MCH Lead Poisoning Toolkit: Lessons on Using Data for Improvement
October 26, 2021
Lead poisoning is 100% preventable. Lead poisoning occurs when lead enters the bloodstream and builds up to toxic levels. Many different factors such as the source of exposure, length of exposure, and underlying susceptibility (e.g., child’s age, nutritional status, and genetics) affect how the body handles foreign substances.
About 3.6 million American households have children under 6 years of age and lead exposure hazards. According to the CDC, about 500,000 American children between the ages of 1 and 5 years have blood lead levels at or above the CDC blood lead reference value (the level at which CDC recommends public health actions begin). CDC currently uses a blood lead reference value of 5 micrograms per deciliter to identify children with blood lead levels that are higher than most children's levels.
This means that millions of children have a higher risk of neurological damage and are more likely to face learning difficulties, behavior and speech problems, hearing loss, and other health and developmental concerns. At its highest levels, lead exposure can even result in death.
Low-income families and racial and ethnic minority groups are more likely to live in outdated housing where these environmental hazards are more common, making lead poisoning a critical focal point for efforts seeking to improve population health and reduce health inequities.
Children ingest and absorb lead at a greater rate than adults, and are more vulnerable to its effects. Most children get lead poisoning from paint in homes built before 1978 when they breathe or swallow the dust from chipped paint on their hands and toys. Even drinking water has the potential for lead exposure due to things as lead pipes, faucets and fixtures.
The Maternal and Child Environmental Health Collaborative Improvement and Innovation Network (MCEH CoIIN), a national initiative led by the Association of Maternal and Child Health Programs (AMCHP) developed the MCH Lead Poisoning Toolkit to share innovative practices and methods. Nine state teams conducted tests of change toward the aim of improving access to systems and services that address the needs for pregnant women, infants, children, and families who might be exposed to lead. NICHQ provided quality improvement expertise and technical assistance for the MCEH CoIIN—offering state teams guidance on using data and measurement to determine where improvements have been made and areas that still require change.
Below are tips and take-aways for data collection and using data for Improvement from the three-year Collaborative Improvement and Innovation Network (CoIIN).
Examine & Analyze Population Data
At the state or local level, the primary source of blood lead surveillance data is usually the state-based Childhood Lead Poisoning Prevention Program (CLPPP) and/or the state-based Adult Blood Lead Epidemiology & Surveillance (ABLES) program. These programs are responsible for collecting, managing, and reporting data to ensure that children and adults with elevated BLLs receive appropriate follow-up and management.
At the beginning of an improvement project, it is useful to examine the population data that is available to you. Population data refers to information and data about a specific group of people.
- the number of children tested for lead poisoning
- the average blood lead level (BLL) per month
- the number of children who tested positive for lead poisoning and received a confirmatory test
Data like this guides teams in identifying focus areas that need improvement and helps them prioritize how to invest their time and effort in their improvement work. After there is a successful track record of positive changes that result in improvement for a specific focus area, the next step is to plan how to scale this area of focus into a statewide population success.
Troubleshooting data limitations is important. A state may lack the ability to drill down into its health data and may be guided by using hot spot maps that show high density of aging homes, high-risk industrial areas, and areas that are underserved by primary care. Hot spot maps are created using available data or even by using subject matter knowledge and experience of public health workers.
Use Data to Inform Your Team Aim
After examining and analyzing your population data, teams will need to create an aim statement that provides a clear and explicit summary of what your team hopes to achieve over a specific amount of time including the magnitude of change you will achieve.
Research shows teams who develop a good aim perform better. A good aim statement captures the voice of those you serve. It provides alignment of multiple stakeholders, helps keep the team focused on the tasks at hand, creates the urgency to accomplish the goal, provides a vision of what success looks like, and serves as a predictor of success.
A useful improvement aim statement includes:
- By when
- What you want to accomplish
- For whom
- How much improvement, in measurable terms, that you want to achieve
Each state in the MCEH CoIIN developed an aim statement. All states were given guidance to follow this format: By August 2020, our team will decrease exposure to lead from major sources and/or increase access to systems of care for children ages 0- < 72 months so that they:
- Decrease by 10% blood lead levels in children ages 0- <72 months.
- Increase, by 25% or more, the # of children ages 0- <72 months that receive a screening test for blood lead levels.
- Increase, by 25% or more, the # of children ages 0- <72 months with confirmed elevated blood lead levels who receive care in a medical home.
- Increase, by 25% or more, the # of providers who are following the CDC recommendations for follow-up of children ages 0- <72 months with confirmed elevated blood lead levels
Here is an example of how the Alabama CoIIN team customized the aim statement: “By August 2020, we want to reduce childhood lead poisoning prevalence by 10% through education and outreach and collaborate effectively with internal partners to provide Alabama’s lead affected children with the most up-to-date and innovative care, increasing care coordination referrals by 25%.”
After you discover your team’s aim, you can use your population data to select a population of focus.
The Louisiana state team’s aim was to improve lead screening in children ages 0-6 years by 25% within 18 months. After looking at their state-level data and consulting the driver diagram, the team chose to leverage partnerships and formed an alliance with a large Women, Infants, and Children (WIC) Center in a New Orleans suburb.
In order to make effective changes, you want to be sure you understand the system you are aiming to improve. One tool that is helpful in doing this is a driver diagram. Driver diagrams are used to conceptualize an issue and provide the theory behind any project. They help you determine the components of a system that help you move toward a goal and lead the team to ideas.
The Louisiana state team devised a plan to meet families at the WIC Center to take lead samples and talk to families about lead testing and follow-up. If this worked, the plan was to spread the changes across the state in all WIC sites.
In all types of quality improvement efforts, sustainability is a vital consideration that often goes overlooked until the project’s final stages. With the right balance of foresight and strategy, however, team leaders can plan for sustainability as a project gets underway. This lets teams seamlessly support sustainability and create quality improvement projects with truly powerful impact.
Plan-Do-Study-Act (PDSA) cycles are a tool to support improvers to test, measure and refine proposed changes quickly and effectively, making them a critical tool for quality improvement (QI) work. Ensure your PDSA cycles have a sturdy foundation by mastering the planning stage. Read more for important tips
During their tests of change, or Plan-Do-Study-Act (PDSA) cycles, the team learned how to work together with WIC to determine how and when testing will happen, by whom, and what resources were needed. They developed a detailed plan of action to test children at a high attendance time when parents received WIC vouchers. They also coordinated resources in order to promote the Lead Testing Days. The Louisiana Lead Team distributed lead poisoning prevention educational materials and National Lead Poisoning Prevention Week awareness packets to parents at the Crescent City WIC Clinic and trained families on the importance of childhood lead testing and ways to prevent childhood lead poisoning. WIC Clinic staff were trained on the importance of childhood lead testing and ways to prevent childhood lead poisoning. Lead Team staff created a spreadsheet of all training events that occurred in September and October and events that occurred during National Lead Poisoning Prevention Week.
Eventually, the Lead Team added a screening question about lead testing to the WIC intake form. This is an example of making a lasting system change.
In every stage of the quality improvement process, moving toward sustainability means keeping sight of the project’s ultimate goal.
The Louisiana Team wrote “As a result of the Louisiana Healthy Homes and Childhood Lead Poisoning Prevention Program (LHHCLPPP) participating in the MCEH CoIIN and through the targeted approaches we have used such as the PDSA Worksheet and the 30-60-90 Day Action Planning Worksheet, we have increased lead testing at one clinic. This has increased our overall lead testing rate and we have tested more children in a shorter period of time. We can see how the change in strategies did drive improvement. We hope that through the lessons learned at this one clinic, we can replicate our strategies at other clinics. Essentially, we hope that this will result in increased lead testing among children ages one and two.”