CQN Team Presentation

State Name: OREGONPractice Name: Doernbecher General PediatricsTeam Members: Art Jaffe, Julie Johnson, Lisa Johnson, Beech Burns

GLOBAL CQN AIMWe will build a sustainable quality improvement infrastructure within our practice to achieve measurable improvements in asthma outcomesSpecific 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

Key Drivers

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

CQN Asthma Project Practice Key Driver Diagram Version 2.0

Progress Since Learning Session 1

1. Engaging Your QI Team and Your Practice-- QI team is actively functioning-- Clinic staff, faculty, and residents participating-- Dept Chairman and hospital administrator providing financial and advocacy support-- Have had formal conferences for clinic staff-- Have had formal resident conference and ongoing continuity clinic conferences-- Regular email updates to faculty and residents

Progress Since Learning Session 1

2. Using A Planned Care Approach-- Have developed a triple-tiered system to ensure use of CQN form with all asthmatic patients-- Have done small-scale PDSA to evaluate use of home-made EMR template to replace CQN, and elected not to change over at this time

Progress Since Learning Session 1

3. Developing An Approach to Use of Protocols-- Have developed consistency in listing “asthma” on the EMR’s Problem List

- may be a foundation for eventual registry-- Currently focusing on standardizing use of Asthma Action Plan-- Investigating use of a standardized assessment form, e.g., ACT, as permanent tool instead of CQN-- Requesting funds for spirometry in the new budget cycle

PDSA Cycles

PDSA Title: Evaluate An EMR Template To Replace the Paper CQN Form

Plan: Write and load a template for a CQN form into EMR; use it for 5 days; evaluate perceptions about its utility

Do: Clinic residents only used it for 2 or 3 patients; found it was too cumbersome and time-consuming to use

Study: Electronic template was too inefficient

Act: Senior resident and QI Team decided to ADAPT the form by creating a shorter version to try during the following week

PDSA Cycles

PDSA Title: Evaluate A Simpler EMR Template

Plan: Write and load a new and simpler form into EMR; use it for 5 days; evaluate perceptions about its utility

Do: The template’s author tried it with 1 patient; found it was still too cumbersome

Study: Electronic template was too time-consuming to use

Act: Senior resident and QI Team decided to ABANDON designing an EMR template, and to continue using CQN form

EQIPP Graphs:% of Patients with Optimal Care

EQIPP Graphs: % of patients with a validated instrument to

determine level of control

EQIPP Graphs: % of patients with step-wise approach to identifying

treatment options or adjustment of therapy

EQIPP Graphs: % of patients with flu shot given or

recommended

EQIPP Graphs: % of patients with asthma action plan

Office Flow Document Asthma patients

identified at the front desk

At time of parent check in, encounter form is given to

parent . Parent is asked to fill out their part of the encounter

form Questions 1-10

Once parent input is

completed the form is paper

clipped to vitals intake slip.

Patient is ready to be

seen by Physician

During the visit the

physician fills out the remainder ofform while havingInformed clinical

discussionQuestions

11-27

Patient with new

diagnosis of Asthma, form is pulled and

filled out concurrently.

Asthma is documented as a problem

in EPIC.

Completed form returned to completed form box in workroom.

Physician completes the form

immediately after the visit

NO

YES

Offi

ce V

isit

-P

rew

ork

Dur

ing

Offi

ce

Vis

itP

ost V

isit

Act

iviti

es

Nurse Leader orPhysician Leader removes

encounter form and verifies for

completeness

If necessary circle back with

Physician or patient family by phone to obtain

missing informationNO

All necessary information on

the form is entered into EQIPP and

Registry (if you have one), no

incomplete entry, no batching

YES

List of active patients

without forms is regularly generated,

reviewed and updated

Any patients with missing forms are Targeted for pro-active communication

During Flu Shot Season: Post-card,Phone call and letters

DCH Clinical Assessment Process Map

YES

NO

Nursing staff to identify asthma

patient and initiate encounter form

Physician to identify asthma

patient and initiate encounter form

NO

YES

YES

Key Learnings

1. Our practice isn’t as good at providing asthma care as we would like to think we are.

2. Involvement in this project has led to a Hawthorne Effect

3. A registry is a critical component of improving care to a population. A large-scale, expensive EMR is not necessarily conducive to supporting a registry.

4. A large and very complex social structure such as an academic medical center provides both support for, and challenges to, quality improvement.

5. We need to balance process and outcome measures