Chapter Quality Network Asthma Pilot Project
PRACTICE PRE-WORK
MATERIALS
Part 1: General Information
Welcome to the Chapter Quality Network
Asthma Pilot Project!
Thank you for your participation in the Chapter Quality Network (CQN) Asthma Pilot Project.
We are delighted to have the opportunity to work with your practice team to make improvement
happen together!
The CQN asthma pilot project is being led by the national office of the American Academy of
Pediatrics and is providing the Alabama, Maine, Ohio and Oregon Chapters with tools, resources
and technical support to lead a quality improvement (QI) effort amongst 10 to 15 member
practices. Chapters will support these practices in implementing the new National Heart, Lung,
and Blood Institute (NHLBI), National Asthma Education and Prevention Program (NAEPP),
Expert Review Panel 3 (EPR3) asthma guidelines within practices. The CQN Asthma Pilot
Project is available to your local AAP chapter through the generous support of the Merck
Childhood Asthma Network, Inc (MCAN), the American Board of Pediatrics (ABP) and the
Academy’s Friends of Children Fund.
In this practice pre-work packet, you will find information that will help you to plan for your
participation in the CQN Asthma Pilot Project. This packet includes specific activities that we
ask you to complete prior to the first Learning Session, [insert date of first learning session], as
well as detailed instructions for completing these tasks.
Some technical language used in this packet may be unfamiliar. Please check the glossary in
Appendix E of this document for clarification. More detailed explanations will follow at the first
Learning Session. We will also be holding a practice pre-work conference call which will be
helpful in answering any questions you might have.
Please be sure to contact [Insert name of the Chapter Project Manager] at [insert email
address] or [insert phone number], if you have any questions.
We are excited that you are participating! We look forward to working with and learning from
you.
1
TABLE OF CONTENTS
Practice Team Preparation Checklist ..................................................... 3
CQN Asthma Pilot Project Charter ........................................................ 4
Key Driver Diagram .................................................................. 8
Participant Activities Overview ............................................................. 12
Practice Pre-work Activities and Instructions........................................ 13
Identify Your Team’s Aim......................................................... 13
Prepare a Storyboard .................................................................. 15
Action Period Activities Overview ........................................................ 16
Communications ........................................................................ 17
Conference Call Tips & Information ......................................... 18
APPENDICES
Appendix A: Learning Session 1 - Registration and Logistics .............. 20
Appendix B: CQN Collaborative Chapter &
Leadership Contact Information ............................................................ 22
Appendix C: Model for Improvement ................................................... 26
Appendix D: Improvement Glossary ..................................................... 29
2
PRACTICE TEAM PREPARATION CHECKLIST
The following is an activities checklist for the practice pre-work period leading up to Learning
Session 1 on [insert date of first learning session]. Your practice team will have the opportunity
to discuss these activities with the Quality Improvement Consultant (QIC) on the practice prework call.

Review this practice pre-work packet.

Meet as a team (start getting organized, discuss roles and responsibilities)

Participate in one practice pre-work call. Your entire QI practice team
(approximately 4 people) needs to participate on this call. Anyone is welcome to
join though.
Practice Pre-work Calls
[insert date/time of first pre-work call]
-OR[insert date/time of second pre-work call]
Call-in Number: 877-621-0220
Access code: 8750505#
If you cannot attend, please notify Chapter Project
Manager at [insert phone number/email for
Chapter Project Manager]. Lots of information
will be covered on this call, so do your best to
attend the call.




Identify your team’s aim.
Prepare a Storyboard to share at the first Learning Session. Email your Storyboard
to Insert name of the Chapter Project Manager]
Complete the Learning Session Registration Form (Appendix A) and fax the
registration form to insert phone number/email for Chapter Project Manager].
(Please complete a form for each person attending the Learning Session).
Briefly review the NHLBI/NAEPP EPR3 Asthma Guidelines:
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
Please bring any questions your may have about the guidelines to the first learning
session
3
CQN ASTHMA PILOT PROJECT CHARTER
Background
The Academy developed the Chapter Alliance for Quality Improvement (CAQI) to serve as a
resource to chapter leaders as they advance quality improvement (QI) initiatives within their
chapters for pediatric practices. Since its inception, the CAQI has worked to support chapters
by disseminating information about QI efforts, providing opportunities for chapter leaders to
learn from one another and monitoring the QI needs and progress of chapters. The ultimate aim
of the CAQI is to transform chapters’ capacity to engage practices in existing local QI efforts
and/or to serve as the centerpiece of a sustainable quality improvement program.
Evidence of the need for this type of transformation was highlighted in a needs assessment
conducted with chapter leaders. Results from the 2007 Chapter QI Needs Assessment
emphasized the continued momentum for QI work amongst chapters. An increased number
(53%) of chapter leaders report being involved in QI activities in 2007 compared with 42% in
20061.
Structurally, each chapter is unique and their capacity for supporting QI work is variable. With
many the first step is learning more about quality improvement work and the role they can play
in promoting it. The majority of leaders report needing assistance in building infrastructure to
support QI amongst member practices. When chapters were asked to share their current
structure only a quarter of them reported the presence of a member or committee to champion QI
efforts within the chapter and a mere 12% reported the presence of a mechanism to collect
improvement data from multiple practices1.
Building infrastructure to transform the role of chapters is complex and involves the components
of leadership commitment, communication systems, data collection systems, partnerships with
state entities, and strong relationships with and involvement from physicians2. It is not easy for a
membership organization to coach their members through QI projects without having a strong
rapport with their members. Chapters who take on this work are redefining their role vis ǎ vis
their membership as they urge practices to make changes, review their data and provide
feedback. This transformation is a process and will unfold over time; ultimately leading to the
chapter being valued more by their membership.
The increased interest in QI by chapter leaders is not surprising given the upcoming
recertification requirements of the American Board of Pediatrics (ABP) Maintenance of
Certification (MOC) Program. As of January 1, 2010 board certified pediatricians seeking a
renewal certificate will be required to complete all four parts of the Pediatric Maintenance of
Certification Program (PMCP). The fourth component, Performance in Practice, will recognize
pediatrician efforts in imbedding quality improvement (QI) into their everyday practice of
1
2007 Chapter Quality Improvement Needs Assessment Report. Chapter Alliance for Quality Improvement.
American Academy of Pediatrics.
2
Building Local Capacity for Improvement: A Resource Guide for Chapters. Butts-Dion S. ,Crowe V., Birken SA,
Dolins JC, Lannon CA. Partnerships for Quality. Cincinnati Children’s Center for Health Care Quality. American
Academy of Pediatrics.
4
medicine. The ABP will approve QI projects meeting certain standards while providing board
certified pediatricians who participate in the QI projects credit toward maintenance of their ABP
certification.
The American Academy of Pediatrics (AAP) is developing the Chapter Quality Network (CQN)
to invest in the valuable and unique support structure offered by AAP chapters as a provider of
quality improvement (QI) programs that meet the ABP MOC requirements. The CQN will be a
program of the Chapter Alliance for Quality Improvement (CAQI) and is intended to be a means
to assist state AAP chapters in developing capacity to support quality improvement activities of
member practices. The initial CQN program will focus on asthma and be built upon existing
AAP programs.
Through participation in the CQN, chapters will learn QI methods, how to apply these methods
and how to leverage the chapter’s unique position to lead and catalyze improvement. Member
practices will adapt changes that result in improved asthma care while obtaining part four credit.
The long term goal is to create the basis of a sustainable, chapter-based approach supporting
improvements in pediatric care.
Scope of the Problem
Despite excellent intentions and pockets of superb care, a major opportunity exists to improve
care for children with asthma and their families, as much care is still delivered in ways that are
not consistent with the evidence. Affecting nine million children, childhood asthma is the most
common serious pediatric chronic diease. African-American and Puerto Rican children have a
higher prevalence of asthma compared with non-hispanic white children.3 Furthermore, the
incidence of pediatric asthma continues to grow; it accounts for 14.7 million missed school days
a year and 44% of all asthma hospitalizations4.
During August 2007, under the auspices of the National Heart, Lung, and Blood Institute
(NHLBI) the National Asthma Education and Prevention Program (NAEPP) issued the first
comprehensive update in a decade of asthma guidelines for the diagnosis and management of
asthma (NHLBI Expert Review Panel 3 (EPR3)asthma guidelines). The guidelines emphasize
the importance of asthma control and introduce new approaches for monitoring asthma. The
AAP recognizes that increased exposure to the new guidelines coupled with implementation
support will decrease gaps in care and help move towards optimal care for children with asthma.
The State of Childhood Asthma, United States, 1980 – 2005. December 29, 2006. Akinbami LJ. U.S
Department of Health and Human Services, Centers for Disease Control and Prevention, National Center
for Health Statistics.
4
American Academy of Allergy, Asthma and Immunology. http://www.aaaai.org/media/resources/media_kit/
asthma_statistics.stm
3
5
Chapter Involvement in QI Work
Evidence for the efficacy of state-led improvement projects have been demonstrated by the
Partnership for Quality (PFQ) and the Improving Performance in Practice (IPIP) programs. The
PFQ, funded by the Agency for Healthcare Research and Quality and led by the Academy,
successfully engaged 10 chapters, 127 practices, and 186 physicians in a national QI project
aimed at improving care for children with ADHD. The Improving Performance in Practice
Program, funded by the Robert Wood Johnson Foundation and led by the American Board of
Medical Specialties, has engaged seven states in an improvement project which uses practice
redesign to implement best practices to improve asthma and diabetes care processes.
The PFQ and IPIP programs have shown that chapters can work at both the state and practice
levels to successfully engage and support their members in QI work. PFQ demonstrates the
work chapters can accomplish at the state level to support improvements in pediatric care at the
practice level, while IPIP points to the potential role of chapters in supporting their member
practices through QI education, practice redesign and the implementation of best practices with
assistance from a Quality Improvement Coach (QIC). Within the CQN Asthma Program, a QIC
can help chapters guide practices on the use of QI strategies through efforts of a chapter
collaborative learning community.
Program Mission
The CQN Asthma Pilot Project works at the practice, state and national levels to build a
network of AAP chapters and enhance their ability to lead quality improvement
collaboratives to achieve measurable improvements in the health outcomes of children.
This will be accomplished by creating a platform and learning environment to support
chapters in accomplishing their aims and outcomes. The program will produce a new, high
performing group of chapter leaders who will work together to develop a new model of service
to chapter members.
The CQN Asthma Pilot Project will provide four chapters with tools, resources and technical
support to lead this quality improvement (QI) effort. Chapters selected to participate will gain
QI knowledge and will work to increase their capacity to support member practices in QI efforts.
In addition, participating chapters will have the opportunity to help shape this pilot program.
The Academy is applying to the ABP for MOC QI project approval so that participating chapters
can offer members part IV performance in practice credit for completion of the project.
Providing ABP, MOC part IV credit adds value to chapter membership.
In addition to educational resources, support for the program includes access to a Quality
Improvement Consultant (QIC) from Cincinnati Children’s Hospital Medical Center. The QIC
will help chapters to assist practices in making system-based changes that improve care for
children with asthma within a medical home. The Academy’s Education in Quality Improvement
in Pediatric Practice (EQIPP) asthma module will be used as the data collection tool and the
national office will provide monthly data reports to chapters and practices to provide feedback on
practice performance.
6
Practice High Leverage Changes
Practices will also implement “high level” system changes that have been found to be successful
in achieving improvements in the health outcomes of children with asthma. The practice
changes fall into the following categories:





Engaging Your Asthma QI Team and Your Practice
Using a Registry to Manage Your Asthma Patient Population
Using a Planned Care Approach to Ensure Reliable Asthma Care in the Office
Developing an Approach to Employing Protocols
Providing Self-Management Support
Key Driver Analysis (Figure 1)
The key driver diagram was developed in order to identify pathways to optimal outcomes for
asthma patients. It is a way to organize and see the relationship between this projects goal, the
high level changes that will get you to your goal (Key Driver), and the specific interventions that
a practice needs to do (Interventions).
7
Figure 1:
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
Engaging Your Asthma 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
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
Using a Planned Care
Approach to Ensure Reliable
Asthma Care in the Office
* 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 Asthma 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
Choose and Implement Registry
Determine staff workflow to support registry
Populate registry with patient data
Routinely maintain registry data
Use registry to manage patient care & support population management
Select template tool
Determine staff workflow to support template
Use template with all patients
Ensure registry updated each time template used
Monitor use of template
Select & customize evidence-based protocols for asthma
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
8
Methods/Goals
The CQN Asthma Project’s improvement efforts rest on a number of tightly linked and highly
successful frameworks:
1. The Model for Improvement – Based on building knowledge sequentially; multiple,
planned tests of change allows learning to be captured while during the pilot or testing
phase. This approach reduces the risk of lengthy planning periods and lost time and
effort.
2. The Breakthrough Series Model – A Learning Collaborative brings together healthcare
organizations in multi-disciplinary teams to improve care for a designated health
condition. After teams complete set practice pre-work activities, they will attend four
learning sessions (2 face to-face and two by webinar) during a 12 month period. Teams
will learn best practices and plan tests of change with guidance from improvement
faculty. During the following action periods, chapter and practice teams will analyze
their progress with input from a Quality Improvement Coach (QIC), develop strategies to
overcome barriers to change, and plan for further spread of the changes.
3. The Chronic Care Model – Identifies the essential elements of a health care system that
encourages high quality child health care. These elements are the community, the health
system, self-management support, delivery system design, decision support and clinical
information systems. Many of the chronic care components are similar to those of the
medical home.
CQN Measures and Goals
We have established the following goals based on the key driver analysis and expert consensus.
Each participating practice will be asked to establish aims consistent with the goals of CQN.
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
Secondary/Optional Measures
 >90% of patients have reasons for lack of asthma control identified
 >90% of patients provided with education and self-management materials
 >90% of patients with follow-up appointment
 >90% of patients over 5 yrs of age have spirometry within last 1-2 years
9
Please note this project will also be collecting data on the following two additional outcome
measures.
 % of patients with an asthma-related ED or urgent care visit within the past 12 months.
 % of patients with an asthma-related hospitalization within the past 12 months.
Since baseline data needs to be collected for this measure, targets have not yet been set.
Collaborative Expectations
The AAP National and Chapter Leadership Team will:
1. Provide clinical expertise, coaching and leadership on:
 Improving care for patients with asthma
 Diagnosis, treatment, self management support and referral for patients with
asthma
2. Provide evidence-based clinical and quality improvement information and tools for teams
to use when making specific improvements within their practice
3. Provide tools, forms, and other aids to help with measuring, tracking, and sustaining
changes initiated by practice teams
4. Provide each practice team monthly feedback charts/reports on data collected on
implementation and outcomes
5. Provide extranet for posting of individual team’s charts, submitted monthly report and
aggregates information and library of tools and training materials
6. Offer coaching to practice improvement teams on applying the Model for Improvement
to implement key changes at the learning sessions, on monthly conference calls and
through the listserv.
7. Provide communication methods to keep participants connected to the faculty and to
colleagues during the collaborative, such as the extranet website and collaborative
listserv.
Participating practices are expected to:
Effective participation in a Learning Collaborative requires a small, multidisciplinary team from
each practice.
1. Full participation of the practice QI Team for approximately 16 months, including
attendance at each Learning Session and participation in monthly conference calls.
The QI practice team from the Pediatric Practice typically consists of several members:
 Physician Leader
 Nurse or someone with clinical responsibility
 Administrative Staff/Office Manager Member
 Back-up person
(One of these people must commit to being the day-to-day leader)
10
2. Formal commitment by a Senior Leader (in many practices, this is often the Senior/Lead
Physician, Medical Director, Executive, or Center Director) of your practice or
organization to support you in this endeavor, provide necessary resources and the time to
devote to testing and implementing changes in the site.
3. One member of the core team should be designated as the site’s Day-to-Day Leader. A
Day to day leader is defined as the individual who is responsible for organizing day-today activities, including coordinating regular team meetings, managing improvement
responsibilities, and ensuring that reports and/or data are collected and reported by their
due date.
4. Participation in ongoing data collection through the Academy’s Asthma Education on
Quality Improvement for Pediatric Practice (EQIPP) to ensure that the changes you are
making are resulting in improvements
5. Submission of monthly data and progress reports
6. Willingness and commitment to implement rapid and widespread key practice changes
including: engagement of the asthma core team, implementation of a registry, planned
care, use of practice protocols and provision of self-management support.
7. Regular access to, and use of, email and the Internet for ongoing support, information,
and communication among teams.
8. Hold a weekly meeting with your QI practice Team to make plans and facilitate changes.
Expectations for practices seeking part IV credit for American Board of Pediatrics, Maintenance
of Certification are intended to support the successful achievement of collaborative goals:
For practices
 Presence of a documented process map that details reliable data collection at the time of
the visit
 Established QI Team
 QI team representation at all learning sessions and monthly calls
 Achieve optimal care by year 1 for 70% of the sample population
For physicians
 Complete data collection at the time of the visit with an encounter form for decision
support
 Review practice level data and practice level performance
 Attend monthly practice quality improvement meetings
 On average, enter a minimum of 5 patient visits per month for 7 out of 10 data cycles
11
PARTICIPANT ACTIVITIES OVERVIEW
Learning Sessions
Learning Sessions are the major events of the Collaborative. Through plenary sessions, small
group discussions, and team meetings, attendees have the opportunity to:





Learn from faculty and colleagues
Receive individual coaching from faculty members
Gather new knowledge on the subject matter and process improvement
Share experiences and collaborate on improvement plans
Problem solve improvement barriers
Schedule for the [insert chapter name] Learning Sessions
Learning Session 1
[insert date of first learning session]
(face to face meeting)
Learning Session 2
To be determined
(webinar)
Learning Session 3
To be determined
(face to face meeting)
Learning Session 4
To be determined
(webinar)
12
PRACTICE PRE-WORK ACTIVITIES AND INSTRUCTIONS:
WHAT YOU NEED TO DO BEFORE THE FIRST LEARNING SESSION
The first Learning Session will set your course for the collaborative. Participants have more success
when they come to this meeting well prepared. To prepare your practice for the first Learning
Session, we will expect each team to work together to complete the following tasks:
1. Identify Your Team’s Aim Statement
Write your aim statement. An aim statement answers the question: What are we trying to accomplish?
It is an explicit statement summarizing what your practice plans to achieve during the project. An aim
statement will focus your team’s actions, helping to improve asthma care to children in your practice. It
should be specific, measurable, actionable, relevant, and time bound. Your team will have an
opportunity to revise your original aim statement during the first Learning Session. It is perfectly
alright to keep the provided aim statement and not make any changes if it reflects what you want to
accomplish.
State your aim clearly, and use specific numeric goals. Teams make better progress when they have
unambiguous, specific goals. Setting numeric targets clarifies the aim, helps to focus change efforts, and
directs measurement activities.
As you begin to consider your team’s aims, be sure to do the following:
A. Involve the organization’s senior leaders
Leadership must align the aim with strategic goals of the organization. They should also
help identify an appropriate patient population for initial focus of the team’s work.
B. Base the goals in your aim on existing data or organizational needs
Examine available information about asthma care within your practice. Refer to the CQN
Goals in the Charter and focus on issues that matter most to your patients and families.
For example, instead of an aim statement that states:
Primary Pediatrics will improve asthma care.
Your aim statement should be specific, measurable, actionable, relevant, and time bound:
Project Aim Statement
Global Aim Statement
We will build a sustainable quality improvement infrastructure within our practice to achieve
measurable improvements in asthma outcomes
Specific Aim Statement
From fall 2009 to fall 2010, we will achieve measurable improvements in asthma outcomes by
implementing the NHLBI guidelines and making CQN Asthma Pilot Project’s key practice
changes
13
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
Secondary/Optional Measures
 >90% of patients have reasons for lack of asthma control identified
 >90% of patients provided with education and self-management materials
 >90% of patients with follow-up appointment
 >90% of patients over 5 yrs of age have spirometry within last 1-2 years
Guidelines for Individualizing Your Aim Statement:
- Discuss the aim statement with your team
o Consider your target population, connecting to other initiatives occurring at your
practice, etc.
- Edit the Specific Aim Statement for your practice, so the wording reflects what your
practice wants to accomplish. Your aim statement should articulate to others what you
are specifically trying to accomplish.
- Review the goals and measures. If your practice is planning on working on something
that is not addressed, please add a numeric goal/measure and bring to the Learning
Session..
14
II. Prepare a Storyboard to Display at Learning Session I
Each Learning Session is designed to create an environment conducive to sharing and
learning. At the first Learning Session, there will be a storyboard display from all
participating practice teams. Your audience will be the other teams, Collaborative Faculty,
and Collaborative Leadership. At this first Learning Session, assume that there is little or no
familiarity with your organization, setting, population, improvement aims, or special
interests/activities related to improving perinatal care. Use your storyboard to tell your
team’s story descriptively, clearly, and creatively. Photos, collages, and other illustrations
are encouraged.
“Your story” must fit into a space approximately 30 x 40 inches. It may be created from one
large poster or a collection of letter-sized sheets. Ten to 12 sheets can fit in the available space,
depending on arrangement. The use of individual sheets (done on Word, PowerPoint, or by
hand) is convenient for carrying while traveling. Poster boards, push pins, and other supplies
will be provided at the Learning Session..
Storyboard Outline
Here is a possible outline for what you might include in your storyboard:
 Name & Location of Organization
 Brief Description of your organization (Providers, Staff, Community or Population
Characteristics, etc)
 Improvement Team (Names, Titles, Roles) (What you each wanted to be when
growing up, just for fun!)
 Team’s Improvement Aim for Project
 Initial Ideas for Improvement
 Other Relevant Information (e.g., current programs/activities targeted to asthma care)
*Creative Idea: a recent group created a storyboard with a baseball theme. The physician leader
was the “Coach”, the office manager was the “General Manager”, and the RN was the “Closer”.
Display Tips
 Fewer WordsMore Pictures and Graphics
 Real People Pictures…. At Least of Your Team! (Hint, Hint )
 Font Size as Big as Possible
 Fancy Not Necessary
 Color to Highlight Key Messages If No Color Printer, Use Bright Highlighters
15
ACTION PERIOD ACTIVITIES OVERVIEW
Between Learning Sessions
The time between Learning Sessions is called an Action Period. During Action Periods, practice
team members work within their practices to test and implement an organizational approach to
improving asthma care. Although participants focus on their own organizations, they remain in
contact with other teams enrolled in the collaborative and with Collaborative Faculty and
Leadership. This communication takes the form of Listserv (group e-mail), the CQN Extranet,
and conference calls. In addition, collaborative team members share the results of their
improvement efforts in monthly reports. Participation in Action Period activities is not limited to
those who attend the Learning Sessions. We expect the participation of other team members and
support persons in your practice as you carry out Action Period activities.
Another feature of the Action Periods are the monthly practice conference calls. QI practice teams
will join the other teams in the collaborative to describe their tests of change and share learning
gained through successes and failures. Guidance and support is provided by the faculty and staff
who facilitate these calls. We encourage the core improvement teams to invite members of their
extended teams to attend these calls as well.
Action Period 1 Conference Calls Dates and Times
Call #1
[insert dates for your action period 1 conference call]
Call #2
[insert dates for your action period 1 conference call]
Call #3
[insert dates for your action period 1 conference call]
Call #4
[insert dates for your action period 1 conference call]
Call #5
[insert dates for your action period 1 conference call]
16
COMMUNICATIONS
Collaborative Listserv
In order to facilitate communication among practice teams, each chapter will lead their own
collaborative listserv. Once practices have been enrolled in the project they will be added to
their chapter’s listserv.
How does it work?
Once added to the listserv a message will automatically be sent to everyone on the distribution
list. If anyone replies, the reply will be sent to everyone on the distribution list. Information
posted on this listserv is confidential. Please do not share with anyone outside of the listserv
without permission from the person who posted the information.
What kind of information is shared on the listserv?




Updates from all teams about improvement efforts
Conference call schedules and reminders
Details about Learning Sessions
Questions from faculty or for faculty or other
Why should I participate?



Everyone will learn from the experiences of the entire group through sharing successes
and failures of the “small” change cycles
Get help from other teams and faculty with problem-solving and identifying strategies to
overcome barriers
The more information teams share, the more learning that will occur
What kind of information should NOT be shared on the listserv?



Information posted is confidential. Please do not share with anyone outside of the listserv
without permission from the person who posted the information
Confidential patient information (names, patient ID numbers) should never be shared
The American Academy of Pediatrics (AAP) provides this list as a forum for the
exchange of views among its members in matters of professional interest. The AAP is not
responsible for, and does not endorse or necessarily agree with the views expressed
through this list. Such views are solely those of the individuals who express them
Keep in Mind


Conversations often evolve from their initial ‘Subject.’ Please be aware of the ‘Subject’
header and make the appropriate changes to accurately reflect the content of the email.
Use the “reply” button with caution. If you are replying about logistics, for example, you
do not need to involve the entire list.
If you have any questions or would like to be removed from the list,
please contact Vanessa Shorte at vshorte@aap.org
17
CONFERENCE CALL TIPS & INFORMATION
Purpose of Collaborative Conference Calls







Share Successes
Plan Strategies to make Improvements
Share Challenges
Share Learning
Get Support
Hear New Ideas
Periodic Clinical Updates
Ongoing Responsibilities




Be prepared to report on your progress during the last month
Attend calls regularly. Calls last 1 hour
Who should attend? Practice QI Team (example: Physician leader, Office Manager, RN)
Invite other interested staff for general interest topics (i.e., clinical topics)
Responsibilities of Call Participants






DO NOT PUT THE CALL ON HOLD the music will disrupt the teleconference. MUTE
button is fine. If you are paged and have to go to another line, hang up and dial back in if
needed.
The facilitator will take “roll call” so that everyone is aware who is on the call.
Many phones are very sensitive and we ask that you keep background noise to a
minimum. Keeping the MUTE button on when not speaking is fine, especially cell
phones.
If you are have a comment or question and are not able to participate, please let the
facilitator know after the call so we can post your question on the listserv and correct this
for the next call.
Please identify yourselves each time you speak.
Feel free to direct your questions/comments to specific individuals.
18
Appendixes
19
Appendix A: Learning Session 1 - Registration and Logistics
CQN Learning Session I
[insert date and time]
Learning Session I Dates and Times:
Wednesday September 3rd begin at 12:00pm
Thursday September 4th 8:00am-3:00pm
Hotel and Conference Facility Location
Columbus Marriott Northwest
5605 Blazer Pkwy
Dublin, OH 43017
Phone: 1-614-791-1000
Toll Free: 1-888-801-7133
Fax: 1-614-791-1001
Method of Reservations
Individual attendees must make their own reservations for the Learning Session directly with
Marriott Central Reservations at 1-888-801-7133 or online at Marriott.com
Please reference Chapter Quality Network Learning Session when making your reservations to
obtain the group rate.
***Individuals are more than welcome to make hotel accommodations at other nearby facilities.
Hotel Parking is Free
Meals (The following meals will be provided for all participants)
Dinner (Wednesday)– Marriott Northwest – Columbus, OH
Breakfast (Thursday) – continental breakfast – Marriott Northwest – Columbus, OH
Lunch (Thursday) – Marriott Northwest – Columbus, OH
20
Appendix A: Learning Session 1 - Registration and Logistics
To register for Learning Session 1, please return this Registration Form [insert chapter
manager contact information]
Name & Title of Attendees:
AAP ID #
Food Preference
1.
 Chicken  Fish  Vegetarian
2.
 Chicken  Fish  Vegetarian
3.
 Chicken  Fish  Vegetarian
Organization
Address
City
State
Phone*
Fax
ZIP
Email
*Please provide contact information for your team’s day-to-day leader (key contact)
21
Appendix B: CQN Collaborative Chapter & Leadership Contact Information
CQN [insert chapter name] Team
[insert Chapter Physician Leader Name]
Chapter Physician Leader
Insert Picture
if available
[insert brief bio and contact information]
[insert Asthma Expert Name]
Asthma Expert
Insert Picture
if available
[insert brief bio and contact information]
[insert Chapter Manager Name]
Chapter Manger
Insert Picture
if available
[insert brief bio and contact information]
22
Appendix B: CQN Collaborative Chapter & Leadership Contact Information
CQN National Leadership Team
Judith C. Dolins, MPH
Principle Investigator
Judy Dolins is the Director of the Department of Community, Chapter and State Affairs at the American
Academy of Pediatrics. The department works to advance child health at the state and local levels through
advocacy, community-based programs and the development of organizationally sound chapters. Ms. Dolins
is a member of the Advisory Board of the National Center for Medical-Legal Collaboration at Boston
Medical Center. She also serves on the Advisory Board of the Vermont Child Health Improvement
Programs (VCHIP) Improvement Partnership Initiative. She has the overall responsibility for the
development, implementation, and success of the project.
Robert Perelman, MD FAAP
Physician Director
Dr. Perelman is Associate Executive Director and Director of the Department of Education at the American
Academy of Pediatrics (AAP). In his role with the AAP, he is responsible for projects across the spectrum
of Graduate Medical Education, CME/CPD and scholarly journals/professional periodicals. He represents
AAP on several national initiatives related to quality including, but not limited to: the American Board of
Medical Specialties (ABMS) Improving Performance in Practice and Committee on Maintenance of
Certification, the Alliance for Pediatric Quality (APQ), the National Quality Forum (NQF) and the
American Board of Pediatrics Committee on Maintenance of Certification.
Peter Margolis, MD PhD
Project Lead
Dr. Margolis is a general pediatrician, epidemiologist and serves as the Co-Director of Cincinnati
Children’s Hospital Center for Health Care Quality. He is nationally-recognized for his expertise in
improvement science and systems improvement. As a consultant to the CQN program, Dr Margolis is
serving as the Project Lead and is developing the design of the program, providing oversight for curriculum
development and mentorship for the development of the measures and the translation of the measurement
strategy into specific data collection tools and reports.
Keith Mandel, MD FAAP
Improvement Advisor
Dr. Mandel is Vice President of Medical Affairs for the physician-hospital organization (PHO) at
Cincinnati Children’s Hospital Medical Center. He currently leads the PHO efforts to improve the
outcomes of care for children with asthma across a network of 40 practices, with significant improvement
in network-level outcome measures. As a consultant to the CQN program, he is sharing key learnings from
the PHO asthma initiative to inform the assessment, design, and implementation phases and helping to
define key drivers/interventions of focus for achieving the overall aim of the network. He will also provide
consultation relative to engaging payors on rewarding quality and designing pay-for-performance
programs.
Ramesh Sachdeva, M.D., Ph.D., M.B.A, FAAP
Improvement Advisor
Dr Sachdeva serves as the Medical Director of Quality Initiatives at the Academy along with working at the
Children’s Hospital of Wisconsin as the Executive Vice President of National Outcomes Center and is on
staff as an intensivist. Dr. Sachdeva serves as an Improvement Advisor to the CQN program and will
provide guidance to chapter leadership when implementing the change package and high leverage changes
to improve children’s health outcomes.
23
Appendix B: CQN Collaborative Chapter & Leadership Contact Information
Divvie Powell, MSN, RN
Senior Quality Improvement Consultant
Ms. Powell is a Senior Quality Improvement Consultant at The Center for Health Care Quality (CHCQ) at
Cincinnati Children’s Hospital Medical Center. Her background is in psychiatric mental health nursing;
process improvement and work redesign; and training and curriculum development. She has 20 years of
experience in health care leadership, leading change efforts, planning and implementing new programs, and
working with multiple groups to improve care. Ms. Powell has served as Project Director for
Collaboratives for asthma, preventive services, children in foster care, cystic fibrosis, chronic illness in
specialty care, medical home, advanced access, and dissemination projects over the last 11 years. She has
been part of the consulting team to RAND for a pilot collaborative on preparedness for pandemic influenza
in public health agencies. Her role on the CQN team from CHCQ is to provide consultation to the team on
collaborative methods. Ms. Powell received both her undergraduate and graduate degrees in nursing from
the University of North Carolina – Chapel Hill
Laura Conley, MHSA
Quality Improvement Consultant
Ms. Conley is a Quality Improvement Consultant at Cincinnati Children’s Hospital Medical Center. Most
recently, she participated in an ADHD Collaborative in Cincinnati focused on practice office flow redesign,
sustainability, and spreading the model for improvement. Ms. Conley will work directly and intensely with
the four selected chapters to develop and implement the learning sessions and as well as to help chapters
coach practices.
Vanessa Shorte, MPH
Program Manager
Ms. Shorte is the Manager of Chapter Improvement Activities at the American Academy of Pediatrics.
Through the Chapter Alliance for Quality Improvement (CAQI), she provides consultation and technical
assistance to chapter leadership on chapter infrastructure building and the implementation of quality
improvement programs. As Program Manager of the CQN she is responsible for managing the overall
program at the national, chapter and practice levels.
Lori Morawski, MPH CHES
EQIPP Manager
Ms. Morawski serves as the Manager of Quality Improvement Programs at the American Academy of
Pediatrics. She is directly responsible for the development of new EQIPP modules in coordination with the
physician-led EQIPP Planning Committee at the AAP. As the CQN EQIPP manager, Ms Morawski is
responsible for developing CQN interface and reporting mechanisms through EQIPP, serving as the liaison
to EQIPP programmers and providing feedback to the program measurement strategy.
24
The following material is included as background reading.
Appendix C: Model for Improvement
Appendix D: Improvement Glossary
25
Appendix C: Model for Improvement
Why A Model? What Purpose?
Improvement Principles

Provide organizing structure to guide thinking

Listen to patients and families

Ensure discipline and thoughtfulness

Tap knowledge of the system by involving staff

Support improvement principles

Understand processes and interactions in system

Facilitate improvement


Foster common language
Use disciplined method in successive cycles to
test changes

Test on small scale; move rapidly to improve

Measure to learn and to understand variation
Model for Improvement
3 Key Questions for Improvement
What are we trying to accomplish?
AIM
Test Ideas & Changes in
Cycles for Learning & Improvement
How will we know that a
change is an improvement?
MEASURES
Act
What changes can we
make that will result in
an improvement?
IDEAS
Plan
Study Do
26
Appendix C: Model for Improvement
Question 1: What are we trying to accomplish?
AIM: A specific, measurable, time-sensitive statement of expected results of an improvement process.
A strong clear aim gives necessary direction to improvement efforts, and is characterized as:
 Intentional, deliberate, planned
 Unambiguous, specific, concrete
 Measurable with a numeric goal, preferably one that provides a “stretch” to motivate
significant improvement
 Aligned with other organizational goals or strategic initiatives
 Agreed upon and supported by those involved in the improvement and leaders
Make your aim actionable and useful. Include:
 A general description of what you hope to accomplish
 Specific patient population who will be the focus
 Some guidance for carrying out the activities to achieve aim
Question 2: How will we know that a change is an improvement?
MEASURES: Measures are indicators of change. To answer this key question (“How will
we know that a change is an improvement”), several measures are usually required. These
measures also can be used to monitor a system’s performance over time. In Plan-Do-StudyAct (PDSA) cycles, measurement used immediately after an idea or change has been tested
helps determine its effect.
In improvement, key measures and measurement should:
 Clarify and be directly linked to goals
 Seek usefulness over perfection
 Be integrated into daily work whenever possible
 Be graphically and visibly displayed
 For PDSA cycles, be simple and feasible enough to accomplish in close time
proximity to tests of change
Question 3: What changes can we make that will result in an improvement?
IDEAS: Ideas for change or change concepts to be tested in a PDSA cycle can be derived from:
 Evidence or results of research/science
 Critical thinking or observation of the current system
 Creative thinking
 Theories, questions, hunches
 Extrapolations from other situations
When selecting ideas to test, consider the following:
 Direct link to the aim and goals
 Likely impact of the change (avoid low-impact changes)
27
Appendix C: Model for Improvement






Potential for learning
Feasibility
Logical sequencing
Series of tests that will build on one another
Scale of the test (3 patients, NOT 30)
Shortness of the cycle (1 week, NOT 1 month)
Tips to make the most of PDSA cycles and tests of change:
 Think a couple of cycles ahead
 Plan multiple cycles to test and
Test Ideas & Changes in
Cycles for Learning & Improvement
adapt change
 Scale down size of test (# of
patients, location)….A “cycle of 1”
is often appropriate
What
refinements or
modifications need to be made
What’s the next cycle?
 Do more cycles, at a smaller scale
Objective
Questions&
predictions
(What will happen & why)
Plan to carry out the cycle
(Who, what, where, when)
and faster pace instead of fewer,
bigger, slower
Act
 Test with volunteers first
 Don’t seek buy-in or consensus for
Plan
Study
Do
the test
 Be innovative and flexible to make
analysis
to predictions
What did you learn?
What conclusions can you
draw from this test?
test feasible
 Collect useful (and only just
Complete
Carry
Compare
Document
out the plan
experience,
problems, surprises
Collect data as planned;
begin analysis
enough) data during each test
 Test over a wide range
of conditions
 Learn from failures as
Repeated PDSA Cycles To Test A Change
well as successes
 Communicate what
ge
led
w
o
n
you’ve learned
D

ata
Ideas
Inf
P D
S A
R
n
eme
efin
K
PD
SA
support
n
atio
m
r
o
P D
S A
 Engage leadership
g
nin
ear
L
&
ts
tati
dap
A
&
ons
to
al
gin
O ri
Changes that
result in
improvement
a
I de
Successive tests of a change
build knowledge &
create a ramp to improvement
28
Appendix D: Improvement Glossary
Action Period
The period of time between Learning Sessions when teams work on improvement in their practice or
office settings. They are supported by the Collaborative Leadership, and they are connected to other
teams.
Aim
A written, measurable, and time sensitive statement of the expected results of an improvement process.
Key Driver Diagram
The Key Driver Diagram organizes the theory of improvement for a specific aim, connects the
aim/outcome, key drivers and interventions to create a learning structure. The key drivers provide a
focus for changes to test.
Learning Session
Usually, a two-day meeting during which participating organization teams meet with faculty and
collaborate to learn key changes in the topic area including how to implement changes, an approach for
accelerating improvement, and a method for overcoming obstacles to change. Teams leave these
meetings with new knowledge, skills, and materials that prepare them to make immediate changes.
Measure
An indicator of change. Key measures should be focused, clarify your team’s aim, and be reportable.
A measure is used to track the delivery of proven interventions to patients and to monitor progress over
time.
Model for Improvement
An approach to process improvement, developed by Associates in Process Improvement, which
helps teams accelerate the adoption of proven and effective changes.
PDSA Cycle
A structured trial of a process change. Drawn from the Shewhart cycle, this effort includes:
Plan - a specific planning phase;
Do - a time to try the change and observe what happens;
Study - an analysis of the results of the trial; and
Act - devising next steps based on the analysis.
This PDSA cycle will naturally lead to the Plan component of a subsequent cycle.
Prework Packet
A workbook containing a complete description of the project, along with expectations and activities
to complete prior to the first Learning Session.
Prework Period
The time prior to the first Learning Session when teams prepare for their work in the project, including
selecting team members, scheduling initial meetings, consulting with senior leaders, preparing their aim,
and initiating data collection.
Team
The group of individuals, usually from multiple disciplines, that participates in and drives the
improvement process. A core team of 3 to 4 individuals attends the Learning Sessions, but a larger
team of 6 to 8 people participates in the improvement process in the organization.
29
Appendix D: Improvement Glossary
Test
A small scale trial of a new approach or a new process. A test is designed to learn if the change
results in improvement and to fine-tune the change to fit the practice and patients. Tests are carried
out using 1 or more PDSA cycles.
30