1. CQN Team Presentation Ohio Cleveland Clinic Children’s Hospital Kim Giuliano, MD Sharon O’Brien, MA Ivana Wilson, Medical Secretary

3. Progress Since Learning Session 1 Adaptation of CQN form into EMR Incorporation of CQN form at every visit for patients with asthma Simplified process for generating asthma action plans leading to dramatic increase in usage Generation of asthma education handout with successful incorporation into some patient encounters Modest increase in use of spirometry “Optimal care” increased from 6% to 79%

4. Office Flow Document MA/RN puts revised CQN form with provider only questions on top of patient identification sheet Patient is ready to be seen by Physician During the visit the physician fills out the provider form while having Informed clinical Discussion Questions 11-27 Patient with new diagnosis of Asthma, form is pulled and filled out concurrently Completed form returned to asthma form collection tray Physician completes the form immediately after the visit NO YES During Office Visit Post Visit Activities Nurse Leader removes encounter form and verifies for completeness If necessary, circle back with Physician or patient family by phone to obtain missing information NO All necessary information on the form is entered into EQIPP by medical secretary Paper copy kept on file at secretary’s desk Any patients with missing forms will be contacted to schedule office visit based on periodic electronic chart review MA/RN rooms pt. If asthma med noted during medication reconciliation, MA/RN asks parents questions #1-10 and enters responses into medical record MA/RN gives asthma education handout to parent

5. TEST 1 What: CQN paper form Who (population): 5 pts Who (executes): Giuliano When: 2 clinic sessions in Oct PD SA TEST 2 What: EMR form Who (population): Giuliano pts Who (executes): Sharon O. When: week of 10/19/09 PD SA TEST 3 What:: Expansion of EMR form Who (population): all asthma pts Who (executes): entire office staff When: week of 10/26/09 PD SA TEST 1 What: EMR Asthma Action Plan using letter template Who (population): Giuliano pts Who (executes): Giuliano When: week of 10/26/09 PD SA TEST 2 What:: EMR Asthma Action Plan using “dot phrase” Who (population): Giuliano pts Who (executes): Giuliano When: 10/30/09 PD SA TEST 3 What:: EMR Asthma Action Plan using “dot phrase” Who (population): all asthma pts Who (executes): all MDs When: 11/6/09 PD SA TEST 1 What:: Handouts given when verbal teaching not done Who (population): Giuliano pts Who (executes): Giuliano When: 12/1409 PD SA TEST 2 What:: Handouts given during rooming process Who (population): Giuliano pts Who (executes): Sharon and Carmen When: week of 12/21/09 PD SA TEST 3 What:: Handouts given during rooming process Who (population): all patients Who (executes): RNs and MAs, MDs if not completed prior When: week of 1/11/10 PD SA TEST 4 TBA PD SA CQN FormAsthma Action PlanEducation Handout PDSA Ramps

6. PDSA Cycles PDSA Title: ASTHMA ACTION PLANS  Plan: Distribute asthma action plans to patients during office visit. Giuliano prints asthma action plan in letter template format during patient encounters for one week.  Do: Carried out plan but at a significant time expense. Time prevented asthma action plans from being given out at every visit.  Study: Modest improvement compared to previous performance. Results did not match predictions.  Act: Adapt

7. PDSA Cycles PDSA Title: ASTHMA ACTION PLANS  Plan: Distribute asthma action plans to patients during office visit. Giuliano to create new “dot phrase” in EMR. Giuliano to use dot phrase on all asthma pts this week.  Do: Carried out plan on 100% of identified pts this week. Much less time than previous format (approx. 60 seconds). Observed positive remarks from parents.  Study: Results matched predictions. Improved performance.  Act: Adopt

8. PDSA Cycles PDSA Title: ASTHMA ACTION PLANS  Plan: Distribute asthma action plans to patients during office visit. Giuliano presents new format at provider meeting. All providers agree to trial.  Do: Cycle carried out as planned with all providers using on at least one patient.  Study: Results exceeded predictions. Action plans given to 87% of pts vs. 6% at baseline.  Act: Adopt

9. EQIPP Graph Asthma Action Plan

10. EQIPP Graph Optimal Care

11. Key Learnings  Testing on small scale first helps with group “buy- in”  Measures that are simple and do not involve significant increase in office visit time are implemented most successfully  Incorporation of nursing in more active roles in patient encounter has positive impacts in nursing attitudes and patient satisfaction