1. Improving Asthma Care in Cincinnati: The Journey Stephen Pleatman, MD Pediatrician, Suburban Pediatric Associates, Inc. Board Member, Ohio Valley Primary Care Associates, L.L.C. Cincinnati, Ohio AAP Chapter Quality Network Asthma Initiative Alabama Chapter-Learning Session 1 September 17, 2009 Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

2. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

3. Objectives To describe our improvement journey, what’s been achieved, and key challenges along the way To describe what we have learned To describe the impact to patients, families, staff and physicians Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

4. Network Perspective Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

5. PHO: Background/Structure Primary Care Practices (IPA) Effectiveness/ efficiency PHO Focus CCHMC Focus Specialists Hospital 39 pediatric practices 40% of regional pediatric population 12,500 asthma patients Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

6. PHO Asthma Initiative: Key Driver Diagram AIM To improve evidence-based care for 12,500 children with asthma across 39 primary care practices (40% of regional pediatric population), with at least 90% of all-payor asthma population receiving “perfect care” (composite measure), thus reducing asthma-related ED/urgent care visits, admissions, acute office visits, missed school days, missed work days, and activity limitation; and, improving parent/patient confidence and degree of asthma control KEY DRIVERS/INTERVENTIONS (high scalability focus) Physician leadership at Board and practice level Network-level goal setting by Board (network-level performance defines success) Measurable practice participation expectations/requirements (linked to ABP-MOC approval) Multidisciplinary practice quality improvement teams Web-based registry, with all-payor population identification/reconfirmation Real-time patient, practice, and network-level data/reporting Transparent, comparative practice data on process and outcome measures Concurrent data collection/use of decision support tool, based on high reliability principles/workflow changes Aligning P4P/incentive design with improvement objectives Key components of evidence-based care (“perfect care”) Population segmentation, with focus on “high-risk” cohort Cross-practice communication/shared learning to spread successful interventions Integration of multiple administrative/electronic data sources (hospital, practice, payor) Network and practice-level sustainability plans AIM To strengthen improvement knowledge/capability within primary care practices, thus enhancing sustainability of current and future improvement efforts Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

7. Network-Level Asthma Data/Results Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

8. Practice Perspective Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

10. Urgency for Change Parental perceptions of variation in care. Adoption of medical advances in asthma care. Population identification and severity classification. Data collection made knowledge gaps visible. Documenting quality. Earning P4P reward. Transparency of comparative practice data. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

11. Challenges “Our practice is already busy enough.” “There’s no additional pay for the extra work.” “We’re already doing a good job.” “I already have my way of doing things—it’s ok if others want to go down this path.” Sensitivity to measuring quality of care among physicians. Reluctance to “standardize” practice around evidence-based care. “Research project.” “Not sure initiative will improve care.” Communication within practice. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

12. Getting Started Pre-existing focus on asthma population. Recruiting practice commitment—connected with inherent desire to “do the right thing.” Leadership. Committed quality team. Defining key roles. Communication, communication, communication. “Realistic” decision support/data collection tool. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

13. Executing the Work Developing the data collection tool Mapping our process to build a foundation of highly reliable data collection Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

14. October, 2003 Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

15. 10 months later… Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

16. 2 ½ years later… Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

18. Practice Improvement Capability: Areas of Focus Commitment. Leadership. Communication. Reliability of data collection. Data entry. Interventions to improve clinical asthma care. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

19. The “Ideal”….. Physician, nurse, and practice manager (quality leadership team) meets regularly to review project status/data/reports, and discuss improvement opportunities. Physician administrative leader visibly supports project and encourages improvement work. Project information/updates discussed with physicians and staff at regular practice meetings, data/information shared, and input/feedback recruited. Quality leadership team discusses data collection process at regular intervals and identifies/pursues opportunities to improve reliability. Accuracy and timeliness of data entry monitored and addressed. Improvement interventions pursued using test of change methodology. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

20. Using Registry/Data to Drive Improvement (deferred to registry presentation) Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

21. Key Learnings Leadership Develop quality improvement team Effective communication Build consensus within practice Use disconfirming data to drive improvements and sustain engagement Recruit parent involvement/feedback to accelerate improvement. Improve “reliability”—build improvement into daily work. Learn from others—don’t reinvent the wheel. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

22. Impact on Our Practice Parents more confident and knowledgeable. Nurses report reduced volume of phone calls. Positive feedback from families has energized practice and helped sustain improvement work. Clinicians proactively engaging patients and parents in more meaningful dialogue to improve care vs. more “passive” approach of the past. Data has uncovered issues/gaps not previously identified. Discussing how to spread improvement work to other conditions. Positioned to win on current/future P4P programs. Appreciate value of registry. Staff roles/responsibilities revised to sustain improvement efforts. Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

23. Patient/Parent and Staff Perspectives Copyright © 2009 Cincinnati Children’s Hospital Medical Center; all rights reserved

24. This is Hard Stuff This takes lots of work to initiate and sustain.

25. Thank You!!

26. Questions?

27. Contact Information Stephen Pleatman, MD Pediatrician, Suburban Pediatric Associates, Inc. Board Member, Ohio Valley Primary Care Associates, L.L.C. 513-336-6700 spleatman@cinci.rr.com Keith Mandel, MD Vice President of Medical Affairs, Physician-Hospital Organization Cincinnati Children’s Hospital Medical Center 513-636-4957 keith.mandel@cchmc.org