1. Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation Oregon Oregon Hillsboro Pediatric Clinic, LLC Hillsboro Pediatric Clinic, LLC Dana Nason, M.D., Nanette Dahlquist, M.D. Cindy Donley, CPNP, Sandra Alvarez, BS

2. Progress Summary Since Learning Session 1 Asthma Care protocol was found to be successful in providing optimal quality asthma care to our identified patients. Quality improvement systems increase the quality of care offered on an ongoing basis. EQIPP data helped CQN asthma team evaluate and discuss results with the medical providers to determine the need for future changes or additions to both process and content of standardized HPC asthma patient care. Constructed manual registry.

3. Reasons for Success Built on previous asthma QI initiative and other clinic QI projects through Tuality Health Alliance “Gold Standard Program”. Selected asthma population from recall system currently in place. Members of team have successfully worked together for many years. A little “OCD” can go a long way.

4. Optimal Asthma Care

5. Spirometry

6. Asthma Action Plan

7. Flu Shot

8. First PDSA Cycle PDSA Title: CQN form completion in waiting room  Plan: test success of parent completion of CQN form filled out in waiting room prior to asthma recall visits.  Do: began with asthma patients of Dr. Nason; first day was not part of routine, so readied forms were in drawer when first patient arrived. The rest of the first day and subsequent days the forms were handed out in the waiting room.  Study: can be implemented with minimal impact to patient flow. Successful test.  Act: continue with current procedure expanding to additional providers.

9. CQN Form Completion in Waiting Room PDSA Ramp #1 TEST 4 What: parent completes CQN form while in waiting room Who (population): asthma patients of Dr. Nason Who (executes): Front office manager offered further training and education re: importance of CQN form completion to front office staff. Process returned to previous procedure: CQN team member identifies asthma patients on schedule, prepares CQN form, adds alert “please give asthma form” on face sheet of EMR, and front office staff gives form to parent to complete upon checking in. Where: waiting room When: while waiting for asthma recall appointment with Dr. Nason TEST 3 What: parent completes CQN form while in waiting room Who (population): asthma patients of Dr. Nason Who (executes): CQN team member identifies asthma patients on schedule, prepares CQN form, created patient appointment list, and front office staff gives form to parent to complete upon checking in. Where: waiting room When: while waiting for asthma recall appointment with Dr. Nason TEST 2 What: parent completes CQN form while in waiting room Who: (population): asthma patients of Dr. Nason Who (executes): CQN team member identifies asthma patients on schedule, prepares CQN form, adds alert “please give asthma form” on face sheet of EMR. Front office staff gives form to parent to complete upon checking in. Where: waiting room When: while waiting for asthma recall appointment with Dr. Nason TEST 1 What: parent completes CQN form while in waiting room Who (population): asthma patients of Dr. Nason Who (executes): CQN team member identifies asthma patients on schedule, prepares CQN form, adds alert “please give asthma form” on face sheet of EMR, and gives form to parent to complete upon checking in. Where: waiting room When: while waiting for asthma recall appointment with Dr. Nason

10. Expanding CQN Form Completion to All Provider Participation: PDSA Ramp #2 TEST 4 What: parent completes CQN form while in waiting room Who (population): asthma patients of all doctors and nurse practitioners Who (executes): Front office staff Where: waiting room When: while waiting for asthma recall appointment with all doctors and nurse practitioners TEST 3 What: parent completes CQN form while in waiting room Who (population): asthma patients of all doctors Who (executes): front office staff Where: waiting room When: while waiting for asthma recall appointment with all doctors TEST 2 What: parent completes CQN form while in waiting room Who: (population): asthma patients of Drs. Nason and Mandi Who (executes): front office staff Where: waiting room When: while waiting for asthma recall appointment with Dr. Nason and Dr. Mandi TEST 1 What: parent completes CQN form while in waiting room Who (population): asthma patients of Dr. Nason Who (executes): front office staff Where: waiting room When: while waiting for asthma recall appointment with Dr. Nason

11. Patients Counseled as to Importance of Annual Flu Shots: PDSA Ramp #3 TEST 3 What: providers to counsel patients re: importance of annual flu immunization at all medical appointments Who (population): asthma patients Who (executes): CQN team to query individual providers when counseling not done is indicated on CQN form Where: clinic setting When: during all medical appointments TEST 2 What: providers to counsel patients re: importance of annual flu immunization at all medical appointments Who: (population): asthma patients Who (executes): CQN medical leader re-educates medical providers to counsel patient re: flu vaccine if vaccine is unavailable OR offers vaccine at all appointments if due. After re-education all medical providers to stress importance of annual flu shot Where: clinic setting When: during all medical appointments TEST 1 What: provider to counsel patient as to importance of annual flu immunization OR offers flu vaccine during flu season Who (population): all asthma patients Who (executes): all medical providers Where: clinic setting When: during all medical appointments

12. Identify patients with asthma recall appointments. Prepare the CQN data collection form If in active flu season and vaccine is due, administer flu shot. If between seasons, annual flu shot is recommended. Once parent input is completed, the form is placed outside exam door Parent given form for completion in exam room if not received in waiting room. MA checks to see if any help needed to complete the form. Language/reading barriers? Patient is ready to be seen by Provider During the visit the physician fills out the remainder of form while having informed clinical discussion Provider completes the form, template and flow sheet immediately after the visit Office Visit - Prework During Office Visit Post Visit Activities CQN administrative team member verifies form completeness Patient with new diagnosis of Asthma, CQN form is pulled and filled out completely during the visit. Hillsboro Ped. Clinic Clinical Assessment Process Map – Paper/EHR Chart System NO YES MA selects age appropriate asthma recall template and asthma control flow sheet Provider selects and completes asthma initial template and initiates asthma control flow sheet. MA will obtain spirometry on patients 6 years and older Create asthma recall YES NO Create flu shot recall On patient arrival, appropriate language form given to parent to fill out first page in WR (or completed in exam room) NO All necessary information on the form is entered into EQIPP by the CQN administrative team member. (no incomplete entry.) Completed form scanned into EHR. YES If necessary circle back with provider to obtain missing information Problem Areas: Solutions: *CQN forms being missed at patient check in. * Back office to give form when missed by front desk. *Incomplete forms turned in. *CQN team to return incomplete form to provider for completion. *Providers inaccurately completing form. *CQN MD leader to question/counsel provider on accuracy of information. *Providers inconsistently creating future *CQN team member to review registry and recalls. Input recalls into EMR. MD leader to re-instruct providers on importance of recalls.

14. Key Learnings  PDSA cycles were not always successful but remain educational.  Different situations led to different barriers.  Creating manual asthma registry taught us that some asthma patients go unidentified, resulting in lower rates of optimal asthma care.  It is important to have buy-in of all staff members to achieve goals successfully.

15. HPC Future Plans Expand from optimum episodic care to improved population management with sustainable protocols. Consider established registry for case management. Continue providing optimal quality asthma care to patients. Develop new asthma encounter form questionnaire, similar to CQN encounter form.