1. CQN Team Presentation State Name: Alabama Practice Name: Infants’ and Children’s Clinic, Florence, AL Team Members: Grant Allen, MD; Kelli McAffee,RN; Angela Alexander January 14, 2010

3. Progress Since Learning Session 1 -Identify work flow: understand how the way we work affects what gets done at the visit. -Encounter forms: moving the practice from filling out 5 forms to filling out the form for every asthma patient. -Encounter forms: using the form as a guide to correct practices. -Encounter forms: using our progress with data to launch into new areas of improvement. -Protocols: due to our success with our early data and visible change in practice habits, improved work flow and increased value of services, we can now begin to work on standardizing controller and rescue refill protocols as well as follow up visits. -EMR: with success of the encounter form we can now move to its use in our EMR -Registry: once we have EMR data we can build our registry

4. TEST 1 What: test 3 AAP Who: 3 patients 1 st week Who: Dr Allen Where: Main office When: Sept 20 PD SA TEST 2 What: chosen plan for 3 MDs Who: 3 patients each Who: 3 MDs Where: Main office When: Sept 27 PD SA TEST 3 What: modified AAP Who: all patients Who: MDs Where: Main office When: Oct 1 PD SA TEST 4 What: edited AAP Who: all patients Who: MDs and NPs Where: Main office When: November PD SA TEST 1 What: CQN form Who: 5 patients Who: Dr Allen Where: Main office When: Sept 20 PD SA TEST 2 What: CQN form Who: 5 patients Who : MDs Where: Main office When: Sept 27 PD SA TEST 3 What: Edited form Who: asthma patients Who: MDs Where: Main office When: Oct 1 PD SA TEST 4 What: refined form Who: asthma patients Who: MDs and NPs Where: Main office When: November PD SA TEST 1 What: CQN form with physician AAP at workstations Who MDs Who : MDs given forms at desk Where: Main office When: start of program PD SA TEST 2 What: modified form/AAP at workstations Who : MDs Where: Main office When: Oct/Nov PD SA TEST 3 What: forms Who : MDs/NPs Who : MD/NP Where: both offices When: Nov PD SA TEST 4 What: form in EMR Once developed, will have to rethink office flow as well as motivation to get form completed PD SA Asthma Action PlansEncounter formsForm location PDSA Ramps

5. EQIPP Graphs % of patients with optimal care

6. EQIPP Graphs  % of asthma patients who have a current written Asthma Action Plan explained to them.

7. EQIPP Graphs % of patients with self management materials

8. Office Flow Document Asthma patients identified at time of service by provider Forms and Asthma Action Plans located at computer stations in hall, nurse or provider asks/gives questions to parent before PFTs/ during visit Once parent input is completed the form is returned to provider Is there an opportunity for completeness check at this point in the process During the visit the physician fills out the remainder of form while having Informed clinical discussion Patient with new diagnosis of Asthma, form is pulled and filled out concurrently Completed form to provider workstation Physician completes the form immediately after the visit NO YES Office Visit - Prework During Office Visit Post Visit Activities All necessary information on the form is entered into EQIPP before end of month Clinical Assessment Process Map – Paper Chart System

9. Key Learnings  Pushback can come from unexpected sources  Some cycles are better than others  The registry is both the easiest and hardest thing to accomplish.  Our office is going through an upgrade, so our project has to compete for IT attention  Small tests really work faster than we thought  The AAP testing went really fast