Oxford Pediatrics

1. Oxford Pediatrics • Summary of Progress • Provider Education • All our providers were educated regarding step-wise treatment for asthma as well as specific use and indications for all controller medications, spacers, and spirometry. • Implementation of Step-wise Approach for asthma • A flip chart is now available in all exam rooms. • Standardization of Asthma Treatment within our practice • Registry • We have a paper list that is checked periodically and an alert is placed on those patients charts. • CQN form • All our providers our using our CQN form now.

2. Oxford Pediatrics • Summary of Progress • Asthma Action Plan • We have adopted an asthma action plan that is used for all our patients. • We have created a template for our EMR and are testing that template. • Asthma Education Materials Adopted • We have a five page handout that is given to every asthma patient and reviewed at each visit. • We have a box of teaching tools available at each office. • Increasing Use of Spirometry • We are using spirometry more frequently to assess our asthma patients.

3. ED visits Hospitalizations Optimal Care Key asthma indicators (graph below) EQIPP data graphs-February Data

4. Spirometry for dx. Validated instrument used to determine the current level of control Patients where a reason is identified for poor control Patients where spirometry is scheduled or has been used obtained in the last 1-2 years Patients where the step wise approach is used to identify, adjust, and maintain therapy. EQIPP data graphs-February Data

5. Flu shot Asthma Action Plan Self Management Education Materials F/u recommendation % of well controlled patients EQIPP data graphs

6. Interventions Key Drivers Oxford Pediatrics Key Driver Diagram We meet at least monthly. We have entered data regularly. We have reviewed our data. Engaging your QI Team and Your Practice Using a Registry We have looked into a registry. Aim Using a Planned Care Approach To Ensure Reliable Asthma Care in the Office From fall of 2009 to fall of 2010, we will achieve measurable improvements in asthma outcomes by implementing the NHLBI guidelines by making key practice changes. We have developed our CQN form and implemented it into our office visits. We have revised our asthma action plan. Developing an Approach to Employing Protocols All our providers were educated regarding the recommended guidelines and stepwise approach. A laminated flip chart is available in every exam room. Providing Self Management Support We have obtained patient education materials. We assess degree of control and patient/family management comfort at every visit.

7. Plan Plan Plan Do Do Do Plan Do Act Act Act Act Study Study Study Study PDSAs and RampsEducating Providers

8. Plan Plan Plan Do Do Do Plan Do Act Act Act Act Study Study Study Study PDSAs and RampsImplement CQN form

9. Plan Plan Do Do Plan Do Act Act Act Study Study Study PDSAs and RampsImplement CQN form

10. Plan Plan Do Do Plan Do Act Act Act Study Study Study PDSAs and RampsImplement CQN form

11. Plan Plan Plan Do Do Do Plan Do Act Act Act Act Study Study Study Study PDSAs and RampsStandardize Use of Asthma Action Plan

12. Plan Plan Plan Do Do Do Plan Do Act Act Act Act Study Study Study Study PDSAs and RampsStandardize Use of Asthma Action Plan

13. Asthma patient identified in “Alert” area of EMR for all patients on Registry Data Collection form, Asthma Action Plan, & Teaching materials placed with Patient Route slip Office Flow Diagram – Oxford Pediatrics. Office Visit - Prework -Missed opportunities-patients not on asthma list or who come for another reason. -Forms not placed with route slip Provider reviews form with family, discusses asthma including management and educational materials Asthma Action Plan completed, copies of plan and educational materials given to family for school or caregivers Patient scheduled for follow up visit and spirometry During Office Visit Patient and family complete Question 1-12 Patient Data Collection form Medical Assistant interviews family and gives form to previously identified asthma patients and any newly identified possible asthma patients Time and staffing constraints for spirometry Time constraints depending on visit type. Provider completes EQUIPP portion of Asthma Data Collection Both forms reviewed by Asthma Nurse Coordinator and entered into EQUIPP Post Visit Activities Forms scanned into EMR New patients placed on registry Incomplete forms

14. Oxford Pediatrics Asthma Project Process -form introduced at doctor’s meeting -forms placed on chart -forms placed in exam rooms -MA training -Materials available in every room -Asthma folders in every room -asthma folders in every room -MA training -signs regarding our asthma focus placed in waiting rooms -MA’s encourage families to complete forms -AAP placed with route slip -AAP available in every room -F/u is part of CQN form -F/u is part of route slip -clinical alert box -past medical and family history forms -symptom history INTERVENTIONS Asthma materials placed with chart MA’s give patients form Family/patient complete form Provider reviews form with family Identify patients Asthma Action Plan done F/u scheduled CURRENT PROCESS -Family refuses -Family is focused on other problems/concerns -Form is not returned to MA or provider -Family comes in for another problem and provider forgets. -Provider is time limited -not always placed on chart -not available in every room -cumbersome process -time consuming -providers forgot to recommend an appointment -parent does not schedule before they leave but “will call for an appointment” -Failure to check the asthma list -Failure to check the clinical alert box -Patients come in for another problem and we miss an opportunity to review asthma care -Patients come in for another problem and we miss an opportunity to review asthma care -materials not copied -MA forgets to place materials with route slip FAILURE MODES

15. Oxford Pediatrics Asthma Project Process -Front desk assigned to scan forms -there is a scan folder -form is on back of patient form -form collection boxes in all offices -box in each office -asthma nurse tracks down providers for incomplete forms -form EQUIPP friendly -we have an asthma list -CQN form used for visit -nurses trained for spirometry INTERVENTIONS Provider completes EQUIPP portion of form. Forms reviewed by asthma nurse Data entered Into EQUIPP Forms scanned Into EMR. Spirometry scheduled New patients placed on asthma list. CURRENT PROCESS -sometimes unable to assign form to a provider -Sometimes forms don’t make it back to scan pile after data entry -asthma list is not updated -registry is costly -registry is time consuming to maintain -Front desk fails to ask parents to schedule -Only available in one office -patients can’t cooperate -patients don’t show up -form sometimes not placed in collection box -form not always fully filled out -sometimes unable to assign form to a provider FAILURE MODES

16. Key Learning • The process of measuring requires standardization. • The process of coming together does open avenues for change. • Small tests of change are important. • Spirometry may or may not be useful.

17. Future Plans • Attempt to standardize use of spirometry • Investigate ways to improve spirometry techniques • Research options for a registry