Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Oregon Practice Name: Doernbecher Pediatric Westside Team Members: Angie Pena, Jeff Miller, Kerry Jones, Debi Hungerford

Progress Summary Since Learning Session 1 1.Now assessing asthma control with a validated instrument, initially using the CQN encounter form, and now using the Asthma Control Test as our primary validated instrument. 2.Now consistently using a stepwise approach to ensure appropriate treatment. We have the AH! Asthma Health Clinical Guidelines available in each exam room. 3.We are increasing the number of our patients who have an Asthma Action Plan. Paper plans available in English and Spanish in each exam room, and we now have a plan available on our EMR as well. 4.We are still in process of obtaining patient education materials, and providing training to staff about proper use of inhalers and spacers. 5.All our providers and clinic staff are supportive and on board with this effort.

Measure Name: % of patients with asthma ages 6 months and older who have received a flu shot or flu shot recommendation within past 12 months Insert EQIPP graphs that will help to tell your improvement story Follow the instructions to take a picture of your graph and paste it into Powerpoint. 100% Oct NovDecJanFebMarAprMayJunJulAugSepOct 1. Along the top of the PDF document, click on 'Tools' 2. Click on 'Select and Zoom' 3. Click on 'Snap Shot Tool' 4. Your mouse arrow becomes a cross, and you will click on one corner of the graph and drag it to the other corner of the graph. When you unclick, you have just taken a picture of the graph. 5. You can then copy it in Powerpoint by clicking 'copy'.

Measure Name: % of patients in which the stepwise approach is used to identify treatment therapy and adjust or maintain therapy based asthma control Follow the instructions to take a picture of your graph and paste it into Powerpoint. 1. Along the top of the PDF document, click on 'Tools' 2. Click on 'Select and Zoom' 3. Click on 'Snap Shot Tool' 4. Your mouse arrow becomes a cross, and you will click on one corner of the graph and drag it to the other corner of the graph. When you unclick, you have just taken a picture of the graph. 5. You can then copy it in Powerpoint by clicking 'copy'.

Measure Name: % patients who have a current written asthma action plan explained to them at visit Follow the instructions to take a picture of your graph and paste it into Powerpoint. 1. Along the top of the PDF document, click on 'Tools' 2. Click on 'Select and Zoom' 3. Click on 'Snap Shot Tool' 4. Your mouse arrow becomes a cross, and you will click on one corner of the graph and drag it to the other corner of the graph. When you unclick, you have just taken a picture of the graph. 5. You can then copy it in Powerpoint by clicking 'copy'.

Measure Name: % of patients for whom a follow up appointment to monitor asthma control is recommended Follow the instructions to take a picture of your graph and paste it into Powerpoint. 1. Along the top of the PDF document, click on 'Tools' 2. Click on 'Select and Zoom' 3. Click on 'Snap Shot Tool' 4. Your mouse arrow becomes a cross, and you will click on one corner of the graph and drag it to the other corner of the graph. When you unclick, you have just taken a picture of the graph. 5. You can then copy it in Powerpoint by clicking 'copy'.

TEST 1 What: CQN Form Avail. Who (population): asthma visits Who (executes): Front office Where: Check in When: one week PD SA TEST 2 What: Spanish CQN form Who (population): spanish pts-asthma visits Who (executes): Front office Where: Check in When: one week PD SA TEST 3 What: CQN form in rooms Who (population): asthma visits Who (executes): M A/RN/MDs Where: Exam Rooms When: four weeks PD SA TEST 4 What: CQN forms available Who (population): all asthma pts Who (executes): front office/MA/RN/MD Where: Check in/Exam Room When: four weeks PD SA TEST 1 What: Asthma Action Plan available Who (population): asthma pts Who (executes): MD Where: MD workroom When: four weeks PD SA TEST 2 What: Asthma Action Plan in rooms Who (population): asthma pts Who (executes):MD Where:Exam Rooms When: two weeks PD SA TEST 3 What: Revised plan-more user friendly Who (population): asthma patients Who (executes): MD Where: exam rooms When: four weeks PD SA TEST 4 What: asthma action plan on EPIC Who (population): asthma patients Who (executes): MD Where: exam room computers When: presently PD SA TEST 1 What: Asthma pts entered in recall list in EPIC Who (population): asthmatics for flu shot clinic Who (executes): front office Where: check out When: two weeks PD SA TEST 2 What: Asthma pts entered in recall list in EPIC Who (population): pts requesting asthma med refills Who (executes): MD Where: CC in EPIC to front office/lead When: four weeks PD SA TEST 3 What: Send letter to pts on recall list Who (population): asthma pts on recall list Who (executes): front office Where: front office When: presently PD SA TEST 4 What: Pts scheduling asthma appts from list Who (population): asthma pts on recall list Who (executes): parents and front office Where: front office When: present & future PD SA Distribution of Asthma Quest. Asthma Action Plan Asthma Recall PDSA Ramps

Asthma patients identified at the front desk by appt notes or by parent. At time of parent check in, encounter form is given to parent to complete on a clipboard. Parent is asked to fill out their part of the encounter form Questions 1-10 Parent completes form in waiting area. Back office staff prepare patient to be seen. Encounter form given as needed. Clarify Asthma Severity Physician completes the form after the visit. Patient Chart Completed Office Visit - Prework During Office Visit Post Visit Activities All necessary information on the form is entered into EQIPP CQN Encounter form collected by office lead Office Flow Chart-Doernbecher Westside Sign placed in lobby asking parents to complete form. If in active flu season and vaccine is due, administer flu shot. Physician confirms asthma on patients problem list in EMR Asthma medicine refill requests sent to M.D., meds refilled, request generates a cc to office lead Recall for future appt entered by lead. Letter sent to patient to make appt to review their asthma management & control. Form completed, MD may review prior to room entry Physician reviews patient encounter form with parent and patient during visit supporting medical decision making. Physician gives form if asthma dx has not been identified previously. If > 6 yrs old, nursing staff obtain spirometry (if asthma follow up appt) New Asthma diagnosis, encounter form pulled by MD and completed by patient Asthma medication adjusted via step wise approach Asthma action plan reviewed, updated, given. Education materials given Patient Checks Out. Follow up appointment made. Follow up appt made sooner if recent exacerbation or poor control At check out a flu and asthma recall are created. Monthly data reviewed New Goals/Feedback discussed at staff meeting Data posted on bulletin board Weaknesses: Asthma action plan inconsistently scanned in EMR. Time consuming finding ???? Time in clinic to analyze data is limited

Our CQN Encounter Form Through March we did not modify the CQN encounter form, and used the original form. In April, we began using the Asthma Control Test in English and Spanish as our encounter form and the English TRACK form. During visit, we make sure to obtain the additional pertinent information needed for complete data entry.

Other Because we are still capturing patients who have not been in yet (as we have a large population of asthmatics) we believe the asthma control graph will mostly be impacted towards the end of this year and will continue to improve beyond the project’s end.

Key Learnings  Involvement in this project has made us more familiar with the Asthma Guidelines.  Our clinicians are now more comfortable with and so are using the Asthma Action Plans consistently.  We are now better able to help guide families to manage their child’s asthma, reviewing the step-wise approach to care directly with them.

Barriers and Successes Barriers: 1.Time 2.Busy staff 3.Patient compliance, having patients come in for their asthma follow ups. 4.We do not yet have spirometry. 5.As part of a large institution, our end goal of a registry is not yet a reality. Successes: 1.All of our providers and staff are supporting the goal to improve our asthma care. 2.We ran a successful flu clinic. 3.We are providing better asthma care with patients leaving with asthma action plans and having planned follow up.

Future Plans We will soon have spirometry available in our office. We are: –continuing to increase the number of patients completing the Asthma Control Test. –working to improve recall and follow up of asthmatics –collecting effective materials for patient education In the far future, a registry!