ROUGH EDITED COPY
EHDI
SEGELL ROOM
"Lessons Learned Through Recent Connecticut EHDI Program Diagnostic Audiology Center Collaboration
One Small Change At a Time."
MARCH 9, 2015
2:00 P.M.
CAPTIONING PROVIDED BY:
ALTERNATIVE COMMUNICATION SERVICES, LLC
P.O. BOX 278
LOMBARD, IL 60148
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This is being provided in a roughdraft format. Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.
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>MODERATOR: Good afternoon. I am Dr.Jeanette Miller. I'm from the Lexington Hearing and Speech centre in Lexington, Kentucky. And I am glad you are here today for this session. You can't hear me? I can hear myself. Okay. That okay. It's on. Yes. This course today is "Lessons Learned Through Recent Connecticut EHDI Program Diagnostic Audiology Center Collaboration. And it's One Small Change At a Time."
As we get prepared, make sure your cell phones are off so that they don't ring during this session. Also, the salmoncolored sheet, when you are finished with this program, whether it's at the end of this one or in the next 30 minutes, just leave it on the chair as you leave. I would appreciate that. Thank you.
> AMY MIRIZZI: Okay. So let's see, does this mic seem to be working for everyone? Okay. Great. Good afternoon. We're here to talk to you about our recent collaboration. I'm Amy Mirizzi, the Connecticut EHDI coordinator. I work out of the did Department of Public Health, and I'm here, my copresenter is Nancy Bruno, who's the audiology manager at Connecticut Children's Medical Center, which is one of the two children's hospitals in Connecticut.
In our learning objectives, what we're hoping you get out of this session is that you're able to identify the benefits of a collaboration between an EHDI program and a diagnostic audiology center, understand the value in both successful and unsuccessful tests of change. Anybody who does QI knows that we don't always find success with what we think we may. And also, to examine ideas to advance quality improvement work in your home state. So Nancy and I really started our work in quality improvement with the improving hearing screening and intervention systems learning collaborative, which many of you are probably familiar with, and we've continued our QI work with the QI team in our state, as well as through some more individual sessions with our QI advisor, Allison Ward, so that's been a really beneficial, ongoing relationship, and she's helped us work through our improvements in our system.
So I wanted to start just by giving some baseline data to give you an idea of where Connecticut was in 2012. We worked through the learning collaborative beginning partway through 2012, so there were 37,294 births,.67% of babies were lost at that point. So no screening on record. Connecticut pretty consistently screens 99% of babies. And 577 babies did not pass. Those of those babies that did not pass in 2012, 63% had we had documentation of them completing diagnostic audiological evaluation and 50 of those had a confirmed hearing loss. And of those 50, moving down to intervention, 84% were referred to birth to 3, which is our Part C or early intervention program in Connecticut, and 70% subsequently enrolled in birth to three. So in looking at our numbers, we really decided that where we need to focus is on the loss to followup between screening and diagnosis, and we kind of identified three areas that or three categories that those kids were likely falling in to, and that would be true loss to followup, where they really didn't go for an evaluation and have any subsequent testing. And then there's another category of children that are lost in the process somewhere, so they make some kind of connection with an audiological center, but for whatever reason don't ever complete diagnosis.
And then the group of kids that we know are lost to documentation, so they did seek followup, but the results weren't reported to the state EHDI program.
So I wanted to give you also a little bit of background on some of our protocols in Connecticut. For a smallish in having 29 birth facilities and six diagnostic testing centers, infant diagnostic testing centers, we kind of have some wide variability in the protocols that are carried out at different points, so in terms of when the referral is made, for a group of hospitals it's at discharge, so the first and second screening are done prior to discharge, and then the referrals made if the baby doesn't pass at this point. But for a third of hospitals, there's a final outpatient rescreening that takes place after the first and second screening. The family comes back at around two weeks and has that final screening if they don't pass if they don't pass at that point, that's when those hospitals make the referral.
Also, in regards to who makes the referral, in some hospitals, it's the hospital staff. In others, it's the primary care provider following the baby after discharge. And then also when we're looking at where audiology services are available, sometimes it's within the same system, so then the baby can be referred directly, so those would be hospitalbased audiology centers, but sometimes there is no audiology center at a hospital so they're needing to connect with their families to a center outside of their healthcare system. So Nancy put together this map just to represent all the different variables that we have to take into consideration when we're looking at making improvements to our system, so the smiley faces are the birth hospitals, and the different colors represent those different protocols I describe. And the stars are the diagnostic centers. So some of those are hospitalbased, some are independent, so you get an idea of when we're looking at designing planning to do study cycles and small tasks of change, we have to be creative if we're going to be able to work on something that would apply statewide, and alternatively, if we find a successful change and we're thinking about spread, it may only be applicable to then take that to facilities that have a protocol that works within those changes. So wanted to give you that background before I talked about some of the more specific changes that we looked at making over the last few years.
And these are not in chronological order, it's just that we tried to kind of put it in an order that would make sense for today's presentation.
This first one I want to talk about is focusing on reducing loss of followup from screening to diagnosis, and it was a plan that we developed to improve referring hospital's ability to connect families directly to a diagnostic audiology center, so that's the whole idea of making a direct referral to audiology prior to discharge, which a lot of states have found some success with, and what we did in Connecticut is we provided packets to hospitals that did not have inhouse audiology services, and the packets included I apologize, this is a wordy slide. I know that's not probably the best way. We should have left some of those details out, but the packets included contact information for scheduling and for clinical questions, appointment cards for patients, as well as patient information such as the importance of followup, how to prepare their child for testing and things like that.
And as we studied this protocol and we started with just a couple hospitals, and the state EHDI program then was able to monitor referrals from that individual hospital and Connecticut Children's could track the number of appointments scheduled via the new protocol, so it was really important to have that collaborative network to be able to tell if we weren't getting the numbers we thought, is it because the hospital didn't have the referrals that we expected them to over the time period we were studying, or was it because something wasn't working with the protocol?
So we both jointly recruited facilities. We started with two hospitals. We saw some limited success, and we were able to expand it a little bit more, and we're working on spreading it to a fifth facility. So when we looked at this did this new protocol actually lead to an increase in the number of babies referred for diagnostic followup at the hospital level, we realized that what we thought would be a short test of change because of the number of referrals coming out of those facilities we selected, it was kind of more of a longterm PDSA cycle, which, you know, the ideal cycle is a short, quick kind of thing, but it you know, we're sharing that it doesn't always work that way, and there's still some value, we feel, to continuing the cycle and working with hospitals on implementing these changes.
What else do I want to say about that?
Talk about the next one. So the next activity that we worked on, and this isn't real traditional kind of PDSA, it's more of a supporting activity, but it was with the intent to motivate birth facilities to make improvements to their universal newborn hearing screening programs, especially the referral protocol by providing them with annual statistics in an easytoread report card format, which a lot of states have. Connecticut historically has provided hospitals with statistics, but what we wanted to do is look at providing it in a more effective way where they could really kind of see where their areas of success were, and where maybe there was room for improvement. So we developed a Connecticut EHDI report card for all the birth facilities. We did pilot it with a few, made some tweaks, and then we sent it out to all of them.
So that's the part that doesn't necessarily fall in to the this PDSA where maybe you would have just sent it to a few, but because of the nature of the activity, it made more sense to send it to everybody.
And what we provided on it was three years of trend data, so there are 2011, '12 and '13 screening rate, referral rate and loss to followup rate, as well as their individual facility statistics for 2013, and we ranked them to encourage them some healthy competition among all the other hospitals in the state, based on their screening rate and their followup rates. And we sent it to the nurse manager of the well baby nursery, the chief of pediatrics, the director of neonatology, where it applied, and the audiology manager, and in a couple of cases, the audiology manager oversees their newborn screening program. So I think that was part of the success is that we included a number of stakeholders at the hospital, so kind of encourage conversation at that level, and our study of this activity, we heard from nine birth facilities after these went out in the spring of last year, and they were looking at ways to improve their program based on what they saw on the report card. A lot of them were looking at where they ranked and looking at their trend data and wanted to work with us to come up with ways to make improvements. So we saw this as really successful. Four of those hospitals have initiated new referral protocol as a result, and so we are going to adopt this format moving forward and use it again this spring. To give them their 2014 data.
And then the last change that I'm going to talk about before I pass it on to my copresenter, again, focusing on reducing loss to followup between screening and diagnosis, and this was looking at our tracking and outreach protocol, so we wanted to improve communication with the medical home in Connecticut, which is typically the primary care provider office in order to better facilitate followup, and historically we've sent tracking letters, like many states do, in Connecticut, and due to some system support issues when we were moving from our old database to our new database, there was a period of time that these letters did not go out very consistently, or at all, and we saw our loss to followup increase, so we knew we needed to return to sending those letters out, and we designed it as a PDSA for learning because we wanted to really be able to try to measure the effectiveness of the letters, and so we started sending the tracking letters to both the parent of a baby who does not pass newborn hearing screening and copying the primary care provider of record, and through a series of PDSA cycles, and we determined seven weeks postscreening would be a good time frame for many babies, that hits right before their twomonth well visit, so we think that might contribute to the success of the timing. And so we ran multiple PDSA cycles. We ended up running them for a lot longer than would be maybe typical because we were gaining so much information, and what we really found is that we had more of a problem with loss to documentation than we had originally predicted, so babies had followup, but it hadn't been reported to the state EHDI Program, so that was really valuable information, so we sent 147 letters to healthcare providers and families over a 15month period. We were looking at this. And 67% could be classified as complete when we looked at them at a later date, so that was significant reduction in loss to followup. I'm not implying that the letters necessarily had a cause and effect on the followup. In some cases they may have prompted a referral and prompted a family to followup, but like I said before, what it allowed us to gain is better documentation of followup that had occurred. So we certainly adapted this as a great example of what happens when you have a support system change. So we had a new database that allowed us to automate some of this some of the lettersending so that it wasn't so time intensive, and made it more sustainable piece of our tracking and outreach protocol.
So I just want to take a minute, so we started with some of our baseline data. After looking at some of these changes within our system, I just wanted to show some of the statistics in terms of followup. So we started sending letters July 1st, 2013, so I our loss to followup rate from the previous 12 months, so 7/1/12 to 6/30, 2013, and then we started sending letters July 1st, 2013, moving forward, and we saw our loss to followup go from 30% down to 12%. As a result of these some of the changes I've talked about, and then also some of the changes that my colleague, Nancy Bruno, is going to talk about. So I'm going to have her take over from here.
> NANCY BRUNO: Hi. I am Dr.Nancy Bruno, and I am an audiologist and speechlanguage pathologist, and we are collaborating with the Department of Public Health. I work at Connecticut Children's Medical Center, which is a standalone children's hospital, so we don't have any birthing facilities, being a children's hospital, but we do have a very extensive newborn intensive care unit about 70 beds, and we are a diagnostic audiology center. Because we don't have a birth facility, a lot of people who come to us and use our services are people who come from the hospitals that Amy has been describing that don't have audiology services available in those hospitals themselves. So the collaboration worked very well in terms of working with DPH to connect the children to us, and then our big challenge was making sure that they didn't get lost in the diagnostic followup process. And I look at that in two ways. First of all, we want them to get through the process, but second of all, they need to not only get through it, but get through it in a timely way, because we're trying to meet our 136 objectives, with three months being the time frame by which we want that diagnostic to be complete.
Let's see if I can get this going. So first thing we did was take a look at how they could get lost in the process, and one of the problems is multiple visits, and on the calendar you can see that there's some push pins with different colors and I think of red as a noshow, and I would be very happy if we had that few noshows. Unfortunately, we have a lot of cancels and noshows. And I don't know about other people, but we have about twice as many appointments on the books as children actually complete. So our cancellation rate is about 26, 27%. Our noshow rate is about 6 to 7%. I actually look at that as pretty positive, because we have a lot of cancellations. That means those people communicated back to us and told us they weren't coming. That's much better than noshowing. And when they communicate back to us, we can sometimes capture the reason that they had to cancel or not come in, and develop an action plan, and I'm going to talk about that a little bit more going forward.
Another thing that causes them to get lost is incomplete results. Sometimes because of infant sleep schedules. So looking at that, I know that there are many people who have done PDSAs on how to address this, and it's not uncommon to need a couple of appointments to really complete your diagnostic workup on a child. We would like it to take less than that. 80% of the children that come to see us have a completed diagnostic in the second visit that they attend. That doesn't mean they only have two appointments. They could have some noshows and some cancellations mixed in there, but the diagnostic in 80% of cases is a completed at their second visit that they actually come in.
We have some children that take longer. They may have very complex medical needs. As I said, we have a 70bed newborn intensive care unit. We do ECMO, we do some very complicated things, and some of those children don't even get out of the hospital by the time they're three months or even six months of age, so that can have an impact. And those children, because they have complex medical needs, tend to have higher noshow and cancellation rates so we have to try and address them. We have children with delayed referral to us. We want to make a diagnosis by three months of age. It's disappointing but true that we have some children that are not referred to us until they're already three months of age, and that's a problem. Some of that relates back to what Amy was talking about in terms of the complexity of our pathways for the birth centers connecting with the diagnostic centers in Connecticut. And then we have some indirect referrals, so sometimes people don't get referred to audiology. They get referred to ENT, or they get referred somewhere else before being referred to audiology, and we do have a very good collaboration, both with community ENT physicians and ENT physicians who work within Connecticut Children's Medical Center. So what we try to do there is if somebody comes in and they've been referred to ENT, they try and capture the reason. If the staff that are trying to schedule that patient find that the parent says anything about newborn hearing screening, they try to connect the audiology visit with that so that we capture those children. So we looked at all of these kinds of things in terms of trying to develop some PDSAs to address this, and looked at a couple of things that would address the cancellations and noshows. A couple of things that would potentially look at getting complete results in a fewer number of visits, and also I'm going to talk a little bit not about multiple visits, but about connecting your results back to the EHDI system so they understand what you've done.