Transcript KEY DRIVERS/INTERVENTIONS

Improving Asthma Care in Cincinnati:
The Journey
Stephen Pleatman, MD
Pediatrician, Suburban Pediatric Associates, Inc.
Board Member, Ohio Valley Primary Care Associates, L.L.C.
Cincinnati, Ohio
AAP Chapter Quality Network Asthma Initiative
Alabama Chapter-Learning Session 1
September 17, 2009
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
I have no relevant financial relationships with
the manufacturers(s) of any commercial
products(s) and/or provider of commercial
services discussed in this CME activity.
Objectives
To describe our improvement journey, what’s been achieved,
and key challenges along the way
To describe what we have learned
To describe the impact to patients, families, staff and
physicians
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Network Perspective
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
PHO: Background/Structure
Primary Care Practices (IPA)
PHO Focus
PHO Focus
39 pediatric
practices
Effectiveness/
efficiency
40% of regional
pediatric population
Effectiveness/
efficiency
12,500 asthma
patients
Specialists
Hospital
CCHMC Focus
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
PHO Asthma Initiative: Key Driver Diagram
KEY DRIVERS/INTERVENTIONS
AIM
To improve evidence-based care for
12,500 children with asthma across
39 primary care practices (40% of
regional pediatric population), with
at least 90% of all-payor asthma
population receiving “perfect care”
(composite measure), thus reducing
asthma-related ED/urgent care visits,
admissions, acute office visits,
missed school days, missed work
days, and activity limitation; and,
improving parent/patient confidence
and degree of asthma control
(high scalability focus)
Physician leadership at Board and practice level
Network-level goal setting by Board (network-level performance
defines success)
Measurable practice participation expectations/requirements (linked to
ABP-MOC approval)
Multidisciplinary practice quality improvement teams
Web-based registry, with all-payor population
identification/reconfirmation
Real-time patient, practice, and network-level data/reporting
Transparent, comparative practice data on process and outcome
measures
Concurrent data collection/use of decision support tool, based on high
reliability principles/workflow changes
AIM
To strengthen improvement
knowledge/capability within
primary care practices, thus
enhancing sustainability of current
and future improvement efforts
Aligning P4P/incentive design with improvement objectives
Key components of evidence-based care (“perfect care”)
Population segmentation, with focus on “high-risk” cohort
Cross-practice communication/shared learning to spread successful
interventions
Integration of multiple administrative/electronic data sources (hospital,
practice, payor)
Network and practice-level sustainability plans
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Network-Level
Asthma Data/Results
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Practice Perspective
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Urgency for Change
• Parental perceptions of variation in care.
• Adoption of medical advances in asthma care.
• Population identification and severity classification.
• Data collection made knowledge gaps visible.
• Documenting quality.
• Earning P4P reward.
• Transparency of comparative practice data.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Challenges
• “Our practice is already busy enough.”
• “There’s no additional pay for the extra work.”
• “We’re already doing a good job.”
• “I already have my way of doing things—it’s ok if others want to go
down this path.”
• Sensitivity to measuring quality of care among physicians.
• Reluctance to “standardize” practice around evidence-based care.
• “Research project.”
• “Not sure initiative will improve care.”
• Communication within practice.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Getting Started
Pre-existing focus on asthma population.
Recruiting practice commitment—connected with inherent
desire to “do the right thing.”
Leadership.
Committed quality team.
Defining key roles.
Communication, communication, communication.
“Realistic” decision support/data collection tool.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Executing the Work
Developing the data collection tool
Mapping our process to build a foundation of highly reliable
data collection
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
October, 2003
Asthma Patient Data Collection Form
How severe is patient’s asthma? (circle appropriate level)
SEVERE
PERSISTENT
---------------------------------
MODERATE
PERSISTENT
---------------------------------
MILD
PERSISTENT
---------------------------------
MILD
INTERMITTENT
---------------------------------
Days
Continual (more than 1
episode/day)
Days
Daily (1 episode/day)
Days
3-6 days/week but, not
every day
Days
0-2 days/week
OR
OR
OR
OR
Nights
Frequent
Nights
5 or more nights/month
Nights
3-4 nights/month
Nights
0-2 nights/month
Typical asthma symptoms:
cough, shortness of breath, wheezing, chest tightness, waking at night, decreased ability to perform usual activities
Is patient on controller medication?
(circle yes or no; if yes, circle one or more medications listed below, as applicable)
Yes
inhaled steroid
long-acting bronchodilator
oral steroid
leukotriene modifier
cromolyn or nedocromil
theophylline
other (please specify) ____________________________________________________________________
No
Was a written asthma management plan provided to family?
(circle one)
Yes
No
Parents should answer the following two questions . . .
Has patient had a flu shot during the 2003-2004 season?
(circle one)
Yes
No
If “No”, please indicate action taken:
________________________________
If patient is 6 years of age or older, how many days of school were missed over
the last three months due to asthma? _________________ (write in number of days)
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10 months later…
ASTHMA DATA COLLECTION FORM
Patient Name: _________________________________
Provider Name: _____________________________________
Date of Birth:
_________________________________
Practice Name: _____________________________________
Date of Visit:
_________________________________
Other patient identifier (OFFICE USE ONLY):_________________
Insurance Company: _____________________________
Well Visit
Asthma Sick Visit
Other Sick Visit
PARENTS - PLEASE COMPLETE THE FOLLOWING SECTION:
My child does not
attend school or daycare
1. *How many days of school or daycare has your child missed due
to asthma in the past 6 months?
2. *How many days of work have you or your spouse missed due to your child’s
asthma in the past 6 months?
3. *How many times has your child visited the Emergency Room or Urgent Care
Clinic due to asthma in the past 6 months?
4. *How many times has your child been admitted to the hospital due to asthma in
the past 6 months?
5. *How confident are you in your ability to manage your child’s asthma on a scale of 1-10? (PLEASE CIRCLE)
NOT CONFIDENT = 1
6.
2
3
4
5
6
7
8
9
10 = VERY CONFIDENT
How frequently has your child experienced episodes of cough, shortness of breath, wheezing, chest
tightness, or reduced activity due to asthma during the DAY in the past month? (PLEASE CIRCLE)
More than once per day
Once per day
3-6 days per week, but not every day
0-2 days per week
7. How frequently has your child experienced episodes of cough, shortness of breath, wheezing, chest
tightness, or waking up due to asthma at NIGHT in the past month? (PLEASE CIRCLE)
7 or more nights per month
5-6 nights per month
3-4 nights per month
0-2 nights per month
PHYSICIANS - PLEASE COMPLETE THE FOLLOWING SECTION:
8.
SEVERE
PERSISTENT
9.
Asthma diagnosis tentative
*How would you classify the patient’s asthma severity? (PLEASE CIRCLE ONE)
MODERATE
PERSISTENT
MILD
PERSISTENT
MILD
INTERMITTENT
*Is the patient on controller medication (e.g. inhaled steroid, leukotriene modifier, YES
nedocromil, cromolyn, long-acting bronchodilator)?
NO
10. *Does the family have a written asthma management plan?
YES
NO
UNKNOWN
11. *Is the patient currently followed by a specialist?
YES
NO
UNKNOWN
YES
NO
Name of specialist:__________________________________
12. *If NO, do you plan to refer the patient to a specialist?
Name of specialist:
Please fax to Tri State Child Health Services at (513)636-7540
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
2 ½ years later…
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
inical Assessment Process Map – Suburban Pediatrics
Office Visit
Patient signs in
Medical Assistant
gives parent
responses on
paper form to
Physician
Medical Assistant
views patient
record in EMR
Physician decision to fill
out form during the visit
EMR alerts
Medical Assistant
if child has a
diagnosis of
asthma
Medical Assistant
gives assessment
form to parent
Parent completes
top half of
assessment form
If time permits,
Medical Assistant
will enter parent
responses into
EMR
Physician entry – preferred method
Physician enters
physician
responses into
EMR during visit
Medical Assistant
reviews
assessment form
and enters parent
responses into
EMR, if needed
Medical Assistant/Asthma Nurse entry – alternate method
Medical Assistant
collects paper
form, forwards to
proper physician
for entry into EMR
Medical Assistant/
Asthma Nurse
assists with form
completion in EMR
Paper forms are
collected and
entered into the
EMR by the
Asthma Nurse
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Practice Improvement Capability:
Areas of Focus
• Commitment.
• Leadership.
• Communication.
• Reliability of data collection.
• Data entry.
• Interventions to improve clinical asthma care.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
The “Ideal”…..
• Physician, nurse, and practice manager (quality leadership team)
meets regularly to review project status/data/reports, and discuss
improvement opportunities.
• Physician administrative leader visibly supports project and
encourages improvement work.
• Project information/updates discussed with physicians and staff at
regular practice meetings, data/information shared, and
input/feedback recruited.
• Quality leadership team discusses data collection process at regular
intervals and identifies/pursues opportunities to improve reliability.
• Accuracy and timeliness of data entry monitored and addressed.
• Improvement interventions pursued using test of change
methodology.
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Using Registry/Data to Drive
Improvement
(deferred to registry presentation)
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Key Learnings
Leadership
Develop quality improvement team
Effective communication
Build consensus within practice
Use disconfirming data to drive improvements and sustain
engagement
Recruit parent involvement/feedback to accelerate
improvement.
Improve “reliability”—build improvement into daily work.
Learn from others—don’t reinvent the wheel.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Impact on Our Practice
• Parents more confident and knowledgeable.
• Nurses report reduced volume of phone calls.
• Positive feedback from families has energized practice and helped
sustain improvement work.
• Clinicians proactively engaging patients and parents in more
meaningful dialogue to improve care vs. more “passive” approach of
the past.
• Data has uncovered issues/gaps not previously identified.
• Discussing how to spread improvement work to other conditions.
• Positioned to win on current/future P4P programs.
• Appreciate value of registry.
• Staff roles/responsibilities revised to sustain improvement efforts.
Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved
Patient/Parent and Staff
Perspectives
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This is Hard Stuff
This takes lots of work to initiate and sustain.
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Thank You!!
Questions?
Contact Information
Stephen Pleatman, MD
Pediatrician, Suburban Pediatric Associates, Inc.
Board Member, Ohio Valley Primary Care Associates, L.L.C.
513-336-6700
[email protected]
Keith Mandel, MD
Vice President of Medical Affairs,
Physician-Hospital Organization
Cincinnati Children’s Hospital Medical Center
513-636-4957
[email protected]