Chapter Quality Network (CQN)

Asthma Pilot Project Team Progress Presentation

State Name: OhioPractice Name: Willoughby Hills Cleveland ClinicTeam Members: Lisa Dolovacky, MA Loreen Rudd, RN Rachel Peterson, MSN/CNP Marianne Sumego, MD

GLOBAL CQN AIMWe will build a sustainable quality improvement infrastructure within our practice to achieve measurable improvements in asthma outcomesSpecific Aim From fall 2009 to fall 2010, we will achieve measurable improvements in asthma outcomes by implementing the NHLBI guidelines and making CQN’s key practice changes

Measures/Goals

Outcome Measures: >90% of patients well controlled

Process Measures >90% of patients have “optimal” asthma care (all of the following) assessment of asthma control using a validated instrument stepwise approach to identify treatment options and adjust therapy written asthma action plan patients >6 mos. Of age with flu shot (or flu shot recommendation)

>90% of practice’s asthma patients have at least an annual assessment using a structured encounter form

Engaging Your QI Team and Your Practice*The QI team and practice is active and engaged in improving practice processes and patient outcomes

Using a Registry to Manage Your Asthma Population *Identify each asthma patient at every visit *Identify needed services for each patient *Recall patients for follow-up

Using a Planned Care Approach to Ensure Reliable Asthma Care in the Office * CQN Encounter Form * Care team is aware of patient needs and

work together to ensure all needed services are completed

Developing an Approach to Employing Protocols * Standardize Care Processes * Practice wide asthma guidelines

implemented

Providing Self management Support

* Realized patient and care team relationship

Key Drivers

Interventions

Form a 3-5 person interdisciplinary QI Team

Formally communicate to entire practice the importance and goal of this project

Meet regularly to work on improvement

All physicians and team members complete QI Basics on EQIPP

Collect and enter baseline data

Generate performance data monthly

Communicate with the state chapter and leaders within the organization

Turn in all necessary data and forms

Attend all necessary meetings and phone conferences

Select and install a registry tool

Determine staff workflow to support registry use

Populate registry with patient data

Routinely maintain registry data

Use registry to manage patient care & support population management

Select template tool from registry or create a flow sheet

Determine workflow to support use of encounter form at time of visit

Use encounter form with all asthma patients

Ensure registry updated each time encounter form used

Monitor use of encounter form

Select & customize evidence-based protocols for your office

Determine staff workflow to support protocol, including standing orders

Use protocols with all patients

Monitor use of protocols

Obtain patient education materials

Determine staff workflow to support SMS

Provide training to staff in SMS

Assess and set patient goals and degree of control collaboratively

Document & Monitor patient progress toward goals

Link with community resources

CQN Asthma Project Practice Key Driver Diagram Version 2.0

90 day goals For Learning Session 2

• 1. Develop an asthma registry• 2. Review use of a best practice alert potential to identify patients• 3. To engage our practices (local)• 4. Develop evidence-based protocols via epic.• 5. Increase use of action plans for asthma care• 6. Evidenced based protocols for our offices

Learning session 1 summary

• Tested use of our asthma CQN encounter forms

• Developed an asthma action plan • Gather asthma education materials• Engaging our practice• Identifying barriers to practice,

engagement• Developed smart set• Education for our Staff

Spirometry used to establish diagnosis

Number of patients with an action plan

Patients Well controlled Asthma

PDSA Cycles

PDSA Title: Asthma action plan

Plan: Increase uniform asthma action plan use

Do: Monitor use of new AAP form

50% of patients from 4 providers in one month will have AAP completed

Study: Evaluate improvement with March data set

93% compliance Month of March for 4 providers

Act: Adopt plan; receive feedback on plan/improvements. Continued communication regarding use and availability of action plan

PDSA Cycles

PDSA Title: Blue Dot Trial• Plan: Identification of patients with asthma; blue dot on schedule

next to pediatric asthma patients age 2-18

• Do: Count number of forms vs. blue dots on schedule for provider– 80% forms will be completed for identified asthma patients

• Study: Reviewed 4 providers use in March– did not meet our predictions.

• Act: Adapt plan; adjust office flow diagram, one on one sessions, emails, reminders, feedback from MA/Provider

TEST 1What:: Paper copy CQN formWho: Sumego and PetersonWhere: ProvidersWhen: 11/09Who (executes): QI team

P D

S A

TEST 2What:: Revised electronic versionWho: 3-4 providersWhere: Med/peds & PedsWho (executes): QI teamWhen: 12/09

P D

S A

TEST 3What: integrated process EMR/paperWho: All providersWho (executes): QI teamWhere: Medpeds & PedsWhen: 12/09

P D

S A

TEST 4What: tracking form useWho: 4 providersWho: (executes): Rachel and LisaWhere: 40% forms completedWhen:2/10 and 3/10

P D

S A

TEST 1What:: ID patients/Blue dotWho Sumego,MDWho (executes): Lisa QI teamWhere: Med/Peds dept.When: 1/10

P D

S A

TEST 2What:: Roll out blue dotWho: 2 providersWho: (executes):LisaWhere: Med/Peds deptWhen: 1/10

P D

S A

TEST 3What: Roll out all dept.Who: All providersWho (executes): MAWhere: Med/Peds & PedsWhen 2/10

P D

S A

TEST 4What: Monitor use blue dotWho: 4 selected providersWho (executes): RachelWhere: Chart review med/peds & PedsWhen: 3/10

P D

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TEST 1What:: Asthma action planWho: All providersWho (executes): Sumego/PetersonWhere Med/Peds and PedsWhen: 11/09

P D

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TEST 2What:: Education about plan useWho : all providers:Who (executes): QI TeamWhere: Breathe Easy LuncheonWhen: 1/10

P D

S A

TEST 3What:: Uniform EMR AAPWho (population): all providersWho (executes): Sumego (letter)QI team (roll out)Where: Med/Peds and PedsWhen:2/10

P D

S A

TEST 4What; Assess use AAPWho: 4providers use of letterVs. nonstandardWho (executes) :RachelWhere: Chart review med/peds& peds 93% useWhen: 3/10

P D

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CQN use Identification Action plan use

PDSA Ramps

MA checks provider schedule daily and notes asthma patients

by problem list, history, or medication list. Puts blue dot on

schedule to mark asthma patient for reminder. Checks

again each afternoon for same day add on.

MA gives questionnaire to parent to fill out or verbally asks

the questions and enters into EPIC version

Parent/MA completes form and hands to provider when enters room

Patient may be identified with asthma during exam that was not previously noted

(acute visit, add-on visit, new diagnosis of asthma) Questionnaire copies outside of exam room door

Completes parent portion in room.

Provider fills out remainder of the form and discusses

management collaboratively with patient based on asthma control &

NHLBI guidelines

MA/RN carries out orders

Patient checks out

PSR schedules appropriate consults and follow-up

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RN/MA places form in CNP basket

CNP verify for completeness

If not complete will send back to

provider for missing

information. Or call patient.

Data entered into EQIPP weekly and Registry

(when we have one) Paper forms

in binder

Office Work Flow – CCF Willoughby Hills

Other pre-work preparations:• MA/RN stocks each room with asthma encounter forms• MA/RN ensures available spacers/supplies

Change in patient’s plan of care:• Asthma action plan updated & copy provided• Spirometry ordered if indicated• Rx escripted; spacer provided• Pertinent written asthma materials provided• Flu vaccination provided as appropriate• Follow up in 2-4 weeks• Consults ordered as needed

No change in patient’s plan of care:

• Asthma action plan copy provided

• Spirometry ordered if indicated

• Refills escripted; spacer use confirmed

• Pertinent written asthma materials provided

• Flu vaccination provided as appropriate

• Routine follow up

MD/ MA hands completed forms to Nurse Leader

Loreen Rudd RN

Rachel Peterson MSN CNP

PROBLEM POINTS

Difficulty getting “blue dots” on provider schedule

Time constraints/Provider “buy in”

Incomplete forms

No registry capability as of yet

Copy of Your CQN Encounter Form

Asthma Encounter/Data Collection Form

Provider Name: ________________________________________ Patient Name: ________________________________________

Date of Birth: ____/____/____ Date of Visit: ____/____/____

Insurance Company: ___________________________________

Well visit Asthma Visit Other Sick Visit 1. How many days of school/daycare has your child missed due to asthma in the past 6 months? _______ # of days

Does not attend

2. How many work days have you or your spouse missed due to your child’s asthma in the past 6 months? _______ # of days

3. Has your child visited the Emergency Room or Urgent Care Center due to asthma in the past 12 months? YES NO

If yes, how many times? _______

4. Has your child been admitted to the hospital due to asthma in the past 12 months? YES NO

If yes, how many times? _______

5. How comfortable are you in your ability to manage your child’s asthma, rated on a scale of 1-10? (Please circle)

Not Comfortable = 1 2 3 4 5 6 7 8 9 10 = Very Comfortable

6. During the past week, how often did your child use a fast acting or quick relief medication, at times other than before exercise? (includes Albuterol, Ventolin®, Proventil®, Xopenex®)

not at all less than 1 time per day 1-3 times per day 4 or more times per day not sure

7. When are asthma symptoms worse? (Check all that apply)

winter spring summer fall during exercise

8. How often does asthma limit your child’s activities?

not at all a little of the time some of the time most of the time all of the time

9. Over the previous 2 to 4 weeks, how frequently has your child experienced episodes of cough, shortness of breath, wheezing or reduced activity due to asthma during the DAY?

1. < or equal to 2 days / week > two days / week but not daily Daily Throughout the day

10. Over the previous 2 to 4 weeks, how frequently has your child experienced episodes of cough, shortness of breath, wheezing or waking up due to asthma at NIGHT?

2. < 2 times / month 3-4 times a month > 1 time / week but not nightly Often 7 times / week

11. How would you rate your child’s asthma control during the past month?

not controlled at all poorly controlled somewhat controlled well controlled completely controlled

Office Use Only: ENTER FIELD INTO

EQIPP #1

Office Use Only: ENTER FIELD INTO

EQIPP #2

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Copy of Your CQN Encounter Form

12a. If in active flu season (Sept.-March), was flu shot administered? YES shot date: ___/___/_____

NO-reason: _______________________________________ Patient younger than 6 months, other contraindications, or vaccine unavailable

12 b. If between seasons (April-Aug.) was a recommendation made? YES NO

13. Asthma severity level: (refer to the EPR3 Control Tables 4-2a, 4-2b, and 4-6)

Severe Persistent Moderate Persistent Mild Persistent Intermittent

14. Is the patient on a controller medication? YES NO

If YES, does the patient/parent report using controller medications daily? YES NO Started this visit

15. For patients who use rescue/controller inhalers, is a spacer utilized? YES NO NA (Maxair® and dry powder inhalers do not require spacer)

16. Has the patient received oral steroids for bronchospasm within the past 12 months? YES NO 17 a. Does the patient have a written asthma action plan? YES NO

17 b. If yes, was the plan updated as needed and reviewed with the patient and/or family at this visit? YES NO

18. Were asthma self-management education and materials (other than or in addition to the asthma action plan) provided and explained to the patient and family at this visit? (Examples include correct medication techniques, avoiding environmental triggers, and getting help to quit smoking. See Figure 3–13 in EQIPP, Delivery of Asthma Education by Clinicians During Patient Care Visits for more information.)

YES NO

19. Has the patient been seen by an allergist or pulmonologist during the last 12 months for assistance with asthma management due to severity of illness? (refer to specialist referral criteria)

Specialist: ___________________________________ YES NO Referred this visit 20. Were validated questions used to determine the current level of asthma control

(if validated tool used or parent completed entire parent section, check “yes”)? YES NO

21 a. Physician assessment of control: What is the patient’s current level of control during the past month? (review the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Report 3 (EPR-3) control tables (refer to the EPR-3 Control Tables 3-5a, 3-5b, 3-5c, 4-2a, 4-2b, 4-6, 4-3a, 4-3b, 4-7)

Well Controlled Not Well Controlled Very Poorly Controlled 21 b. If “not well controlled” or “very poorly controlled”:

Did you identify reasons for lack of control? (Examples: exposure to allergens, tobacco smoke, indoor or outdoor pollutants and irritants, nonadherence to medication regimen) YES NO

22. Have you used the age –appropriate NHLBI EPR-3 stepwise table to identify treatment options or to adjust therapy based on asthma control? (refer to the Stepwise Tables 4-1a, 4-1b, 4-5)

YES NO

23. For patients age 5 years and older, is spirometry currently scheduled, or have results been obtained within the last 1 year? (refer to Box 3-2)

YES date____/____/_____ NO Younger than 5 years 24. Follow Up Visit: Return in: _____ weeks, or _____ months Return visit date (Optional): _____ / _____ / _____

Note: You may have to go back in the patient chart to find this historical information. If the information is unavailable, check not documented. 26. Were one or more asthma key indicators present when considering the diagnosis of asthma? (refer to Box 3-1)

YES NO Not Documented

27. Were lung function measures by spirometry used to establish the asthma diagnosis? (refer to Box 3-2)

YES NO Age inappropriate, younger than 5 years Not Documented

Office Use Only: IF “YES” IN EITHER 12A or 12B ENTER FIELD INTO EQIPP #9

Office Use Only: ENTER FIELD INTO

EQIPP #10

Office Use Only: ENTER FIELD INTO

EQIPP #10

Office Use Only: ENTER FIELD INTO

EQIPP #5

Office Use Only: ENTER FIELDS INTO

EQIPP #6A and 6B

Office Use Only: ENTER FIELD INTO

EQIPP #8

Office Use Only:

ENTER FIELD INTO EQIPP #7

Office Use Only:

If a follow-up visit was scheduled ENTER FIELD

INTO EQIPP #12

Office Use Only: ENTER FIELD INTO

EQIPP #3

Office Use Only:

ENTER FIELD INTO EQIPP #4

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Epic Version Parent Questionnaire

• Asthma Control Parent Questionnaire:

• 1. Has your child visited the ER or urgent care due to asthma in the past 12 months? {YES (DEF)/ NO:2058::"Yes"}

• 2. Has your child been admitted to the hospital due to asthma in the past 12 months? {YES (DEF)/ NO:2058::"Yes"}

• 3. How many days of school/daycare has your child missed due to asthma in the past 6 months? {NUMBER:30898}

• 4. How may work days have you or your spouse missed due to your child's asthma in the past 6 months? {NUMBER:30898}

• 5. How comfortable are you in managing your child's asthma, rated on a scale of 1-10 (1=not comfortable, 10=very comfortable)? {NUMBER:29773}

• 6. During the past week, how often did your child use a fast acting or quick relief medication at times other than before exercise? {ALBUTEROL USE:70290}

• 7. When are your child's asthma symptoms the worst (select all that apply)? {TIMING-ASTHMASX:70291}

• 8. How often does asthma limit your child's activities? {ACTIVITY IMPACT:70292}• 9. Over the previous 2-4 weeks, how frequently has your child experienced episodes of

cough, SOB, wheezing or reduced activity due to asthma during the DAY? {FREQUENCY DAY SX:70293}

• 10. Over the previous 2-4 weeks, how frequently has y our child experienced episodes of cough, SOB, wheezing or waking up due to asthma at NIGHT? {FREQUENCY NIGHT SX:70295}

• 11. How would you rate your child's asthma control during the past month?{ASTHMA CONTROL:70296}

Practice Engagement

Breathe Easy Luncheon January 2010

Nancy Wyse Respiratory therapist

Spoke with providers, Medical assistants, and nurses in Med/Peds and Pediatrics

Great turn out across the board!

Provided pizza, salad, and drinks!

MDI instruction

Spacer technique/Use

Nebulizer technique/Use

Update on newer products, DPI

Opportunity for questions, sharing, collaboration, and review

Free lunch incentive to Medical assistant and Provider Team for encounter forms collected each month

Key Leanings Change takes hard work, but is possible!

Slow going

Repetitive

Team work

Success drives change and engagement

Easier to make further changes when data can show improvement!

Barriers and Successes

• Barriers– Engagement : time, other responsibilities/projects, lack of

interest– Geography (2 departments, different schedules,

meetings)– Meetings– EMR

• Identification of patients with EMR• Registry

• Success– action plan use greatly improved– lunch and learn attendance– Data shows improvement! Well controlled asthma,

increasing toward optimal care– All providers on board!– Standardized forms for encounters, smart set, AAP

Future Plans

• Improvements on Asthma Action plan• Dinner/Lunch with speaker• Registry capabilities; work with other

health centers• Standardized educational handouts (in the

works)– Possible videos in EPIC

• Breath Easy Luncheon II– Pulmonary function testing– In the works currently