1. Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Ohio Practice Name: Willoughby Hills Cleveland Clinic Team Members: Lisa Dolovacky, MA Loreen Rudd, RN Rachel Peterson, MSN/CNP Marianne Sumego, MD

3. 90 day goals For Learning Session 2 1. Develop an asthma registry 2. Review use of a best practice alert potential to identify patients 3. To engage our practices (local) 4. Develop evidence-based protocols via epic. 5. Increase use of action plans for asthma care 6. Evidenced based protocols for our offices

4. Learning session 1 summary Tested use of our asthma CQN encounter forms Developed an asthma action plan Gather asthma education materials Engaging our practice Identifying barriers to practice, engagement Developed smart set Education for our Staff

5. Spirometry used to establish diagnosis

6. Number of patients with an action plan

7. Patients Well controlled Asthma

8. PDSA Cycles PDSA Title: Asthma action plan  Plan: Increase uniform asthma action plan use  Do: Monitor use of new AAP form  50% of patients from 4 providers in one month will have AAP completed  Study: Evaluate improvement with March data set  93% compliance Month of March for 4 providers  Act: Adopt plan; receive feedback on plan/improvements. Continued communication regarding use and availability of action plan

9. PDSA Cycles PDSA Title: Blue Dot Trial Plan: Identification of patients with asthma; blue dot on schedule next to pediatric asthma patients age 2-18 Do: Count number of forms vs. blue dots on schedule for provider –80% forms will be completed for identified asthma patients Study: Reviewed 4 providers use in March –did not meet our predictions. Act: Adapt plan; adjust office flow diagram, one on one sessions, emails, reminders, feedback from MA/Provider

10. TEST 1 What:: Paper copy CQN form Who: Sumego and Peterson Where: Providers When: 11/09 Who (executes): QI team PD SA TEST 2 What:: Revised electronic version Who: 3-4 providers Where: Med/peds & Peds Who (executes): QI team When: 12/09 PD SA TEST 3 What: integrated process EMR/paper Who: All providers Who (executes): QI team Where: Medpeds & Peds When: 12/09 PD SA TEST 4 What: tracking form use Who: 4 providers Who: (executes): Rachel and Lisa Where: 40% forms completed When:2/10 and 3/10 PD SA TEST 1 What:: ID patients/Blue dot Who Sumego,MD Who (executes): Lisa QI team Where: Med/Peds dept. When: 1/10 PD SA TEST 2 What:: Roll out blue dot Who: 2 providers Who: (executes):Lisa Where: Med/Peds dept When: 1/10 PD SA TEST 3 What: Roll out all dept. Who: All providers Who (executes): MA Where: Med/Peds & Peds When 2/10 PD SA TEST 4 What: Monitor use blue dot Who: 4 selected providers Who (executes): Rachel Where: Chart review med/peds & Peds When: 3/10 PD SA TEST 1 What:: Asthma action plan Who: All providers Who (executes): Sumego/Peterson Where Med/Peds and Peds When: 11/09 PD SA TEST 2 What:: Education about plan use Who : all providers: Who (executes): QI Team Where: Breathe Easy Luncheon When: 1/10 PD SA TEST 3 What:: Uniform EMR AAP Who (population): all providers Who (executes): Sumego (letter) QI team (roll out) Where: Med/Peds and Peds When:2/10 PD SA TEST 4 What; Assess use AAP Who: 4providers use of letter Vs. nonstandard Who (executes) :Rachel Where: Chart review med/peds & peds 93% use When: 3/10 PD SA CQN useIdentificationAction plan use PDSA Ramps

11. MA checks provider schedule daily and notes asthma patients by problem list, history, or medication list. Puts blue dot on schedule to mark asthma patient for reminder. Checks again each afternoon for same day add on. MA gives questionnaire to parent to fill out or verbally asks the questions and enters into EPIC version Parent/MA completes form and hands to provider when enters room Patient may be identified with asthma during exam that was not previously noted (acute visit, add-on visit, new diagnosis of asthma) Questionnaire copies outside of exam room door Completes parent portion in room. Provider fills out remainder of the form and discusses management collaboratively with patient based on asthma control & NHLBI guidelines MA/RN carries out orders Patient checks out PSR schedules appropriate consults and follow-up Office Visit - Prework During Office Visit Post Visit Activities RN/MA places form in CNP basket CNP verify for completeness If not complete will send back to provider for missing information. Or call patient. Data entered into EQIPP weekly and Registry (when we have one) Paper forms in binder Office Work Flow – CCF Willoughby Hills Other pre-work preparations: MA/RN stocks each room with asthma encounter forms MA/RN ensures available spacers/supplies Change in patient’s plan of care: Asthma action plan updated & copy provided Spirometry ordered if indicated Rx escripted; spacer provided Pertinent written asthma materials provided Flu vaccination provided as appropriate Follow up in 2-4 weeks Consults ordered as needed No change in patient’s plan of care: Asthma action plan copy provided Spirometry ordered if indicated Refills escripted; spacer use confirmed Pertinent written asthma materials provided Flu vaccination provided as appropriate Routine follow up MD/ MA hands completed forms to Nurse Leader Loreen Rudd RN Rachel Peterson MSN CNP PROBLEM POINTS Difficulty getting “blue dots” on provider schedule Time constraints/Provider “buy in” Incomplete forms No registry capability as of yet

12. Copy of Your CQN Encounter Form

14. Epic Version Parent Questionnaire Asthma Control Parent Questionnaire: 1. Has your child visited the ER or urgent care due to asthma in the past 12 months? {YES (DEF)/ NO:2058::"Yes"} 2. Has your child been admitted to the hospital due to asthma in the past 12 months? {YES (DEF)/ NO:2058::"Yes"} 3. How many days of school/daycare has your child missed due to asthma in the past 6 months? {NUMBER:30898} 4. How may work days have you or your spouse missed due to your child's asthma in the past 6 months? {NUMBER:30898} 5. How comfortable are you in managing your child's asthma, rated on a scale of 1-10 (1=not comfortable, 10=very comfortable)? {NUMBER:29773} 6. During the past week, how often did your child use a fast acting or quick relief medication at times other than before exercise? {ALBUTEROL USE:70290} 7. When are your child's asthma symptoms the worst (select all that apply)? {TIMING- ASTHMASX:70291} 8. How often does asthma limit your child's activities? {ACTIVITY IMPACT:70292} 9. Over the previous 2-4 weeks, how frequently has your child experienced episodes of cough, SOB, wheezing or reduced activity due to asthma during the DAY? {FREQUENCY DAY SX:70293} 10. Over the previous 2-4 weeks, how frequently has y our child experienced episodes of cough, SOB, wheezing or waking up due to asthma at NIGHT? {FREQUENCY NIGHT SX:70295} 11. How would you rate your child's asthma control during the past month?{ASTHMA CONTROL:70296}

15. Practice Engagement  Breathe Easy Luncheon January 2010  Nancy Wyse Respiratory therapist  Spoke with providers, Medical assistants, and nurses in Med/Peds and Pediatrics  Great turn out across the board!  Provided pizza, salad, and drinks!  MDI instruction  Spacer technique/Use  Nebulizer technique/Use  Update on newer products, DPI  Opportunity for questions, sharing, collaboration, and review  Free lunch incentive to Medical assistant and Provider Team for encounter forms collected each month

16. Key Leanings  Change takes hard work, but is possible!  Slow going  Repetitive  Team work  Success drives change and engagement  Easier to make further changes when data can show improvement!

17. Barriers and Successes Barriers –Engagement : time, other responsibilities/projects, lack of interest –Geography (2 departments, different schedules, meetings) –Meetings –EMR Identification of patients with EMR Registry Success –action plan use greatly improved –lunch and learn attendance –Data shows improvement! Well controlled asthma, increasing toward optimal care –All providers on board! –Standardized forms for encounters, smart set, AAP

18. Future Plans Improvements on Asthma Action plan Dinner/Lunch with speaker Registry capabilities; work with other health centers Standardized educational handouts (in the works) –Possible videos in EPIC Breath Easy Luncheon II –Pulmonary function testing –In the works currently