Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Alabama Practice Name: Huntsville Pediatric Associates Team Members: Katie Gunter, MD Cathy Radzinski, LPN, BBA Robin Riggs, Practice Manager 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 Progress Summary Since Learning Session 1 •Asthma pt’s identified through report run in practice management system •All 7 physicians entering Data into EQIPP monthly •Protocols implemented for phone triage nurses regarding influenza vaccination, medication refills and follow-up OV for asthma patients •Asthma action plan written and installed on EVERY desktop in patient areas •All nursing staff trained in use of spirometry machine •Report run in practice management system to ID asthma pt’s needing spirometry (criteria=>5 yrs of age and no spirometry in past 12 months) •Researched registry options. Currently working with RMD to implement registry at HPA Refinements: add HPA logo to form and make available to all doctors Next cycle: Develop workflow to have handout distributed by nurse to parent before Dr. enters exam room to improve efficiency. Completed analysis Compare to predictions: Does add time. Is easy to incorporate. By doing encounter form parents realize child’s control better; identifies areas of confusion with management Encounter form itself easy to use and important in identifying patient’s with suboptimal asthma control. Need to develop better way to get the form to parents sooner in the visit to improve efficiency PDSA Act Plan Study Do •Implement use of encounter form •Questions: •Will it take too much time? •Will parents understand it? •Will it be easy to incorporate? •Will it provide better care? •Predictions: •Will take significant time to incorporate into visit. •Parents will understand the form. •Who/What/When: Dr. Gunter to use on asthma patients in both WCC and sick visits Dr. Gunter using encounter form Experience: Easy to use Problems: does add approx 5 min to each visit Surprises: parents like it Collecting data and entering in EQIPP; begin analysis Refinements: have type-in option on action plans for those patients with special instructions/unique meds etc Next cycle: incorporate action plan into EMR (for now, scan in forms to chart). Completed analysis Compare to predictions: Does add time. Is easy to incorporate. By giving action plan parents feel more comfortable with what to do at home and when to call office In discussing the plan with parents, able to identify areas of confusion with management Phone nurses notice parents refer to their action plan during calls PDSA Act Plan Study Do •Provide updated action plan to patient at every encounter •Questions: •Will it take too much time? •Will parents understand it? •Will it be easy to incorporate? •Will it provide better care? •Predictions: •Will take time to create each action plan and explain it to parents. •Parents will feel more comfortable with asthma management. •Who/What/When: Dr. Gunter will create action plan template with the assistance of other MDs in the practice. All MDs will then use the action plan template and distribute plans at all asthma pt encounters. Dr. Gunter created action plan template Experience: Easy to use Problems: does add approx 5 min to each visit. Need to adjust drop down options within the template Surprises: parents like it and find it very helpful Collecting data and entering in EQIPP; begin analysis Refinements: would like spirometry and EMR to communicate with each other Completed analysis Compare to predictions: Nurses comfortable with performing spirometry. Is easy to incorporate (especially with scheduling spirometry in “shot clinic” (Does not need to be seen by MD for spirometry to be conducted). Spirometry useful in assessing patients with unclear diagnosis/ identifying control in some who are unclear of their symptoms PDSA Act Plan Study Do •Every asthma patient should have spirometry done within the last year if age appropriate •Questions: •How will this fit into office visit? •Will it help in assessment of asthma control? •Who will conduct spirometry testing? •Predictions: •Not all nurses comfortable with spirometry •Will help in assessing asthma control in some patients •Results will be useful in explaining asthma control with families (ie. The need for preventative meds) •Who/What/When: •Nurse identifies whether or not spirometry done within the last year. •MD responsible for scheduling spirometry (at that visit vs at future time) Workflow designed to capture those in need of spirometry Experience: nurses all instructed on spirometry Problems: no interface between spirometry and EMR. Requires entering data manually Surprises: MANY patients in need of spirometry Collecting data and entering in EQIPP; begin analysis Refinements: make sure all MDs have handouts readily available to ensure use (ie. Put on desktops and at nurses station). Completed analysis Compare to predictions: Does add time to visit. Is easy to incorporate. Parents appreciative. Phone nurses note parents seem more confident in understanding symptoms and control. PDSA Act Plan Study Do •Provide more education to parents to help with understanding and compliance •Questions: •Will this take too much time? •Will it help with overall asthma control? • What areas of education are the most useful? •Predictions: •Will add time to visit (<5min) •Will help with compliance and subsequently asthma control •Who/What/When: •MDs to review several different education handouts and choose those which are the most relevant. •MDs to distribute as indicated MDs selected handouts and started distributing Experience: different MDs using different handouts (based on preference) Problems: not all MDs using handouts consistently Surprises: parents seem receptive to the education Collecting data and entering in EQIPP; begin analysis PDSA Ramps P D S A TEST 1 What:CQN Encounter Form Who (population):asthma pts Who (executes): Dr. Gunter Where:HPA When:Sept. 23, 2009 CQN Encounter Form S A TEST 3 What:Blank Asthma Action Plan installed for MD’s to “fill in blanks” on their own (can choose from this or drop-down version) Who (population):asthma pts Who (executes):MD’s Where:clinic When: well or sick visits P D S A S A S A S A S A P D P D P D P D TEST 3 What:Spirometry schedule Who (population):asthma pts. Who (executes):MD/nurses Where:immunization clinic When: schedule q day 9a or 1:30 p in immunization clinic TEST 3 What:Encounter Form-Entering Data Who (population):MD’s Who (executes):MD’s Where:HPA When:By Equipp Deadline TEST 2 What:Revised Encounter Form Who (population):asthma pts. Who (executes): ALL 7 MD’s Where:HPA When:Oct. 1, 2009 P D TEST 2 What:Spirometry Who (population):asthma pts. Who (executes):nurse with MD orders Where:Treatment Room When:at sick or well visit TEST 2 What:Asthma Action Plan Word Doc with drop down installed on all MD Desktops Who (population):asthma pts. Who (executes):all MD’s Where:clinic When:Beginning 10/15/2009 sick visit P D P D S A S A TEST 1 What:Train Nurses in use of machine Who (population):Clinical Nursing Staff Who (executes):Cathy Radzinski, Teri Franklin Where:Treatment Room When:Jan. 17, 2009 Spirometry TEST 1 What:Develop office Asthma Action Plan Who (population):asthma pts. Who (executes):Asthma CQN Team Where:Dr. Gunter clinic hours When: October 1, 2009 Asthma Action Plan Huntsville Pediatric Associates Asthma Encounter Workflow Pre-Visit Run report in Practice Management to find asthma pts. Who are in need of flu shot and have not had an OV in past 6 mos. Difficulty d/t # of asthma pts. Call these patients and schedule for flu shot and/or follow-up asthma visit Phone Nurses to follow Asthma Protocol Access Asthma Action Plan in Imaging to assist in triage Visit Nurses not always catching asthma patients at visit Post Visit Asthma Patient identified by nurse during office visit. Asthma Action Plan given to patient Asthma Encounter Form given to parent/patient to complete patient section of form Flu Vaccine offered (if applicable) Nurse checks form for completeness Form is put in exam room door for Dr. 2 copies are printed One for patient and one to be scanned into EMR Nurses and Physicians remember to add Asthma to problem list if patient is asthmatic. Physicians please classify asthma severity. Asthma Action Form is completed (with medication adjustments if needed) Physician orders Spirometry if needed. CPT codes: 94010 for first 94060 for second Nurses and MD’s need to do better at listing “asthma” to problem list Not all asthma pts. have action plan Refill medications, schedule follow-up office visit and/or immunization if indicated Nurse schedules asthma recheck appt. Physician fills out Physician section of form Phone call nurses can access scanned copy of Asthma Action Plan to assist in triage Physician keeps completed encounter forms in folder at desk Physician pulls 5 encounter forms and enters data into EQIPP monthly Data is reviewed by the practice during monthly meeting Huntsville Pediatrics CQN Encounter Form F:\Patient Asthma Questionnaire CQN Encounter Form 2010.rtf Key Learnings Reassessing and revising asthma action plan and workflows to maximize compliance and asthma control. The importance of scheduling follow-up visits for asthmatic patients. Barriers and Successes Barriers: • Time required to learn and follow workflows. • Identifying and following up with EVERY asthma patient. • EMR lacks adequate reporting functionality and does not interface with our spirometry machine. Successes: • Increase spirometry use. • Full buy-in on use of CQN Encounter Form by all seven physicians at HPA. • Full participation by these seven physicians in data gathering and creation of PDSA’s. Other Information • Improve on distribution of educational materials for asthma patients at every visit. In particular: -asthma triggers -using inhalers correctly • Need more frequent review on asthma care and management with nursing staff. Future Plans • Implement registry to assist in tracking asthma patients. • Improve asthma education by providing additional information regarding asthma, triggers, and management of symptoms. • Purchase new EMR that will contain registry functions, enable practice to write their own templates and interface with spirometry machine. • Continue PDSA cycles in respect to workflows.