AAP Alabama State Chapter Shared Vision

James C. Wiley, MD, FAAPChapter Physician Project Leader

“I have the following financial relationships with the manufacturers(s) of any commercial products(s) and/or provider

of commercial services discussed in this CME activity:”

Research Support from: Speakers’ Bureau: Glaxo Smith Kline and Behavioral Diagnostics

Co.

It is my obligation to disclose to you (the audience) that I am on the Speakers Bureau for Glaxo Smith Kline and Behavioral Diagnostics Co. However, I acknowledge that today’s activity is certified for CME credit and thus cannot be promotional. I will give a balanced presentation using the best available evidence to support my conclusions and recommendations.”

State Quality Improvement Strategic Plan

• Alabama Chapter-AAP QI Committee created

• Collaboration with Alabama Medicaid – Alabama Healthcare Improvement and Quality Alliance (AHIQA)

• Alabama Chapter Aim Statement• Future Endeavors

CQN Impact MAINE

OHIO

OREGON

ALABAMA

• Learn about Alabama’s QI Committee• Understand the “gap” in care• Understand why this work is important• Become familiar with the goals for this

project

Goals

Global AimWe will build a sustainable quality improvement infrastructure within the Alabama Chapter-AAP to achieve measurable improvements in the health outcomes of children within our member practices.

Specific AimFrom April 2009 to November 2010, we will lead a quality improvement collaborative and achieve measurable improvements in asthma outcomes with the participating 10 to 15 practices by implementing the National Heart, Lund and Blood Institute (NHLBI) asthma guidelines.

Alabama Chapter-AAP Individualized Aim Statement

SECTION 1 (AIMS)

Goal: 90% of the CQN Asthma Pilot Practices will achieve 80% perfect care by September 2010.

Goal: 90% of the CQN Asthma Pilot Practices will use a structured encounter form 90% of the time by September 2010.

Outcome Goal: 90% of the CQN Asthma Pilot Practices will reach 80% of patients “well controlled” by September 2010.

What is Optimal Asthma Care?Optimal Asthma Care - % of patients with all of the following:•patients with assessment of asthma control using a validated instrument•patients which stepwise approach is used to identify treatment options or adjust therapy•patients with asthma action plan •patients 6 months and older with a flu shot or flu shot recommendation

Alabama Chapter-AAP Individualized Aim Statement

SECTION 2 (GOALS)

Long Term Goals

Goal: All CQN Asthma Pilot Practices will use a population based registry

Goal: 90% of the CQN Asthma Pilot Practices using a population based registry will achieve 90% perfect care by August 2012

Other Action Items: •The CQN Asthma Pilot Practices will submit annual follow-up data in August 2011 and August 2012, with the Chapter Team providing quarterly check-in/follow-up calls/emails.•The CQN Asthma Pilot Practices will host an Asthma QI Project sharing session/summit at the Chapter’s 2011 Spring Meeting in April 2011•The chapter will push out results of the CQN project and lessons learned on QI infrastructure to Chapter members through a variety of communication efforts: newsletter tips, case studies, etc.•The chapter will collaborate with Alabama Medicaid Agency and Blue Cross Blue Shield of Alabama to design and fund a second phase of pilot practices based on results of this quality improvement project.

Alabama Chapter-AAP Individualized Aim Statement

SECTION 3 (LONG TERM GOALS)

Optimal Care

>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)

Asthma Admissions/10K

0

2

4

6

8

10

12

14

Baseline Post

As

thm

a A

dm

iss

ion

s/1

0K

PHO

Comparison Group

56%

36%

Baseline: 3 year average (10/1/00-9/30/03)

Post: 2 year average (10/1/06-9/30/08)

Commercial insurance only

CCHMC encounters only

Patients ≥ 2 yrs. of age

8 county primary service area

ICD-9 code of 493.xx in primary position

PHO vs. Comparison Group Asthma Admissions: Pre/Post Impact

Keith Mandel, MD; Cincinnati Children’s Hospital Medical Center

10

Change Concepts• Engaging Your Asthma 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 *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 Driver Diagram

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

What is the Quality Gap?

• How QI came to me….

• The gap between the care we know is best and our ability to deliver it, every time, to every patient in the way they need it.

Defining the Gap: Asthma

• Affecting nine million children, childhood asthma is the most common serious pediatric chronic disease. The incidence of pediatric asthma continues to grow; it accounts for 14.7 million missed school days a year and 44% of all asthma hospitalizations[1]

• During August 2007, under the auspices of the National Heart, Lung, and Blood Institute (NHLBI) the National Asthma Education and Prevention Program (NAAEP) issued the first comprehensive update in a decade of asthma guidelines for the diagnosis and management of asthma (NHLBI asthma guidelines). The guidelines emphasize the importance of asthma control and introduce new approaches for monitoring asthma. The AAP recognizes that increased exposure to the new guidelines coupled with implementation support will decrease gaps in care and help move towards optimal care for children with asthma.

[1] American Academy of Allergy, Asthma and Immunology. http://www.aaaai.org/media/resources/media_kit/ asthma_statistics.stm

The Story of Improvement

Stephen Pleatman, MDPediatrician, Suburban Pediatric Associates, Inc.Board Member, Ohio Valley Primary Care Associates, L.L.C.Cincinnati, Ohio

Asthma Care a Year From Now

• Easier use of the asthma guidelines by physicians and staff

• Better understanding of asthma for patients and families

• Better systems so your office members can function as an efficient team

• Knowing your patients and being ready for their visits

• The best care for every patient, every time