Transcript Toledo Children Primary Care Team Members

Chapter Quality Network (CQN)
Asthma Pilot Project
Team Progress Presentation
State Name: Ohio
Practice: Toledo Children Primary Care
Team Members:
Toledo Children Primary Care
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
• Improved engagement of QI team – providers are meeting monthly to discuss use of NHLB
guidelines for care of asthma patients in our office. Staff are meeting frequently to discuss
best processes for improving efficiency of providing asthma care. QI data turned in monthly.
Team attending all required meetings and phone conferences.
• Improving Follow up - Developing system to identify asthma patients by color labeling charts.
Reviewing ideas for use of registry for Asthma patients. Scheduling follow up appointments at
asthma visits, calling for follow up appointments after ER visits.
•Increasing use of Planned care approach – developing and implementing improved workflow
to support use of protocols with all providers, developed new asthma visit note to use at
Asthma visits. Trained staff on correct use of Spirometry testing. Completing spirometry
testing on patients per provider order.
•Approach to Employing Protocols – Standardizing processes for each provider and staff to
best implement use of evidence-based protocols with all patients. Providing Asthma Action
Plan to all patients at asthma visit.
•Self management support – Evaluating educational materials that help patients and family
learn self management of disease process. IE: written material, asthma education per
individual patient or group. Phone education vs. in-person education.
Asthma Action Plan
Follow - up
Spirometry
Spirometry
Antonio 17 yr
T’onna 12 yr
IQmarkTM Digital Spirometer
www.midmarkdiagnostics.com
Spirometry ?
•
Low FEV1 is associated with increase risk for severe exacerbations.
•
Regular monitoring of pulmonary function is particularly important for
asthma patients who do not perceive their symptoms until airflow
obstruction is severe. There is no readily available method of detecting the
“poor perceivers.” The literature reports that patients who had a near-fatal
asthma exacerbation, as well as older patients, are more likely to have poor
perception of airflow obstruction.
•
Two large, retrospective cohort studies have shown that a reduction in
FEV1 at an annual visit is associated with increases in the risk of an attack
of wheezing and shortness of breath over the next 12 mo.
Spirometry
PDSA Cycles
PDSA Title:
 Plan: Perform Spirometry testing in office
 Do: Train nurses to accurately complete testing on
appropriate asthmatic patients
 Study: Validate results of Spirometry testing for
accurate results on appropriate asthmatic patients
 Act: Increase number of accurate tests on
appropriate asthmatic patients
PDSA Ramps
P D
P D
S A
S A
TEST 4
What: Perform Spirometry test
Who (population): 5 pt. per week
Who (executes): All trained nurses
Where: Office
When:Dec. 2009
P D
S A
TEST 3
What: Perform Spirometry test
Who (population): 2-3 pts. Per week
Who (executes): 1 trained nurse
Where: Office
When:Nov. 2009
P D
P D
S A
P D
S A
TEST 3
What: Validate results between
trained nurses
Who (population): 3 pateints
Who All Providers
Where: Ofice
When: June 2010
TEST 3
What: Spirometry testing
Who (population10 patients/week
Who (executes): all trained nurses
Where: Office
When: May 2010
P D
S A
TEST 2
What: Perform Spirometry test
Who (population): 1 patient/week
Who (executes):1 trained nurse
Where: Office
When:Oct. 2009
P D
S A
TEST 2
What Validate results Spirometry vs
Formal PFT
Who (population): 1-2 pts.
Who (executes): All trained nurses
Where: Office
When:Feb 2010
P D
S A
S A
TEST 1
What: Perform Spirometry test
Who (population): Train nursing staff
Who (executes):Resp therapist: John
Where: Office
When: October 2009
Spirometry testing
TEST 4
What: Spirometry testing
Who (population): All patients
Who (executes): All trained nurses
Where:Office
When: June 2010
TEST 1
What: Validate accurate results
Who (population): 5 – 10 pts
Who (executes): All trained nurses
Where: Office
When: Jan 2010
Monitering results Spirometry
P D
S A
TEST 2
What: Spirometry testing
Who (population): 2-5 pts/week
Who (executes): All participating providers
Where: office
When: April 2010
P D
S A
TEST 1
What: Spirometry testing
Who (population): 1 patient
Who (executes): Participating providers
Where:Office
When:March 2010
Expand Use of Spirometry testing
Office Visit Prework
During Office
Visit
Scheduler identifies patient
with asthma when setting
up chart. CQN data
collection form is put in
these charts.
Asthma education material
put in these charts
including Asthma Action
Plan
(Each provider work flow
different, requiring different
method for each of them)
Post Visit
Activities
Nurse/CRA who rooms
patient gives parent
patient encounter form and
helps them complete form
if needed.
Administrative team
member returns
incomplete forms to
provider/CPNP
Toledo Children's Primary Care: Clinical Assessment
Process Map – Paper Chart System
CQN encounter forms readily
accessible in each POD when
asthma pt. indentified after
chart set up
DR. or CPNP
gives patient
encounter form
to complete if
they feel
appropriate for
that days visit.
Physician/CPNP orders
spirometry if appropriate
Patient is
ready to be
seen by
provider
If in active flu season and
vaccine is due, administer
flu shot. If between
seasons, annual flu shot is
recommended
During the visit the
Physician/CPNP
reviews pt. questionnaire
and completes
provider
questionnaire
(difficult to devote time to
complete these forms)
Nurse
completes
spirometery
testing
Physician/CPN/
discusses
asthma control
Working on
Creating
Asthma
recall
registry
system
Physician/CPNP
Completes all forms
and gives to administrative
team member to
enter data
into equipp.
(difficult to devote time to
complete these forms)
Physician/CPNP/RN/LPN gives/reviews
asthma action plan. Gives and reviews
asthma educational materials. Offers in home
asthma education. Reviews patient
encounter form for completeness
( Evaluating multiple methods of providing
education to lead to best self management)
Nurse/CRA
sends referral
to Caring
Service Home
Health Care if
accepted by
family or
available group
asthma
education at
hospital
CQN Encounter Form
Asthma Care Encounter Form
for documentation at visit
Key Learning
 Change is difficult. It is easier to implement small
changes.
 Obtaining data helps measure outcome.
 Education, education, education.
 Collaboration with community health care resource
is very important.
Barriers and Successes
1. Time.
2. Absence of EMR.
3. Variations in care.
1.Quality of care.
2. Increased Asthma education to staff ( protocols for medications refills,
f/u visits)
3- Improved teaching to future health care providers.
4- Guidelines and protocols improves efficiency and staff satisfaction,
and reduces unnecessary variations of care.
5- Spirometry
Future Plans
• EMR/Registry
• Continue PDSA’s for efficient use of asthma encounter
forms
• Continue Team meetings providers and staff
• Continue to evaluate methods of patient and family
education to help families improve self management of
Asthma.