Transcript TEST 1

Oxford Pediatrics
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Summary of Progress
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Provider Education
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Implementation of Step-wise Approach for asthma
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A flip chart is now available in all exam rooms.
Standardization of Asthma Treatment within our
practice
Registry
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All our providers were educated regarding step-wise
treatment for asthma as well as specific use and indications
for all controller medications, spacers, and spirometry.
We have a paper list that is checked periodically and an alert
is placed on those patients charts.
CQN form
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All our providers our using our CQN form now.
Oxford Pediatrics
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Summary of Progress
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Asthma Action Plan
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Asthma Education Materials Adopted
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We have adopted an asthma action plan that is used for all
our patients.
We have created a template for our EMR and are testing that
template.
We have a five page handout that is given to every asthma
patient and reviewed at each visit.
We have a box of teaching tools available at each office.
Increasing Use of Spirometry
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We are using spirometry more frequently to assess our
asthma patients.
EQIPP data graphs-February Data
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ED visits
Hospitalizations
Optimal Care
Key asthma indicators
(graph below)
EQIPP data graphs-February Data
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Spirometry for dx.
Validated instrument used
to determine the current
level of control
Patients where a reason is
identified for poor control
Patients where spirometry
is scheduled or has been
used obtained in the last
1-2 years
Patients where the step
wise approach is used to
identify, adjust, and
maintain therapy.
EQIPP data graphs
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Flu shot
Asthma Action Plan
Self Management
Education Materials
F/u
recommendation
% of well
controlled patients
Oxford
Pediatrics
Key Driver
Diagram
Aim
From fall of 2009 to fall of
2010, we will achieve
measurable improvements
in asthma outcomes by
implementing the NHLBI
guidelines by making key
practice changes.
Key Drivers
Engaging
your
QI
Team and Your
Practice
Using a Registry
Using a Planned Care
Approach To
Ensure Reliable
Asthma Care in the
Office
Developing an
Approach to
Employing
Protocols
Providing Self
Management
Support
Interventions
We meet at least monthly.
We have entered data
regularly.
We have reviewed our data.
We have looked into a
registry.
We have developed our CQN
form and implemented it
into our office visits.
We have revised our asthma
action plan.
All our providers were educated
regarding the recommended
guidelines and stepwise
approach.
A laminated flip chart is available
in every exam room.
We have obtained patient
education materials.
We assess degree of control and
patient/family management
comfort at every visit.
PDSAs and Ramps
Educating Providers
Pla
n
Act
Plan
Act
Pla
n
Act
Do
Study
TEST 1
What: Educating providers
and getting “buy in”
regarding the asthma
project
Who (population): All
providers
Where: Drs. Meeting
When: Oct. 12
Who: CQN team
Results: There were lots of
questions regarding
guidelines, medications,
spirometry, etc.
Pla
n
Act
Do
Stud
y
Do
Study
TEST 1
What: Educating providers
regarding guidelines and
getting “buy in” regarding
the asthma project.
Who (population): All
providers.
Where: Drs. Meeting
When: Oct. 23
Who executes: CQN team
Results: Laminated chart
brought to meeting and
providers educated
regarding guidelines and
controllers. Charts placed
in all exam rooms.
TEST 2
What: Educating providers
and getting “buy in”
regarding asthma project.
Who (population): All
providers
Where: Drs. Meeting
When: Nov. 2nd
Who executes: CQN team
Results: Charts are helpful
Guidelines are clear. Need
more guidance regarding
spirometry. All providers
start using CQN form and
laminated chart guidelines.
Next PDSA ramp, obtain
spirometry guidelines.
Do
Stud
y
PDSAs and Ramps
Implement CQN form
Pla
n
Act
Plan
Act
Pla
n
Act
Pla
n
Act
Do
Study
TEST 1
What: Modify our existing
form
Who (population): CQN
team
Where: Oxford office
When: Oct. 12-13
Who: Terri-Asthma nurse
Results: new form did not
work-data difficult to enter.
TEST 1
What: Modify our CQN form
according to data entry
Who (population): CQN
team
Where: Oxford office
When: Oct. 14-15
Who executes: TerriAsthma Nurse and one
provider
Results: The form is easy to
use and it is much easier to
enter data.
Stud
y
Do
Stud
y
Do
Study
Do
TEST 2
What: Implement CQN form
Who (population): Expand
to three providers.
Where: Oxford and Ross
locations
When: Oct. 16-Oct. 22
Who executes: Three
providers
Results: Form is easy to
use but the patient form and
provider form don’t always
stay together and
sometimes get lost. Also, it
takes time to look up key
diagnostic criteria.
TEST 3
What: Revise Implemented
CQN form-parent form on
one side and provider form
on the other side.
Who (population): CQN
team
Where: :Oxford Office
When: Oct. 23-24
Who executes: Asthma
Nurse-Terri
Results: Now all the data is
in one place. Next PDSA
cycles are to add the key
diagnostic criteria to the
form and then implement
the new form.
PDSAs and Ramps
Implement CQN form
Plan
Act
Pla
n
Act
Pla
n
Act
TEST 1
What: Implement double
sided form.
Who (population): One
provider
Where: Oxford office
When: Oct. 25
Who: Terri-Asthma nurse,
One provider
Results: Forms are not
getting lost.
Stud
y
Do
Study
Do
Study
Do
TEST 2
What: Implement double
sided form.
Who (population): Two
providers
Where: Oxford and Ross
offices
When: Oct. 26-28
Who executes: TerriAsthma Nurse and two
providers
Results: The form is easy to
use, data is easy to enter,
and forms are not getting
lost.
TEST 3
What: Implement double
sided CQN form
Who (population): Expand
to all providers.
Where: All three locations
When: Oct. 30-Nov. 5th
Who executes: CQN team
Results: Amount of data
collected increased. Form
is easy to use and also
helps direct the asthma
visit.
PDSAs and Ramps
Implement CQN form
Plan
Act
Pla
n
Act
Pla
n
Act
TEST 1
What: Add key diagnostic
criteria to the form and
implement new form.
Who (population): One
provider
Where: Oxford office
When: Oct. 25
Who: Terri-Asthma nurse,
One provider
Results: It seems to save
time.
Stud
y
Do
Study
Do
Study
Do
TEST 2
What: Implement new form
with key diagnostic criteria
added.
Who (population): Two
providers.
Where: Oxford and Ross
offices
When: Oct. 26-28
Who executes: TerriAsthma Nurse and two
providers
Results: The form is easy to
use and now takes less
time.
TEST 3
What: Implement new form
with key diagnostic criteria
added.
Who (population): Expand
to all providers.
Where: All three locations
When: Oct. 30-Nov. 5th
Who executes: CQN team
Results: Amount of data
collected increased. Form
is easy to use and also
helps direct the asthma
visit.
PDSAs and Ramps
Standardize Use of Asthma Action Plan
Pla
n
Act
Plan
Act
Pla
n
Act
Pla
n
Act
Do
Study
TEST 1
What: Chose asthma action
plan
Who (population): All
providers
Where: Drs. Meeting
When: Oct. 12
Who executes: All providers
Results: A plan is chosen
TEST 1
What: Implement asthma
action plan
Who (population): all
providers
Where: all offices
When: Starting Nov. 1
Who executes: Asthma
nurse and all providers
Results: Number of asthma
patients with a AAP went
up, but it was not 100%.
Stud
y
Do
Stud
y
Do
Study
Do
TEST 2
What: Implement asthma
action plan for all patients.
Who (population): All
patients
Where: all offices
When: Jan. 4th
Who executes: All providers
Results: Numbers
improved but patients with
mild asthma (only on
albuterol) were not getting
AAPs. It was difficult to
document in the EMR. It
requires scanning.
TEST 1
What: Implement AAP
template in EMR
Who (population): Charge
nurse
Where: Oxford office
When: April 8th
Who executes: One
provider
Results: It works but needs
revision. Still missing some
medications. Symptoms
are used more than peak
flows so they need to be
emphasized.
PDSAs and Ramps
Standardize Use of Asthma Action Plan
Pla
n
Act
Plan
Act
Pla
n
Act
Pla
n
Act
Do
Study
TEST 2
What: Implement revised
AAP in EMR
Who (population): Charge
nurse
Where: All offices
When: April 12th
Who executes: Charge
nurse
Results: AAP is improved
but is still missing
medications.
Do
Study
Next PDSA cycle, review
form at provider meeting
and discuss further
changes.
Do
Stud
y
Do
Stud
y
Office Visit Prework
During Office
Visit
Asthma patient identified in “Alert” area of
EMR for all patients on Registry
Data Collection form, Asthma Action Plan, &
Teaching materials placed with Patient
Route slip
Medical Assistant interviews
family and gives form to
previously identified asthma
patients and any newly
identified possible asthma
patients
Office Flow Diagram – Oxford Pediatrics.
-Missed opportunitiespatients not on asthma
list or who come for
another reason.
-Forms not placed with
route slip
Patient and family complete
Question 1-12 Patient Data
Collection form
Provider
reviews form
with family,
discusses
asthma
including
management
and
educational
materials
Post Visit
Activities
Time constraints
depending on visit type.
Provider completes EQUIPP portion
of Asthma Data Collection
Incomplete forms
Both forms
reviewed by
Asthma Nurse
Coordinator and
entered into
EQUIPP
Forms
scanned into
EMR
New patients
placed on
registry
Asthma
Action Plan
completed,
copies of
plan and
educational
materials
given to
family for
school or
caregivers
Patient
scheduled for
follow up visit and
spirometry
Time and staffing
constraints for
spirometry
FAILURE MODES
CURRENT
PROCESS
INTERVENTIONS
Oxford Pediatrics Asthma Project Process
-clinical alert
box
-past medical
and family
history forms
-symptom
history
Identify
patients
-Failure to
check
the
asthm
a list
-Failure to
check
the
clinical
alert
box
-Patients
come
in for
anothe
r
proble
m and
-signs regarding
our asthma
focus placed in
waiting rooms
-MA’s encourage
families to
-form
introduced at
doctor’s
meeting
-forms
placed on
chart
-forms
placed in
exam rooms
-MA training
-Materials
available
in every room
-Asthma folders
in every room
-asthma
folders
in every
room
-MA training
Asthma materials
placed with chart
MA’s give
patients form
Family/patient
complete form
Provider reviews
form with family
-materials
not
copie
d
-MA
forge
ts to
place
mater
ials
with
route
slip
-Patients
come
in for
anoth
er
proble
m and
we
miss
an
opport
unity
to
review
asthm
a care
-Family
refus
es
-Family is
focus
ed on
other
probl
ems/
conce
rns
-Form is
not
retur
ned
to MA
-Family
come
s in
for
anoth
er
probl
em
and
provi
der
forge
ts.
-Provider
is
time
complete forms
-AAP placed
with route
slip
-AAP available
in every room
Asthma Action
Plan done
-not
-not
-
alway
s
place
d on
chart
availa
ble in
every
room
cumb
erso
me
proce
-F/u is
part of
CQN form
-F/u is part
of route
slip
F/u scheduled
-providers
forgo
t to
reco
mme
nd an
appoi
ntme
nt
-parent
does
not
sched
ule
befor
e
FAILURE MODES
CURRENT
PROCESS
INTERVENTIONS
Oxford Pediatrics Asthma Project Process
-CQN form
used for visit
-nurses
trained for
spirometry
Spirometry
scheduled
-Front desk
fails to
ask
parent
s to
sched
ule
-Only
availa
ble in
one
office
-patients
can’t
cooper
ate
-patients
don’t
-form is on
-box in
back of patient
each office
form
-asthma nurse
-form
tracks down
collection
providers
boxes in
for incomplete
all offices
forms
Provider
completes
EQUIPP portion
of form.
Forms
reviewed
by asthma nurse
-form EQUIPP
friendly
-there is a
scan folder
Data entered
Into EQUIPP
-form
someti
mes
not
placed
in
collecti
on box
-form not
always
fully
filled
out
-sometimes
unable
to
assign
form
to a
provid
er
-Front
desk
assigned
to scan
forms
some
times
unabl
e to
assig
n
form
to a
provi
der
Forms scanned
Into EMR.
-
Some
times
forms
don’t
make
it
back
to
scan
pile
after
data
entry
-we have
an asthma list
New patients
placed on
asthma list.
-asthma
list is
not
updat
ed
-registry
is
costly
-registry
is
time
consu
ming
to
maint
ain
Key Learning
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The process of measuring requires
standardization.
The process of coming together does open
avenues for change.
Small tests of change are important.
Spirometry may or may not be useful.
Future Plans
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Attempt to standardize use of spirometry
Investigate ways to improve spirometry
techniques
Research options for a registry