Chapter Quality Network (CQN)

Asthma Pilot Project Team Progress Presentation

State Name: OhioPractice: Toledo Children Primary CareTeam Members:

Toledo Children Primary Toledo Children Primary CareCare

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

Progress Summary Since Learning Session 1

• Improved engagement of QI team – providers are meeting monthly to discuss use of NHLB guidelines for care of asthma patients in our office. Staff are meeting frequently to discuss best processes for improving efficiency of providing asthma care. QI data turned in monthly. Team attending all required meetings and phone conferences.• Improving Follow up - Developing system to identify asthma patients by color labeling charts. Reviewing ideas for use of registry for Asthma patients. Scheduling follow up appointments at asthma visits, calling for follow up appointments after ER visits.•Increasing use of Planned care approach – developing and implementing improved workflow to support use of protocols with all providers, developed new asthma visit note to use at Asthma visits. Trained staff on correct use of Spirometry testing. Completing spirometry testing on patients per provider order.•Approach to Employing Protocols – Standardizing processes for each provider and staff to best implement use of evidence-based protocols with all patients. Providing Asthma Action Plan to all patients at asthma visit. •Self management support – Evaluating educational materials that help patients and family learn self management of disease process. IE: written material, asthma education per individual patient or group. Phone education vs. in-person education.

Asthma Action Plan

Follow - up

Spirometry

Spirometry

Antonio 17 yr T’onna 12 yr

IQmarkTM Digital Spirometer www.midmarkdiagnostics.com

Spirometry ?

• Low FEV1 is associated with increase risk for severe exacerbations. • Regular monitoring of pulmonary function is particularly important

for asthma patients who do not perceive their symptoms until airflow obstruction is severe. There is no readily available method of detecting the “poor perceivers.” The literature reports that patients who had a near-fatal asthma exacerbation, as well as older patients, are more likely to have poor perception of airflow obstruction.

• Two large, retrospective cohort studies have shown that a reduction

in FEV1 at an annual visit is associated with increases in the risk of an attack of wheezing and shortness of breath over the next 12 mo.

Spirometry

PDSA Cycles

PDSA Title:

Plan: Perform Spirometry testing in office

Do: Train nurses to accurately complete testing on appropriate asthmatic patients

Study: Validate results of Spirometry testing for accurate results on appropriate asthmatic patients

Act: Increase number of accurate tests on appropriate asthmatic patients

TEST 1What: Perform Spirometry testWho (population): Train nursing staffWho (executes):Resp therapist: JohnWhere: OfficeWhen: October 2009

P D

S A

TEST 2What: Perform Spirometry testWho (population): 1 patient/weekWho (executes):1 trained nurseWhere: OfficeWhen:Oct. 2009

P D

S A

TEST 3What: Perform Spirometry testWho (population): 2-3 pts. Per weekWho (executes): 1 trained nurseWhere: OfficeWhen:Nov. 2009

P D

S A

TEST 4What: Perform Spirometry testWho (population): 5 pt. per weekWho (executes): All trained nursesWhere: OfficeWhen:Dec. 2009

P D

S A

TEST 1What: Validate accurate resultsWho (population): 5 – 10 ptsWho (executes): All trained nursesWhere: OfficeWhen: Jan 2010

P D

S A

TEST 2What Validate results Spirometry vsFormal PFTWho (population): 1-2 pts.Who (executes): All trained nursesWhere: OfficeWhen:Feb 2010

P D

S A

TEST 1What: Spirometry testingWho (population): 1 patientWho (executes): Participating providersWhere:OfficeWhen:March 2010

P D

S A

TEST 2What: Spirometry testingWho (population): 2-5 pts/weekWho (executes): All participating providersWhere: officeWhen: April 2010

P D

S A

TEST 3What: Spirometry testingWho (population10 patients/weekWho (executes): all trained nursesWhere: Office When: May 2010

P D

S A

TEST 4What: Spirometry testingWho (population): All patientsWho (executes): All trained nursesWhere:OfficeWhen: June 2010

P D

S A

Spirometry testingMonitering results Spirometry

Expand Use of Spirometry testing

PDSA Ramps

P D

S A

TEST 3What: Validate results between trained nurses Who (population): 3 pateintsWho All ProvidersWhere: OficeWhen: June 2010

Scheduler identifies patient with asthma when setting

up chart. CQN data collection form is put in

these charts.

Asthma education material put in these charts

including Asthma Action Plan

(Each provider work flow different, requiring different method for each of them)

If in active flu season and vaccine is due, administer

flu shot. If between seasons, annual flu shot is

recommended

CQN encounter forms readily accessible in each POD when

asthma pt. indentified after chart set up

Physician/CPNP/RN/LPN gives/reviews asthma action plan. Gives and reviews asthma educational materials. Offers in

home asthma education. Reviews patient encounter form for completeness

( Evaluating multiple methods of providing education to lead to best self management)

Nurse/CRA sends referral

to Caring Service Home Health Care if accepted by

family or available group

asthma education at

hospital

During the visit the Physician/CPNP

reviews pt. questionnaire and completes

provider questionnaire

(difficult to devote time to complete these forms)

Physician/CPN/discusses

asthma control

Off

ice

Vis

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Pre

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urin

g O

ffic

e V

isit

Pos

t V

isit

Act

iviti

es

Physician/CPNP Completes all forms

and gives to administrative team member to

enter data into equipp.

(difficult to devote time to complete these forms)

Physician/CPNP orders spirometry if appropriate

Toledo Children's Primary Care: Clinical Assessment Process Map – Paper Chart System

Nurse completes

spirometery testing

Patient is ready to be

seen by provider

Working on Creating Asthma recall

registry system

Nurse/CRA who rooms patient gives parent

patient encounter form and helps them complete form

if needed.

Administrative team member returns

incomplete forms to provider/CPNP

DR. or CPNP gives patient

encounter form to complete if

they feel appropriate for that days visit.

CQN Encounter Form

Asthma Care Encounter Formfor documentation at visit

Key Learning Change is difficult. It is easier to implement

small changes.

Obtaining data helps measure outcome.

Education, education, education.

Collaboration with community health care resource is very important.

Barriers and Successes

1. Time. 2. Absence of EMR.

3. Variations in care.

1.Quality of care.

2. Increased Asthma education to staff ( protocols for medications refills, f/u visits)

3- Improved teaching to future health care providers.

4- Guidelines and protocols improves efficiency and staff satisfaction, and reduces unnecessary variations of care.

5- Spirometry

Future Plans• EMR/Registry EMR/Registry • Continue PDSA’s for efficient use of asthma

encounter forms• Continue Team meetings providers and staff• Continue to evaluate methods of patient and

family education to help families improve self management of Asthma.