Upload
hesper
View
32
Download
3
Embed Size (px)
DESCRIPTION
State Name: Oregon Practice Name:PHMG-Barger Pediatrics Team 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) - PowerPoint PPT Presentation
Citation preview
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