Transcript Chapter Quality Network (CQN)

Chapter Quality Network (CQN)
Asthma Pilot Project
Team Progress Presentation
Ohio Chapter
Cleveland Clinic Foundation
Marymount/ Independence
Dr. Michelle Medina
Dr. Charles Davis
Dr. Richard So
Dr. Karen Vargo
Joyce Trusnik MA
Kathy Maclean LPN
Lynda Stamm LPN
Ginger Bassett LPN
Bridgette Vilella MA
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
Key Driver: Engaging your Asthma QI Team and
practice
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Team now composed of 4 doctors, 5 nurses and 1 PSR across 2 sites; have
all completed QI basics
Doctors have come on-board sequentially
Monthly meetings to discuss progress; regular communication by email
among team members
Progress Summary Since
Learning Session 1
Key Driver: Using a Registry to Manage your
Asthma population
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Patient Lists exist that may be used towards a registry
Asthmatics at the moment are being identified and surveyed as they come
in for appointments but not prospectively
At Marymount site, responsibility for maintaining list shared by doctor and
MA/RN
Progress Summary Since
Learning Session 1
Key Driver: Using a Planned Care Approach to
ensure Reliable asthma care in the office
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SmartSets developed within EMR (Epic)
Use of SmartSets not universal
MDs responsible for loading template within the visit---should MAs do this
as they room?
Asthma Smart Set
Progress Summary Since
Learning Session 1
Key Driver: Developing an approach to Employing
Protocols
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Use of MaineHealth asthma guidelines flip-charts universal
SmartSets incorporate stepwise guidelines and can be accessed in EMR
Use of protocols universally has not been tracked
Stepwise Guidelines within Smart Set
Progress Summary Since
Learning Session 1
Key Driver: Providing Self-management Support
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Online and paper materials available
Some nurses/MAs aware of materials and have a long history of using
them/ providing teaching
Not all nurses/MAs trained yet
Collaborative approach with patients is working, with anecdotal positive
feedback from families; systematic accounting of goal-setting and degree of
control achieved not yet in place
Optimal Asthma Care
Asthma Action Plan
Use of a Validated Instrument to
Measure Control
Stepwise Approach to Therapy
Flu Shot
Use of Spirometry
To Establish Diagnosis
Every 1-2 years
Asthma Complications
ED/ Urgent Care Visits
Hospitalizations
Well Controlled Asthmatics
PDSA Ramps
P D
P D
P D
S A
S A
S A
TEST 4
Track use of CQN form
All Asthmatic encounters
All MDs, RNs, MAs
Marymount & Indep office
Ongoing
P D
TEST 4
Track use of CQN form
All Asthmatic encounters
All MDs, RNs, MAs
Marymount & Indep office
Ongoing
P D
P D
P D
S A
S A
S A
TEST 3
Track use of CQN form
Pre-ID, New-ID, & Un-ID
Asthmatics
Dr. Medina, MA, RN, PSR
Marymount office
January- February 2010
TEST 3
Use CQN form in 5 visits
Pre-identified Asthmatics
Dr. Vargo, LPN
Independence office
March 2009
S A
TEST 2
Use CQN form in all visits
Pre-identified, newly-identified &
Unidentified Asthmatics
Dr. Medina, MA, RN, PSR
Marymount office
December-January 2010
TEST 3
Provide AAP from SmartSet
All Asthmatic encounters
Dr. Medina
Marymount
January – February 2010
P D
P D
S A
S A
TEST 2
Use CQN form in all visits
Pre-identified, newly-identified &
Unidentified Asthmatics
Dr. Davis, Dr. So, LPNs
Independence office
January 2009
TEST 2
Provide written asthma plan
Pre-identified, newly-identified &
Unidentified Asthmatics
Dr. Medina
Marymount
December – January 2010
P D
P D
P D
S A
S A
S A
TEST 1
Use CQN form in 5 visits
Pre-identified Asthmatics
Dr. Medina, MA
Marymount office
November 2009
Use of encounter forms
TEST 1
Use CQN form in 5 visits
Pre-identified Asthmatics
Dr. Davis, Dr. So, LPNs
Independence office
December 2009
Engage Independence in QI project
TEST 4
Provide AAP from SmartSet/EPIC
Templates
All Asthmatic encounters
All MDs
Marymount & Indep office
February- April 2010
TEST 1
Provide written asthma plan for
5 Pre-identified Asthmatics
Dr. Medina
Marymount office
November 2009
Asthma Action Plan
Reliability PDSA
Aim: To monitor the reliability of use of the CQN
Encounter Form in every visit with an Asthmatic
PLAN: ID every patient with hx of asthma in MD daily schedule and provide
them encounter form
DO: MA reviews history/problem list/ directly asks pt about asthma during
check-in; MA provides encounter form; MD/RN checks list of asthmatics
scheduled against #forms completed at end of the day
STUDY: Reliability increased over a period of 7 weeks as more doctors and
nursing staff added to study from 45% to 100%
ACT: Adopt identification of asthma in MA check-in procedure and recheck
sustainability of change in another few weeks
Reliability of CQN Form
100
90
80
70
60
50
40
30
20
10
0
% Reliability
Week Week Week Week Week Week Week
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5
6
7
Pre-Office
Visit
During Office
Visit
Office Work Flow – CCF Marymount/Independence
Scheduled asthma patients identified
daily (well visit, asthma follow-up visit)
by nurse leader; list generated and
note attached to appointment schedule
Identified asthma patient
arrives; MA rooms patient and
hands parent/patient asthma
patient questionnaire; MA
attaches provider questionnaire
to visit slip for MD
Post Visit
Activities
Patient identified with asthma
not previously noted (acute
visit, add-on visit, new
diagnosis of asthma); MD/MA
hands patient questionnaire
Nurse leader and MD review
asthma registry to determine
patients who need follow-up
(work on registry in progress)
Other pre-work preparations:
• MA stocks each room with asthma
encounter forms
• MA ensures available spacers
Change in patient’s plan of
care:
• Asthma action plan updated &
Management
decisionmaking
collaboratively
between MD
and patient
based on
NHLBI
guidelines
Parent/ patient
completes
questionnaire
and hands form
to MD; ensuing
discussion based
on answers to
both
questionnaires
MD/ MA hands completed
forms to Nurse Leader
Nurse/ MA/ PSR conduct
phone follow-up;
Appointments scheduled;
Nurse may start encounter
form based on phone
interview
Nurse Leader
compiles
encounter forms
and assures
completeness
copy provided
• Spirometry ordered if indicated
• Rx escripted; spacer provided
• Pertinent written asthma
materials provided
• Flu vaccination provided as
appropriate
• Follow up in 2-4 weeks
• Consults ordered as needed
No change in patient’s plan
of care:
• Asthma action plan copy
provided
• Spirometry ordered if indicated
• Refills escripted; spacer use
confirmed
• Pertinent written asthma
materials provided
• Flu vaccination provided as
appropriate
• Routine follow up
Nurse leader enters patient data into
EQIPP bi-weekly and files paper
forms;
Each MD reviews run charts regularly;
Monthly meeting to discuss progress
and plan changes
MA carries out
orders;
Patient checks out;
PSR schedules
appropriate
consults and
follow-up
CCF CQN Encounter Form
Asthma Improvement Project Parent Questionnaire
Patient name
______________________________
Provider name
______________________________
1.
2.
DOB __________
DOV __________
Has your child visited the Emergency Room or Urgent Care Center due to asthma in the past 12 months?
Has your child been admitted to the hospital due to asthma in the past 12 months?
 Yes
many times?
 Yes
 No
 No
If yes, how
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?
 Less than or equal to 2 days per week
 More than two days per week but not daily
 Daily
 Throughout the day
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?
 Less than or equal to 2 times per month
 3-4 times a month
 More than 1 time per week but not nightly
 Often 7 times per week
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®, ProAir®, Proventil®, Xopenex®)
 Not at all  Less than once per day  1-3 times per day  4 or more times per day  Not sure
How often does asthma limit your child’s activities?
 Not at all  a little of the time
 Some of the time
 Most of the time
 All of the time
How many days of school/daycare has your child missed due to asthma in the past 6 months? _______ # of days
 Does not attend
How many work days have you or your spouse missed due to your child’s asthma in the past 6 months? _______ number of days
How comfortable are you in your ability to manage your child’s asthma, rated on a scale of 1-10? (Please circle)
Not Comfortable =
1 2 3 4 5 6 7 8 9 10 = Very Comfortable
When are asthma symptoms worse? (Check all that apply)
 Winter
 Spring
 Summer
 Fall
 During exercise
How would you rate your child’s asthma control during the past month?
 Not controlled at all  Poorly controlled  Somewhat controlled  Well controlled  Completely controlled
CCF CQN Encounter Form
Asthma Improvement Project Provider Questionnaire
Patient name
______________________________
DOB __________
Provider name
______________________________
DOV __________
3. Were one or more asthma key indicators present when considering the diagnosis of asthma?
 Yes  No
 Not documented
4. Were lung function measures by spirometry used to establish the asthma diagnosis?
 Yes  No
 Age inappropriate, younger than 5 years
5. Was a validated instrument used to determine the current level of asthma control?
 Yes  No
6. 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, non-adherence to medication regimen)
 Yes  No
7. Is spirometry currently scheduled or have results been obtained within the last 1 or 2 years?
 Yes  No
 Age inappropriate, younger than 5 years
8. Have you used the age-appropriate NHLBI stepwise table used to identify treatment options or to adjust therapy based on asthma control?
 Yes  No
9. Has a flu shot been administered or recommended within the past 12 months?
 Yes  No
 Patient younger than 6 months or contraindications
10. 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
11. 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
12. Was a follow-up appointment scheduled to monitor asthma control?
 Yes  No
Asthma severity level:  Severe Persistent  Moderate Persistent
 Mild Persistent  Intermittent
Is the patient on a controller medication?  Yes
 No
If yes, does the patient/parent report using controller medications daily?
 Yes  No
 Started this visit
For patients who use rescue/controller inhalers, is a spacer utilized?
 Yes  No
 Not applicable
Has the patient received oral corticosteroids for asthma within the past 12 months?
 Yes  No
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?
 Yes  No
 Referred this visit
Key Learnings
 Change is difficult
 Change requires motivators that are not always
the obvious ones (this is true of patients as it is
true of medical staff)
 To manage a population with chronic disease, a
more comprehensive approach needs to be taken
Barriers and Successes
• Majority of practice physicians now engaged
• Development of SmartSet templates for use in
EMR
• Increased use of written asthma plans
• Increased use of stepwise approach to therapy
• Increased patient satisfaction/ comfort level with
asthma care at home
Barriers and Successes
• Delayed engagement to project and differential
start among physicians
• Non-universal use of SmartSet templates among
physicians/ patient sets/ visit type
• “Easy” way not always the “consistent” way
• Time required for each visit
Future Plans
• Increase functionality of current patient lists
• Engage MDs, RNs, MAs, PSRs in maintaining
patient lists
• Determine staff workflow to increase compliance
with protocols (ie, standing orders)
• Monitor MD use of protocols (chart review?)
• Engage RNs who provide nurse triage to use
action plans
• Engage other staff in asthma education
• Patient survey of engagement/ satisfaction
During Office
Visit
Pre-Office
Visit
Proposed Changes to Office Work Flow – CCF Marymount/Independence
Scheduled asthma patients identified
daily (well visit, asthma follow-up visit)
by nurse leader; list generated and
note attached to appointment schedule
Identified asthma patient
arrives; MA /LPN rooms patient
and hands parent/patient
asthma patient questionnaire;
MA/LPN attaches provider
questionnaire to visit slip for
MD; MA/LPN drops in
Asthma SmartSet
Post Visit
Activities
Patient identified with asthma
not previously noted (acute
visit, add-on visit, new
diagnosis of asthma); MA hands
patient questionnaire; MA/LPN
drops in Asthma SmartSet
Nurse leader and MD review
asthma registry to determine
patients who need follow-up
Other pre-work preparations:
• MA /LPN stocks each room with asthma encounter forms
• MA/LPN ensures available spacers
• Each patient room stocked with education materials /
terminal has links to asthma education
Management
decisionmaking
collaboratively
between MD
and patient
based on
NHLBI
guidelines
Parent/ patient
completes
questionnaire
and hands form
to MD; ensuing
discussion based
on answers to
both
questionnaires
MD/ MA hands completed
forms to Nurse Leader
Nurse/ MA/ LPN/ PSR
conduct phone follow-up;
Appointments scheduled;
Nurse may start encounter
form based on phone
interview
Nurse Leader
compiles
encounter forms
and assures
completeness
Change in patient’s plan of
care:
• Asthma action plan updated &
copy provided
• Spirometry ordered if indicated
• Rx escripted; spacer provided
• Pertinent written asthma
materials provided
• Flu vaccination provided as
appropriate
• Follow up in 2-4 weeks
• Consults ordered as needed
No change in patient’s plan
of care:
• Asthma action plan copy
provided
• Spirometry ordered if indicated
• Refills escripted; spacer use
confirmed
• Pertinent written asthma
materials provided
• Flu vaccination provided as
appropriate
• Routine follow up
Nurse leader enters patient data into
EQIPP bi-weekly and files paper
forms;
Each MD reviews run charts regularly;
Monthly meeting to discuss progress
and plan changes;
Chart review to monitor use of
protocols
MA /LPN carries
out orders;
MA/LPN/RN
provides/
reinforces
asthma
education;
Patient checks out;
PSR schedules
appropriate
consults and
follow-up