Chapter Quality Network (CQN)

Asthma Pilot Project Team Progress Presentation

State Name: OREGONPractice Name: Doernbecher General PediatricsTeam Members: Art Jaffe, MD, Lisa Johnson, RN and Julie Johnson, RN

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

1. Engaged QI Team and Practice-- QI team is actively functioning

-- Clinic staff, faculty, and residents participating-- Dept Chairman and hospital administrator providing financial and advocacy support-- Have had formal and informal conferences for clinic staff, residents and faculty-- Update monthly progress on our clinical bulletin board in practice

Progress Since Learning Session 1

2. Using A Planned Care Approach-- Have developed a triple-tiered system to ensure use of CQN form with all asthmatic patients-- Have done small-scale PDSA to evaluate use of home-made EMR template to replace CQN, and elected not to change

-- Implemented ACT (Asthma Control Test) as our validated instrument tool along with CQN form.

Progress Since Learning Session 1

3. Developing An Approach to Employ Protocols-- Have developed consistency in listing “asthma” on the EMR’s Problem List

- may be a foundation for eventual registry-- Created and implemented use of Asthma Action Plan in EMR-- Using ACT (Asthma Control Test) as a standardized assessment tool and now investigating use of a TRACK in conjunction with ACT-- Spirometry approved and investigating type of spirometer

to be ordered-- Established workflow to documenting ACT scores in EMR

% of patients who have a current written asthma plan explained to them

at this visit

What We Have Learned

1. Paper asthma action plan too cumbersome and did not allow flexibility to update and review.

2. Asthma action plan in EMR allows us the flexibility to update and review with each visit.

3. We need colored printers to allow us to give current asthma action plan to families in useful and meaningful format.

% of patients in which a validated instrument is used to determine the current level of asthma

control

What We Have Learned

1. We determined a process to document ACT scores in EMR using PSDA ramps.

2. We needed a formal process to disseminate information to our large practice and staff.

3. We need a validated instrument to determine the current level of asthma control in our younger population (currently investigating TRACK form).

PDSA Cycles

PDSA Title: Evaluate an EMR template to replace the paper CQN form

Plan: Write and load a template for a CQN form into EMR; use it for 5 days; evaluate perceptions about its utility.

Do: Clinic residents only used it for 2 to 3 patients and found it too cumbersome and time consuming to use.

Study: Electronic template was too inefficient.

Act: Senior resident and QI team decided to ADAPT the form by creating a shorter version to try.

PDSA Cycles

PDSA Title: Evaluate a simpler EMR Template

Plan: Write and load a new and simpler form into EMR; use it for 5 days; evaluate perceptions about its utility.

Do: The template’s author tried it with one patient; found it was still too cumbersome.

Study: Electronic template was too time-consuming to use.

Act: Senior resident and QI Team decided to ABANDON designing an EMR template, and to continue using CQN form or an alternative.

PDSA Cycles

PDSA Title: Using Asthma Control Test (ACT) in conjunction with CQN form (paper version) and document ACT score in the EMR problem list.

Plan: Implement use of ACT form and document score.

Do: Put ACT and CQN on one sheet of paper; distribute to asthmatic patients. Have provider add ACT score to the EMR problem list.

Study: ACT form distributed, but score not reliably entered in EMR problem list. 4/11 were entered into EMR.

Act: ADAPT. Further educate MDs to document ACT score in EMR problem list.

PDSA Cycles

PDSA Title: Educating MDs on documenting ACT scores.

Plan: Educate MDs to document ACT scores on the EMR problem list.

Do: Educate MDs at monthly division meeting and weekly residents’ continuity conferences.

Study: Increased compliance, but found difficulty in accessing score in EMR problem list. 8/10 ACT scores entered.

Act: ADAPT. ACT scores not easily viewed in EMR problem list. Noticed if ACT scores documented in details section of problem list, ACT scores were easily viewed.

PDSA Cycles

PDSA Title: Documented ACT scores easily viewed in EMR

Plan: Educate MDs to document ACT scores in the details section of EMR problem list.

Do: At monthly staff meeting, QI team educated MDs where to document ACT scores in EMR.

Study: Scores easily viewed in EMR. Increased compliance. 10/11 ACT scores entered. Staff is engaged in this process!

Act: ADOPT!

PDSA Cycles

PDSA Title: Develop Asthma Action Plan for EMR

Plan: Develop Asthma Action Plan for EMR

Do: EPIC Physician Champion and CQN QI MD will develop an asthma action plan in our EMR and roll out in our practice.

Study: Personalized asthma action plan documented in EMR, but unable to give asthma action plan to patient at end of clinic visit.

Act: ADAPT. Need to find a process to give patients asthma action plans at end of clinic visits.

PDSA Cycles PDSA Title: Asthma Action Plan in After Visit Summary (AVS)

Plan: Using a dot phrase, asthma action plans will be placed in AVS “patient instruction’s section” of EMR, so patients can receive personalized asthma action plans at the end of their clinic visits.

Do: Educate MDs in practice to implement above plan and elicit feedback.

Study: Feedback is positive. Asthma action plans being distributed at clinic visits, but we need colored printers for patients to identify which zone they are in (green, yellow or red).

Act: ADAPT: Submitted request for colored printers and waiting approval from administration.

TEST 1What: Create EMR templateWho: for MD useWho: QI residentWhere: ClinicWhen: 10/8

P D

S A

TEST 2What: Simpler EMR templateWho: for MD useWho: Senior clinic residentWhere: ClinicWhen: 10/15

P D

S A

EMR Template Validated Instrument Validated Instrument - continued

PDSA Ramps

TEST 1What: CQN EMRWho: Resident Who: Sr ResidentWhere: EMRWhen: 10/19 to 10/23

P D

S A

TEST 2What: CQN EMR #2Who: Sr. ResidentWho: Sr. ResidentWhere: EMRWhen: 11/2 to 11/6

P D

S A

TEST 3What: ACT FormWho: Clinic StaffWho: MDsWhere: ClinicWhen: 3/22 to 3/30

P D

S A

TEST 4What: Educating MDsWho: MDsWho: QI TeamWhere: ClinicWhen: 3/31 to 4/7

P D

S A

TEST 5What: Document ACT scoreWho: MDsWho: MDsWhere: ClinicWhen: 4/8/ to 4/14

P D

S A

TEST 1What: Asthma Action Plan in EMRWho: EPIC MD Champion andCQN QI MDWho: MDsWhere: Clinic/EMRWhen: 2/1 to 3/11

P D

S A

TEST 2What: Asthma Action Plan in AVSWho: Patients with asthmaWho: MDsWhere: ClinicWhen: 3/12 to 3/18

P D

S A

Asthma Action Plan

PDSA Ramps

Office Flow Document

Copy of Our CQN Encounter Form

Copy of Our CQN Encounter Form

Copy of Our CQN Encounter Form

Other

• ACT forms are available in Spanish

Key Learnings that include Barriers and Successes

1. Our practice isn't as good at providing asthma care as we thought we were, but we are improving with our participation in this QI project.

2. A registry is a critical component of improving care to a population. Our EMR does not support a registry at this time.

3. A large and very complex social structure, such as an academic medical center, provides both support for, and challenges to, quality improvement.

4. Despite the challenges, our practice can do meaningful QI studies.

Future Plans

1. Implement spirometry use in our practice.2. Implement TRACK form to our younger

population in our practice.3. Create a document flow sheet in EMR to

record, track, and trend ACT scores.4. Continue to explore possibilities of

developing a registry within our EMR.