Measurement and Reporting

Carrie Phillipi, MD, PhDAsthma Expert

&Laura Conley, MHSA

Quality Improvement Consultant

I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or

provider of commercial services discussed in this CME activity

Objectives1) Share principles for monthly reporting

and data sharing2) Discuss the major components of the

reporting process3) Review the flow of monthly data

Principles for Monthly Reporting Data Sharing

• Data Transparency• Practice coaching• Data is a tool to measure

performance!

Data Collection Components• EQIPP Asthma Module (designed

for the CQN project)• Practice Narrative Report

Asthma EQIPP Module

What is EQIPP• Launched in 2002• Robust Quality Improvement educational

program– Evidence-based– Translates research into practice– Weaves QI principles with clinical content – Interactive and action oriented

3 SECTIONS Overview

Course landing page

Provides course goals and objectives

Lists Key Clinical Activities

Links to key areas within the course (Helpful Links)

3 SECTIONS Improvement

Activities Enter Baseline Data Analyze Measures Aims & Changes

Create Improvement Plan

Enter Follow Up Data

3 SECTIONS Learning

EQIPPment QI Basics Key Clinical Content Case Studies Team Learning Tools

Typical User Flow

Overview

QI Basics

Collect Baseline Data

Analyze Results

EQIPP Comparisons

• Analyze Measures with your QI practice team

• Run Charts– Comparisons – Goal– Practice– Chapter – District– All CQN Subscribers

Run Charts for Collaborative Learning

Practice Level Data

P ercent of patients well controlled based on physicians use of NHLBI EP R3 Control Tables

0

20

40

60

80

100

August September October NovemberMonth

Practice: 240

Run Charts for Collaborative Learning

Practice Level Data Aggregate Across the Chapter

P ercent of patients well controlled based on physicians use of NHLBI EP R3 Control Tables

0%20%40%

60%80%

100%

August September October November

Month

Perc

enta

ge

Chapter Name: Alabama Chapter

Practice NarrativeProject management tool to inform

chapter teams of each practice’s progress on the key changes

Engagement of the Asthma Core Team Use of a registry to manage a population Planned care Employ protocols Provide self-management support

Monthly TimelineBeginning of Month Mid Month End of Month

EQIPP Data Set OpensEnter a minimum of 5 patient visits

Month Practice Conference Call

Practice QI Team Meeting Can occur anytime during the month

Complete Practice Narrative

Important Dates• First data collection cycle closes

Friday October 16, 2009– QI basics and baseline data entry

should be completed• Data set closes the last business

day of each month• Feedback about data provided to

practices during monthly action call

Data CalendarOCTOBER 2009

Sun Mon Tue Wed Thu Fri Sat

1Oregon LS1

2Oregon LS1

3

4 5 6 7 8 9Reminder about data deadline is sent to chapter teams. Ohio LS1

10Ohio LS1

11 12 13 14 15 16Deadline for submission of data (data deadline)

17

18 19 20 21Chapter Leadership Group Conference Call

22 23 24

25 26 27 28 29 30 31

Maintenance of Certification Part IV Requirements

Criteria for Individual Physician Participation:

• Complete data collection at the time of visit with an encounter form for decision support

• Review practice level data and practice level performance monthly

• Attend monthly practice quality improvement meetings

• On average enter a minimum of 5 patient visits per month in at least 7 of 10 data cycles

Maintenance of Certification Part IV Requirements

Criteria for practice involvement • Presence of a documented process map

that details reliable data collection at the time of the visit

• Established QI Team• QI team representation at all learning

sessions and monthly calls once enrolled in the project.

Achieve optimal care by year 1 for 70% of the sample population