Improving Asthma Care Holger Link, M.D.

Carrie Phillipi, M.D., Ph.D. Art Jaffe, M.D.

Outline• Why You do Care • Building teams and partnerships to improve

patient outcomes• The Doernbecher Experience

Why You Do Care

75,000

JonathanDavidHenry

How can we partner with our patients and others to

achieve better outcomes?

What are we trying to accomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Act Plan

Study Do

AsthmaNurseEducators

AsthmaEducationPackets

DischargeEducationChecklist

What is Chapter Quality Improvement?

The involvement of AAP chapters in state and/or local activities aimed at improving the quality of care for children. These activities involve measurement and the collection of data over time to assess changes in practice performance.

Pediatric Member

Practices

State PartnersPublic Health,

Payors, Children’s hospitals

American Academy of PediatricsChapters

Improve Children's’ Health

Key Players• American Academy of Pediatrics

- Project Lead• Cincinnati Children’s Hospital Medical

Center- QI expertise and coaching• 4 Chapters- Alabama- Maine- Oregon- Ohio• 49 practices• 282 Clinicians

• Sandra Miller

• Theresa Rice

• Holger Link & Carrie Phillipi

• Arthur Jaffe (OPS)

The Oregon Chapter Team

Peace Health Medical Group RiverbendPeace Health Medical Group BargerPeace Health Medical Group SouthPeace Health Medical Group DowntownHillsboro PediatricsSouthern Oregon PediatricsOregon Medical Group Garden WayChildhood Health Associates of SalemLegacy Emanual Childrens ClinicDoernbecher PediatricsDoernbecher Pediatrics Westside

The Oregon Practices

CQN Asthma Pilot Project MAINE

OHIO

OREGON

ALABAMA

11 Practices

13 Practices

13 Practices

12 Practices

49 Practices

282 Clinicians

Improvement Methods

How are we doing at the National Level?Practice System Changes

Registry Implementation Status

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100%

Practices with a Registry Practices without aregistry

National

Oregon

How are we doing at the National Level?Practice System Changes

Options for Practices without a Registry

0%

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Using an Excel database asalternative

Actively discussing/ exploringregistry

Not discussing/ exploringregistry

National Oregon

Commitment to Quality as a result of CQN Participation

No change in my

commitment to QI, 9%

No Change in my commitment to QI work, 9%

More committed to QI work, 91%

Chapter Team Perspective: Value of Program Components

0%

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100%

Sharedlearning

Serving as a QILeader

Improvementexpertise

Data Reports Assistancefrom National

ABP Part IV CME Credit

5 (very valuable) 4 3 2 1 (Not Valuable)

Improvement Work

Improvement WorkContinuous tests

of change

SustainabilityImbed in everyday work

Scale Up & SpreadTaking local improvement

And actively disseminating itacross a chapter and/or practice

Our First 6 months

Our DCH Experience

Art JaffeJulie JohnsonLisa JohnsonEveryone on the Gen Peds Clinic Team

GOALS

• Describe structure and process• Discuss our local focus• Show baseline data• Choosing PDSA’s and tracking results• Successes and challenges• The future: sustainability and generalizability

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

Base-line: % Well-controlled (visits vs patients?)

Base-line: % Well-controlled (visits vs patients?)

OOPS!

No data reported back from AAP!!

% Well-controlled Through July, 2010

DCH General Pediatrics Clinic Oregon

Base-line: % Optimal Care

DCH General Pediatrics Clinic Oregon

Drilling Down On Optimal Care

Validated Instrument Step-wise Approach to Care

Drilling Down On Optimal Care

Flu shot given or recommended Use of Asthma Action Plan

Targets of Opportunity

1. Validated Instrument- ACT and TRACK forms

2. Asthma Action Plan- PDSA iterations of plans- EPIC issues- The saga continues

Optimal Care: Good News in June!!!

DCH General Pediatrics Clinic Oregon

And then there was July

DCH General Pediatrics Clinic Oregon

The Future

• Sustainability- What happens when the project ends?

• Generalizability- Asthma management throughout Oregon- Chronic care management in DCH

• Registry- Management of populations, not patients- Clinical care vs. research data base- Options for all of us