Transcript Chapter Quality Network (CQN)

Chapter Quality Network (CQN)
Asthma Pilot Project
Team Progress Presentation
State Name: Ohio
Practice Name: Willoughby Hills
Cleveland Clinic
Team Members:
Lisa Dolovacky, MA
Loreen Rudd, RN
Rachel Peterson, MSN/CNP
Marianne Sumego, MD
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
90 day goals
For Learning Session 2
• 1. Develop an asthma registry
• 2. Review use of a best practice alert potential
to identify patients
• 3. To engage our practices (local)
• 4. Develop evidence-based protocols via epic.
• 5. Increase use of action plans for asthma care
• 6. Evidenced based protocols for our offices
Learning session 1 summary
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Tested use of our asthma CQN encounter forms
Developed an asthma action plan
Gather asthma education materials
Engaging our practice
Identifying barriers to practice, engagement
Developed smart set
Education for our Staff
Spirometry used to establish diagnosis
Number of patients with an action
plan
Patients Well controlled Asthma
PDSA Cycles
PDSA Title: Asthma action plan
 Plan: Increase uniform asthma action plan use
 Do: Monitor use of new AAP form
 50% of patients from 4 providers in one month will have AAP
completed
 Study: Evaluate improvement with March data set
 93% compliance Month of March for 4 providers
 Act: Adopt plan; receive feedback on plan/improvements. Continued
communication regarding use and availability of action plan
PDSA Cycles
PDSA Title: Blue Dot Trial
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Plan: Identification of patients with asthma; blue dot on schedule next to
pediatric asthma patients age 2-18
•
Do: Count number of forms vs. blue dots on schedule for provider
– 80% forms will be completed for identified asthma patients
•
Study: Reviewed 4 providers use in March
– did not meet our predictions.
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Act: Adapt plan; adjust office flow diagram, one on one sessions, emails,
reminders, feedback from MA/Provider
PDSA Ramps
P D
P D
S A
S A
S A
TEST 4
What: tracking form use
Who: 4 providers
Who: (executes): Rachel and Lisa
Where: 40% forms completed
When:2/10 and 3/10
P D
TEST 4
What: Monitor use blue dot
Who: 4 selected providers
Who (executes): Rachel
Where: Chart review med/peds
& Peds
When: 3/10
S A
P D
S A
P D
TEST 3
What: integrated process
EMR/paper
Who: All providers
Who (executes): QI team
Where: Medpeds & Peds
When: 12/09
P D
P D
P D
S A
TEST 3
What: Roll out all dept.
Who: All providers
Who (executes): MA
Where: Med/Peds & Peds
When 2/10
P D
S A
S A
TEST 4
What; Assess use AAP
Who: 4providers use of letter
Vs. nonstandard
Who (executes) :Rachel
Where: Chart review med/peds
& peds
93% use
When: 3/10
TEST 3
What:: Uniform EMR AAP
Who (population): all providers
Who (executes): Sumego (letter)
QI team (roll out)
Where: Med/Peds and Peds
When:2/10
S A
P D
TEST 2
What:: Revised electronic
version
Who: 3-4 providers
Where: Med/peds & Peds
Who (executes): QI team
When: 12/09
P D
TEST 2
What:: Roll out blue dot
Who: 2 providers
Who: (executes):Lisa
Where: Med/Peds dept
When: 1/10
S A
S A
TEST 1
What:: Paper copy CQN form
Who: Sumego and Peterson
Where: Providers
When: 11/09
Who (executes): QI team
CQN use
TEST 1
What:: ID patients/Blue dot
Who Sumego,MD
Who (executes): Lisa QI team
Where: Med/Peds dept.
When: 1/10
Identification
TEST 2
What:: Education about plan use
Who : all providers:
Who (executes): QI Team
Where: Breathe Easy Luncheon
When: 1/10
P D
S A
TEST 1
What:: Asthma action plan
Who: All providers
Who (executes): Sumego/Peterson
Where Med/Peds and Peds
When: 11/09
Action plan use
Office Visit Prework
During Office
Visit
MA checks provider schedule
daily and notes asthma patients
by problem list, history, or
medication list. Puts blue dot on
schedule to mark asthma
patient for reminder. Checks
again each afternoon for same
day add on.
Office Work Flow – CCF Willoughby Hills
Other pre-work preparations:
• MA/RN stocks each room with asthma
encounter forms
• MA/RN ensures available
spacers/supplies
MA gives questionnaire to
parent to fill out or verbally asks
the questions and enters into
EPIC version
Parent/MA
completes form
and hands to
provider when
enters room
Provider fills out remainder
of the form and discusses
management collaboratively with patient
based on asthma control &
NHLBI guidelines
Patient may be identified with asthma during exam that was
not previously noted
(acute visit, add-on visit, new diagnosis of asthma)
Questionnaire copies outside of exam room door
Completes parent portion in room.
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
MA/RN
carries out
orders
No change in patient’s
plan of care:
Patient
checks out
• Asthma action plan copy
provided
PSR
schedules
appropriate
consults and
follow-up
• Spirometry ordered if
indicated
• Refills escripted; spacer
use confirmed
MD/ MA hands completed forms to Nurse Leader
Loreen Rudd RN
Rachel Peterson MSN CNP
• Pertinent written asthma
materials provided
• Flu vaccination provided
as appropriate
• Routine follow up
Post Visit
Activities
PROBLEM POINTS
Difficulty getting “blue dots” on provider schedule
Time constraints/Provider “buy in”
Incomplete forms
No registry capability as of yet
RN/MA places form in
CNP basket
CNP verify for completeness
If not complete
will send back to
provider for
missing
information. Or
call patient.
Data entered into
EQIPP weekly
and Registry
(when we have
one) Paper forms
in binder
Copy of Your CQN Encounter Form
Asthma Encounter/Data Collection Form
Provider Name: ________________________________________
Patient Name: ________________________________________
Date of Birth: ____/____/____
Date of Visit: ____/____/____
Insurance Company: ___________________________________
Well visit
Asthma Visit
Other Sick Visit
1.
How many days of school/daycare has your child missed due to asthma in the past 6 months?
_______ # of days
2.
How many work days have you or your spouse missed due to your child’s asthma in the past 6 months? _______ # of days
3.
Has your child visited the Emergency Room or Urgent Care Center due to asthma in the past 12 months?
Does not attend
YES
NO
If yes, how many times? _______
Office Use Only:
ENTER FIELD INTO
EQIPP #1
4.
Has your child been admitted to the hospital due to asthma in the past 12 months?
YES
NO
Office Use Only:
ENTER FIELD INTO
EQIPP #2
PARENT SECTION
If yes, how many times? _______
1.
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 =
1
2
3
4
5
6
7
8
9
10
= Very Comfortable
6.
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®)
7.
When are asthma symptoms worse? (Check all that apply)
not at all
winter
less than 1 time per day
spring
1-3 times per day
summer
fall
4 or more times per day
not sure
during exercise
8.
How often does asthma limit your child’s activities?
9.
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?
< or equal to 2 days / week
> two days / week but not daily
Daily
Throughout the day
not at all
a little of the time
some of the time
most of the time
all of the time
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.
< 2 times / month
3-4 times a month
> 1 time / 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
well controlled
completely controlled
Copy of Your CQN Encounter Form
12a. If in active flu season (Sept.-March), was flu shot administered?
NO-reason: _______________________________________
YES
shot date: ___/___/_____
Patient younger than 6 months, other contraindications, or vaccine unavailable
12 b. If between seasons (April-Aug.) was a recommendation made?
YES
Office Use Only:
IF “YES” IN EITHER 12A or 12B
ENTER FIELD INTO EQIPP #9
NO
13. Asthma severity level: (refer to the EPR3 Control Tables 4-2a, 4-2b, and 4-6)
Severe Persistent
Moderate Persistent
Mild Persistent
14. Is the patient on a controller medication?
YES
Intermittent
NO
If YES, does the patient/parent report using controller medications daily?
15. For patients who use rescue/controller inhalers, is a spacer utilized?
(Maxair® and dry powder inhalers do not require spacer)
YES
NO
YES
NO
16. Has the patient received oral steroids for bronchospasm within the past 12 months?
PROVIDER SECTION
17 a. Does the patient have a written asthma action plan?
YES
YES
Started this visit
NA
NO
NO
Office Use Only:
ENTER FIELD INTO
EQIPP #10
17 b. If yes, was the plan updated as needed and reviewed with the patient and/or family at this visit?
YES
NO
18. 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.)
YES
Office Use Only:
ENTER FIELD INTO
EQIPP #10
NO
19. 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:
20. 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
21 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
3-5a, 3-5b, 3-5c, 4-2a, 4-2b, 4-6, 4-3a, 4-3b, 4-7)
Well Controlled
Not Well Controlled
Very Poorly Controlled
Office Use Only:
ENTER FIELDS INTO
EQIPP #6A and 6B
21 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
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)
YES
Office Use Only:
ENTER FIELD INTO
EQIPP #8
NO
23. 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)
YES
date____/____/_____
NO
Younger than 5 years
24. Follow Up Visit: Return in: _____ weeks, or _____ months Return visit date (Optional): _____ / _____ / _____
Office Use Only:
ENTER FIELD INTO
EQIPP #7
Office Use Only:
If a follow-up visit was
scheduled ENTER FIELD
INTO EQIPP #12
Note: You may have to go back in the patient chart to find this historical information. If the information is unavailable, check not documented.
26. Were one or more asthma key indicators present when considering the diagnosis of asthma? (refer to Box 3-1)
YES
NO
Office Use Only:
ENTER FIELD INTO
EQIPP #3
Not Documented
27. Were lung function measures by spirometry used to establish the asthma diagnosis? (refer to Box 3-2)
YES
NO
Age inappropriate, younger than 5 years
Not Documented
Office Use Only:
ENTER FIELD INTO
EQIPP #4
Epic Version Parent Questionnaire
•
Asthma Control Parent Questionnaire:
•
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}
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Practice Engagement
 Breathe Easy Luncheon January 2010
 Nancy Wyse Respiratory therapist
 Spoke with providers, Medical assistants, and nurses in Med/Peds and
Pediatrics
 Great turn out across the board!
 Provided pizza, salad, and drinks!
 MDI instruction
 Spacer technique/Use
 Nebulizer technique/Use
 Update on newer products, DPI
 Opportunity for questions, sharing, collaboration, and review
 Free lunch incentive to Medical assistant and Provider Team for
encounter forms collected each month
Key Leanings
 Change takes hard work, but is possible!
 Slow going
 Repetitive
 Team work
 Success drives change and engagement
 Easier to make further changes when data can show
improvement!
Barriers and Successes
• Barriers
– Engagement : time, other responsibilities/projects, lack of
interest
– Geography (2 departments, different schedules, meetings)
– Meetings
– EMR
• Identification of patients with EMR
• Registry
• Success
– action plan use greatly improved
– lunch and learn attendance
– Data shows improvement! Well controlled asthma, increasing
toward optimal care
– All providers on board!
– Standardized forms for encounters, smart set, AAP
Future Plans
• Improvements on Asthma Action plan
• Dinner/Lunch with speaker
• Registry capabilities; work with other health
centers
• Standardized educational handouts (in the
works)
– Possible videos in EPIC
• Breath Easy Luncheon II
– Pulmonary function testing
– In the works currently