CHILDREN’S HEALTHCARE
IMPROVEMENT COLLABORATIVE
Idaho Pediatric Asthma Learning Collaborative
Project Summary
Introduction
Final Data
Letter to Providers
End-of-Project Survey
Sustainability Plan
Asthma Action Plan Telephone Survey
June 29, 2012
This document was developed under grant CFDA 93.767 from the U.S. Department of Health and Human
Services, Centers for Medicare & Medicaid Services. However, these contents do not necessarily
represent the policy of the U.S. Department of Health and Human Services, and you should not assume
endorsement by the Federal Government.
With Thanks to Our Partner Organizations
Introduction
As a recipient of the CHIPRA Grant, Idaho Medicaid offered an Asthma Learning
Collaborative to pediatric practices serving Medicaid populations, with the goal of
improving patient tracking, asthma testing, care plans, and ultimately the health
of pediatric asthma patients.
Eight practices from Nampa, Boise, Twin Falls, and Pocatello, with a total of 20
pediatricians, answered the call and the Pediatric Asthma Learning Collaborative
kicked off in September 2011, culminating in March 2012.
During the learning collaborative (baseline, plus six months of quality
improvement), 20 records from each participating pediatrician for patients with
an asthma diagnosis, were randomly audited each month. From each record, 14
data points were gathered. De-identified data was submitted to the CHIPRA
Quality Improvement (QI) Coach via QI TeamSpace—a secure, online,
collaboration environment. The QI Coach aggregated and analyzed the records.
The First Learning Collaborative on Asthma Sees Success. Physicians saw
improved outcomes from patients and created better health practices. Practices
focused on improving their rates on four core measures:
1. Classification of severity level at least 90% of the time.
2. Percent classified persistent on inhaled corticosteroids at least 90% of the
time.
3. Percent classified persistent on any controller medication at least 90% of
the time.
4. Percent of time an Asthma Action Plan created at least 80% of the time.
To assess progress and sustainability, participating pediatricians completed an
End-of-Project Survey and parents of children with asthma in the eight clinics
were invited to participate in a telephone survey.
Clinic numbers referenced in this report have been randomly assigned.
Final Data
Asthma LC – Project Data
Percent of Patients Classified
P-Value < 0.0001
100%
85%
75%
80%
85%
82%
84%
Jan
Feb
Mar
64%
50%
48%
25%
0%
Baseline
Oct
Nov
Dec
Asthma LC – March Project Data
Percent of Patients Classified
Clinic Variability
100%
100%
100%
100%
100%
100%
75%
75%
66%
67%
50%
25%
0%
Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8
Asthma LC – Severity Classification
0%
25%
50%
75%
100%
1%
1%
Baseline
54%
15%
14%
Not classified
15%
Intermittent
Persistent
Mild
1%
2%
Moderate
Severe
March
14%
30%
31%
22%
Asthma LC – Project Data
Percent on Persistent Controller Medication
P-Value Not Significant
100%
95%
98%
98%
Baseline
Oct
Nov
93%
95%
98%
99%
Dec
Jan
Feb
Mar
75%
50%
25%
0%
Asthma LC – Project Data
Percent on Persistent ICS
P-Value < 0.03
100%
75%
90%
96%
91%
93%
Nov
Dec
88%
94%
99%
50%
25%
0%
Baseline
Oct
Jan
Feb
Mar
Asthma LC – Project Data
Asthma Action Plan Created
P-Value < 0.0001
100%
75%
67%
50%
57%
57%
Nov
Dec
62%
56%
42%
25%
18%
0%
Baseline
Oct
Jan
Feb
Mar
Asthma LC – March Project Data
Percent Asthma Action Plan Created
Clinic Variability
100%
100%
100%
100%
90%
75%
65%
50%
33%
25%
15%
0%
0%
Clinic 1 Clinic 2 Clinic 3 Clinic 4 Clinic 5 Clinic 6 Clinic 7 Clinic 8
Asthma LC – Balancing Measures
Project Wide
Baseline
10.0%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
Oct - Mar
9.3%
7.7%
4.5%
2.0%
Rate of Spirometry Ordered
(p-NS)
Rate of Referral to a Specialist
(p<0.03)
Asthma LC – Balancing Measures
Project Wide
100%
75%
83%
60%
50%
7%
22%
20%
25%
2%
3%
10%
37%
50%
Dr. Who
66%
75%
Clinic X
99%
95%
100%
86%
100%
100%
98%
90%
100%
Project
0%
Classified Persistent Persistent
on
on any
ICS
controller
AAP
Spirometry Referral
Control
documented
Letter to Providers
June 29, 2012
Providers,
Thank you so much for your feedback regarding the Asthma Learning
Collaborative 2011. Attached are the summaries of your responses to our End-ofProject survey, the Sustainability Plans, and the Asthma Action Plan (AAP)
telephone surveys. Our hope is that you will find additional ideas for quality
improvement in your practice from the project summaries.
The AAP telephone surveys demonstrated that the AAP's were an effective
educational tool since the majority of families had the plans, knew their green
and yellow zone medications, and a quarter had used them to provide care for
their child. We were unable to differentiate between surveys that were
conducted after a phone review and those that were not.
Final project data is viewable on QITeamSpace and through the Idaho CHIC
website. However, access to any individual provider data will be limited to project
staff. St. Luke’s, as the institutional sponsor for this learning collaborative, will
have a copy of the project data (down to the individual level) stored through the
end of 2019 in order to meet American Board of Pediatrics' requirements.
We will contact you again in October of this year (2012) to follow up on your
success with your sustainability plan and to give you the opportunity to submit a
follow-up data set. We look forward to continuing our communication with you
regarding asthma care in your practice.
Sincerely,
The CHIC project team
End-of-Project Survey
QUESTION: What positive impact has your practice had and/or have your patients
seen as a result of this project?
Positive Impact
0
1
2
3
4
5
6
7
8
More patients have AAPs and clear
documentation of their disease
Improved care coordination/
physician collaboration
Increased classification of Asthma Severity
Patients/families have better understanding
of how they can manage asthma symptoms
Critically evaluating care process and
identifying areas for improvement
Families are using more pre-visit care
Improved asthma control in
moderate-to-severe patients
Improved asthma education for families
More pulmonary function tests being performed
Patients missing fewer days of school
Patients better able to participate
in daily activities
Reduced phone calls, office visits, and ED calls
due to availability of AAP at home with families
Idaho Pediatric Asthma Learning Collaborative, June 2012
1
QUESTION: What was the greatest barrier(s) that you encountered during this
project?
Barriers/Challenges
0
1
2
3
4
5
6
7
8
Time on paperwork, follow-up, and explaning AAPs
Combining asthma care with other types of visits
Getting started/ organizing information and options
Trying to spread concept to larger organization
Project communication among staff
Creating efficient process to document AAP in EHR
Identifying asthma patients before visit
Developing registry capability to identify patients
Lack of available nursing staff for asthma education
Transitioning onto EHR at the same
time as this Learning Collaborative
Idaho Pediatric Asthma Learning Collaborative, June 2012
2
QUESTION: Which measure was most difficult to achieve?
Difficult Measure to Achieve
0
1
2
3
4
5
6
7
8
Creating AAP when visit was for another reason
Making sure the AAP was documented in the EHR
Creating and distributing AAP
Time to complete audits/develop sustainability plan
Coordinating patient hand-outs (ACT forms)
Documenting asthma Control
Documenting asthma Severity
Gathering data while transitioning to new EMR
Getting patients to follow-up as directed
Remembering to order spirometry when indicated
Idaho Pediatric Asthma Learning Collaborative, June 2012
3
QUESTION: Did anyone in the practice use the ACT?
Use Asthma Control Test (ACT)?
No
3
Yes
5
Idaho Pediatric Asthma Learning Collaborative, June 2012
4
QUESTION: What unintended consequences have you seen, good or bad?
Unintended Consequences of Project
0
1
2
3
4
5
6
7
8
None
Longer clinic visits because of AAPs
Improved collaboration among office staff
(IT, billing)
AAP can be complicated for families to understand
Delays to the clinic schedule
Dividends in adult asthma care (partners)
Improved documentation
Improved opportunity to teach resident physicians
Improved parent education
Increased awareness of asthma symptoms
More consideration of asthma as a diagnosis
Phone nurse now asks family to pull out their AAP
Parents like asthma update during non-asthma visit
Better quality of life for severe asthmatic patients
Idaho Pediatric Asthma Learning Collaborative, June 2012
5
QUESTION: Please list the THREE most notable changes you’ve made.
Most Notable Change(s) Made
0
1
2
3
4
5
6
7
8
More consistent use of AAPs
Increased classification of asthma severity
Improved documentation and consistent coding
More appropriate dosing of corticosteroids
Practice has created an electronic AAP
Better equipped to keep patients out of hospital/ER
More concern about asthma patients as individuals
Making follow-up calls to check on patient’s ability
to follow AAP and answer questions about asthma
Follow-up visit documented at every visit
Tracking flu vaccine status
More collaboration/evaluation
of approach to asthma
Idaho Pediatric Asthma Learning Collaborative, June 2012
6
QUESTION: Have you spread your changes clinic or system-wide?
Spread Changes?
No
4
Yes
4
QUESTION: On a scale from 1-10 (1 low, 10 high), how confident are you in
continuing to improve your asthma process or in holding your gains?
Confidence in Continuing to Improve
High 10
9
10
9
8
8.5
9
8
8
8
8.4
7
7
6
5
4
3
2
Low
1
1
2
3
4
5
6
7
8
Avg.
Clinics
Idaho Pediatric Asthma Learning Collaborative, June 2012
7
QUESTION: Please note anything else you would like to add.
Additional Comments
0
1
2
3
4
5
6
7
8
Please provide reminder emails/tips
for sustainability on a regular basis
Project helped to “fine-tune” asthma care
for providers and helped to improve
care delivered to patients
There is a need for easy access to AAP
(or even auto-population) on the EHR
ACT was not helpful to all providers or
applicable to all patient populations
Please provide LC PowerPoints for
in-clinic staff/provider asthma training
Considering scheduling nurse-only
asthma visits in the future
Reminder for sustainability plan
and follow-up data collection
The MOC credit was helpful
Idaho Pediatric Asthma Learning Collaborative, June 2012
8
Specific Aims and Measures for Sustainability by Clinic
QUESTION: What are your goals for sustaining process?
Clinic #
Aim
Measure
1
Increase compliance with and understanding of the
written AAP with patients on a Q 6 month f/u
schedule.
Improved compliance scores on patients
who received 3 month interval reminders
of AAP.
2
Incorporate the ACT use.
Increase use of AAP.
Provide Influenza vaccine to at least 50% of Asthma
patients in our registry by the end of November.
Periodic chart review.
Periodic chart review.
Chart review in December 2012.
3
Ensure asthma chart diagnoses include severity, not
just “RAD” or “asthma”.
Ensure flu shots given to asthmatic patients each
fall.
Educate our clinic providers on in-office asthma
classification and stepwise treatment.
Run report on old ICD9 codes on Dec 1,
2012.
Run report on asthma patients not
received flu shots on Dec 1, 2012.
Run report on old ICD9 codes on Dec 1,
2012. Also use pre/post test comparison.
4
Review the EMR asthma template and request
feedback from other providers quarterly (every 3
months)
Self-discipline
Maintain our rate of handing out asthma action
plans at > 50%, and improve it further if possible
(will complete EMR query quarterly)
EMR query
Maintain our rate of labeling severity of asthma at > EMR query
70%, and improve it further if possible (will
complete EMR query quarterly)
5
Document Asthma action plan, control status and
accurate diagnosis 100% of the time.
We will pull 10 random charts from each
provider and look at the data.
100% of our persistent asthmatics will be on
inhaled corticosteroids.
We will pull 10 random charts from each
provider and look at the data.
Each of our patient’s with asthma will have followup specified at the end of their visit.
We will pull 10 random charts from each
provider and look at the data.
Also we want to look in October of this year who
still has a generic diagnosis of asthma NOS on their
problem list-with that information we can then
contact those patients to follow up asthma.
Idaho Pediatric Asthma Learning Collaborative, June 2012
9
(Continued.) What are your goals for sustaining process?
Clinic #
6
7
8
Aim 1
Measure 1
Every patient with a diagnosis of asthma that is seen
from June 2012 to December 2012 will have an
asthma action plan initiated.
Monthly reports and audits will be done
to check charts and/or patient records for
the AAPs.
A system will be created to allow for time to provide
adequate asthma education either by the provider
or the nurse educator for the patient by December
2012.
Time will be allotted in the schedule for
asthma education both in the providers
schedule and follow up asthma education
with the designated asthma specialist in
the nurse clinic schedule.
Will continue to provide follow up calls to patients
and develop a plan to identify those who need calls,
consistency in the follow up calls, and who will be
responsible for those calls.
Monthly reports and audits will be done
to check for documentation of phone
follow up.
We will incorporate the AAP (via scan or template)
into the EHR.
We will document severity of asthma in the EHR.
We will develop/look for better automated
reporting systems for easier chart audits.
Perform chart audits monthly.
Continue ACT.
Continue AAP.
100% of kids classified.
Chart review.
Chart review.
Chart review.
Perform chart audits monthly.
Study the new EHR system to look
for/build better reporting tools.
QUESTION: How confident is your team with being able to implement your plan?
Confidence in Implementing Plan
Confident
5
5
4
4
4
4
5
4
4
4
8
Avg
3
2
2
Not
1
Confident
1
2
3
4
5
6
7
Clinics
Idaho Pediatric Asthma Learning Collaborative, June 2012
10
QUESTION: How can CHIC project staff help with sustaining your improvement over
time?
0
CHIC Role
1
2
3
4
5
6
7
8
Reminder/ email
Ongoing communication
Tips/ training
Nothing/ no comment
QUESTION: Who submitted the survey?
Survey Submitted by
Administrative
Champion
1
Physician
Champion
2
Practice
Team
2
All Involved
Physicians
3
Idaho Pediatric Asthma Learning Collaborative, June 2012
11
Asthma Action Plan (AAP) Telephone Survey
Summary results
QUESTION #1: Do you remember getting an AAP for your child?
Remember Getting AAP
Percent Yes
100%
100%
100%
100%
95%
84%
75%
75%
63%
50%
60%
25%
0%
0%
1
n=6
2
n=40
3
n=31
4
n=12
5
n=41
6
n=8
7
n=10
8
n=0
Avg
n=148
QUESTION #2: Do you still have a copy of the AAP?
Still Have AAP
Percent Yes
100%
100%
100%
87%
75%
67%
50%
73%
75%
73%
58%
25%
0%
0%
1
n=6
2
n=40
3
n=31
4
n=12
5
n=40
6
n=8
7
n=6
Idaho Pediatric Asthma Learning Collaborative, June 2012
8
n=0
Avg
n=143
12
QUESTION #3: Have you used the AAP since the last visit?
Used AAP
Percent Yes
100%
100%
75%
67%
50%
50%
50%
33%
25%
29%
22%
5%
0%
0%
1
n=6
2
n=40
3
n=30
4
n=12
5
n=41
6
n=8
7
n=6
8
n=0
Avg
n=143
QUESTION #4: What medications is your child supposed to take every day (Green
Zone)?
Green Zone Meds
Answered correctly
100%
100%
100%
100%
75%
94%
93%
90%
83%
75%
50%
25%
0%
0%
1
n=6
2
n=40
3
n=30
4
n=12
5
n=41
6
n=8
7
n=6
Idaho Pediatric Asthma Learning Collaborative, June 2012
8
n=0
Avg
n=143
13
QUESTION #5: What medications is your child supposed to take if in the Yellow
Zone?
Yellow Zone Meds
Answered correctly
100%
100%
100%
86%
75%
83%
88%
90%
83%
75%
50%
25%
0%
0%
1
n=6
2
n=40
3
n=29
4
n=12
5
n=41
6
n=8
7
n=6
Idaho Pediatric Asthma Learning Collaborative, June 2012
8
n=0
Avg
n=142
14
Asthma Action Plan
Idaho Pediatric Asthma Learning Collaborative, June 2012
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Idaho Pediatric Asthma Learning Collaborative, June 2012
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