Transcript CQN Team Presentation Kim Giuliano, MD Sharon O`Brien, MA

CQN Team Presentation
Kim Giuliano, MD
Sharon O’Brien, MA
Ivana Wilson, Medical Secretary
Version 2.0
CQN Asthma Project Practice Key Driver Diagram
Key Drivers
GLOBAL CQN AIM
We will build a sustainable quality
improvement infrastructure within our practice
to achieve measurable improvements in
asthma outcomes
Specific 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
Interventions
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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
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
PDSA Ramps
P D
P D
P D
S A
S A
S A
TEST 3
What:: EMR Asthma Action Plan
using “dot phrase”
Who (population): all asthma pts
Who (executes): all MDs
When: 11/6/09
TEST 3
What:: Expansion of EMR form
Who (population): all asthma pts
Who (executes): entire office staff
When: week of 10/26/09
P D
P D
P D
S A
S A
S A
TEST 2
What:: Handouts given during
rooming process
Who (population): Giuliano pts
Who (executes): Sharon and
Carmen
When: week of 12/21/09
TEST 2
What:: EMR Asthma Action Plan
using “dot phrase”
Who (population): Giuliano pts
Who (executes): Giuliano
When: 10/30/09
TEST 2
What: EMR form
Who (population): Giuliano pts
Who (executes): Sharon O.
When: week of 10/19/09
P D
P D
P D
S A
S A
S A
TEST 1
What: CQN paper form
Who (population): 5 pts
Who (executes): Giuliano
When: 2 clinic sessions in Oct
CQN Form
TEST 1
What: EMR Asthma Action Plan
using letter template
Who (population): Giuliano pts
Who (executes): Giuliano
When: week of 10/26/09
Asthma Action Plan
TEST 3
What:: Handouts given during
rooming process
Who (population): all patients
Who (executes): RNs and MAs,
MDs if not completed prior
When: week of 1/11/10
TEST 1
What:: Handouts given when
verbal teaching not done
Who (population): Giuliano pts
Who (executes): Giuliano
When: 12/1409
Education Handout
Pre Visit
During Office
Visit
OFFICE FLOW DIAGRAM
Patients ID by signal lights in
EMR, stickers that ID patients
(go on the sheets, physician
questions)
MA/RN rooms pt.
If asthma med
noted during
medication
reconciliation,
MA/RN asks
parents
questions #1-10
and enters
responses into
medical record
MA/RN puts
revised CQN
form with
provider only
questions on top
of patient
identification
sheet
During the visit the
physician fills out
the provider
form while having
Informed clinical
Discussion
Questions 11-27
Patient is
ready to
be seen
by
Physician
Patient with
new
diagnosis of
Asthma, form
is pulled and
filled out
concurrently
YES
NO
PFT/ spirormetry
ordered if
needed
Parent/patient
education
handout given
Post Visit
Activities
YES
Nurse Leader removes
encounter form and
verifies for
completeness
NO
NO
Nurse Leader checks
form to see if f/u appt
recommended
YES
All necessary
information on
the form is
entered into
EQIPP by
medical
secretary
If necessary
circle back with
physician or
patient family by
phone to obtain
missing
information
Paper copy
kept on file at
secretary’s
desk
YES
Nurse Leader checks
EMR to see appt
was scheduled
NO
Nurse leader
gives name
to PSR to call
and schedule
appt
Completed
form returned
to asthma
form
collection tray
Physician
completes
the form
immediately
after the visit
Pull list of asthma patients from EMR every 3
months. If no form on file, letter sent to home
to schedule asthma appointment.
CQN Encounter Form
Parent
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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)? {TIMINGASTHMASX: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 Form
Provider
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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 controlled
6b:
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, nonadherence 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 “buyin”
 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