Boston Children’s Hospital Heart Center ACPC Quality Network Pilot

Boston Children’s Hospital Heart Center ACPC Quality Network Pilot Experience: Counseling for Elevated Body Mass Index Lauren Hartwell, MPH Candidate Quality Improvement Consultant, Cardiology 1

Overview Change Strategies Project Timeline Challenges Lessons Learned Ongoing Efforts 2

QNet Quality Improvement Pilot Elevated BMI Project Team Site Administrator: Susan Saleeb MD Data Collection & Analysis: Lauren Hartwell MPH(c) BMI Pilot Physician Lead: Sarah De Ferranti MD MPH BMI Pilot Team: Sarah Atwood RN Jennifer Bachman CPNP, MSN, RN Caroline Brantley MS, RD, LDN David Brown MD Steven Colan MD Lauren Danforth BSN, RN Sarah De Ferranti MD MPH Jesse Esch MD Jeremy Fox MD Kevin Friedman MD David Fulton MD Naomi Gauthier MD Skylar Griggs RD Michelle Gurvitz MD David Harrild MD, PhD Lauren Hartwell MPH(c) Mariam Irshad MPH Kathy Jenkins MD, MPH Ronald Lacro MD Jami Levine MD Laura Mansfield MD Renee Margossian MD Mary Mullen MD, PhD Jane Newburger MD, MPH Terry Saia PNP Susan Saleeb MD Tajinder Pal Singh MD

QNet Quality Improvement Pilot Strategies for Improving BMI Counseling Change Strategies 1. Analyzed available medical record system for opportunities to flag elevated BMI Existing entries in “Problem List” Electronic linking of education sheets Automatic EMR calculation and permanent storing of percentiles 2. Working on electronic red flag for elevated BMI

QNet Quality Improvement Pilot Strategies for Improving BMI Counseling Change Strategies, continued 3. Developed new BMI patient/family education sheet with insights from: Preventive cardiology group Nutritionists Nurses Parent focus group 4. Partnering with new Cardiac Rehabilitation Program

QNet Quality Improvement Pilot Strategies for Improving BMI Counseling Change Strategies, continued 5. Recruited RN support to identify eligible patients Alert physician of need for counseling Distribute counseling materials Assist in documentation of counseling – IT change

QNet Quality Improvement Pilot Strategies for Improving BMI Counseling Change Strategies, continued 6. Encouraged physicians/NPs to document counseling in multiple ways: Select from “Problem List” Use Autotext statements Enter in discussion section of letter Document referral to local or Heart Center nutritionist

QNet Quality Improvement Pilot Elevated BMI Project Timeline Jan/Feb 2017 Mar 2017 Recruited physicians, nurses, and dieticians Disseminated metric details, MOC timeline & requirements Kick-off meeting of working group Reviewed baseline data Reviewed nutrition education handouts Brainstormed changes Apr/May 2017 Recruited IT to facilitate EMR changes Developed new BMI education sheet – distributed to clinics Email to cardiologists to raise awareness Jun/Jul 2017 Refined BMI education sheet through parent focus group Developed and refined staff education Engagement through broad contact 8

QNet Quality Improvement Pilot Elevated BMI Project Timeline Aug 2017 Reviewed Q2 2017 data – initial assessment postintervention Involvement of fellows through education Targeted education to RNs, NPs, and CAs in clinic Sep 2017 Discussed best practices for weight management counseling Submitted BMI education form for hospital-wide use Seeking BMI prevalence data on CHD and other patients Oct 2017 Continuing education to nursing staff BMI screening tips distributed to nursing staff BMI education sheet approved for hospital use 9

Education Sheets for Elevated BMI Counseling

QNet Quality Improvement Pilot Counseling for Elevated BMI Challenges 1. Large department ( 70 cardiologists) – Spreading the word – Small core group involved in QI Numerous subspecialists and sub-subspecialists Maintaining interest – Change is slow - - message stagnates Email, postings ineffective Message fatigue Inboxes overburdened

QNet Quality Improvement Pilot Counseling for Elevated BMI Challenges (continued) 2. Variable Buy-In Single encounter patients Patients with active issues – recent procedure, etc. “Job of the pediatrician” Counseling is “ineffective” Easy to measure counseling, hard to measure effect Metric fatigue (meaningful use, etc.) 3. Metric may need some exclusions Trisomy 21, other syndromes Acute care issues

QNet Quality Improvement Pilot Counseling for Elevated BMI Lessons Learned 1. Sharing vetted counseling material is appreciated (true for both BMI and TOF) 2. Sharing data is powerful – Center performance over time – Comparison to national mean 3. MOC helps a lot!!!

BCH Heart Center QNet Results Counseling for Elevated BMI

QNet Quality Improvement Pilot Counseling for Elevated BMI Ongoing Efforts 1. Automated flag for elevated BMI – RED 2. Ongoing cardiology staff and fellow education – Future Cardiology Grand Rounds, Fellows clinics 3. Disseminating best practices for counseling 4. Applying metric to adult cardiac patients 5. Particular efforts to target CHD patients – Ongoing review of elevated BMI prevalence data – Integration into Cardiac Fitness Program

Thank You! 16