Transcript PDSA Title

Chapter Quality Network (CQN)
Asthma Pilot Project
Team Progress Presentation
State Name: Ohio
Practice Name: Locust Pediatric Care
Group
Team Members:
Kay Rose, Jo Murray,
Lee Orin, Cooper White, David Baum, Holly
Ross, Beth Tenda
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
Optimal Care
Spirometry to establish
diagnosis
Spirometry scheduled or
obtained
Self-management
PDSA Cycles
PDSA Title: Encounter form implementation
 Plan: Provide encounter form and have completed by the time
provider sees the patient
 Do:
 Tracking with office flow education
 Education of front desk and MA staff
 Stickers
 Educating parents
 Study: Back desk tracking for compliance ~90%
 Act: Reformat and educate
PDSA Cycles
PDSA Title: Action Plan
 Plan: Improve understanding/utility of form
 Do: Redesign plan (maybe more of a task)
 Study: Survey patients (old vs new)
 Act: Patients preferred original form – reworked
original form to increase information while keeping
format the same
Failure Mode Effects Analysis
For each process step, list all potential solutions/ testable interventions.
Office flow
FAILURE MODES
CURRENT
PROCESS
INTERVENTIONS
Process Name _________________________________
Stickers
Problem
lists
Meds
Dx list
Self-ID
Change
front desk
procedure
Staff
education
Forms in
rooms
Pens &
clipboards
in rooms
Staff
education
Parent
education
Identify
charts
Encounter
form to
family
Form
completion
Stickers
ignored
No
stickers
Float
secretary
Medlist
ignored
Misssed
chances
to ID chart
Parent
resistance
Staff
resistance
Parent not
doing form
No form in
room
Literacy
Competing
priorities
Missing
pens &
clipboards
Flipcharts
in rooms
Provider
education
Form
discussion
Lack of time
Parent
resistance
Health
literacy
Training
Education
Written
pamphlets
Phone
education
Refills
Case Mgt
with
insurance
Education
self
reliance
No shows
Resistance
Time
Language
Literacy
Resistance
Contact
problems
List all potential reasons each process step might not work. In other words, list the points of failure.
PDSA Ramps
P D
P D
P D
S A
S A
S A
TEST 4
What:
Who (population):
Who (executes):
Where:
When:
TEST 4
What: Universal availability
Who (population): all asthma pts
Who (executes): MA, check in secretaries
Where: Front desk & exam rooms
When:Pre/during visit
TEST 4
What:
Who (population):
Who (executes):
Where:
When:
P D
P D
P D
S A
S A
S A
TEST 3
What:
Who (population):
Who (executes):
Where:
When:
TEST 3
What: Availability
Who (population): all asthma pts
Who (executes): MA, check in secretaries, providers
Where: Front desk, Triage, exam rooms
When: pre & during visit
P D
P D
P D
S A
S A
S A
TEST 2
What: Reexamine AAP
Who (population): Patients
Who (executes): Providers
Where: Exam rooms
When: Patient visits
TEST 2
What: Availability
Who (population): all asthma pts
Who (executes): MA
Where:Triage room
When: Triage
TEST 2
What:
Who (population):
Who (executes):
Where:
When:
P D
P D
P D
S A
S A
S A
TEST 1
What: improve action plan
Who (population): Patients
Who (executes): Providers
Where: Exam rooms
When: Patient visits
PDSA Title: Action Plan
TEST 1
What: Form Utility
Who (population): Sample asthmatics
Who (executes): Providers
Where: Exam room / work desk
When: Selected asthma visits
PDSA Title: Encounter form
TEST 3
What:
Who (population):
Who (executes):
Where:
When:
TEST 1
What:
Who (population):
Who (executes):
Where:
When:
PDSA Title
Office Visit
- Prework
During
Office Visit
Office Flow Process Map
Patient’s
charts
identified with
sticker.
Patient identified by provider
Forms in triage room.
Sticker identified at check-in
and asthma form given to
family to complete while
waiting to be roomed.
Unidentified patient given form
By MA during triage.
Forms in triage room.
Post Visit
Activities
Provider
completes
asthma info
form and
asthma action
plan.
Data entered into EQIPP by
available staff weekly.
Entered forms stored for
entry into registry when it is
available..
Scripts and Asthma Action Plan
given
Spirometry scheduled
Follow-up scheduled
Info form copied – one form to
chart & one to folder for data
entry
Provider discusses asthma form information
and helps family complete if necessary.
Provides education and assess need for
medications and spirometry.
Parent/patient
completes form
while waiting
for provider
Back desk Check-out:
Non-marked charts identified and
marked
RN provides
asthma
education as
needed
Forms checked for completeness
Incomplete forms returned to
providers for completion.
CQN Encounter Form
Note: You may have to go back in the patient chart to find this historical information. If the information is unavailable, check not documented.
12. Were one or more asthma key indicators present when considering the diagnosis of asthma? (refer to Box 3-1)
Office Use Only:
YES
Patient Name: ________________________________________
Date of Birth: ____/____/____
Date of Visit: ____/____/____
YES
Provider Name:________________________________________
Well visit
Asthma Visit
NO
ENTER FIELD INTO
EQIPP #3
Not Documented
Note: You may have to go back in the patient chart to find this historical information. If the information is unavailable, check not documented.
13. Were lung function measures by spirometry used to establish the asthma diagnosis? (refer to Box 3-2)
Office Use Only:
NO
Age inappropriate, younger than 5 years
Other Sick Visit
Severe Persistent
This questionnaire is used to help your provider determine your child’s current level of asthma control. Please answer questions 1-11 on this page.
Your provider will discuss with you the results and how they relate to ongoing therapy.
Moderate Persistent
15. Is the patient on a controller medication?
Mild Persistent
Intermittent
YES
Started this visit
NO
If YES, does the patient/parent report using controller medications daily?
16. For patients who use rescue/controller inhalers, is a spacer utilized?
(Maxair® and dry powder inhalers do not require spacer)
1.
How many days of school/daycare has your child missed due to asthma in the past 6 months?
2.
How many work days have you or your spouse missed due to your child’s asthma in the past 6 months? _______ # of days
_______ # of days
3.
Has your child visited the Emergency Room or Urgent Care Center due to asthma in the past 12 months?
Office Use Only:
ENTER FIELD INTO
EQIPP #1
YES
NO
Office Use Only:
ENTER FIELD INTO
EQIPP #2
If yes, how many times? _______
PARENT SECTION
5.
How comfortable are you in your ability to manage your child’s asthma, rated on a scale of 1-10? (Please circle)
Not Comfortable =
6.
9.
4
5
6
7
8
9
10
= Very Comfortable
less than 1 time per day
1-3 times per day
4 or more times per day
not sure
spring
summer
fall
a little of the time
most of the time
3-4 times a month
more than once a week but not nightly
Often 7 times / week
11. How would you rate your child’s asthma control during the past month?
not controlled at all
poorly controlled
somewhat controlled
Not Well Controlled
Office Use Only:
ENTER FIELDS INTO
EQIPP #6A and 6B
Very Poorly Controlled
20 b. If “not well controlled” or “very poorly controlled”:
Did you identify reasons for lack of control? (Examples: exposure to allergens, tobacco smoke, indoor or outdoor pollutants and
irritants, nonadherence to medication regimen)
YES
NO
21. For patients age 5 years and older, is spirometry currently scheduled, or have results been obtained within the last 1 year?
(refer to Box 3-2)
Office Use Only:
ENTER FIELD INTO
EQIPP #7
YES
date____/____/_____
NO
Younger than 5 years
22. Have you used the age –appropriate NHLBI EPR-3 stepwise table to identify treatment options or to adjust therapy based on asthma
control? (refer to the Stepwise Tables 4-1a, 4-1b, 4-5)
Office Use Only:
ENTER FIELD INTO
EQIPP #8
NO
24a. Does the patient have a written asthma action plan?
YES
shot date: ___/___/_____
Patient younger than 6 months, other contraindications, or vaccine unavailable
completely controlled
YES
Office Use Only:
IF “YES” IN EITHER 12A
or 12B ENTER FIELD
INTO EQIPP #9
NO
24 b. If yes, was the plan updated as needed and reviewed with the patient and/or family at this visit?
YES
NO
Office Use Only:
ENTER FIELD INTO
EQIPP #10
25. 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 this visit? (Examples include correct medication techniques, avoiding environmental triggers, and getting help to quit
smoking. See Figure 3–13 in EQIPP, Delivery of Asthma Education by Clinicians During Patient Care Visits for more information.) Office Use Only:
YES
ENTER FIELD INTO
EQIPP #11
NO
26. Follow Up Visit: Return in: _____ weeks, or _____ months
well controlled
NO
23 b. If patient has not yet received a flu shot during the current season (Sept.-March), or if between seasons,
was the flu shot recommended?
YES
NO
all of the time
Over the previous 2 to 4 weeks, how frequently has your child experienced episodes of cough, shortness of breath, wheezing or reduced
activity due to asthma during the DAY?
2 or fewer days per week
more than two days per week but not daily
Daily
Throughout the day
2 or fewer times per month
Well Controlled
23a. If in active flu season (Sept.-March), was the flu shot administered?
10. Over the previous 2 to 4 weeks, how frequently has your child experienced episodes of cough, shortness of breath, wheezing or waking
up due to asthma at NIGHT?
2.
YES
3-5a, 3-5b, 3-5c, 4-2a, 4-2b, 4-6, 4-3a, 4-3b, 4-7)
NO-reason: _______________________________________
some of the time
NA
20 a. Physician assessment of control: What is the patient’s current level of control during the past month? (review the National
Heart, Lung, and Blood Institute (NHLBI) Expert Panel Report 3 (EPR-3) control tables (refer to the EPR-3 Control Tables
YES
during exercise
How often does asthma limit your child’s activities?
not at all
1.
3
When are asthma symptoms worse? (Check all that apply)
winter
8.
2
During the past week, how often did your child use a fast acting or quick relief medication, at times other than before exercise?
(includes Albuterol, Ventolin®, Proventil®, Xopenex®)
not at all
7.
1
PHYSICIAN SECTION
NO
If yes, how many times? _______
Has your child been admitted to the hospital due to asthma in the past 12 months?
NO
NO
18. Has the patient been seen by an allergist or pulmonologist during the last 12 months for assistance with asthma management due to
severity of illness? (refer to specialist referral criteria)
Specialist: ___________________________________
YES
NO
Referred this visit
Office Use Only:
19. Were validated questions used to determine the current level of asthma control
ENTER FIELD INTO
(if validated tool used or parent completed entire parent section, check “yes”)?
YES
NO
EQIPP #5
Not Applicable
YES
YES
YES
17. Has the patient received oral steroids for bronchospasm within the past 12 months?
Does not attend
4.
ENTER FIELD INTO
EQIPP #4
Not Documented
14. Asthma severity level: (refer to the EPR3 Control Tables 4-2a, 4-2b, and 4-6)
Return visit date (Optional): _____ / _____ / _____
Office Use Only:
If a follow-up visit was
scheduled ENTER FIELD
INTO EQIPP #12
This form was developed specifically for the AAP Chapter Quality Network Asthma Pilot Project and originally developed by the Physicians
Hospital Organization at Cincinnati Children’s Hospital Medical Center
Other
• Please add in any other information that you
think it important to communicate.
Key Learnings
 We are improving our care
 We are just short of 90% optimal care
 Spirometry rates are improving
 We have yet to see a meaningful impact on patient
outcomes, but expect to see this by December
Barriers and Successes
• Staff buy-in – has improved, but still with some
resistance
• Time
• In spite of the barriers, our care continues to
improve.
Future Plans
• Registry after EPIC is implemented
• We will be leaning heavily on our EPIC-literate
colleagues in the next several months