The first PDSA cycle focused on cuing the providers to ensure that they were reviewing the paper questionnaire about adolescent health screening. “We asked our medical assistants to insert the paper questionnaire sideways into the patient folders to give the providers a visual cue to stop and review the documents during the visit,” she said. The second PDSA cycle consisted of the introduction of a TB risk assessment form and a well-adolescent visit “cheat sheet” that was distributed to pediatric residents in electronic and hard copy forms, while the third PDSA targeted residents more heavily by giving them a 1-hour lecture about adolescent primary care, and sending an e-mail reminder to rotating residents about necessary screening.
In general, there was an increase for all of the process measures from baseline to the end of the study period, but a certain amount of attrition occurred between PDSA cycles 2 and 3. For example, the TB assessment was 19% at baseline, 27% after PDSA cycle 1, 85% after PDSA cycle 2, and 50% after PDSA cycle 3; screening for sexual activity was 81% at baseline, 91% after PDSA cycle 1, 100% after cycle 2, and 95% after cycle 3; while vaccine review was 57% at baseline, 72% after PDSA cycle 1, 100% after cycle 2, and 80% after cycle 3.
“We managed to improve our screening rates overall for almost all of the measures we were looking at,” Dr. Kumar said. “There was a lot of buy-in and support behind this project from the patients, providers, administrators, and office staff. Considering that we were not allowed to make changes to our EMR, we got a lot of bang for our buck.”
The attrition in many of the process measures by PDSA cycle 3 “highlights the fundamental need we have for systemic solutions rather than relying on individuals to change their behavior,” Dr. Kumar said. “The residents responded positively to the interventions that were targeted towards them. Many indicated that their understanding of adolescent preventive care improved. But they also said it was a lot to learn in a 1-month rotation. The only way we’re going to create sustainable change is to focus on system-based solutions.”
She said that staff at Children’s Hospital Los Angeles Teen Health Center are “working to use these results as leverage to expand EMR functionality to include a recall system for annual physicals; to create provider alerts to inform the provider when the patients are due for their next annual screening; and electronic versions of the questionnaires that the patients can complete and have downloaded directly to the EMR,” she said. “We also recognize the importance of improving longitudinal teaching around adolescent health throughout pediatric residency programs, and not just during a 1-month rotation.”
Dr. Kumar reported having no relevant financial conflicts.
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