Quality Improvement. South Carolina's commitment to improving pediatric health care is apparent in its Quality Through Technology and Innovation in Pediatrics (QTIP) program housed at the South Carolina Department of Health and Human Services. QTIP was started in 2010 under a Children's Health Insurance Program Reauthorization Act (CHIPRA) federal grant. Currently, 30 practices throughout the state participate in the QTIP program. From 2010 to 2015, QTIP focused on improving CHIPRA's core indicators among pediatric practices. Currently, QTIP is working on improving the implementation of Bright Futures recommendations including developmental screening, well-child visit completion rates, immunization completions, preventive oral health services, obesity prevention, maternal depression screening, autism spectrum disorder screening, family-centered care, and social determinants of health. In addition to aligning with Bright Futures measures, QTIP's initiatives also support the efforts of South Carolina's Medicaid provider—Healthy Connections—to improve pediatric well-child visits.
The QTIP program encourages pediatric practices to use the quality improvement (QI) technique to self-measure the above-mentioned indicators. QTIP medical director, Francis Rushton, MD, believes that the "quality improvement techniques, as outlined in the Model for Improvement using PDSA [plan, do, study, act] cycles, is a great way to measure where you stand against national standards and also to introduce some new procedures and processes into your practice." A recent QTIP quality report highlights QTIP's significant improvements among several different measures, with a case study on measurements at the 9- and 24-month well-child visits in relation to Bright Futures.
QTIP provides practices with technical assistance through phone calls and site visits. During monthly phone calls, practices can discuss different topics of interest, including the Bright Futures recommendations. During site visits, which occur twice a year, the QTIP team reviews the practice's Bright Futures data and how the practice compares to similar practices throughout the state.
Oral Health. Improving pediatric oral health has been a priority in South Carolina. The QTIP program has participated in these efforts by encouraging practices to perform oral health exams and oral risk assessments and to apply fluoride varnish for at-risk children. In the past 5 years, the program has seen an approximately 7-fold increase in fluoride application among QTIP practices. QTIP also provides trainings to certify clinicians as oral practitioners so that they can perform fluoride varnish applications. Fluoride varnish application training courses are scarce in South Carolina, thus QTIP facilitates the process and has trained more than 300 clinicians. In addition, the program recommends that practices document in medical records whether fluoride exposure was discussed with parents, the child's dental home, and whether the child was referred to a dentist. The program's work in oral health has shaped statewide policies by extending the age that Healthy Connections will pay for fluoride varnishing procedures.
Learning Collaboratives: The QTIP program holds annual learning collaboratives in January and July. Between 80 and 100 participants attend each session. Each pediatric practice sends a lead practitioner, a lead nurse, and an office administrator as part of its QI team. The collaboratives emphasize basic models for QI techniques and provide the opportunity for practices to learn from renowned speakers and from one another. The sessions are led by the QTIP medical director, project director, a behavioral health specialist, and a QI coach. Recent invited presenters included representatives from Georgia, New Jersey, and Virginia. The QTIP program has a strong partnership with the South Carolina Chapter of the American Academy of Pediatrics (AAP). The chapter provides academic guidance, and the learning collaboratives are linked to chapter meetings to increase attendance. The project director, Lynn Martin, explains that an important component of the learning collaboratives is allowing practices to share successes and failures so that they can learn from one another.
Family Engagement: The QTIP program strives to involve families in the QI process by encouraging practices to engage parents. Involving parents in the QI process can be beneficial for practices because it increases quality, safety, patient satisfaction, and adherence to care, while saving costs. During the program's July 2016 learning collaborative, 2 sessions were dedicated to family engagement and ways in which different practices and organizations have involved families in their clinics' improvement processes. Several practices highlighted the challenges involved with parental engagement such as nonparticipation, lack of responses on surveys and online platforms, difficulty using virtual/Skype meetings with a Medicaid population, and inability to assign parents to lead initiatives and offer potential solutions to these challenges.
QTIP has also partnered with the local organization Family Connection of South Carolina to provide practices with advice and evidence-based materials about efficient and effective ways to involve parents. Recommendations from Family Connections included identifying interested parents and including them in targeted improvement activities, creating a Patient Advisory Committee (PAC) and being willing to proactively make changes based on the PAC's suggestions, using e-mail or phone consultations to receive patients' feedback if they fail to attend meetings, and creating an evaluation form for parents to complete after a visit.
Promotion: The QTIP program provides participating practices with copies of the Bright Futures/AAP Periodicity Schedule. During the learning collaborative meetings, the program has invited national AAP representatives to speak about the Bright Futures Guidelines, specifically what the Guidelines recommend during the 9- and 24-month well-child visits.