CQN Team Presentation

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

• Policy for incorporation of CQN form at every visit for patients with asthma

• Simplified process for generating asthma action plans in EMR

• Multiple revisions of office flow diagram to improve reliability

• Monthly reliability reports given to MDs and nursing staff

• Designed asthma education sheet to be given to all asthma patients at every visit

• EMR report generated by IT department of all patients in practice who have been prescribed a controller medication for asthma

• EMR report requested from IT department of all patients in practice who have a diagnosis of asthma

Optimal Care

Use of Validated Tool

Asthma Action Plan

Asthma Education

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

CQN Form Asthma Action Plan Education Handout

PDSA Ramps

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

YES

Dur

ing

Off

ice

Vis

itP

ost

Vis

it A

ctiv

itie

s 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 Pull list of asthma patients from EMR every 3months. If no form on file, letter sent to home

to schedule asthma appointment.

OFFICE FLOW DIAGRAM

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

reconciliation, MA/RN asks

parents questions #1-10

and enters responses into medical record

Patients ID by signal lights in EMR, stickers that ID patients (go on the sheets, physician

questions)

Parent/patient education

handout given

PFT/ spirormetry ordered if needed

YES

Nurse Leader checksform to see if f/u appt

recommended

NO

YES

Nurse Leader checksEMR to see apptwas scheduled

YES

NONurse leader gives name

to PSR to call and schedule

appt

Pre

Vis

it

CQN Encounter FormParent

• 1. Has your child visited the ER or urgent care due to asthma in the past 12 months? {YES (DEF)/ NO:2058::"Yes"}

• 2. Has your child been admitted to the hospital due to asthma in the past 12 months? {YES (DEF)/ NO:2058::"Yes"}

• 3. How many days of school/daycare has your child missed due to asthma in the past 6 months? {NUMBER:30898}

• 4. How may work days have you or your spouse missed due to your child's asthma in the past 6 months? {NUMBER:30898}

• 5. How comfortable are you in managing your child's asthma, rated on a scale of 1-10 (1=not comfortable, 10=very comfortable)? {NUMBER:29773}

• 6. During the past week, how often did your child use a fast acting or quick relief medication at times other than before exercise? {ALBUTEROL USE:70290}

• 7. When are your child's asthma symptoms the worst (select all that apply)? {TIMING-ASTHMASX:70291}

• 8. How often does asthma limit your child's activities? {ACTIVITY IMPACT:70292}• 9. Over the previous 2-4 weeks, how frequently has your child experienced episodes

of cough, SOB, wheezing or reduced activity due to asthma during the DAY? {FREQUENCY DAY SX:70293}

• 10. Over the previous 2-4 weeks, how frequently has y our child experienced episodes of cough, SOB, wheezing or waking up due to asthma at NIGHT? {FREQUENCY NIGHT SX:70295}

• 11. How would you rate your child's asthma control during the past month? {ASTHMA CONTROL:70296}

CQN Encounter FormProvider

• Has your child visited the Emergency Room or Urgent Care Center due to asthma in the past 12 months? Yes No

• Has your child been admitted to the hospital due to asthma in the past 12 months? Yes No If yes, how many times? ________

• Were one or more asthma key indicators present when considering the diagnosis of asthma?Yes No Not documented

• Were lung function measures by spirometry used to establish the asthma diagnosis?Yes No Age inappropriate, younger than 5 years

• Was a validated instrument used to determine the current level of asthma control? Yes No

• What is the patient’s current level of control during the past month?Well controlled Not well controlled Very poorly controlled6b: If “not well controlled” or “very poorly controlled”:

• Did you identify reason(s) for lack of control? (Examples: exposure to allergens, tobacco smoke, indoor or outdoor pollutants and irritants, non-adherence to medication regimen)

Yes No• Is spirometry currently scheduled or have results been obtained within the last 1 or 2 years?

Yes No Age inappropriate, younger than 5 years• Have you used the age-appropriated NHLBI stepwise table used to identify treatment options or to adjust therapy based on asthma

control? Yes No

• Has a flu shot been administered or recommended within the past 12 months?Yes No Patient younger than 6 months or contraindications

• Does the patient have a written asthma action plan? Yes No

• 10b. If yes, was the plan updated as needed and reviewed at this visit? Yes No

• Were asthma self-management education and materials (other than or in addition to the asthma action plan) provided and explained to the patient and family at any visit? Yes No

• Was a follow-up appointment scheduled to monitor asthma control? Yes No_____ Needs to schedule in ______ months_____ Already has upcoming appt scheduled

EMR Patient Lists

• In Feb, IT Department pulled list of all asthma patients who had been prescribed controller medications

• Letter sent to patients’ home requesting them to schedule asthma visit

• Utilizing list as tool in absence of availability/feasibility of registry

EMR Patient List

Letter to Asthma Patients

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

Barriers and Successes

• Barriers– Registry creation requires involvement of IT

department that is responsible for entire institution. Priority is low.

– Time

• Successes– Physician and nursing participation– Improved care for our patients

Future Plans

• Continue monthly audits to improve physician and nursing reliability

• Follow up letters or phone calls to patients on controller medications who did not respond to initial mailing re: asthma follow up appointment

• Letters to be sent to all asthma patients in September for flu vaccine

• Follow up letters to asthma patients 1st week of December if has not had flu vaccine

• Continue to use EMR generated lists for identification of asthma patients if unable to utilize registry function within EMR