Child Abuse and Neglect Risk Assessment: Quality Improvement in a Primary Care Setting

OBJECTIVES: Practicing Safety is an American Academy of Pediatrics toolkit to help practices address child abuse and neglect (CAN) risk by increasing screening and providing resources. The objectives in an urban practice serving lowincome children were to 1) standardize CAN risk assessment and developmental screening, and 2) improve resource provision. METHODS: A quality improvement initiative to standardize CAN risk assessment, using materials adapted from Practicing Safety, was conducted through the use of SmartTools in an electronic health record. The Edinburgh Postnatal Depression Scale and Parents Evaluation of Developmental Status were used to assess maternal depression and child development, respectively. Charts were reviewed in waves pre-, immediate post-, and early post-implementation (waves 1 to 3); monthly for 6 months (waves 4 to 9); and quarterly for 12 months (waves 10 to 13) to assess screening and resource provision for 6 domains: infant crying, maternal depression, development, discipline, temper tantrums, and toilet training. RESULTS: A total of 581 charts were reviewed (92, 95, and 94 for waves 1 to 3, respectively; 30 each for waves 4 to 13). Screening for infant crying, maternal depression, development, and discipline rose from 0% pre-implementation to over 50% post-implementation. Screening for temper tantrums and toilet training rose from 6% to 72% and from 36% to 82%, respectively. For all measures, resource provision improved over time, and all improvements were maintained for 1.5 years post-implementation. CONCLUSIONS: Incorporating an adapted version of Practicing Safety into an electronic health record is a practical and effective approach to improving CAN risk assessment and resource provision. This quality improvement initiative is an example of a practice-wide improvement that resulted in clinical practice change.