Check-Ups Made Simple:
Implementation of a Pediatric
Well-Child Visit Checklist
Beth Groff, MD
St. Anthony North Family Medicine
Residency
Westminster, CO
Objectives
• Identifying need for change in Pediatric
Well-Child visits
• Our experience with a multidisciplinary
Pediatric Care CQI team
• Implementation of Checklist
• Discussion of results
Family Physician Scope of Practice and
Care of Children
ABFM President Warren Newton
JABFM, Nov/Dec 2011, Commentary
•
•
“….It seems clear from our demographic data that the scope of
practice for most family physicians is narrowing significantly. Many
family physicians report spending no time on preoperative or postoperative
care (80% to 90%) or maternity care (85%). This is not surprising. What is
surprising, however, is the number of family physicians who report no time
spent on office surgery (almost 60%), mental health (>55%), or care of
children (>25%). Moreover, our data suggest that our scope of practice
seems to be narrowing rapidly…
… there has been an almost seven percent drop of family physicians
who report any time spent in the care of children over the last four
years. To be clear: large majorities of family physicians continue to take
care of children, especially in underserved areas and for adolescents... but
a seven percent drop over four years represents approximately 5
thousand fewer family physicians reporting any time seeing children.”
Kid-Friendly Family Medicine
• Physician comfort and skill
• Support staff comfort and skill
• Patient comfort and confidence
Are residents receiving enough training in
pediatric care to successfully include it in
their future practices?
Focus on the Well-Child Check
at St. Anthony North FM
Issues Identified
– Lack of provider knowledge of up-to-date
screening recommendations
– Frustration with patient flow given multiple
screenings and tasks to be accomplished in a
20-minute patient visit
Pediatric CQI Team
• Multidisciplinary team of faculty, residents,
front office, nurse/MA staff
• Goal #1: Creation of a Pediatric WellChild Visit Checklist
– Easy-to-read reference for both providers and
staff
– Improve Quality of Care
– Improve Efficiency of Visits
The Checklist
• Created and implemented by the entire team
• Clinical team members each worked on a
selected age
• Faculty member helped with screening
guidelines
• Team leader compiled recommendations into
chart format
• Posted at nurses stations, preceptor room,
emailed to all providers
St. Anthony North Family Medicine Clinic
Well Child Visits Provider Checklist (revised 8/24/12)
Age
Birth
Measurements/Screenings
o Weight/length/head
circumference
o New born genetic screen
Immunizations
o Hepatitis B
Miscellaneous
o
o
o
Don’t heat bottles in microwave
Crib slats should be < width of can of soda
Temp should be taken rectally or under the arm – not in the mouth
until age 4.
Know CPR/1st aid
Rear facing car seat in back seat
Never leave baby alone in bath, car, high places, with sibling or pet
Consider vit D supplementation if exclusively breastfed (400IU/day)
Back to Sleep
See birth recommendations
o Weight/length/head
circumference
o Weight/length/head
circumference
o New born genetic screen
o Weight/length/head
circumference
o ASQ
o
o
o
o
o
o
o
o
o
See birth recommendations
o Hepatitis B
o Pentacel (Diphtheria,
Tetanus, Pertussis, Polio,
Hib)
o Rotavirus (oral)
o Prevnar (Pneumococcal)
o
o
o
o
o
o
See birth recommendations
No solids including cereal until about 6 mo
Clean baby’s gums with a clean, wet cloth
Do not put bottle nipples or pacifiers in sweetened liquids
No honey or cow’s milk until 1 year of age
Family structure, parents going back to work
4 Months
o Weight/length/head
circumference
o ASQ
o Pentacel
o Rotavirus
o Prevnar
6 Months
o Weight/length/head
circumference
o ASQ
o Reach Out and Read book
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Sleeping schedule
No bottle in bed
Should gain about 20gm/day
No baby walkers
Consider vit D supplementation if exclusively breastfed (400IU/day)
Start Fe fortified cereal/solids: 3 meals/day +breast milk or formula
One new food q3-5 days looking for allergies
Start using sippy cups
Sits unassisted
Bedtime routine
Assess fluoride intake
2-5 Days
2 Weeks
2 Months
Hepatitis B
Pentacel
Rotavirus
Prevnar
Flu shot if needed (if 1st
time need another in 4
weeks)
St. Anthony North Family Medicine Clinic
o Weight/length/head
circumference
o Cavity Free at 3
o ASQ
o Reach Out and Read book
o Weight/length/head
circumference
o Anemia screen- H/H
o Lead screen
o ASQ
o Reach Out and Read book
o Flu shot if needed (if 1st
time need another in 4
weeks)
15 Months
o Weight/length/head
circumference
o ASQ
o Reach Out and Read book
o
o
o
o
18 Months
o Weight/length/head
circumference
o MCHAT (Autism Screening)
o Cavity Free at 3
o ASQ
o Reach Out and Read book
o Weight/length/head
circumference
o MCHAT (Autism Screening)- if
not done at last visit
o Repeat lead screen if MCD
o Cavity Free at 3
o ASQ
o Healthy Lifestyle Screening
o Reach Out and Read book
o Hepatitis A
o Flu shot if needed (if 1st
time need another in 4
weeks)
9 Months
12 Months
2 Years
o Prevnar
o Hepatitis A
o Flu shot if needed (if 1st
time need another in 4
weeks)
Pentacel
MMR
Varicella
Flu shot if needed (if 1st
time need another in 4
weeks)
o Flu shot if needed (if 1st
time need another in 4
weeks)
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Continue BM or formula until 1yr
Introduce cup
Limit juice to < 4oz/day
Safety-proof home
Clean gums w/clean, wet cloth
Wean to cup, serve cow’s milk (low fat ok for high obesity risk kids)
Feed self w/spoon and finger foods
Schedule dental visit, brush teeth
Discipline- redirection, reinforce good behavior*never hit or spank
Safety-proof home
Car seat- continue rear facing if possible but can be front facing if
>1yr and >20lbs.
Continue rear facing car seat if possible
Safety- proof home
Can continue whole milk until age 2 (lowfat ok if not underweight)
Brush teeth/schedule dental visit
Discipline- redirection, reinforce good behavior* never hit or spank
Vocab: 6-20 words
Family dinner time
See 15 month section
Must be in a 5 point harness car seat in the backseat until
40lbs/4yrs.
Low fat/skim milk if not already switched
Healthy eating, let toddler self feed, avoid choking hazards- nuts,
popcorn, whole grapes, etc.
Discipline- redirection, time out (1 min per yr of age)
Safety-proof home, water safety, helmets
Limit screen time
Toilet training- ok to wait
Dental visit/brushing teeth
3 Years
4-5 Years
o Weight, height, BP
o Vision Screening
o Cavity Free at 3
o MCHAT (Autism Screening)
o ASQ
o Healthy Lifestyle Screening
o Reach Out and Read book
o Flu shot if needed (if 1st
time need another in 4
weeks)
o Weight, height, BP
o Vision Screening
o ASQ
o Healthy Lifestyle Screening
o Reach Out and Read book
o
o
o
o
o
6-10 Years
o Weight, height, BP
o Vision Screening
o Healthy Lifestyle Screening
11-18 Years
o Weight, height, BP
o Vision Screening
o Screen for Drug/Alcohol/
Tobacco abuse
o Screen for sexual activity/STI
o Healthy Lifestyle Screening
Dtap
IPV
MMR
Varicella
(Supplemental Prevnar if
needed)
o Flu shot if needed (if 1st
time need another in 4
weeks)
o Flu shot if needed (if 1st
time need another in 4
weeks if <9 yrs)
o Menactra (Meningococcal)
(age 11-12 with booster at
age 16) or single dose if
age 13-18.
o Tdap (age 11-12)
o Gardasil (HPV) (1st dose
age 11-12- minimum age
is 9, 2nd dose 1-2 months
after 1st dose, 3rd dose 6
months after 1st dose)
o Flu shot if needed
o
o
o
o
o
o
Must be in a 5 point harness car seat in the backseat until
40lbs/4yrs.
Teach name/phone number
Help with simple chores
Toilet training
3-4 word sentences
Dental visit/brushing teeth
Teach about strangers
Must be in a 5 point harness car seat in the backseat until
40lbs/4yrs.
Knows name/phone number
Helps with simple chores
Dental visit/brushing teeth
Discuss good touch/bad touch
Preschool/head start
o
o
o
o
o
o
o
o
o
o
o
o
Nutrition and activity- avoid high salt, sugar foods
Vocabulary > 2,000 words
Safety & injury prevention
Sunscreen
Encourage regular bed time at 8-9pm
Age 4-8, >40lbs- back seat in booster seat/car seat
Hygiene- bathing, brushing, flossing
Limit screen time
Encourage physical activity
Self-esteem
Sex education
injury prevention- safety equipment for sports
o
o
o
o
o
o
o
Growth and Development Cards
CAVITY FREE AT THREE – SANFM
(“Pediatric Oral Health Screen” for Medicaid patients)
Can do at each well-child visit from infancy until 4th birthday
Recommended routinely at 9m, 18m, 2y and 3y
Risk Assessment:
Y
Y
Y
Y
Y
N
N
N
N
N
(See full risk assessment in LSS)
Caregiver or sibling dental caries/disease
Lacks dental home
White, black or brown dental spots
High risk dietary and feeding habits
Brushing teeth less than twice daily with fluoride toothpaste
If all answers are NO child is low risk.
Any Y answer, child is high risk.
LOW RISK
HIGH RISK
-Flouride Varnish today, reapply up to every 6 months
(if not provided by Dental Home)
-Oral Health Handout (Smiles for Life)
-Refer to Dental Home by 12 months
-Flouride Varnish today, even if caries
present, reapply up to every 3 months
(if not provided by Dental Home)
- Oral Health Handout (Smiles for Life)
-Refer to Dental Home ASAP
Advise ALL PATIENTS:
<2 yrs – Brush with rice-sized smear of fluoride toothpaste 2X/day
2 -5 yrs brush with pea-sized amt fluoride toothpaste 2X/day
Assess fluoride intake starting at 6 months, rx if indicated
See a dental provider every 6 months
Review other age-specific anticipatory guidance -(see Oral Health Handout)
BILLING/CODING:
ICD-9 Codes : Obvious White Spots V72.2
Obvious Decay 521.02, 521.03
Resident/Faculty Survey Monkey
• 1) How confident are you that you are providing parents
with the most current, complete, and useful anticipatory
guidance at each well child visit?
• 2) How confident are you that you are addressing
everything that should be addressed at each well child
visit, according to current recommendations and
guidelines?
• 3) How efficient would you say well child checks are in
our clinic right now?
Nurse/MA Paper Survey
• 1) How satisfied are you with the amount of time you and
your provider have to address all issues at well child
check visits?
• 2) Do you feel that parents leave well child check visits
feeling educated and confident about their child’s
development and well being?
• 3) Do you feel confident that our providers are up to date
on latest recommendations for pediatric well care?
Provider Results Pre-Checklist
4/2012
60
50
40
not confident
30
slightly confident
somewhat confident
20
confident
10
very confident
0
Anticipatory
Guidance
2.89
Current
Guidelines
2.44
Efficiency
2.70
Provider Results Post-Checklist
10/2012
70
60
50
not confident
40
slightly confident
30
somewhat confident
20
confident
10
very confident
0
Anticipatory
Guidance
3.15
Current
Guidelines
2.67
Efficiency
2.89
Provider Results
4
3
Pre-Checklist
2
Post-Checklist 2012
1
Post-Checklist 2013
0
Anticipatory
Guidance
Current
Guidelines
Efficiency
Provider Data
3.5
3
2.5
2
Pre-checklist
1.5
Post-checklist 2012
1
Post-checklist 2013
0.5
0
Anticipatory
Guidance
Current Guidelines
Efficiency
Nurse/MA survey results
5
4
3
Pre-Checklist
2
Post Checklist 2012
1
Post Checklist 2013
0
Time for
visit
Parent
education
Providers
up-to-date
Nurse/MA survey results
4.5
4
3.5
3
2.5
Pre-Checklist
2
Post Checklist 2012
1.5
Post Checklist 2013
1
0.5
0
Time for visit
Parent education Providers up-todate
Factors Affecting Results
• Turnover in residents and staff
• Increasing confidence as academic year
progresses regardless of intervention
• Significant clinic changes may have had a
negative impact
– Wave scheduling implemented in fall 2012
• Other CQI/clinic improvements may
impact efficiency
Implications and Opportunities
• Checklist may improve perception of
quality and efficient care
– Unclear if data actually bear this out
• EMR-embedded checklist?
– Prompts for orders, anticipatory guidance
– More cumbersome to update/change
– Limits preparation prior to visit
Wrapping up….
• Remember, kidfriendly care is fun!
• Your experiences?
What is working or
not working with wellchild checks for you?