Pediatric Rheumatology Care and Outcomes
Improvement Network
(PR-COIN)
APPLICATION
PACKET
JIA Collaborative and Lupus Pilot Collaborative
We are grateful for the support for this project from:
The Arthritis Foundation
Anonymous donors
American College of Rheumatology
The Cincinnati Children’s Hospital Research Foundation
The Pediatric Center for Education and Research in Therapeutics at Cincinnati Children’s Hospital
Medical Center, the Agency for Healthcare Research and Quality
Version May 21, 2014
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APPLICATION CHECKLIST FOR TEAMS
Thank you for your interest in the Pediatric Rheumatology Care and Outcomes Improvement Network (PRCOIN). This application packet serves the purpose of enrollment in both the PR-COIN juvenile idiopathic
arthritis (JIA) collaborative and the systemic lupus erythematosus (“Lupus”) pilot collaborative. Please make
sure to return the application to the PR-COIN Coordinating Center once this application is fully completed with
signatures (pr-coin@cchmc.org).
PR-COIN JIA Collaborative:
PR-COIN-JIA is a “Learning Network” of rheumatology care teams that conduct quality improvement
projects to help deliver better clinical care. PR-COIN-JIA works as a network to move research findings on
new or better treatments more quickly to everyday use. The PR-COIN-JIA Steering Committee is directing
this project with quality improvement support and project coordination from the James M. Anderson
Center for Health Systems Excellence at Cincinnati Children's Hospital Medical Center (CCHMC) in
Cincinnati, Ohio, USA.
This application packet is to guide you in understanding our network and to facilitate preliminary activities
to complete to become an active PR-COIN –JIA team.
 Please review this packet and the accompanying PR-COIN-JIA Charter that describes our Learning
Network with respect to the JIA Collaborative, goals, benefits, and requirements.

Submit the following to join PR-COINs JIA initiative:
 Intent to Apply Form (page 5)
 Site Application Form (page 6) within one month of submitting your intent including:
 Senior Leader Agreement
 Core Site Team Information
You will be notified via email of your application status.
Upon approval and admittance to PR-COIN JIA, PR-COIN representatives will support your team in
completing these remaining required activities:
Submission of human subjects research protection regulatory documents (hereafter referred to
as IRB) as required by your local hospital or clinic e.g. Institutional Review Board. To support your
IRB application, new teams will receive PR-COINs IRB protocol plus recommended verbiage for
parent consent and patient assent forms.
Submission of two data sharing legal agreements. PR-COIN partnered with the American College
of Rheumatology (ACR) to house team data in their Rheumatology Clinical Registry (RCR) for the
JIA Collaborative:
1) The “Registry Participation Agreement” with ACR must be completed so that your team may
submit data.
2) A second legal form, the “Limited Data Use Agreement” with CCHMC, permits the transfer of
your team data from the registry (ACR RCR) to the PR-COIN Coordinating Center for analysis.
Data collection cannot begin until both legal agreements and your IRBs approval are finalized
so start this process early!
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PR-COIN Lupus Pilot Collaborative:
The Lupus Pilot Collaborative is a new effort to replicate the PR-COIN JIA Collaborative Learning Network model
of care for the lupus condition. Member teams will, among other activities, prioritize measures of quality care,
identify requisite data collection variables, pilot data collection processes, evaluate pilot data and recommend
a Key Driver Diagram outlining Aims, Drivers and Interventions expected to improve the outcomes of patients
with lupus. Drs. Rina Mina and Hermine Brunner are initiating this effort with guidance of the PR-COIN
Coordinating Center at the Anderson Center for Systems Excellence at Cincinnati Children’s Hospital Medical
Center.

Submit the following to join PR-COIN’s Lupus Pilot:
 Intent to Apply Form (page 5)
 Site Application Form (page 6) within one month of submitting your intent including:
 Senior Leader Agreement
 Core Site Team Information
You will be notified via email of your application status.
Participation Fee:
Please be advised PR-COIN’s annual membership fee is $12,500 covering July – June for participation in
both the PR-COIN JIA Collaborative and the PR-COIN Lupus Pilot Collaborative. The fee is $10,000 a year
covering July – June for participation in one of the collaborative networks; the JIA Collaborative, or the
Lupus Pilot. The fee is pro-rated based upon date of application.
Please direct questions to pr-coin@cchmc.org
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PR-COIN Leadership and Support
PR-COIN JIA Collaborative Steering Committee Members
Esi Morgan DeWitt, MD, MSCE, Cincinnati Children’s Hospital Medical Center, Chair
Stacy Ardoin, MD, MSc, Nationwide Children’s Hospital
C. April Bingham, MD, Penn State Milton S Hershey Children's Hospital
Beth Gottlieb, MD, MSc, Steven & Alexandra Cohen Children’s Medical Center of New York
Ronald Laxer, MDCM, FRCPC, Hospital for Sick Children, Toronto, Canada
Laura Noonan, MD Levine Children’s Hospital Charlotte NC
PR-COIN JIA Collaborative Coordinating Center and Support Team
Based at the James M. Anderson Center for Health Systems Excellence at Cincinnati Children’s Hospital
Medical Center
Peter Margolis, MD, PhD Improvement Advisor
Esi Morgan DeWitt, MD, MSCE Quality Improvement Leader
Nancy Griffin, BSN, MPA, CPHQ Quality Improvement Consultant
Anne Paul, MBA, MA Project Manager
Jesse Pratt, MS Data Analyst
Jason Stock, BS Data Manager
Lindsey Bergheger, MHA Project Specialist
Lupus Pilot Collaborative Leadership:
Hermine Brunner, MD, MSc, MBA
Hermine.Brunner@cchmc.org
Rina Mina, MD, MS
Rina.mina@cchmc.org
PR-COIN Contact Information
pr-coin@cchmc.org
www.pr-coin.org
Fax 513-636-0171 Attention: PR-COIN
We are glad you are joining us!
Please contact us anytime at
pr-coin@cchmc.org
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Pediatric Rheumatology
Care and Outcomes Improvement Network
INTENT TO APPLY
Please complete this brief Intent to Apply Form and email to pr-coin@cchmc.org
or fax to 513-636-0171 Attn PR-COIN
Our site is planning to participate in the PR-COIN Collaborative:
(Check all that apply)


We will participate in the PR-COIN JIA Collaborative
We will participate in the PR-COIN Lupus Pilot
Organization Name: ______________________________________________ Date: __________________
Key Contact Name: _______________________________________________________________________
Title:___________________________________________________________________________________
Address:________________________________________________________________________________
City: _________________________________ State: __________________ Zip/Postal Code: __________
Phone: __________________________________ Fax: __________________________________________
Email: _________________________________________________________________________________
By submitting this intent to apply, we agree to submit the full application within one month.
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Pediatric Rheumatology
Care and Outcomes Improvement Network
SITE APPLICATION
Interested sites should please complete the information below and return your completed application
to pr-coin@cchmc.org or via fax to
513-636-0171, Attention: PR-COIN
Our site is applying to participate in the PR-COIN Collaborative:

We will participate in the PR-COIN JIA Collaborative

We will participate in the PR-COIN Lupus Pilot
(Check all that apply)
Site Name: ____________________________________________________________________
Site Address: __________________________________________________________________
Name of person completing this questionnaire: _____________________________________
Title: _________________________________________________________________________
Email: ________________________________________________________________________
Phone number: _____________________________
1. Briefly describe the aspects of your hospital/clinic/organization that relate to care of the child with
juvenile idiopathic arthritis or lupus (clinic size, providers (doctors, physician assistant, nurse
practitioners, number of nurses) hospital based or outreach clinics, location (specify; urban, rural,
suburban), social worker in clinic.
2. Please estimate the number of children your site sees each year with newly diagnosed
JIA:
SLE:
3. Please estimate the number of children that currently receive care at your site (patient has had an
appointment within past year):
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JIA:
SLE:
4. At routine clinic appointments, are any of the following data collected:
a. Pain Scores
□ Yes □ No
□
□
b. HRQOL (health related quality of life) Measure
Yes
No
(Indicate which one)________________________________________
□
□
c. Physical Function Measure
Yes
No
(Indicate which one)________________________________________
□ Yes □ No
□ Yes □ No
d. Physician Global Assessment of Disease Activity
e. Parent Assessment of Overall Well-being
5. Does your pediatric rheumatology team utilize an electronic health record (EHR)? Please describe
(name/vendor, how long have you been using this EHR).
a.
If not currently on an EHR, any plans to adopt an EHR in future? Vendor selected?
b.
If currently on an EHR, any plans to switch vendors?
6. Does your pediatric rheumatology team utilize a physical therapist and/or occupational therapist as
part of your outpatient clinical team on a regular basis? Please describe resources available to you for
rehabilitation support.
7. Briefly describe any experience that you or others have in initiating successful improvement activities,
participating in a learning network or any experience with measurement of quality outcomes. In what topic
area(s)? Do you have quality improvement support within the unit structure or from the hospital? Examples of
this support would be: data collection, team facilitation, meeting documentation and planning for
improvement activities aimed at helping you accomplish your goals.
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8. Briefly describe what your organization wants to accomplish as a participant in PR-COIN:
9. Please add any additional information about your setting that may be relevant to this project.
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Site Core Team
A site core team typically consists of a physician or nurse practitioner lead, a member of the ancillary
nursing staff, administrative or clerical staff members, and others as meets your needs.
Team Member 1 – Key Contact
The Key Contact serves as a liaison to disseminate information between your team and PR-COIN and
can coordinate day-to-day activities of the project including regular practice improvement team
meetings, managing improvement responsibilities and ensuring reports and/or data are collected
and reported.
Name: ______________________________________________________________________________
Title: _______________________________________________________________________________
Direct Phone: _________________________________ Direct Fax: ____________________________
Email: ______________________________________________________________________________
Team Member 2
Name: ______________________________________________________________________________
Title: _______________________________________________________________________________
Direct Phone: _________________________________ Direct Fax: ____________________________
Email: ______________________________________________________________________________
Team Member 3
Name: ______________________________________________________________________________
Title: _______________________________________________________________________________
Direct Phone: _________________________________ Direct Fax: ____________________________
Email: ______________________________________________________________________________
Team Member 4 (optional)
Name: ______________________________________________________________________________
Title: _______________________________________________________________________________
Direct Phone: _________________________________ Direct Fax: ____________________________
Email: ______________________________________________________________________________
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SENIOR LEADER/ADMINISTRATOR AGREEMENT
The Senior Leader should be someone outside the improvement team who has
administrative oversight for the clinical area and can support the improvement team
in this endeavor, including removing barriers to improvement.
Name: ___________________________________________________________________________________
Title: ____________________________________________________________________________________
Organization: ______________________________________________________________________________
Direct Phone: _______________________________ Direct Fax: ___________________________________
Email: ___________________________________________________________________________________
Our practice wishes to apply for participation in PR-COIN, the Pediatric Rheumatology Care and
Improvement Outcomes Network. As the Senior Leader, I fully understand the project’s objectives
and expectations and pledge to support our team in their data collection and improvement work
by addressing barriers and resources necessary to achieve PR-COIN improvement goals.
Furthermore I agree that our center will remit
 The $12,500 participation fee annually to join both the JIA collaborative and Lupus pilot
 The $10,000 participation fee annually to join the JIA collaborative only
 The $10,000 participation fee to join the Lupus Pilot only
_______________________________________________________________
Senior Leader Signature
This signature page must be received with your application in order for your application to be considered.
Please fax to (513) 636-0171 Attention: PR-COIN or email to pr-coin@cchmc.org.
The Pediatric Rheumatology Care and Outcomes Improvement Network Project team looks forward
to working with you!
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