Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation

Chapter Quality Network (CQN)

Asthma Pilot Project Team Progress Presentation

State Name: OregonPractice Name:PHMG-Barger PediatricsTeam Members: Lorna Wong, MD, Paul Benda, MD, Tammy Barstow, MD, Heather Rutherford, CMA, Tonja Wells, RN, Michelle Dimitri, CMA, Jamie Brownlee, Cheryl Ivey, and Sandy Campbell, RN

Chapter Quality Network (CQN)

Asthma Pilot Project Team Progress Presentation

State Name: OregonPractice Name:PHMG-Downtown

EugenePediatricsTeam Members: Jeff Joehnk, MD, Chris Hammond, MD, Mary Miller, MD, Richard Hansen, RN, Debra Ard, RN, Dayle Martinez, CMA, Linda Himber, Blanca Quintero, and Sandy Campbell, RN

Chapter Quality Network (CQN)

Asthma Pilot Project Team Progress Presentation

State Name: OregonPractice Name:PHMG-Riverbend Pavilion

Pediatrics Team Members: Christine McKee, MD, Lauren Herbert, MD, Leslie Pelinka, MD, Fay Sunada, MD, Diane Citti, RN, Veronica Hernandez, LPN, Katie Salinas, CMA, Linda Brigleb, Gilma Vergara, and Sandy Campbell, RN

Chapter Quality Network (CQN)

Asthma Pilot Project Team Progress Presentation

State Name: OregonPractice Name:PHMG-South Eugene

Pediatrics Team Members:Jimmy Unger, MD, Debbie Fuerth, MD, Eileen Hanna, RN, Irina Gidenko, CMA, Sara Stout, RN, Virginia Nelson, Sherri Schor, and Sandy Campbell, RN

PeaceHealth Medical Group Pediatrics

We will establish and use sustainable We will establish and use sustainable quality improvement tools within our quality improvement tools within our practices to achieve measurable practices to achieve measurable improvements in asthma outcomes.improvements in asthma outcomes.

From fall 2009 to fall 2010 we will From fall 2009 to fall 2010 we will achieve measurable improvements in achieve measurable improvements in asthma outcomes by implementing asthma outcomes by implementing appropriate NHLBI guidelines, making appropriate NHLBI guidelines, making CQN Asthma Pilot Project’s key practice CQN Asthma Pilot Project’s key practice changes, and with the goal of potential changes, and with the goal of potential incorporation into the EMR.incorporation into the EMR.

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

PHMG QI Measurement points at 1 year, 2 years, and 3 years

•Asthma Action Plan in the EMR: 75% year one, 85% year two, and 90% year three.

•Flu vaccine given or recommended each year: 75% year one, 85% year two, 90% year three.

•Annual asthma checkup with evaluation using accepted asthma encounter form: 75% year one, 85% year two, 90% year three

•Asthma diagnosis marked appropriately on the problem list in the EMR: 75% year one, 85% year two, 90% year three

Asthma Action Plan in the EMR

Goal 75% year one, 85% year two, 90% year threeBaseline to now changes

Barger: 35% to 63%

Downtown Eugene: 100% to 90%

RiverBend Pavilion: 20% to 94%

South: 75% to 100%

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

visit – PHMG Barger Pediatrics

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

visit - PHMG Downtown Eugene Pediatrics

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

visit PHMG RiverBend Pavilion Pediatrics

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

visit - PHMG South Eugene Pediatrics

Flu vaccine given or recommended each year: 75%

year one, 85% year two, 90% year three.

Baseline to Now Changes Barger: 78% to 60% Downtown Eugene: 100% to 100% RiverBend Pavilion: 100% to 94% South: 83% to 100%

% of patients with asthma ages 6 months & older who have received a flu shot or flu shot

recommendation within the past 12 months – Barger Pediatrics

% of patients with asthma ages 6 months & older who have received a flu shot or flu shot

recommendation within the past 12 months – Downtown Eugene Pediatrics

% of patients with asthma ages 6 months & older who have received a flu shot or flu shot

recommendation within the past 12 months – RiverBend Pavilion Pediatrics

% of patients with asthma ages 6 months & older who have received a flu shot or flu shot

recommendation within the past 12 months – South Eugene Pediatrics

Annual asthma checkup with evaluation using accepted asthma encounter form

75% year one, 85% year two, 90% year three

Using our excel registry we will be able to monitor this in the coming years based on the patients we are seeing for

asthma encounters this year.

Asthma diagnosis marked appropriately on the problem list in the EMR

75% year one, 85% year two, 90% year three

• We began measuring this in January of this year

Our baseline and current measurements are:

•Barger: 76% and 100% •Downtown: 73% and 100%•RiverBend: 67% and 100%•South: 52% and 100%

Factors considered for optimal asthma care

• Was the parent/patient questionnaire used to determine the current level of asthma control?

• Was the age-appropriate NHLBI EPR-3 stepwise table used to identify treatment options or to adjust therapy based on asthma control?

• Has the patient received, or had recommended, a flu shot during this flu season?

• Does the patient have a written asthma action plan?

% of patients receiving optimal asthma

care PHMG Barger Pediatrics

% of patients receiving optimal asthma

care PHMG Downtown Eugene Pediatrics

% of patients receiving optimal asthma

care PHMG RiverBend Pediatrics

% of patients receiving optimal asthma

care PHMG South Eugene Pediatrics

Spirometry

PHMG Percentiles

% of patients ages 5 and older in which spirometry is used to establish an asthma

diagnosis – Barger Pediatrics

% of patients ages 5 and older in which spirometry is used to establish an asthma diagnosis – Downtown Eugene Pediatrics

% of patients ages 5 and older in which spirometry is used to establish an asthma diagnosis – RiverBend Pavilion Pediatrics

% of patients ages 5 and older in which spirometry is used to establish an asthma

diagnosis – South Eugene Pediatrics

Obstacles to implementing spirometry recommendations

• Physician’s perception that it rarely alters treatment recommendations

• Accessibility: for many families it means a separate appointment and another ½ day off work/school

• Result reliability: highly dependent on technique and age of patient – small offices don’t have the test volume and personnel to

guarantee reliability– Reliable results are more difficult to obtain on children less

than 8-10 years old

• Cost of obtaining high quality equipment to perform test

Our Spirometry Dilemma

Centralized testing:– Potentially more reliable results– Less expensive, but less accessible for

patientsDecentralized testing:- More accessible for patients- More expensive- Potentially less reliable results- Disruption of patient flow in busy

practice setting

Benefits of Spirometry

• Objective data

• Using routinely will promote better use of spirometry tool, more familiarity, and better results

• Can be an effective tool in distinguishing intermittent asthma from persistent asthma

What we learned from EQIPP data

1. Tipping point with the AAP. 2. Support of the team / meetings, important

for practice change3. Improved formalized use of a step-wise

approach to asthma care4. Shock value of formal data collection.5. Importance of processes. (refills, capturing

patients)

PDSA Cycles

PDSA Title: Encounter Form Completion

Plan: Encounter form will be completed prior to the provider entering the exam room

Do: engage & educate staff, identify patients, create poster for waiting rooms, get encounter form in Spanish

Study: Small sample to broader group

Act: slightly different at each site

TEST 1What: form completionWho (population)patient:Who (executes):PAS StaffWhere: Waiting roomWhen:at arrival

P D

S A

TEST 2What:form completionWho (population)patient:Who (executes)PAS or roomer:Where:in waiting room or exam roomWhen:at arrival or if missed, duringrooming process

P D

S A

TEST 3What:Who (population):Who (executes):Where:When:

P D

S A

TEST 4What:Who (population):Who (executes):Where:When:

P D

S A

TEST 1What: form completionWho (population):patientWho (executes):PAS staffWhere:in waiting roomWhen:at arrival

P D

S A

TEST 2What:form completionWho (population):patiientWho (executes):PAS or roomierWhere:in waiting or iexam roomWhen:at arrival or during rooming

P D

S A

TEST 3What:Who (population):Who (executes):Where:When:

P D

S A

TEST 4What:Who (population):Who (executes):Where:When:

P D

S A

TEST 1What:form completionWho (population)patient:Who (executes):PAS staffWhere:in waiting roomWhen:at arrival

P D

S A

TEST 2What:form completionWho (population):patientWho (executes):rooming nurseWhere:in exam roomWhen:during rooming process

P D

S A

TEST 3What:Who (population):Who (executes):Where:When:

P D

S A

TEST 4What:Who (population):Who (executes):Where:When:

P D

S A

Barger Downtown & RiverBend South

Encounter FormCompletion priorTo MD entering Exam room

PDSA Title: Collection of forms and data entry – test two

• PLAN: Collect encounter forms and enter data into excel registry, EQIPP, and EMR

• DO: engage & educate staff, designate a data entry person at each site, designated person collects forms and enters data

• STUDY: studied and successful

• ACT: adopted at all sites

PDSA Title: Collection of forms and data entry

• PLAN: Collect encounter forms and enter data into excel registry, EQIPP, and EMR

• DO: engage & educate staff, send forms by interdepartmental mail to primary administrator

• STUDY: forms inadvertently sent to medical records, forms left on provider desks, forms lost to the black hole of interdepartmental mail

• ACT: adapted

PDSA Title: completion of electronic asthma action plan

• PLAN: asthma action plan will be completed in the EMR on 75%, 85%, and 90% of patients seen with asthma over the course of the next 3 years

• DO: Physician will complete the AAP during the visit and give copy to patient

• STUDY: not enough time to complete this during visits other than asthma recheck appointments - not happening consistently

• ACT: adapted

PDSA Title: completion of electronic asthma action plan –

test two• PLAN: asthma action plan will be completed in

the EMR on 75%, 85%, and 90% of patients seen with asthma over the course of the next 3 years

• DO: Physician will either complete AAP electronically at time of visit or dictate AAP into note, give patient a handwritten version, and data entry staff will create electronic version during data entry process

• STUDY: studied and successful• ACT: adopted

PDSA Title: Increased rate of flu vaccine administration

• PLAN: Flu vaccine will be given or recommended to 75%, 85%, and 90% of patients with an asthma diagnosis in years 1, 2, and 3

• DO: flu vaccine clinics, flu vaccine capture with all visit types, call patients from registry or other high risk patient lists and schedule for vaccine

• STUDY: studied• ACT: adopted

PDSA Title: Increase number of patients receiving annual asthma check with use of accepted asthma

encounter form

• PLAN: Increase the number of asthma patients receiving an annual asthma check

• DO: increase number of patients on registry, appointments triggered by asthma med refill requests, use form during well child checks in patients with known asthma, include patients being seen for an illness visit with wheezing identified by either provider or rooming nurse

• STUDY: ongoing study being done• ACT: adapted encounter form to increase usage

by non-participating providers within all groups

PDSA Title: Asthma appropriately documented on the EMR problem list

• PLAN: 75%, 85%, and 90% of identified asthma patients will have an asthma diagnosis on the EMR Problem list in years 1, 2, and 3 respectively

• DO: updated by provider, updated by rooming nurse, updated by data entry staff

• STUDY: ongoing study• ACT: currently a combination of the above

is happening at each site. Study continues.

Process Maps

The CQN Encounter Form

• Too lengthy– Revamped form many times to shorten it

• Not user friendly– Suggestions of colleagues, participating and

non-participating

• Providers wanted a form they could score – incorporated the ACT into the form

Key Learnings page 1

Use of a formalized encounter form improved quality of asthma care (surprise – we thought we did a good job before)

Improved asthma quality of care due to standardization of care

Asthma handouts

AAP in EMR (useful for providers and staff)

Identifying and prevention of asthma triggers

Aerochamber use and education

Increased use of inhaled steroids

Change requires process change and engagement

Continued motivation of the entire team promotes teamwork and improves outcomes

Key Learnings page 2 Ongoing monitoring of any process

improvement is important to sustain change

Must set goals and have objective data to support

Implementation of the electronic Asthma Action Plan is easier than previously envisioned

Realization that it is necessary to allow more time to provide optimal asthma care (lengthening office visit time)

Coding appropriately for the visit (most can be 99214)

Other

• Feedback from all staff on how processes are working (participating and non-participating)

• Engaging non participating providers and staff in newly developed processes– Revised encounter form (numerous revisions

before settling on current form)– Change how form is delivered to patient (done

differently at each site)

Barriers

• Tedious, busy work• Registry cost prohibitive• Availability of spirometry in the office (cost, office

flow, clinical utility, accessibility, trained staff)• Time out of the office• Inertia to change• Difficulty of doing during short illness visits• Timing of narrative report makes it difficult to

meet with teams to answer questions appropriately

• Challenges of doing electronic Asthma Action Plan during routine office visit

Future Plans

• Continued engagement of providers and staff to provide optimal asthma care to our patients

• Improving feedback loop of data to providers and staff

• Ongoing monitoring of data for at least 3 years

• Finalizing education materials• Providing all materials in Spanish• Continued entry of data into EQIPP

Future Plans

• Presentation to QC to solicit funding for support of asthma care including formal registry and spirometry

• Revision of forms for hospital asthma admissions

• Consideration of online asthma questionnaires to allow automatic entry of information into a database

• Party for team at the end of project