Chapter Quality Network (CQN)
Asthma Pilot Project
Team Progress Presentation
State Name:
Alabama
Practice Name:
Pediatric Associates of Auburn
Team Members:
Wes Stubblefield, M.D., F.A.A.P., Dianne Carlton,
Erica Bentley, L.P.N.
Version 2.0
CQN Asthma Project Practice Key Driver Diagram
Key Drivers
GLOBAL CQN AIM
We will build a sustainable quality
improvement infrastructure within our practice
to achieve measurable improvements in
asthma outcomes
Specific Aim
From fall 2009 to fall 2010, we will achieve
measurable improvements in asthma
outcomes by implementing the NHLBI
guidelines and making CQN’s key practice
changes
Measures/Goals
Outcome Measures:
 >90% of patients well controlled
Process Measures
 >90% of patients have “optimal” asthma care (all
of the following)
 assessment of asthma control using a
validated instrument
 stepwise approach to identify treatment
options and adjust therapy
 written asthma action plan
 patients >6 mos. Of age with flu shot
(or flu shot recommendation)
 >90% of practice’s asthma patients have at least
an annual assessment using a structured encounter
form
Engaging Your QI Team and
Your Practice
*The QI team and practice is active and
engaged in improving practice processes
and patient outcomes
Using a Registry to Manage
Your Asthma Population
*Identify each asthma patient at every visit
*Identify needed services for each patient
*Recall patients for follow-up
Using a Planned Care
Approach to Ensure Reliable
Asthma Care in the Office
* CQN Encounter Form
* Care team is aware of patient needs and
work together to ensure all needed
services are completed
Developing an Approach to
Employing Protocols
* Standardize Care Processes
* Practice wide asthma guidelines
implemented
Providing Self management
Support
* Realized patient and care team
relationship
Interventions
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Form a 3-5 person interdisciplinary QI Team
Formally communicate to entire practice the importance and goal of this
project
Meet regularly to work on improvement
All physicians and team members complete QI Basics on EQIPP
Collect and enter baseline data
Generate performance data monthly
Communicate with the state chapter and leaders within the organization
Turn in all necessary data and forms
Attend all necessary meetings and phone conferences
Select and install a registry tool
Determine staff workflow to support registry use
Populate registry with patient data
Routinely maintain registry data
Use registry to manage patient care & support population management
Select template tool from registry or create a flow sheet
Determine workflow to support use of encounter form at time of visit
Use encounter form with all asthma patients
Ensure registry updated each time encounter form used
Monitor use of encounter form
Select & customize evidence-based protocols for your office
Determine staff workflow to support protocol, including standing orders
Use protocols with all patients
Monitor use of protocols
Obtain patient education materials
Determine staff workflow to support SMS
Provide training to staff in SMS
Assess and set patient goals and degree of control collaboratively
Document & Monitor patient progress toward goals
Link with community resources
Progress Summary Since
Learning Session 1
1. Beginning with LS1, implemented study on a limited basis with one
provider and expanded to all asthmatic office patients with all providers.
2. Developed reliable process for identifying asthmatic patients and
distributing encounter forms in office flow.
3. Increased identification of asthmatic patients through use of encounter
form and spirometry per guidelines.
4. Increased evidence-based guideline treatment of asthmatic patients by
using NLHBI stepwise approach to therapy.
5. Improved outcomes with increased flu shot recommendations for all
asthmatic patients and regular use of spirometry in follow up.
6. Improved follow up reliability with identification and missed visit calls.
% of Patients with AAP
Spirometry within 1-2 years
F/U appt recommended
Optimal Asthma Care
PDSA Cycle – Follow up
PDSA Title:
 Plan: Recommend follow up to all study patients per
guidelines, expanded to all asthma patients with all providers.
 Do: Asthma patient tagged in EHR. Each visit,
symptoms/medications reviewed by L.P.N. and M.D. and
follow up recommended as appropriate or per guidelines.
 Study: Noted that some patients were not keeping scheduled
appointments for follow up. Implemented “no show” strategy,
front office staff to notify M.D. and L.P.N. if patient missed
appointment. L.P.N. contacted family personally to stress the
importance of keeping scheduled appointments and
reschedule. Noted improvement with keeping appointments
as expected.
 Act: At follow up visit, asthma action plan reviewed, follow up
spirometry scheduled or performed, if indicated. Asthma
action plan modified as needed.
PDSA Ramps
P D
P D
P D
P D
S A
S A
S A
TEST 4
What:: AAP to all asthmatic patients
Who (population): all asthmatic pts
Who (executes): Nurse hands out form,
MD completes
Where: Triage/Exam Room
When: 45 days
S A
TEST 4
What:: Spirometry f/u per guidelines in addition
to initial spirometry for diagnosis
Who (population): All asthmatics
Who (executes): MD orders, nurse performs
Where: Exam room or Lab
When: 45 days
P D
P D
S A
TEST 3
What:: AAP to all identified pts
Who (population): All identified pts
Who (executes): MD
Where: Exam room
When: 30 days
S A
TEST 3
What:: Spirometry to asthmatics per guidelines
Who (population): All asthmatic patients
Who (executes): MD orders, nurse peforms
Where: Exam room or Lab
When:30 days
P D
P D
P D
S A
S A
S A
TEST 2
What:: Provide spirometry per guidelines
(current or new diagnosis only)
Who (population): Limited population
Who (executes): MD orders, nurse performs
Where: Exam room or Lab
When: 15 days
TEST 2
What:: Distribute AAP to all identified pts
Who (population): Alll identified pts
Who (executes): Nursing staff
Where: Triage Area
When: 15 days
P D
P D
S A
S A
S A
Asthma Action Plan (AAP)
TEST 1
What:: Identify pts needing current spirometry
Who (population): Limited population
Who (executes): MD review of chart
Where: Exam room, EHR
When: Immediately
Spirometry
TEST 3
What:: EHR tagging of asthmatic patients
to follow up
Who (population): all asthmatic patients
Who (executes): Front Desk
Where: Front Desk
When: 45 days
TEST 2
What:: Expanding follow up to call asthmatic patients
Who (population): all asthmatic patients
Who (executes): MD
Where: Exam room
When: 15 days
P D
TEST 1
What:: Identifiy asthmatic patients for study
Who (population): Limited population
Who (executes): MD/Nurse
Where: Office flow, MD work area
When: Immediately
TEST 4
What:: Call back for missed appts
Who (population): All identified pts
Who (executes): MD orders through EHR
Front desk performs
Where: Exam room, front desk
When: 60 days
TEST 1
What:: Recommended f/u to study patients per guidelines
Who (population): Study patients only
Who (executes): MD
Where: Exam room
When: Immediately
Follow up
Office Visit Prework
During Office
Visit
ASTHMA
Asthma
PATIENTS
patients
INDENTIFIED
identified by
BYEHR
EHR
FLASHER
PATIENT CHECKS IN AT
FRONT DESK – LPN
REVIEWS PATIENT HISTORY
- I.E., EXPOSURE TO
CIGARETTE SMOKE, FLU
SHOT STATUS, MEDICATION
LIST
PEDIATRIC ASSOCIATES OF AUBURN
LPN GIVES
ASTHMA
ENCOUNTER
FORM TO
PARENT
M.D. REVIEWS ENCOUNTER FORM –
COMPLETES ENCOUNTER FORM IN EHR
REVIEWS HISTORY OF PROGRESS OR
FAILURES WITH CURRENT TREATMENT.
M.D.
PROVIDES
EDUCATION &
ASSESSES
NEED FOR
SPIROMETRY
AND/OR
ALTERNATE
MEDICATION
PLAN
LPN
PERFORMS
SPIROMETRY
IF ORDERED
Post Visit
Activities
ANY NEW OR UNIDENTIFIED
PATIENTS ARE IDENTIFIED
DURING TRIAGE BY LPN
AND GIVEN ASTHMA
ENCOUNTER FORM
FRONT DESK CHECKS FOR
F/U INSTRUCTIONS AT
CHECKOUT FOR ALL ASTHMA PATIENTS
– F/U SCHEDULED AS INDICATED
BY M.D.
NEW/UNIDENTIFIED
ASTHMA PATIENTS
CHARTS ARE FLAGGED
IN EHR
ENCOUNTER FORMS PLACED ON M.D.’S
DESK
M.D. ENTERS
DATA IN TO
EQUIPP – SENDS
FORM TO FRONT
OFFICE FOR
SCAN IN TO
CHART
FRONT OFFICE NOTIFIES
LPN AND M.D OF ANY
ASTHMA PATIENT
MISSED APPTS
M.D. REVIEWS
PATIENT CHART
– LPN CONTACTS
PARENTS TO
RESCHEDULE
FOLLOW UP
APPT
M.D.
REVIEWS
SPIROMETRY
RESULTS –
ADJUSTS
MEDS AS
NEEDED –
ADVISES F/U
AS PER
RESULTS
CQN Encounter Form
Key Learnings
 Obviously, although we felt we performed quality
asthma care, our experience through this project
tells us otherwise.
 However, with a little work and some direction
through the collaborative, we were able to increase
our optimal asthma care into the goal range.
 Our data have not shown significant increases in
our well controlled patients and admission rates
yet, but we plan to see that increase over the next
few months.
Barriers and Successes
• Barriers:
– Being a small office, implementing any change is
usually quick, but requires increased time for the
staff. We have very little extra staff to handle
increased workload (3 non-clinical staff including
office manager).
• Successes:
– We feel that we have integrated this project into our
workflow such that, even when busy, we are able to
complete our forms.
– We were also able to integrate the CQN form into
EHR.
Future Plans
• Identify all prior asthmatic patients through
practice management software and ICD-9
review.
• Implement registry through RMD.
• More formalized asthma education, e.g. spacer
teaching, MDI teaching, DPI teaching
• Formalized staff training
• More integration of project with EHR (starting
with encounter form – Thanks Partners in
Peds!!)