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Clinicians and researchers often tout the newest breakthrough or latest successful intervention. Sharing wins, however, is often done at the expense of sharing obstacles, failures, and subsequent adjustments, which are the cornerstone of quality improvement (QI).13 Here, we share 3 key lessons from 2 hospital-based QI initiatives—the Ohio Timely Recognition of Abuse Injuries (TRAIN) Collaborative and the University of Pittsburgh Medical Center (UPMC) Child Abuse Initiative (UPMC-CAI). Both focus on early identification, proper evaluation, and accurate reporting of child maltreatment. These are important clinical issues because many children who die or nearly die from maltreatment had been evaluated previously by a medical professional who did not recognize abuse and/or did not report it to Child Protective Services.

The TRAIN Collaborative consists of 6 children’s hospitals in Ohio. Modeled after the Institute for Healthcare Improvement’s (IHI) Breakthrough Series Collaborative, TRAIN convened an expert panel and conducted an iterative series of learning sessions and rapid cycles of change. The collaborative focused on improving the health care provider’s recognition of, and response to, potentially abusive injuries in infants 6 months of age and younger.

The UPMC-CAI was a collaboration between UPMC Children’s Hospital of Pittsburgh (CHP) and 13 general emergency departments (EDs) in the UPMC hospital system. Key to this initiative was a child abuse clinical decision support system consisting of a universal child abuse screen4 and triggers developed based on natural language processing and orders placed in the electronic health record (EHR), a pop-up alert for providers, a physical abuse order set, and a child abuse reporting form to assist providers in documenting necessary information for Child Protective Services.

Both initiatives showed success. The TRAIN Collaborative reduced recurrent injury by nearly 75%.5 The UPMC-CAI demonstrated a 4-fold increase in identification of potentially abusive injuries in infants and toddlers.6 Although both experienced success, both also identified several setbacks related to (1) staff turnover; (2) unanticipated differences between academic and community hospitals; and (3) failure to invest early enough or robustly enough in data collection.


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