Chapter Quality Network (CQN)

Asthma Pilot Project Team Progress Presentation

State Name: AlabamaPractice Name: Huntsville Pediatric AssociatesTeam Members: Katie Gunter, MD

Cathy Radzinski, LPN, BBA Robin Riggs, Practice Manager

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

•Asthma pt’s identified through report run in practice managementsystem•All 7 physicians entering Data into EQIPP monthly•Protocols implemented for phone triage nurses regarding influenza vaccination, medication refills and follow-up OV for asthma patients•Asthma action plan written and installed on EVERYdesktop in patient areas•All nursing staff trained in use of spirometry machine•Report run in practice management system to ID asthmapt’s needing spirometry (criteria=>5 yrs of age and no spirometry in past 12 months)•Researched registry options. Currently working with RMD to implement registry at HPA

Plan

DoStudy

Act

PDSA

Dr. Gunter using encounter formExperience: Easy to useProblems: does add approx 5 min to each visitSurprises: parents like it Collecting data and entering in EQIPP; begin analysis

Completed analysisCompare to predictions:

Does add time. Is easy to incorporate.

By doing encounter form parents realize child’s control better; identifies areas of confusion with managementEncounter form itself easy to use and important in identifying patient’s with suboptimal asthma control. Need to develop better way to get the form to parents sooner in the visit to improve efficiency

Refinements: add HPA logo to form and make available to all doctors Next cycle: Develop workflow to have handout distributed by nurse to parent before Dr. enters exam room to improve efficiency.

•Implement use of encounter form•Questions:

•Will it take too much time?•Will parents understand it?•Will it be easy to incorporate?•Will it provide better care?

•Predictions:•Will take significant time to incorporate into visit.•Parents will understand the form.

•Who/What/When: Dr. Gunter to use on asthma patients in both WCC and sick visits

Plan

DoStudy

Act

PDSA

Dr. Gunter created action plan templateExperience: Easy to useProblems: does add approx 5 min to each visit. Need to adjust drop down options within the templateSurprises: parents like it and find it very helpfulCollecting data and entering in EQIPP; begin analysis

Completed analysisCompare to predictions:

Does add time. Is easy to incorporate.

By giving action plan parents feel more comfortable with what to do at home and when to call officeIn discussing the plan with parents, able to identify areas of confusion with management

Phone nurses notice parents refer to their action plan during calls

Refinements: have type-in option on action plans for those patients with special instructions/unique meds etc Next cycle: incorporate action plan into EMR (for now, scan in forms to chart).

•Provide updated action plan to patient at every encounter•Questions:

•Will it take too much time?•Will parents understand it?•Will it be easy to incorporate?•Will it provide better care?

•Predictions:•Will take time to create each action plan and explain it to parents.•Parents will feel more comfortable with asthma management.

•Who/What/When: Dr. Gunter will create action plan template with the assistance of other MDs in the practice. All MDs will then use the action plan template and distribute plans at all asthma pt encounters.

Plan

DoStudy

Act

PDSA

Workflow designed to capture those in need of spirometryExperience: nurses all instructed on spirometryProblems: no interface between spirometry and EMR. Requires entering data manuallySurprises: MANY patients in need of spirometryCollecting data and entering in EQIPP; begin analysis

Completed analysisCompare to predictions:

Nurses comfortable with performing spirometry. Is easy to incorporate (especially with scheduling spirometry in “shot clinic”(Does not need to be seen by MD for spirometry to be conducted).

Spirometry useful in assessing patients with unclear diagnosis/ identifying control in some who are unclear of their symptoms

Refinements: would like spirometry and EMR to communicate with each other

•Every asthma patient should have spirometry done within the last year if age appropriate•Questions:

•How will this fit into office visit?•Will it help in assessment of asthma control?•Who will conduct spirometrytesting?

•Predictions:•Not all nurses comfortable with spirometry•Will help in assessing asthma control in some patients•Results will be useful in explaining asthma control with families (ie. The need for preventative meds)

•Who/What/When:•Nurse identifies whether or not spirometry done within the last year.•MD responsible for scheduling spirometry (at that visit vs at future time)

Plan

DoStudy

Act

PDSA

MDs selected handouts and started distributingExperience: different MDs using different handouts (based on preference)Problems: not all MDs using handouts consistentlySurprises: parents seem receptive to the educationCollecting data and entering in EQIPP; begin analysis

Completed analysisCompare to predictions:

Does add time to visit. Is easy to incorporate.Parents appreciative.Phone nurses note parents seem more confident in understanding symptoms and control.

Refinements: make sure all MDs have handouts readily available to ensure use (ie. Put on desktops and at nurses station).

•Provide more education to parents to help with understanding and compliance•Questions:

•Will this take too much time?•Will it help with overall asthma control?• What areas of education are the most useful?

•Predictions:•Will add time to visit (<5min)•Will help with compliance and subsequently asthma control

•Who/What/When:•MDs to review several different education handouts and choose those which are the most relevant.•MDs to distribute as indicated

TEST 1What:CQN Encounter FormWho (population):asthma ptsWho (executes): Dr. GunterWhere:HPAWhen:Sept. 23, 2009

P D

S A

TEST 2What:Revised Encounter FormWho (population):asthma pts.Who (executes): ALL 7 MD’sWhere:HPAWhen:Oct. 1, 2009

P D

S A

TEST 3What:Encounter Form-Entering DataWho (population):MD’sWho (executes):MD’sWhere:HPAWhen:By Equipp Deadline

P D

S A

TEST 1What:Train Nurses in use of machineWho (population):Clinical Nursing StaffWho (executes):Cathy Radzinski, Teri FranklinWhere:Treatment RoomWhen:Jan. 17, 2009

P D

S A

TEST 2What:SpirometryWho (population):asthma pts.Who (executes):nurse with MD ordersWhere:Treatment RoomWhen:at sick or well visit

P D

S A

TEST 3What:Spirometry scheduleWho (population):asthma pts.Who (executes):MD/nursesWhere:immunization clinicWhen: schedule q day 9a or 1:30 pin immunization clinic

P D

S A

TEST 1What:Develop office Asthma Action PlanWho (population):asthma pts.Who (executes):Asthma CQN TeamWhere:Dr. Gunter clinic hoursWhen: October 1, 2009

P D

S A

TEST 2What:Asthma Action Plan Word Doc with drop downinstalled on all MD DesktopsWho (population):asthma pts.Who (executes):all MD’sWhere:clinicWhen:Beginning 10/15/2009 sick visit

P D

S A

TEST 3What:Blank Asthma Action Plan installed forMD’s to “fill in blanks” on their own (can choose fromthis or drop-down version)Who (population):asthma ptsWho (executes):MD’sWhere:clinicWhen: well or sick visits

P D

S A

CQN Encounter Form Spirometry Asthma Action Plan

PDSA Ramps

Huntsville Pediatric Associates

Asthma Encounter Workflow

Asthma Patientidentified by nurse during office visit.

Asthma Encounter Form given to

parent/patient to complete patient section of form

Nurse checks form for completeness

Form is put in exam room door

for Dr.

Physician fills out Physician section

of form

Physician keeps completed

encounter forms in folder at desk

Physician pulls 5 encounter forms and enters data

into EQIPP monthly

Data is reviewed by the practice during monthly

meeting

Nurses and Physicians remember to add Asthma to

problem list if patient is asthmatic.

Physicians please classify asthma severity.

Physician orders Spirometry if

needed.CPT codes:

94010 for first94060 for second

Asthma Action Form is completed (with medication adjustments if

needed)

Flu Vaccine offered (if

applicable)

Asthma Action Plan given to

patient

Nurse schedules asthma recheck

appt.

2 copies are printed

One for patient and one to be

scanned into EMR

Pre-Visit

Run report in Practice Management to find

asthma pts. Who are in need of flu shot and have not had an OV in past 6

mos.

Call these patients and schedule for flu shot and/or

follow-up asthma visit

Phone Nurses to follow Asthma

Protocol

Access Asthma Action Plan in

Imaging to assist in triage

Refill medications, schedule follow-up office visit and/or immunization if

indicated

Phone call nurses can access scanned

copy of Asthma Action Plan to assist

in triage

Post VisitVisit

Difficulty d/t # ofasthma pts.

Not all asthmapts. have action plan

Nurses not always catching asthma patients at visit

Nurses and MD’s need to do better at listing “asthma” to problem list

Huntsville Pediatrics CQN Encounter Form

F:\Patient Asthma Questionnaire CQN Encounter Form 2010.rtf

Key Learnings

Reassessing and revising asthma action plan and workflows to maximize compliance and asthma control.

The importance of scheduling follow-up visits for asthmatic patients.

Barriers and Successes

Barriers:• Time required to learn and follow workflows.• Identifying and following up with EVERY asthma

patient.• EMR lacks adequate reporting functionality and

does not interface with our spirometry machine.Successes:• Increase spirometry use.• Full buy-in on use of CQN Encounter Form by all

seven physicians at HPA.• Full participation by these seven physicians in

data gathering and creation of PDSA’s.

Other Information

• Improve on distribution of educational materials for asthma patients at every visit. In particular:

-asthma triggers-using inhalers correctly

• Need more frequent review on asthma care and management with nursing staff.

Future Plans

• Implement registry to assist in tracking asthma patients.

• Improve asthma education by providing additional information regarding asthma, triggers, and management of symptoms.

• Purchase new EMR that will contain registry functions, enable practice to write their own templates and interface with spirometry machine.

• Continue PDSA cycles in respect to workflows.