1. 1 Quality Improvement Series Session 9 Windy Stevenson lammersw@ohsu.edu Cindy Ferrell

2. 2 Today’s Agenda

3. 3 Recap Problem: The DCH ambulatory clinic problem lists are incomplete and inaccurate. Problem: Patients with BMI>85%ile do not have obesity or overweight listed on their problem lists. AIM: >95% of patients >2yo seen by a provider in the gen peds clinic or Westside clinic (including acute care; excluding healthy lifestyles) who have a BMI >85%ile will have “BMI; category” listed on their problem list.

4. 4

5. 5 The Science of Reliability Reliability LevelReliability Expression Reliability RateFailure Rate Level 110‾¹80-90% reliable1-2 failures in 10 opportunities Level 210‾²95% reliable<5 failures in 100 opportunities Level 310‾³99% reliable<5 failures in 1000 opportunities Level 6 (Six Sigma) 10‾6<5 failures in 1,000,000 opportunities

6. 6 Let’s envision our ideal state(s) Pt >2yo checked in and ht/wt recorded EPIC uses ht and wt to generate BMI and flags if >85%ile Provider sees flag when…

7. 7 Clinical expectations shape the system  What do we expect of acute care providers? –Is adding to the problem list sufficient? –Is a referral back to the PCP in order? –Should we order labs, etc?  What do we expect of WCC providers and PCP’s? –How can we use this to drive decision support? –What type of care do we envision for each of the 3 groups? –What resources support this?  What are our educational opportunities? –Maximizing the AVS –Starting the conversation  How do we want the alert to fire to make this happen? –Should it fire every time someone opens the chart? – Should it be a ribbon or a pop up? –Should it stop firing if the problem list is populated, independent of whether any care has occurred?

8. 8 Measurement

9. 9 The baseline data Is pending. Let’s assume it is 10%.

10. 10 Next Steps

11. 11 Obesity and Meaningful Use- more opportunity The percentage of patients 2 ‐ 17 years of age who had an outpatient visit with a PCP and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.

12. 12 Take Home Points (review) Real (sustainable) change comes from changing systems, not changing within systems Be specific about what you want to accomplish, and why; be intentional Focus on patients Start before you think you are ready; don’t get paralyzed