Transcript Huntsville Pediatric Associates Team Members

Chapter Quality Network (CQN)
Asthma Pilot Project
Team Progress Presentation
State Name: Alabama
Practice Name: Huntsville Pediatric
Associates
Team Members: Katie Gunter, MD
Cathy Radzinski, LPN, BBA
Robin Riggs, Practice Manager
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 Summary Since
Learning Session 1
•Asthma pt’s identified through report run in practice management
system
•All 7 physicians entering Data into EQIPP monthly
•Protocols implemented for phone triage nurses regarding
influenza vaccination, medication refills and follow-up
OV for asthma patients
•Asthma action plan written and installed on EVERY
desktop in patient areas
•All nursing staff trained in use of spirometry machine
•Report run in practice management system to ID asthma
pt’s needing spirometry (criteria=>5 yrs of age and no
spirometry in past 12 months)
•Researched registry options. Currently working with RMD
to implement registry at HPA
Refinements: add HPA logo to form and make
available to all doctors
Next cycle: Develop workflow to have handout
distributed by nurse to parent before Dr. enters
exam room to improve efficiency.

Completed analysis
Compare to predictions:
Does add time.
Is easy to incorporate.
By doing encounter form parents realize child’s
control better; identifies areas of confusion with
management
Encounter form itself easy to use and important in
identifying patient’s with suboptimal asthma
control. Need to develop better way to get the form
to parents sooner in the visit to improve efficiency

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PDSA
Act
Plan
Study
Do
•Implement use of encounter form
•Questions:
•Will it take too much time?
•Will parents understand it?
•Will it be easy to incorporate?
•Will it provide better care?
•Predictions:
•Will take significant time to
incorporate into visit.
•Parents will understand the
form.
•Who/What/When: Dr. Gunter to use on
asthma patients in both WCC and sick
visits
Dr. Gunter using encounter form
Experience: Easy to use
Problems: does add approx 5 min to
each visit
Surprises: parents like it
Collecting data and entering in
EQIPP; begin analysis


Refinements: have type-in option on action plans
for those patients with special instructions/unique
meds etc
Next cycle: incorporate action plan into EMR (for
now, scan in forms to chart).

Completed analysis
Compare to predictions:
Does add time.
Is easy to incorporate.
By giving action plan parents feel more
comfortable with what to do at home and when to
call office
In discussing the plan with parents, able to
identify areas of confusion with management

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Phone nurses notice parents refer to their action
plan during calls

PDSA
Act
Plan
Study
Do
•Provide updated action plan to patient
at every encounter
•Questions:
•Will it take too much time?
•Will parents understand it?
•Will it be easy to incorporate?
•Will it provide better care?
•Predictions:
•Will take time to create each
action plan and explain it to
parents.
•Parents will feel more
comfortable with asthma
management.
•Who/What/When: Dr. Gunter will create
action plan template with the assistance of
other MDs in the practice. All MDs will
then use the action plan template and
distribute plans at all asthma pt
encounters.
Dr. Gunter created action plan
template
Experience: Easy to use
Problems: does add approx 5 min to
each visit. Need to adjust drop down
options within the template
Surprises: parents like it and find it
very helpful
Collecting data and entering in
EQIPP; begin analysis

Refinements: would like spirometry and EMR to
communicate with each other

Completed analysis
Compare to predictions:
Nurses comfortable with performing
spirometry.
Is easy to incorporate (especially with
scheduling spirometry in “shot clinic”
(Does not need to be seen by MD for
spirometry to be conducted).
Spirometry useful in assessing patients with
unclear diagnosis/ identifying control in some who
are unclear of their symptoms

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PDSA
Act
Plan
Study
Do
•Every asthma patient should have
spirometry done within the last year if
age appropriate
•Questions:
•How will this fit into office
visit?
•Will it help in assessment of
asthma control?
•Who will conduct spirometry
testing?
•Predictions:
•Not all nurses comfortable with
spirometry
•Will help in assessing asthma
control in some patients
•Results will be useful in
explaining asthma control with
families (ie. The need for
preventative meds)
•Who/What/When:
•Nurse identifies whether or not
spirometry done within the last
year.
•MD responsible for scheduling
spirometry (at that visit vs at
future time)
Workflow designed to capture those
in need of spirometry
Experience: nurses all instructed on
spirometry
Problems: no interface between
spirometry and EMR. Requires
entering data manually
Surprises: MANY patients in need of
spirometry
Collecting data and entering in
EQIPP; begin analysis

Refinements: make sure all MDs have handouts
readily available to ensure use (ie. Put on desktops
and at nurses station).

Completed analysis
Compare to predictions:
Does add time to visit.
Is easy to incorporate.
Parents appreciative.
Phone nurses note parents seem more
confident in understanding symptoms and
control.
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PDSA
Act
Plan
Study
Do
•Provide more education to parents to
help with understanding and
compliance
•Questions:
•Will this take too much time?
•Will it help with overall asthma
control?
• What areas of education are the
most useful?
•Predictions:
•Will add time to visit (<5min)
•Will help with compliance and
subsequently asthma control
•Who/What/When:
•MDs to review several different
education handouts and choose
those which are the most
relevant.
•MDs to distribute as indicated
MDs selected handouts and started
distributing
Experience: different MDs using
different handouts (based on
preference)
Problems: not all MDs using
handouts consistently
Surprises: parents seem receptive to
the education
Collecting data and entering in
EQIPP; begin analysis

PDSA Ramps
P D
S A
TEST 1
What:CQN Encounter Form
Who (population):asthma pts
Who (executes): Dr. Gunter
Where:HPA
When:Sept. 23, 2009
CQN Encounter Form
S A
TEST 3
What:Blank Asthma Action Plan installed for
MD’s to “fill in blanks” on their own (can choose from
this or drop-down version)
Who (population):asthma pts
Who (executes):MD’s
Where:clinic
When: well or sick visits
P D
S A
S A
S A
S A
S A
P D
P D
P D
P D
TEST 3
What:Spirometry schedule
Who (population):asthma pts.
Who (executes):MD/nurses
Where:immunization clinic
When: schedule q day 9a or 1:30 p
in immunization clinic
TEST 3
What:Encounter Form-Entering Data
Who (population):MD’s
Who (executes):MD’s
Where:HPA
When:By Equipp Deadline
TEST 2
What:Revised Encounter Form
Who (population):asthma pts.
Who (executes): ALL 7 MD’s
Where:HPA
When:Oct. 1, 2009
P D
TEST 2
What:Spirometry
Who (population):asthma pts.
Who (executes):nurse with MD orders
Where:Treatment Room
When:at sick or well visit
TEST 2
What:Asthma Action Plan Word Doc with drop down
installed on all MD Desktops
Who (population):asthma pts.
Who (executes):all MD’s
Where:clinic
When:Beginning 10/15/2009 sick visit
P D
P D
S A
S A
TEST 1
What:Train Nurses in use of machine
Who (population):Clinical Nursing Staff
Who (executes):Cathy Radzinski, Teri Franklin
Where:Treatment Room
When:Jan. 17, 2009
Spirometry
TEST 1
What:Develop office Asthma Action Plan
Who (population):asthma pts.
Who (executes):Asthma CQN Team
Where:Dr. Gunter clinic hours
When: October 1, 2009
Asthma Action Plan
Huntsville Pediatric
Associates
Asthma Encounter Workflow
Pre-Visit
Run report in Practice
Management to find
asthma pts. Who are in
need of flu shot and have
not had an OV in past 6
mos.
Difficulty d/t # of
asthma pts.
Call these patients
and schedule for
flu shot and/or
follow-up asthma
visit
Phone Nurses to
follow Asthma
Protocol
Access Asthma
Action Plan in
Imaging to assist
in triage
Visit
Nurses not
always
catching
asthma
patients at
visit
Post Visit
Asthma Patient
identified by nurse
during office visit.
Asthma Action
Plan given to
patient
Asthma Encounter
Form given to
parent/patient to
complete patient
section of form
Flu Vaccine
offered (if
applicable)
Nurse checks form
for completeness
Form is put in
exam room door
for Dr.
2 copies are
printed
One for patient
and one to be
scanned into EMR
Nurses and Physicians
remember to add Asthma to
problem list if patient is
asthmatic.
Physicians please classify
asthma severity.
Asthma Action
Form is completed
(with medication
adjustments if
needed)
Physician orders
Spirometry if
needed.
CPT codes:
94010 for first
94060 for second
Nurses and MD’s
need to do better at
listing “asthma” to
problem list
Not all asthma
pts. have action plan
Refill medications,
schedule follow-up
office visit and/or
immunization if
indicated
Nurse schedules
asthma recheck
appt.
Physician fills out
Physician section
of form
Phone call nurses
can access scanned
copy of Asthma
Action Plan to assist
in triage
Physician keeps
completed
encounter forms in
folder at desk
Physician pulls 5
encounter forms
and enters data
into EQIPP
monthly
Data is reviewed
by the practice
during monthly
meeting
Huntsville Pediatrics CQN
Encounter Form
F:\Patient Asthma Questionnaire
CQN Encounter Form 2010.rtf
Key Learnings
 Reassessing and revising asthma action plan and
workflows to maximize compliance and asthma
control.
 The importance of scheduling follow-up visits for
asthmatic patients.
Barriers and Successes
Barriers:
• Time required to learn and follow workflows.
• Identifying and following up with EVERY asthma patient.
• EMR lacks adequate reporting functionality and does not
interface with our spirometry machine.
Successes:
• Increase spirometry use.
• Full buy-in on use of CQN Encounter Form by all seven
physicians at HPA.
• Full participation by these seven physicians in data
gathering and creation of PDSA’s.
Other Information
• Improve on distribution of educational materials
for asthma patients at every visit. In particular:
-asthma triggers
-using inhalers correctly
• Need more frequent review on asthma care and
management with nursing staff.
Future Plans
• Implement registry to assist in tracking asthma
patients.
• Improve asthma education by providing
additional information regarding asthma,
triggers, and management of symptoms.
• Purchase new EMR that will contain registry
functions, enable practice to write their own
templates and interface with spirometry
machine.
• Continue PDSA cycles in respect to workflows.