Transcript Improving Care and Outcomes for Children and Adolescents with

A System for Great Asthma Care
Chapter Quality Network Asthma Pilot Project
Learning Collaborative and Network
Alabama, Maine, Ohio, Oregon
Peter Margolis, MD PhD
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.
Purpose of this Session
• Introduce the system framework
• Discuss how we will use the framework to guide
selection of changes
Purpose of this Session
• Introduce the system framework
• Discuss how we will use the framework to guide
selection of changes
Where Change Happens
Informed,
Empowered Patient
and Family
Productive
Interactions
Improved Outcomes
Prepared,
Proactive
Practice Team
What Does a “Productive Interaction”
Look Like for Chronic Illness Care?
• Evidence-based clinical and behavioral care
• Systematic assessment
– clinical status
– self-management skills
– confidence
• Collaborative definition of problems and solutions
• Tailoring clinical management to family needs and
preferences
• Active sustained follow-up
Why is this so hard to do?
It’s the system!
Every system is perfectly designed to achieve
exactly the results it gets
What will your system look like in
1-2 years?
A short film by Jesse Dylan
Evidence that System Change Works
(Cochrane Review; JAMA 2002; Diabetes 2001)
• 40 studies (85% RCTs) mostly in primary care
• Four categories of interventions
–
–
–
–
Decision support
Delivery system design
Changes to information systems
Self-management
• 19/20 that included self-management had a positive
effect
• All five studies that included all categories had positive
effect
Major Conclusions
• No magic bullet – no single intervention made a
major difference
• Self-management necessary but not sufficient
• More intervention categories, more effect on
patient outcomes
• Therefore, comprehensive system change
needed to change outcomes
What is a System?
• “A network of interdependent components that
work together to accomplish a shared aim.” (WE
Deming)
• The aim of the CQN asthma collaborative
– To achieve measurable improvements in asthma
outcomes by applying NHLBI guidelines and making
key practice changes
Recipe for Improvement
Evidence-Based Changes
Process Improvement Model
What are we trying to accomplish?
How will we know that a change is an improvement?
What changes can we make that will result in
improvement?
System Change Concepts
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
Ed Wagner, MD, MPH: MacColl Institute; Associates in Process Improvement;
Institute for Healthcare Improvement
Act
Plan
Study
Do
Network for Learning
The Map
Simplified Care Model
• Registry
• Templates for planned care
– (e.g., structured encounter form)
• Protocols to standardize care
– Standard Protocols
– Nursing Standing Orders
– Defined Care team roles
• Self-management support
strategies
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
CQN Hi-Leverage Changes
• Use a Registry to Manage Asthma Population
• Use Planned Care to Ensure Reliable Asthma
Care
• Use Protocols
• Provide Self-Management Support
Registries
• Provide timely reminders for providers and
families
• Identify relevant subpopulations for proactive
care
• Facilitate individual patient care planning
• Enable clinicians and care teams to coordinate
care
• Monitor performance of practice team and care
system
Registry Examples
PHO
DocSite
Registry Implementation Plan
1. Select and install a registry tool
2. Determine staff workflow to support registry
use
3. Populate registry with patient data
4. Routinely maintain registry data
5. Use registry to manage patient care (pre-visit)
and support population management (at least
monthly)
REGISTRY
FLOW
OFFICEVISITS
Planned Visit
Chart visit in
normal fashion
Prep chart
no
Registry
Patient?
yes
Download
most recent
Progress Note
Place PN on
front of chart
Medical
Assistant tells
patient: “Take
off your shoes”
Progress Note
employed in visit
Pull chart
Progress Note
returned to
office staff
Patient Info sheet sent
to patient
Walk-in Visit
Updated Progress
Note faxed to office
and placed on Registry
web-site
IPA updates
registry
Progress Note
faxed to IPA
DIABETIC
PROJECT
FLOW
DIAGRAM
Data from
office visit
PACES, CHCF
chart audits
Staged Diabetes
Management
Guideline
Feedback to
clinicians
yes
Pt. enrolled in
diabetic study
Data entered
in registry
Monthly audit of
data in registry
Prompts and
reminders
Office visit:
scheduled,
random
Services
delivered?
Registry note
returned?
Data analysis
Patient
visit
sheet
no
A1c > 9
Pharmacy
data
yes
Risk stratification
Lab
data
BASICS
Case management
Time to Registry Implementation
Planned/Reliable Asthma Care
More on reliability later
• Embed evidence-based guidelines into daily
practice using templates
• Share guidelines and information with families to
encourage participation
• Care team is aware of patients’ needs and work
together to address them (i.e., roles and
responsibilities)
• Integrate specialist expertise and primary care
Planned/Reliable Care (cont)
• Define roles and distribute tasks among team
members
• Expand use of non-medical care team members
• Use planned interactions
• Provide case management services for complex
patients
• Ensure regular follow-up by the care team
PHO
Decision
Support Tool
Implementation Plan
1. Use/create structured encounter form linked to
registry fields (some registries have “visit
planners” that can be customized)
2. Determine staff workflow to support use of
template and other asthma tasks (e.g., teaching
about spacers)
3. Use template with all patients
4. Ensure registry updated each time template used
5. Monitor use of template
Detailed Changes: Protocols
1. Select and customize NHLBI evidence-based
guidelines to office
2. Determine staff workflow to support guideline
use (i.e., protocols including standing orders)
3. Use protocols with all patients
4. Monitor use of protocols
Protocols: Asthma-specific
• Assess and document asthma severity and
control
• Prescribe appropriate asthma medications and
monitor overuse of beta agonists
• Use Asthma Management plans
• Establish visit frequency protocol
• Assess and treat co-morbidities
• Assess, counsel, and prevent exposure to
environmental triggers
Self-management Support
Provide training to staff in SMS techniques
Set patient goals collaboratively
Determine staff workflow to support SMS
Obtain patient education materials (e.g.,
asthma action plans)
 Document and monitor patient progress toward
goals
 Link with community resources (schools,
service organizations)
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Self-Management
• Evidence-based guideline
• Tools to implement key
recommendations
• Collaborative
communication training
Monitoring the Process
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Critical step in high-leverage changes
Different than measurement data
To inform improvement team
Goal is 90% reliable processes
Requires work and planning
Can decrease frequency when process is at 90%
Eight times, eight ways
1.
2.
3.
4.
5.
6.
7.
8.
Charter
Change package
Pre-work and assessment
Learning session curriculum
Team reporting
1-5 self assessment and repeat self assessment
Conference calls
Results
The Breakthrough Series
Select
Topic
Participants
Prework
P
P
Change
Concepts
A
D
S
Expert
Group
LS 1
Supports
E-mail Visits
Phone Documents
Assessments
A
D
S
LS 2
LS 3
What if it were as easy to find out how to
fix a problem in your clinic as it is to fix
your phone?
36
“User-led” innovation networks are
becoming widespread
Examples
• Linux
• Apache Web Server
• Toronto Bus System
• On-line gaming
• Kite surfing
• Human Genome Project
Eric Von Hippel, MIT
Why Networks?
• Inherent motivation to share “how to” knowledge
• Sharing resources reduces development costs
• Turn variation in performance into an asset
– Identify innovators
– Exploit “natural experiments”
• Common metrics allow peers to evaluate each
others’ performance to determine what’s working
Putting It All Together
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Create a strong practice team
Clarify what you are are trying to accomplish
Try high-leverage changes
Measure progress
Refine and customize changes
Share and integrate learning
Common Challenges
• Integrating Registry into work flow
• Existing Electronic Health Record (EHR) needs
modification to function as a Registry
• (In)consistent use of encounter form
• Lack of agreement that protocol is needed
Overcoming Challenges
• Ask questions of Collaborative faculty
• Share challenges on Listserv
• Find links, tools and resources on the Extranet
• Request consultation from another practice
team
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





























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
Transformation:
Being The Best At
Getting Better