Pediatric practices could make significant improvements to their developmental surveillance and screening processes in a short time. This project team’s initiative shows just how quickly your practice can, too.
Strategies for improving the referral process
Pediatricians know developmental delays and disabilities are common (1 in 6 children with developmental disability, 1 in 59 with autism)1,2 because they see them nearly every day. As pediatricians, we also know we have to be very diligent to identify and treat every child with a developmental concern. Although great progress has been made, gaps in surveillance and screening as recommended by the American Academy of Pediatrics (AAP) remain.3,4
In our educational outreach work with the Centers for Disease Control and Prevention (CDC) “Learn the Signs. Act Early.” (LTSAE) program, we found many pediatricians want help identifying developmental concerns. Our project team (including general and developmental-behavioral pediatricians and quality improvement specialists) worked with the AAP Division of Children with Special Needs and the CDC’s LTSAE program to learn more about and improve physicians’ practices around developmental surveillance monitoring (Figure 1), screening (Figure 2), discussion of screening results, referral, and follow-up in the medical home.
We found that pediatric practices, even when already performing developmental screening, could make significant practice and patient care improvements in a short time period. We used learning collaborative and quality improvement (QI) strategies to help 4 pediatric teams (a physician lead plus 3 other members) improve developmental surveillance and screening processes over 6 months.
How the strategies worked
To start, teams learned about developmental surveillance and screening, family engagement, and QI tools and methods. As the project continued, teams joined monthly webinars with content presentations (eg, team-based care, linking families to resources, sustaining change), reviewed monthly aggregate data, planned and initiated plan-do-study-act (PDSA) cycles, and had opportunities to present their work and collaborate. Teams received at least 2 individualized QI coaching calls. Teams submitted monthly QI chart review data and received feedback on process changes, successes, and challenges. Pediatricians earned free American Board of Pediatrics Maintenance of Certification (ABP MOC) Part 4 credit.
During the project period, teams focused on the following measures:
· 90% of patients appropriately screened for risk of developmental, behavioral, and social delays.
· 90% of patients appropriately screened for risk of autism.
· 90% of patients’ families receive a discussion of developmental screening results on the day of screening.
· 90% of patients have referral initiated within 7 calendar days after receiving a concerning (positive) screening result.
At baseline, teams used standardized developmental screening tools more than 80% of the time and autism screening tools more than 90% of the time. Therefore, we emphasized improvement in screening results documentation; discussion of results with families (and documenting discussion); and tracking referrals and follow-up, in addition to the original goals as listed previously. Teams submitted data for 40 chart reviews per month over 5 months.
The results? As outcomes for developmental and autism screening, practice teams continued to make improvements in already high standardized screening processes to above 95% at project conclusion.
As outcomes for discussion and referral measures, teams also found ways to improve consistency of their discussions about screening results, including discussion of developmental anticipatory guidance for families. For both discussion and documentation measures, processes were streamlined, and results were improved from 70.4% for developmental screening and 90% for autism screening at baseline to 100% for both types of screening at conclusion.
All teams identified referrals as an area of special focus for this project. Some reported difficulty in conducting rapid PDSA cycles around referrals because of the lengthy turnaround time involved and processes outside teams’ control.
However, teams were able to test innovative changes within their practices that improved the referral and follow-up process by refining their existing workflow, including:
· creating patient follow-up systems;
· standardizing referral orders; and
· establishing internal referral tracking systems.
Despite high levels of adherence with developmental surveillance and screening recommendations, we found that use of a team approach to fine-tuning details of existing processes led to further improvements. Engagement of all clinical and support staff was critical to the success of the entire team.
“I think everyone has really started ‘waiting less’ and doing more to help and monitor developmental growth in all our patients.”
Discovering gaps in workflow, staffing, record-keeping, and referral process facilitated practicewide efforts to improve efficiency. Teams tested changes to improve multiple unique but interrelated workflows.
“I continue to be amazed by how individual contributions work together to make our overall system better. I also have been reminded about how important a positive attitude is in process change.”
Some successful changes cut across practice components. For example, one team focused on timeliness of screening completion and developed a process for screening completion prior to the clinician entering the room, with the support staff stating, “Let me know when this is completed, and I will tell the doctor you are ready.” This intervention was refined and spread to the rest of the clinic using reminders such as stickers on exam room computer screens.
Additional small tests of change established optimal screen timing and locations for the screening tools. Practice teams agreed that overall visit times did not increase or decrease significantly and communication with patients about developmental screening was somewhat easier.
Clinicians reported that discussions with families of both “passed” and “concerning” screens improved. Many found this to be an important step in providing feedback on skills and developmental anticipatory guidance. Future developmental surveillance and screening may be aided by increasing parents’ knowledge of typical developmental milestones. Teams improved documentation of discussions within their electronic health records, including provider instruction and standardized text.
Teams explored referral tracking options, including paper tracking systems (ie, spreadsheet lists or referral copies in a binder), that allowed for cross-checking for feedback from state early-intervention (EI) programs or other referral resources. (See "Strategies for improving the referral process.")
“This project helped us . . . have documentation on when they [families] went [to a referral], if they did go, and if they had problems getting in. We’re more aware of resources, which is beneficial. We’re more efficient now in getting kids in.”
Teams reported feeling empowered to engage families better while referral processes were underway. Teams also used materials and resources provided in the project “change package” that included information on QI tools, surveillance and screening implementation, screening result discussion, referrals, and billing. Practice teams used and valued free CDC LTSAE family-focused patient education materials (Figure 3).
Teams found LTSAE materials helpful to engage families in developmental surveillance and anticipatory guidance and easy to incorporate into their workflow.
“We laminated the LTSAE developmental sheets and put them in the exam rooms so that sparks discussion when the provider goes in.”
“The thing I like about the milestone sheet is that it’s very literate friendly . . . I would say down to a 6th-grade level. It’s simple and not busy.”
“I found it very helpful to have something in writing to give to the parents in addition to what they hear me say. It augments . . . and reinforces what I say during the visit.”
Teams also shared favorable feedback from parents. “Parents are glad for the booklets. Parents often ask what they should be doing, and they like to know what to expect early on.”
“[Parents] really enjoy learning where their child should be at what point in time and kids like them [LTSAE developmental milestone books], too.”
Teams sought additional guidance regarding payment for screening services and resources and specialists to whom they could refer families. One team obtained a referral directory from their state AAP Chapter and additional resources to optimize billing practices. When asked how teams facilitated spread within their clinics, teams consistently mentioned communication and project champion modeling.
“Our process has been that if there’s an idea to change workflow, start with one provider for a few days and then if it works, try with another. We communicate through e-mails, huddles, and reminders on computers because when you add anything to a workflow, sometimes it takes a bit to ‘stick.’
“We realized that [developmental surveillance and screening] may be the most important thing we do. It’s a priority with well checkups and everybody is realizing that. We’re explaining to nurses and medical assistants how important it is and there’s more talk among staff.”
Teams improved, not only on quality improvement metrics, but in their awareness of the value of developmental surveillance, building relationships with families through surveillance and screening, ensuring concerning results are addressed, and the next steps to help children achieve their optimal development. The changes made by each team varied, but all were perceived to add value to children and families.
Our findings suggest that assessing processes around developmental and autism screening can be helpful in enhancing care for young children and their families. Practices can improve processes in a relatively short period of time, and in ways they may not perceive as needing improvement.
The comprehensive QI Project Toolkit is available on the AAP quality improvement webpage (https://www.aap.org/en-us/professional-resources/quality-improvement/Pages/Developmental-Surveillance-Screening-and-Referral.aspx). Pediatric practices also may be able to receive ABP MOC credit by implementing their own QI project (see application materials at the AAP website: https://www.aap.org/en-us/continuing-medicaleducation/mocportfolio/Pages/getinvolved.aspx.
Authors’ note: The findings and conclusions in this report are those of the contributors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. This report is not intended to provide guidance to the federal government.
1. Baio J, Wiggins L, Christensen DL, et al. Prevalence of autism spectrum disorder among children aged 8 years-Autism and Developmental Disabilities Monitoring Network, 11 sites, United States, 2014. MMWR Surveill Summ. 2018;67(6):1-23.
2. Boyle CA, Boulet S, Schieve LA, et al. Trends in the prevalence of developmental disabilities in US children, 1997-2008. Pediatrics. 2011;127(6):1034-1042.
3. Council on Children With Disabilities; Section on Developmental Behavioral Pediatrics; Bright Futures Steering Committee; Medical Home Initiatives for Children With Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006;118(1):405-420. Erratum in: Pediatrics. 2006;118(4):1808-1809. Reaffirmed August 2014.
4. Lipkin PH, Macias MM, Hyman SL, Coury DL, O’Connor KG. Identification of children <36 months at risk for developmental delay/autism: results of a national survey of pediatricians. Abstract 15. Presented at: 2016 Annual Meeting of the Society for Developmental and Behavioral Pediatrics; September 16-18, 2016; Savannah, GA. Available at: http://www.sdbp.org/meetings/2016/pdfs/SDBP_2016_Abstracts.pdf. Accessed December 13, 2018.