Welcome

1. Welcome Dr. Monica Federico The Children’s Hospital (Aurora, CO) November 2011

2. Improving compliance with Joint Commission asthma action plan standards Monica Federico, MD Director of the Asthma Program Diane Redmond, RN, MSN, CPHQ Daniel Hyman, MD, MMM, Chief Quality Officer

3. Objectives • Briefly review The Joint Commission (TJC) inpatient core measures for asthma • Review how the multidisciplinary team at The Children’s Hospital Denver achieved over 90% compliance with the TJC AAP measure • Discuss the key principals to success with the TJC Asthma Action Plan (AAP) Core Measures • Discuss the barriers

4. TJC Pediatric Inpatient Asthma Core Measures • Short Acting Beta Agonists • Systemic Corticosteroids • Asthma Action Plan (AAP) http://www.jointcommission.org/specifications_manual_fornational_hospital_inpatient_quality_measures/)

5. TJC Pediatric Inpatient AAP requirements An asthma action plan is required for all children discharged from an inpatient unit ages 2-17 with a primary diagnosis of asthma and must include the following elements: • The plan must be written and dated • The plan must indicate a stepwise escalation of care • The plan must include asthma triggers specific to the patient • The plan must include rescue medications and the timing of their use specific to the patient • The plan must include appropriate controller medications or document that controller medications are not indicated • The plan must include the name and phone number of the primary care provider and recommended follow up time with the primary care provider • There must be clear documentation that the plan was given to the patient/family

6. The Children’s Hospital Colorado Experience

8. Our Story • Private, not-for-profit pediatric healthcare network • Statistics • 318 licensed beds • Inpatient units • Main Hospital • 2 inpatient units within community hospitals • 2 urgent care sites • ANCC Magnet designation since 2006

9. Asthma tools in place at TCH • Inpatient asthma clinical care guideline designed and implemented by a multidisciplinary asthma team since 2003. • Electronic medical record (EMR): EPIC

10. Baseline data • Initial data showed that: • AAP creation was 60% for inpatients with asthma • 0% of the AAPs were TJC compliant

11. Our Objectives • Expand our multidisciplinary team to include inpatient unit team members and NOC sites • Improve the TJC AAP creation with a series of Plan/Do/Study/Act cycles • Identify the barriers

12. How do we improve care? Goal: Disseminate and Implement the Guidelines of Care and Address Adherence to Care

13. First Steps: The Team A multidisciplinary team included inpatient: • Providers (attending, resident, and PNPs), RNs and RTs and resident liaisons • Hospital quality staff • Electronic medical record (EMR) staff The team met monthly to implement a series of plan/do/study/act cycles. Pre/post data was reviewed after each cycle.

14. First Steps: The Data An auditor was assigned to perform chart audits, enter data, analyze the data, and create quarterly reports for the JC

15. Plan/Do/Study/Act cycles • Adjust the EMR AAP template to include: • Primary care provider name and phone number • Standardized recommended time for follow up • A prompt for asthma triggers

17. Plan/Do/Study/Act cycles 2. Education for providers, nurses and RT • Note: In most units, RTs created the AAP as part of asthma education 3. Clinical work flow evaluations to assess current processes including the changes made above

18. Plan/Do/Study/Act cycles 4. An EMR asthma alert to ask providers to change the AAP any time a new controller medication was ordered

19. Results • The multidisciplinary team was established in 2008 • Repeat analysis in September of 2011 shows that: • AAP creation was 99% for inpatients and…

20. 2009-2011 Home Asthma Action Management Plan EMR Alert Plans made for repeat education for RT and RL Resident Liasons (RL) Trained

21. Keys to our success

22. Barriers • Turnover of providers and staff • Engaging providers- especially residents • Ensuring medication reconciliation with the AAP at discharge

23. Key Principals • Identify a multidisciplinary team of stakeholders • Assure administrative/hospital support • Engage each clinical unit and evaluate workflow • Standardize the data collection techniques and the data reports • Review the data frequently • Begin rapid cycles to implement change and evaluate the data and workflow before and after each cycle

24. Issues to anticipate • The process takes time! • Resistance to change • Lack of provider investment • Difficulty with flow at discharge including medication reconciliation with the AAP

25. Action steps to achieve your goal • Define your project • Define your data sources • Select the team • Define roles • Meet regularly to review the data and makes plans

26. Questions?

27. Thank you… Please keep your calendar open for our C.A.R.E. Award winner’s presentation on December 6th, at 11 AM EDT. "A Precise Pediatric VAP Detection Tool." Sameer Gupta, Medical Director Pediatric ICU. University of Minnesota Amplatz Children's Hospital in Minneapolis, MN