National Immunization Partnership with the APA: A Quality Improvement Project Specific to HPV Vaccination (NIPA) CDC Grant # 1H23IP000950.

National Immunization Partnership with the APA:

A Quality Improvement Project

Specific to HPV Vaccination(NIPA)

CDC Grant # 1H23IP000950

AGENDA

• Introductions 5min

What to expect from this project…

• Project overview 15min

Timeline 5min

Monthly Collaborative 10min

Study Materials 15min

• Questions?

10min

NIPA CORNET QI Team

• Monthly Call Faculty:– Cynthia Rand, MD, MPH– Paul Darden, MD– Stanley Schaffer, MD, MS– William Stratbucker, MD, MS– Janet Serwint, MD

• Other Project Faculty:– Peter G. Szilagyi, MD, MPH – Sharon Humiston, MD, MPH

Project Goals

Develop a sustainable strategy to train residents and faculty about optimal adolescent immunization methods

Contribute to increased rates of HPV vaccination

Provide excellent QI training

Background & Context• Studies show that what residents learn during training

informs how they later practice

• Teaching residents skills and approaches can improve adolescent immunization delivery

• There are approximately 200 Pediatric residency training programs in the US

• Pediatric faculty need to be trained in order to provide effective training to residents

• The best training occurs in the context in which care is delivered, i.e. immunization delivery in clinic.

Specific Aims

• Develop and execute a national QI project addressing adolescent immunizations with a focus on HPV

• Identify and test strategies to improve health care delivery of HPV vaccines to adolescent males and females

QI Practice Change Strategies

• All sites incorporate Strong Provider Recommendations• Practices choose which other QI strategies to use:

• Prompts to providers to give vaccine at the time of the visit; specifically prompts by nurse/staff at ALL visits (including acute visits)

• Standing Order protocols that empower office personnel to vaccinate, if a patient is due, without direct doctor involvement at the time of patient care at ALL visits

• Reminder Recall systems to notify members of the target population that vaccinations are due or overdue

• Feedback from monthly chart audits to assess process measures

Faculty Responsibilities• Obtain IRB approval or equivalent letter for a quality

improvement (QI) project from your institution• Participate in monthly learning collaborative

teleconferences over 9 month project. Faculty must attend at least 6 calls to receive MOC credit.

• Work with residents to pull baseline chart review audits for baseline data (50 charts)

• Work with residents to pull interim chart reviews and reports for monthly QI Learning Collaborative (10 audits per month)

• Each site asked to keep a running record of practice changes and process assessments

Learning Collaborative Plan

ACGME: Practice-based Learning & Improvement

Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning.   

Resident Learning Requirement:

 MILESTONES:-Practice based learning and improvement-Systematically analyze practice using quality improvement methods, and implement changes with the goal of practice improvement

MOC for Residents: -Residents can now earn Part 4 MOC credit during residency for meaningful participation in QI activities-Resident MOC credit will be “in the bank” for when they become certified. It will then be applied to their first MOC cycle

Resident Learning Requirement (cont’d):

Resident Responsibilities• View/Review ALL orientation and training podcasts• Participate in chart reviews:

Review at least 10 charts of pre- chart audit Review at least 10 charts of post- chart audit Review at least 20 charts of monthly audits (2

months)• Participate in at least 6 phone calls or review

recordings • Participate in review of data analysis• Brainstorm with clinic QI team as to how to make

practice change most effective

Learning Collaborative Plan

Benefits to Participating

• Receive MOC credit after meeting all requirements (faculty and residents)

• Participate in a national QI project for faculty and residents

• Enhanced education in QI principles• Participate in a scholarly project• Receive own site-specific data

Characteristics of CORNET Sites

• 2015- 107 pediatric training programs (54%)

• 130 clinical practice sites

• Mean of 52 residents/program (16-150)

• > 5500 pediatric residents

• Care for > 851,890 pediatric patients

Partnership with NIPN

• NIPN: National Improvement Partnership Network

• Based at University of VT

• A network of over 20 states that have developed

Improvement Partnerships to advance quality and

transform healthcare for children and their families

Characteristics of NIPN Sites

• 2015- 6 State IPs: Alabama, Maine, New Hampshire, New Jersey, Tennessee, Vermont

• An Improvement Partnership (IP) is a durable state or regional collaboration of public and private partners that uses measurement-based efforts and a systems approach to improve child health outcomes and the quality of their healthcare.

NIPA Participation Map

• CORNET – 16 programs (blue markers)• NIPN – 6 states (green markers)

May - June 2015

Enrollment Phase•Program Selection Notification•Contact Information Form•IRB QI proposal submission

July - August 2015

Orientation Phase•Orientation Call – Project Overview/Data Collection•Practice Readiness Assessment/Office Systems Inventory •Begin Baseline Chart Reviews (50)•QI Module Training•Strong Provider Recommendation Training

August 2015 - April 2016

Learning Collaborative Implementation Phase•Monthly Learning Collaborative Calls •Monthly PDSA Self Assessments•Monthly Chart Reviews (10/month)•NIPA Staff Impact Survey (Midpoint)

May 2016

Wrap Up Phase•Begin Post LC Chart Reviews (50)•NIPA Staff Impact Survey (Endpoint)•Office Systems Inventory (Endpoint)•MOC attestation

Project Timeline

YOU ARE

HERE

Responsibilities of Site ParticipantsPRE-Implementation of Practice Change

May -June 2015

Enrollment Phase• Program Selection Notification• Contact Information Form• IRB QI proposal submission

July - August 2015

Orientation Phase•Orientation Call – Project Overview/Data Collection•Practice Readiness Assessment / Office Systems Inventory• Begin Baseline Chart Reviews (50)• QI Module Training - 4 parts ~60 minutes

Intro., Leading change, AIM statements, QI measures•Strong Provider Recommendation Training ~10 minutes

Responsibilities of Site Participants

PRE-Implementation of Practice Change

• Participate in a project orientation call • Obtain IRB approval from each institution

• Complete the Practice Readiness Assessment*

• Complete the Office Systems Inventory*

• Complete training modules by August 7 2015

• Obtain pre data to establish baseline- review a total of 50 charts to be completed by September 1 2015*

If you haven’t already done so, please send in your denominators for randomization

*Data entry online to be completed via REDCap. A site specific link will be provided to each site

Responsibilities of Site Participants

Implementation of Practice Change

Important dates:

Monthly Data due: 5th day of the month

Monthly Calls scheduled: 4th week of the month

August 2015 -

April 2016

Learning Collaborative:- Monthly Learning Collaborative Calls

- Monthly PDSA Self Assessments: Barriers encountered and lessons learned

-Monthly Chart Reviews (10/month) for process measures: missed opportunities

-Staff Impact Survey (Midpoint)

Responsibilities of Site Participants

Post Implementation of Practice Change

MOC attestation:

Use MOC Tracking Log in Virtual Toolkit

Instructions will be sent towards the end of the series of LC calls

May 2016

Wrap Up Phase

Begin Post-LC Chart Reviews (50) for outcome measures: HPV vaccination rates

Post- Office Systems Inventory

Staff Impact Survey (Endpoint)

MOC attestation

Patient Population

• Baseline (50) and post intervention (50) chart audits:• All patients age 11-17 years, 25 males/25 females• Any visit reason (health maintenance, chronic

disease, acute care) in 9 month timeframe• Include all visits, including those up-to-date

with HPV vaccination (different than monthly)• Follow randomization scheme

• Monthly (10 charts/month)• Patient age 11-17 years• Any visit type in the prior month • ONLY IF Eligible for HPV vaccine at the visit

(different than baseline)

QI Project Progress –to date• February 2015

MOC Part IV Credit approved Recruitment of CORNET Practices and NIPN

State IPs

• June 2015 IRBs approved at PI sites 31 CORNET programs expressed interest

Wave 1 participants notified (16 programs)

QI Project –NEXT STEPS Sites to have completed:

Contact Information Form Practice Readiness Assessment Office Systems Inventory IRB QI applications at respective sites Send in denominator for randomization Review of QI training modules and Strong

Provider Recommendation module

CORNET Sites to begin Learning Collaborative calls: August 2015

Learning Collaborative Plan

Tools to help you navigate

• Project Timeline A timeline to help move you through the project

• Listserv addressA way to communicate with your fellow project colleagues

[email protected]

• Virtual ToolkitAn easy way to reference all your project materials

www.academicpeds.org/NIPA

• REDCap for all data entrySecure link to enter data (site specific)

• All data entered electronically via REDCap• All data and survey tools at the practice-level,

not the provider level• Main faculty contact receives email with

practice-specific links to data tools• Main contact shares submission links with

practice team and coordinates data entry• Do not send any forms or medical record

information to the NIPA project team

Data Submission

REDCap Tips

• Most fields are required: cannot move to next page without completing all required fields

• Can save partially completed data and return later to complete: SAVE RETURN CODE

• Review data tools on the Virtual Toolkit – www.academicpeds.org/NIPA - Data Collection

• Distributed: Pre-project• Purpose: Assess practice experience and

comfort with QI to guide practice coaching

Practice Readiness Assessment

• Distributed: Pre- and post-project• Purpose: Describe practice’s current systems for

delivery of HPV vaccine and identify potential areas for system change

• Discuss questions with practice team

Office Systems Inventory

• Distributed: Pre- and post-project*• Purpose: Calculate rates of missed

opportunities, HPV series initiation and completion

Pre- & Post- Intervention Chart Audit

• 50 charts pre- and 50 post-• 25 males• 25 females

*Please send denominator if you haven’t already

• Eligible patients: Adolescents 11-17, seen for any visit type between August 1, 2014 and April 30, 2015

• Randomization procedure• Practice generates list of all patients seen between

8/1/2014 and 4/30/2015• Birthdates between 5/1/1997 and 8/1/2003• Alphabetize patient list and number them 1,2,3…• Email total number of patients (NOT patient list)• Statistician generates random list of numbers

corresponding to patients on site patient list• Patient charts reviewed in that random order

Pre-Intervention Chart Audit

• Chart Audit Patient Log tracks:• Randomization Scheme• Gender and Medical Record Number• REDCap Patient ID

• Calculator function helps you with validation:• Calculate patient age at visit dates• Calculate HPV vaccine eligibility dates• Track # of males and females

Pre-Intervention Chart Audit

• Remember to record REDCap Patient ID in the Patient Log

• NIPA team will reference this number if there are any questions about the data

Pre-Intervention Chart Audit

• Distributed: each month of Learning Collaborative• Purpose: Assess progress and evaluate system

changes• 10 charts per month• Convenience sample: not randomized – suggest

5 males + 5 females from different weeks, days and providers

• All sites: evaluate missed opportunities on monthly basis

• Reminder Recall: select 10 patients contacted via reminder-recall system, audit whether they presented for a visit that month

Monthly Chart Audit

• Baseline/post chart reviews =• Patient Level• EVERY visit in the time frame, whether

eligible for HPV vaccine or not• Monthly chart reviews =

• Visit level• ONLY visits where patients were eligible to

receive HPV vaccine

Monthly Chart Audit

• Distributed: each month of Learning Collaborative

• Purpose: Reflection on Plan-Do-Study-Act cycle• Record successes and barriers you encounter,

examine the progress you have been making through the strategy you selected, and make changes that will lead to maximal improvement of your immunization rates

• Discussed on monthly LC calls

PDSA Self-Assessment Tool

Monthly Data Report

• Distributed: mid- and post-project• Purpose: Balancing measure to evaluate

whether the time and effort required to implement office systems interventions affect staff in planning, scheduling, and conducting visits for adolescents who are due/overdue for HPV vaccine

Staff Impact Survey

Any questions?

Please contact :Nui Dhepyasuwan, MEd

Phone: 703/556 9222 x103  I  Fax: 703/556 8729

[email protected]

Beth King, MPP

Phone: 703/556 9222 x140  I  Fax: 703/556 8729

[email protected]

Listserv: [email protected]