CQN Team Presentation

OhioCleveland Clinic Children’s Hospital

Kim Giuliano, MDSharon O’Brien, MA

Ivana Wilson, Medical Secretary

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 Since Learning Session 1

• Adaptation of CQN form into EMR

• Incorporation of CQN form at every visit for patients with asthma

• Simplified process for generating asthma action plans leading to dramatic increase in usage

• Generation of asthma education handout with successful incorporation into some patient encounters

• Modest increase in use of spirometry

• “Optimal care” increased from 6% to 79%

Office Flow Document

MA/RN puts revised CQN

form with provider only questions on top of patient identification

sheet

Patient is ready to be seen

by Physician

During the visit the physician fills out

the provider form while havingInformed clinical

DiscussionQuestions 11-27

Patient with new

diagnosis of Asthma, form is pulled and

filled out concurrently

Completed form returned

to asthma form

collection tray

Physician completes the

form immediately after the visit

NO

YESDur

ing

Offi

ce

Vis

itP

ost V

isit

Act

iviti

es

Nurse Leader removes encounter form and

verifies for completeness

If necessary, circle back with

Physician or patient family by phone to obtain

missing information

NO

All necessary information on

the form is entered into EQIPP by

medical secretary Paper copy kept on file at secretary’s

desk

Any patients with missing forms will becontacted to schedule office visit based on

periodic electronic chart review

MA/RN rooms pt. If asthma med noted during medication

reconciliation, MA/RN asks

parents questions #1-10

and enters responses into medical record

MA/RN gives

asthma education handout to parent

TEST 1What: CQN paper formWho (population): 5 ptsWho (executes): GiulianoWhen: 2 clinic sessions in Oct

P D

S A

TEST 2What: EMR formWho (population): Giuliano ptsWho (executes): Sharon O.When: week of 10/19/09

P D

S A

TEST 3What:: Expansion of EMR formWho (population): all asthma ptsWho (executes): entire office staffWhen: week of 10/26/09

P D

S A

TEST 1What: EMR Asthma Action Planusing letter templateWho (population): Giuliano ptsWho (executes): GiulianoWhen: week of 10/26/09

P D

S A

TEST 2What:: EMR Asthma Action Planusing “dot phrase”Who (population): Giuliano ptsWho (executes): GiulianoWhen: 10/30/09

P D

S A

TEST 3What:: EMR Asthma Action Planusing “dot phrase”Who (population): all asthma ptsWho (executes): all MDsWhen: 11/6/09

P D

S A

TEST 1What:: Handouts given whenverbal teaching not doneWho (population): Giuliano ptsWho (executes): GiulianoWhen: 12/1409

P D

S A

TEST 2What:: Handouts given duringrooming processWho (population): Giuliano ptsWho (executes): Sharon andCarmenWhen: week of 12/21/09

P D

S A

TEST 3What:: Handouts given duringrooming processWho (population): all patientsWho (executes): RNs and MAs,MDs if not completed priorWhen: week of 1/11/10

P D

S A

TEST 4TBA

P D

S A

CQN Form Asthma Action Plan Education Handout

PDSA Ramps

PDSA Cycles PDSA Title: ASTHMA ACTION PLANS Plan: Distribute asthma action plans to

patients during office visit. Giuliano prints asthma action plan in letter template format during patient encounters for one week.

Do: Carried out plan but at a significant time expense. Time prevented asthma action plans from being given out at every visit.

Study: Modest improvement compared to previous performance. Results did not match predictions.

Act: Adapt

PDSA Cycles PDSA Title: ASTHMA ACTION PLANS Plan: Distribute asthma action plans to patients during

office visit. Giuliano to create new “dot phrase” in EMR. Giuliano to use dot phrase on all asthma pts this week.

Do: Carried out plan on 100% of identified pts this week. Much less time than previous format (approx. 60 seconds). Observed positive remarks from parents.

Study: Results matched predictions. Improved performance.

Act: Adopt

PDSA Cycles PDSA Title: ASTHMA ACTION PLANS Plan: Distribute asthma action plans to

patients during office visit. Giuliano presents new format at provider meeting. All providers agree to trial.

Do: Cycle carried out as planned with all providers using on at least one patient.

Study: Results exceeded predictions. Action plans given to 87% of pts vs. 6% at baseline.

Act: Adopt

EQIPP GraphAsthma Action Plan

EQIPP GraphOptimal Care

Key Learnings Testing on small scale first helps with group

“buy-in” Measures that are simple and do not involve

significant increase in office visit time are implemented most successfully

Incorporation of nursing in more active roles in patient encounter has positive impacts in nursing attitudes and patient satisfaction