Iowa EHDIIowa EHDIIowa EHDIIowa EHDI

Tammy O’HollearnTammy O’HollearnTammy O’HollearnTammy O’Hollearn, Iowa EHDI Coordinator, Iowa Department of Public Health

Vicki HuntingVicki HuntingVicki HuntingVicki Hunting, Quality/Operational Improvement Engineer, Center for Child

Health Improvement & Innovation

1. Demonstrate the use of quality improvement methodologies in improving engagement of medical specialty providers in the follow-up of infants suspected of a hearing loss.

2. Describe the attributes of the Model for Improvement and the Plan-Do-Study-Act process as it relates to Universal Newborn Hearing Screening (UNBHS) and the public health role in assuring access to timely follow-up for infants suspected of a hearing loss.

3. Analyze toolkit survey feedback to evaluate effectiveness of toolkit that was provided.

Vicki Hunting and Tammy O’Hollearn have no relevant financial or nonfinancial

relationships in the products or services described, reviewed, evaluated or compared in this

presentation.

• Loss to diagnosis rates around 45.1% infants with permanent hearing loss may be missing the benefits associated with the Early Hearing Detection & Intervention (EHDI) newborn hearing screening program.

• Less than half of CSHCN are currently linked with a Medical Home (MH).

• Delays in care are worsened by a shortage of pediatric audiology specialty services (audiologists, pediatric ENT/ORL)(White, 2003) especially in rural and underserved areas.

Iowa EHDI Lost to FollowIowa EHDI Lost to FollowIowa EHDI Lost to FollowIowa EHDI Lost to Follow----up Ratesup Ratesup Ratesup Rates

Iowa EHDI 1Iowa EHDI 1Iowa EHDI 1Iowa EHDI 1----3333----6 Data6 Data6 Data6 Data

• Physicians reported a high level of support high level of support high level of support high level of support for universal newborn hearing screening;

� 81.6% judged it to be very important very important very important very important to screen all newborns for hearing loss at birth.

• Although physicians reported confidence in talking with parents about screening results, they indicated a lack of confidence in discussing follow-up procedures and intervention needs.

• Several important gaps in knowledge were identified;

� priorities for education, as based on medical management and parent support.

• Physicians expressed a strong preference for action-oriented resources.

Primary Primary Primary Primary Care Physicians’ Knowledge, Attitudes, and Practices Related to Newborn Hearing Screening. Care Physicians’ Knowledge, Attitudes, and Practices Related to Newborn Hearing Screening. Care Physicians’ Knowledge, Attitudes, and Practices Related to Newborn Hearing Screening. Care Physicians’ Knowledge, Attitudes, and Practices Related to Newborn Hearing Screening. Mary Pat Moeller, Karl R. White and Lenore Shisler, Pediatrics 2006;118;1357-1370, DOI: 10.1542/peds.2006-1008

• Pediatricians and other primary care providers (PCPs) recognize the benefits of early detection early detection early detection early detection and interventioninterventioninterventioninterventionfor permanent hearing loss in infants.

• The current system of newborn hearing screening can be can be can be can be enhanced enhanced enhanced enhanced by strengthening the medical community’s involvement in the process from screening to follow-up.

• Physician roles will be supported through the provision of actionactionactionaction----oriented resources that educate parents and oriented resources that educate parents and oriented resources that educate parents and oriented resources that educate parents and providers providers providers providers about the importanceimportanceimportanceimportance of follow-up and that prepare professionals to incorporate appropriate surveillance procedures in daily practice.

Primary Care Physicians’ Knowledge, Attitudes, and Practices Related to Newborn Hearing Screening. Primary Care Physicians’ Knowledge, Attitudes, and Practices Related to Newborn Hearing Screening. Primary Care Physicians’ Knowledge, Attitudes, and Practices Related to Newborn Hearing Screening. Primary Care Physicians’ Knowledge, Attitudes, and Practices Related to Newborn Hearing Screening. Mary Pat Moeller, Karl R. White and Lenore Shisler, Pediatrics 2006;118;1357-1370, DOI: 10.1542/peds.2006-1008

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Using a methodology to improve care

What are we trying to accomplish?

How will we know a change is an improvement?

What change can we make that will result in an improvement?

Act Plan

Study Do

Act Plan

Study Do

From: Associates in Process Improvement

Aim

Measures

Ideas

Do� Carry out the plan

� Document problems

and unexpected

observations

� Begin analysis of

� the data

Study

Act

� What changes are

to be made?

� Next cycle?

� Questions and

predictions (why)

� Plan to carry out the

cycle (who, what,

where, when)

� Plan for data

collection

Plan

� Complete the analysis of

the data

� Compare data to

predictions

� Summarize what

was learned

• Change/IdeaChange/IdeaChange/IdeaChange/Idea –Ideas for EHDI Toolkit for Primary Care Providers (PCPs)

• PurposePurposePurposePurpose - Obtain feedback on contents of Early Hearing Detection & Intervention (EHDI) Toolkit and determine best method to disseminate

What What What What kinds of information does the PCP need to know after kinds of information does the PCP need to know after kinds of information does the PCP need to know after kinds of information does the PCP need to know after notification that a child has missed or did not pass second notification that a child has missed or did not pass second notification that a child has missed or did not pass second notification that a child has missed or did not pass second hearing screening?hearing screening?hearing screening?hearing screening?

• PCPs might not be aware of EHDI protocols, types of hearing tests, equipment used, how they differ

• Not clear understanding of acronyms in the EHDI/NBHS world

• Where can screens/diagnostic testing be done?

• How much does it cost?

• How to explain information to families.

How How How How does PCP want to receive EHDI information?does PCP want to receive EHDI information?does PCP want to receive EHDI information?does PCP want to receive EHDI information?

• Electronic/paperless; email notifications, list serves, twitter, Facebook

• Not via lunch & learns

• Table sessions at conferences; something to take away for easy reminder

• Periodic updates of developments regarding Newborn Hearing Screening

• Likes flowcharts/ algorhythms

• Pop-ups in Electronic Medical Record

What is the PCPs opinion on contents of What is the PCPs opinion on contents of What is the PCPs opinion on contents of What is the PCPs opinion on contents of the toolkit today?the toolkit today?the toolkit today?the toolkit today?

• Information is valuable, but way too much

• Like idea of a flash drive; organization, folder structure, links

• Less is better

How How How How likely is the PCP to use the items in likely is the PCP to use the items in likely is the PCP to use the items in likely is the PCP to use the items in the toolkit?the toolkit?the toolkit?the toolkit?

• Very likely to use flash-drive

• Office Manager, RN would likely use as well, and would handle hard copies for distribution to rest of office

• Delivery of toolkit might be different by physician/clinic; face-to-face, US Mail (direct to Office Manager/RN)

• Less is more

• Timing is important (“Just in Time” materials)

• Electronic (no snail mail)

• Evidence-based, factual information

• Action-oriented resources

• Easily accessible information (Internet? Flash drives? Interactive, web-based?)

• Multi-tiered approach??? 1-Magnet; 2-Post Card; 3-Flash Drive;

• Understanding current process; If child did not pass or missed their birth screen, letter is sent a letter to families and PCP notifying them of next steps

• PCPs not aware of EHDI in general or costs associated with screening/diagnostics

• Where do PCPs go for education on the importance of early detection and intervention related to hearing loss.

• PCPs don’t always know who is responsible to do what and when. Their role and responsibility is unclear with regard to EHDI process.

• There is not one “best” method to disseminate toolkits; should use multiple methods; electronic/hard copy, list serves, etc.

• Surprised to the lukewarm response to receive continuing education over “lunch and learns”.

• Continue to talk with other PCPs to determine if this is a common mindset and will help us determine how many resources we need for our tool kits.

• Surprised by lack of knowledge on EHDI process and protocols; even with increased communication since 2006

• Are physicians being overwhelmed or inundated with multiple areas regarding children and youth with special health care needs (CYSHCN).

• Use our state system to identify PCPs with children who miss or did not pass outpatient hearing screen and visit with them about the toolkit

• Continue to develop file structure for flash drive; links, develop Iowa EHDI ‘look/feel”

• Ensure MAC/PC/iPad compatibility

• Publicize CDC ‘widget’, Text4baby, and other electronic resources

• Determine how to package ‘hard copies’ of toolkit

• How will we determine/measure the effectiveness of the toolkit?

• What will be our pilot area for distribution?

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Finished ProductFinished ProductFinished ProductFinished Product

How to determine who to send toolkit to?How to determine who to send toolkit to?How to determine who to send toolkit to?How to determine who to send toolkit to?

• Primary Care Providers (PCPs)Primary Care Providers (PCPs)Primary Care Providers (PCPs)Primary Care Providers (PCPs)

o Data said; 605 PCPs would cover 77% of physicians that see the

most kids

• 605 PCPs = 112 physical addresses, sent to Office/Nurse Manager

• Also identified 50 PCPs who didn’t see many kids (rural providers)

• ENTENTENTENT

o Sent to 100% ENTs identified as seeing children in our database

• 81 Birthing Hospitals81 Birthing Hospitals81 Birthing Hospitals81 Birthing Hospitals

o Including Prenatal class instructors

Separate Separate Separate Separate lettersletterslettersletters for each Type of mailing:for each Type of mailing:for each Type of mailing:for each Type of mailing:

• To PCPs from AAP Chapter Champion

• To PCPs from Parent (GBYS Program Coordinator)

• To ENTs

• To Hospitals (Loss & Found Video, other recommended followup info, not full kit)

o Prenatal Class

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How do we know we did a good job?How do we know we did a good job?How do we know we did a good job?How do we know we did a good job?

• Feedback: 23 Question Survey (n=9), Phone call (Redcap n=18)

o 3 Physicians

o 3 Nurses

o 2 Office Admin

o 1 Audiologist

• 99% indicated they opened it and looked trough it!!

• Did the toolkit strengthen your understanding of EHDI?

o 33%/3 said Yes, a great deal

o 56%/5 said Yes, somewhat

o 11%/1 said no, not at all

• How much information did this Toolkit provide you with that will be useful to the monitoring of hearing healthcare?

o 33%/3 said A great deal of useful info

o 67%/6 said Some useful info

o 0 said no useful information

• Will you watch the Loss & Found Video?

o 46%/5 said already watched or planned to watch

o 44%/4 said they probably will not watch it

o 100% who watched it said it was useful

11.1%11.1%11.1%11.1%

33.3%33.3%33.3%33.3%

33.3%33.3%33.3%33.3%

22.2%22.2%22.2%22.2%

FLASH drive FOLDER: Family FLASH drive FOLDER: Family FLASH drive FOLDER: Family FLASH drive FOLDER: Family Support/Guide By Your SideSupport/Guide By Your SideSupport/Guide By Your SideSupport/Guide By Your Side

Looked through it

Plan to look throughit

Will look through itwhen I need to

Probably won't lookthrough it

22.2%22.2%22.2%22.2%

22.2%22.2%22.2%22.2%33.3%33.3%33.3%33.3%

22.2%22.2%22.2%22.2%

FLASH drive FOLDER: Hearing FLASH drive FOLDER: Hearing FLASH drive FOLDER: Hearing FLASH drive FOLDER: Hearing Screening, Diagnosis and followScreening, Diagnosis and followScreening, Diagnosis and followScreening, Diagnosis and follow----upupupup

Looked through it

Plan to look throughit

Will look through itwhen I need to

Probably won't lookthrough it

0.0%0.0%0.0%0.0%

55.6%55.6%55.6%55.6%33.3%33.3%33.3%33.3%

11.1%11.1%11.1%11.1%

Lanyard with EHDI phone numberLanyard with EHDI phone numberLanyard with EHDI phone numberLanyard with EHDI phone number

Will use as a lanyard

Will hang as a referencefor the EHDI phonenumber

Will not use

Will use another way

Other contents:Other contents:Other contents:Other contents:

• CDC Poster: 1CDC Poster: 1CDC Poster: 1CDC Poster: 1----3333----6 Just in Time 6 Just in Time 6 Just in Time 6 Just in Time – 33% said will/may post it

• NCHAM PosterNCHAM PosterNCHAM PosterNCHAM Poster: We have ears so we can hear – 67% said they will/may post it

• Iowa Hands & Voices, GBYS Brochure Iowa Hands & Voices, GBYS Brochure Iowa Hands & Voices, GBYS Brochure Iowa Hands & Voices, GBYS Brochure – 100% said it was very/somewhat useful

o 32% indicated they were not familiar with GBYS

• EI/Early ACCESS brochure EI/Early ACCESS brochure EI/Early ACCESS brochure EI/Early ACCESS brochure – 89% said it was very/somewhat useful

• AAP Screening, Diagnosis, Intervention Guidelines AAP Screening, Diagnosis, Intervention Guidelines AAP Screening, Diagnosis, Intervention Guidelines AAP Screening, Diagnosis, Intervention Guidelines – 100% said it was very/somewhat useful

Other contents:Other contents:Other contents:Other contents:

• How do you want to be informed of changes in best practice or evidence-based practices related to hearing loss?

US Mail 66.7% 6

Iowa EHDI Website 33.3% 3

Email - Please provide 33.3% 3

Webinars 11.1% 1

Social Media; Twitter, Facebook,

Pinterest11.1% 1

Association Newsletters (AAP, IAAFR,

IANP)0.0% 0

In-person professional conferences 0.0% 0

I get my information from other

professional publications0.0% 0

1. Time consuming to gather (order/receive) all documents to place into the toolkit

2. PCP Office Manager is not the best person to send the info too, should have sent to Nurse/Nurse Manager

3. Prediction was it would take a long time to copy files to flash drive in; fact that was a quick/easy process

4. Too many different recipients creates complexity so use same contents for everyone.

5. Offering different types of media (hard copy, personal letters, electronic files) was well received.

6. The lanyard while the most costly, was the most liked

• Started with a problem to solve

• Used methodology to work through it, document it

• Used small tests of change (PDSAs)

• Made some adjustments

• Tested again

• Created toolkit based on feedback

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Tammy O’HollearnTammy O’HollearnTammy O’HollearnTammy O’Hollearn• Iowa EHDI Coordinator

• Bureau of Family Health, Iowa Department of Public Health

• Tammy.OHollearn@idph.iowa.gov

Vicki HuntingVicki HuntingVicki HuntingVicki Hunting• Quality & Operational Improvement Engineer

• Center for Child Health Improvement & Innovation (CCHII), University of Iowa

• Vicki-hunting@uiowa.edu