50% of 9 mo WCC and 24 mo WCC, a parental strength was identified, discussed and documented  Entire group: By November, 85% of patients have documentation in the chart that parental strengths were documented at the most recent visit

9. Step 1  Education Resident noon conference and faculty meeting on bright futures project  Highlighted initial goals including parental strengths Re-addressed at next housestaff-faculty meeting to catch providers who may have missed the initial education session

10. Expectations  We thought everyone was already doing this… now they just needed to document it -- easy, right?  Sites of potential documentation included: Handwritten WCC note Power note for providers on EMR Typed discharge paperwork  Then we did our first chart review…

11.  Push back from all providers regarding time/effort for extra documentation  Overestimated resident and faculty comfort regarding parental strengths Interns vs. residents vs. faculty regarding acceptance  QI fatigue  Lack of education: Difficult to make all providers aware Challenges

12. Step 2  More education- emails, meetings At the start of the 2011-2012 academic year, ALL new interns received orientation regarding the goals and objectives of the project by the lead nurse  Positive reinforcement and “gentle reminder” emails after the chart review

13. Step 2  Providing providers with clear, concise examples in English and Spanish: 13 I am pleased with the way you are breastfeeding. He/she is growing wonderfully! I am impressed with the way you are introducing different types of fruits and vegetables to your child. Thank you for bringing your child to clinic today. It really shows that you want to keep your child safe and healthy. Your methods of discipline are impressive! Great way to promote good behavior! Estoy muy contento/a con la manera en que está amamantando. El/ella esta creciendo maravillosamente! Estoy impresionado/a con la manera en que está introduciendo los diferentes tipos de frutas y vegetales a su niño/a. Gracias por traer a su niño/a a la clínica hoy. Realmente muestra que desea mantener a su hijo/a seguro/a y saludable. Sus métodos de disciplina son impresionantes! Gran manera de promover el buen comportamiento!

14. Challenges  Ongoing issue of documentation How and where providers were documenting wasn’t consistent  Residents Still having trouble finding things to compliment parents on that easily flow into the WCC  Faculty Resistance to documentation

15. Revisions = Forward progress!  Stamp Consistent documentation Providers love check boxes Bold, visual reminder on WCC notes

16. The Stamp 16 Parental Strengths Addressed BF Anticipatory Guidance Handout given Risk assessment addressed

17. Overall Results  Negative Push back to location/size of stamp Potential to check box even if parental strengths were not addressed Incorporating stamping of notes into the flow of the front desk personnel Documentation in EMR (not able to stamp)

18. Overall Results  Positive Improved compliance with check-box stamp Less total documentation Stamp as constant reminder on all WCCs Easier to review in monthly chart reviews 18

19. Did adding parental strengths (whether verbally, written or checky box) change your practice?  Yes- the stamp really helped to remind me and start the visit off with addressing their concerns and strengths.  I generally try to be positive with families but the checky box is definitely a reminder to always find something positive to say.  Seeing it on my EMR template does help remind me to attend to parental strengths.  I felt like the chart review, at first, was a good reminder to give praise and encouragement to parents/families, but now it is a part of my practice. 19

20. Did adding parental strengths (whether verbally, written or check box) change your practice?  Yes, it did change my practice because it made me realize how much more I could congratulate my parentson the good things they’re doing. It’s forced me to think about each individual parent and what they’re doing well.  I like to think that I praised parents for at least one thing on every visit before, but the check box really makes me think of something specific. Before, I was probably saying “oh, great, good job” in response to finding out if a kid was wearing a helmet, brushing BID, etc. Now I’m making more of an effort to say something like “It’s great that you’re reading with your kids. We know this can help with their language development.” I try to give them more of an example of why what they are already doing is important. 20

21. Additional feedback:  Did it change your rapport with patients/families? Yes, no and unsure  Was it an easy change/addition to make? Yes, easy, helpful Check box was a great reminder 21

22. Would you continue to include this in your WCCs if we weren’t doing chart reviews?  I would for sure!  Absolutely!  Yes, but I wouldn’t take the time to document it.  Yes, I would try and continue to include it in my WCCs (I tried to do it in the ED last month)  I would definitely continue to do it in WCCs even if you weren’t reviewing it, but I may not be as likely to document it if the check boxes weren’t there. 22