1. Oxford Pediatrics Summary of Progress Summary of Progress Provider Education Provider Education All our providers were educated regarding step-wise treatment for asthma as well as specific use and indications for all controller medications, spacers, and spirometry. All our providers were educated regarding step-wise treatment for asthma as well as specific use and indications for all controller medications, spacers, and spirometry. Implementation of Step-wise Approach for asthma Implementation of Step-wise Approach for asthma A flip chart is now available in all exam rooms. A flip chart is now available in all exam rooms. Standardization of Asthma Treatment within our practice Standardization of Asthma Treatment within our practice Registry Registry We have a paper list that is checked periodically and an alert is placed on those patients charts. We have a paper list that is checked periodically and an alert is placed on those patients charts. CQN form CQN form All our providers our using our CQN form now. All our providers our using our CQN form now.

2. Oxford Pediatrics Summary of Progress Summary of Progress Asthma Action Plan Asthma Action Plan We have adopted an asthma action plan that is used for all our patients. We have adopted an asthma action plan that is used for all our patients. We have created a template for our EMR and are testing that template. We have created a template for our EMR and are testing that template. Asthma Education Materials Adopted Asthma Education Materials Adopted We have a five page handout that is given to every asthma patient and reviewed at each visit. We have a five page handout that is given to every asthma patient and reviewed at each visit. We have a box of teaching tools available at each office. We have a box of teaching tools available at each office. Increasing Use of Spirometry Increasing Use of Spirometry We are using spirometry more frequently to assess our asthma patients. We are using spirometry more frequently to assess our asthma patients.

3. EQIPP data graphs-February Data ED visits Hospitalizations Optimal Care Key asthma indicators (graph below)

4. EQIPP data graphs-February Data Spirometry for dx. Validated instrument used to determine the current level of control Patients where a reason is identified for poor control Patients where spirometry is scheduled or has been used obtained in the last 1-2 years Patients where the step wise approach is used to identify, adjust, and maintain therapy.

5. EQIPP data graphs Flu shot Asthma Action Plan Self Management Education Materials F/u recommendation % of well controlled patients

6. From fall of 2009 to fall of 2010, we will achieve measurable improvements in asthma outcomes by implementing the NHLBI guidelines by making key practice changes. Key Drivers Interventions Aim Using a Registry Using a Registry Using a Planned Care Approach To Ensure Reliable Asthma Care in the Office Developing an Approach to Employing Protocols Providing Self Management Support Providing Self Management Support We meet at least monthly. We have entered data regularly. We have reviewed our data. We have looked into a registry. We have developed our CQN form and implemented it into our office visits. We have revised our asthma action plan. All our providers were educated regarding the recommended guidelines and stepwise approach. A laminated flip chart is available in every exam room. Engaging your QI Team and Your Practice Oxford Pediatrics Key Driver Diagram We have obtained patient education materials. We assess degree of control and patient/family management comfort at every visit.

7. PDSAs and Ramps Educating Providers Do Study Act Pla n Do Stud y Act Plan Do Stud y Act Pla n Do StudyAct Pla n TEST 1 What: Educating providers and getting “buy in” regarding the asthma project Who (population): All providers Where: Drs. Meeting When: Oct. 12 Who: CQN team Results: There were lots of questions regarding guidelines, medications, spirometry, etc. TEST 1 What: Educating providers regarding guidelines and getting “buy in” regarding the asthma project. Who (population): All providers. Where: Drs. Meeting When: Oct. 23 Who executes: CQN team Results: Laminated chart brought to meeting and providers educated regarding guidelines and controllers. Charts placed in all exam rooms. TEST 2 What: Educating providers and getting “buy in” regarding asthma project. Who (population): All providers Where: Drs. Meeting When: Nov. 2nd Who executes: CQN team Results: Charts are helpful Guidelines are clear. Need more guidance regarding spirometry. All providers start using CQN form and laminated chart guidelines. Next PDSA ramp, obtain spirometry guidelines.

8. PDSAs and Ramps Implement CQN form Do Study Act Pla n Do Stud y Act Plan Do Stud y Act Pla n Do StudyAct Pla n TEST 1 What: Modify our existing form Who (population): CQN team Where: Oxford office When: Oct. 12-13 Who: Terri-Asthma nurse Results: new form did not work-data difficult to enter. TEST 1 What: Modify our CQN form according to data entry Who (population): CQN team Where: Oxford office When: Oct. 14-15 Who executes: Terri- Asthma Nurse and one provider Results: The form is easy to use and it is much easier to enter data. TEST 2 What: Implement CQN form Who (population): Expand to three providers. Where: Oxford and Ross locations When: Oct. 16-Oct. 22 Who executes: Three providers Results: Form is easy to use but the patient form and provider form don’t always stay together and sometimes get lost. Also, it takes time to look up key diagnostic criteria. TEST 3 What: Revise Implemented CQN form-parent form on one side and provider form on the other side. Who (population): CQN team Where: :Oxford Office When: Oct. 23-24 Who executes: Asthma Nurse-Terri Results: Now all the data is in one place. Next PDSA cycles are to add the key diagnostic criteria to the form and then implement the new form.

9. PDSAs and Ramps Implement CQN form Do Study Act Pla n Do Stud y Act Plan Do StudyAct Pla n TEST 1 What: Implement double sided form. Who (population): One provider Where: Oxford office When: Oct. 25 Who: Terri-Asthma nurse, One provider Results: Forms are not getting lost. TEST 2 What: Implement double sided form. Who (population): Two providers Where: Oxford and Ross offices When: Oct. 26-28 Who executes: Terri- Asthma Nurse and two providers Results: The form is easy to use, data is easy to enter, and forms are not getting lost. TEST 3 What: Implement double sided CQN form Who (population): Expand to all providers. Where: All three locations When: Oct. 30-Nov. 5th Who executes: CQN team Results: Amount of data collected increased. Form is easy to use and also helps direct the asthma visit.

10. PDSAs and Ramps Implement CQN form Do Study Act Pla n Do Stud y Act Plan Do StudyAct Pla n TEST 1 What: Add key diagnostic criteria to the form and implement new form. Who (population): One provider Where: Oxford office When: Oct. 25 Who: Terri-Asthma nurse, One provider Results: It seems to save time. TEST 2 What: Implement new form with key diagnostic criteria added. Who (population): Two providers. Where: Oxford and Ross offices When: Oct. 26-28 Who executes: Terri- Asthma Nurse and two providers Results: The form is easy to use and now takes less time. TEST 3 What: Implement new form with key diagnostic criteria added. Who (population): Expand to all providers. Where: All three locations When: Oct. 30-Nov. 5th Who executes: CQN team Results: Amount of data collected increased. Form is easy to use and also helps direct the asthma visit.

11. PDSAs and Ramps Standardize Use of Asthma Action Plan Do Study Act Pla n Do Stud y Act Plan Do Stud y Act Pla n Do StudyAct Pla n TEST 1 What: Chose asthma action plan Who (population): All providers Where: Drs. Meeting When: Oct. 12 Who executes: All providers Results: A plan is chosen TEST 1 What: Implement asthma action plan Who (population): all providers Where: all offices When: Starting Nov. 1 Who executes: Asthma nurse and all providers Results: Number of asthma patients with a AAP went up, but it was not 100%. TEST 2 What: Implement asthma action plan for all patients. Who (population): All patients Where: all offices When: Jan. 4th Who executes: All providers Results: Numbers improved but patients with mild asthma (only on albuterol) were not getting AAPs. It was difficult to document in the EMR. It requires scanning. TEST 1 What: Implement AAP template in EMR Who (population): Charge nurse Where: Oxford office When: April 8th Who executes: One provider Results: It works but needs revision. Still missing some medications. Symptoms are used more than peak flows so they need to be emphasized.

12. PDSAs and Ramps Standardize Use of Asthma Action Plan Do Study Act Pla n Do Stud y Act Plan Do Stud y Act Pla n Do StudyAct Pla n TEST 2 What: Implement revised AAP in EMR Who (population): Charge nurse Where: All offices When: April 12th Who executes: Charge nurse Results: AAP is improved but is still missing medications. Next PDSA cycle, review form at provider meeting and discuss further changes.

13. Asthma patient identified in “Alert” area of EMR for all patients on Registry Data Collection form, Asthma Action Plan, & Teaching materials placed with Patient Route slip Medical Assistant interviews family and gives form to previously identified asthma patients and any newly identified possible asthma patients Patient and family complete Question 1-12 Patient Data Collection form Provider reviews form with family, discusses asthma including management and educational materials Patient scheduled for follow up visit and spirometry Forms scanned into EMR New patients placed on registry Office Visit - Prework During Office Visit Post Visit Activities Both forms reviewed by Asthma Nurse Coordinator and entered into EQUIPP Provider completes EQUIPP portion of Asthma Data Collection Asthma Action Plan completed, copies of plan and educational materials given to family for school or caregivers Office Flow Diagram – Oxford Pediatrics. -Missed opportunities- patients not on asthma list or who come for another reason. -Forms not placed with route slip Time constraints depending on visit type. Time and staffing constraints for spirometry Incomplete forms

14. Identify patients Identify patients Oxford Pediatrics Asthma Project Process FAILURE MODES INTERVENTIONS CURRENT PROCESS -Failure to check the asthm a list -Failure to check the clinical alert box -Patients come in for anothe r proble m and we miss an opport unity to review asthm a care -clinical alert box -past medical and family history forms -symptom history Asthma materials placed with chart Asthma materials placed with chart -materials not copie d -MA forge ts to place mater ials with route slip -MA training -Materials available in every room -Asthma folders in every room MA’s give patients form MA’s give patients form -Patients come in for anoth er proble m and we miss an opport unity to review asthm a care -asthma folders in every room -MA training Family/patient complete form Family/patient complete form -Family refus es -Family is focus ed on other probl ems/ conce rns -Form is not retur ned to MA or provi der -signs regarding our asthma focus placed in waiting rooms -MA’s encourage families to complete forms Provider reviews form with family Provider reviews form with family -Family come s in for anoth er probl em and provi der forge ts. -Provider is time limite d Asthma Action Plan done Asthma Action Plan done -not alway s place d on chart -not availa ble in every room - cumb erso me proce ss -time consu ming -AAP placed with route slip -AAP available in every room F/u scheduled -providers forgo t to reco mme nd an appoi ntme nt -parent does not sched ule befor e they leave but “will call for an appoi ntme nt” -F/u is part of CQN form -F/u is part of route slip -form introduced at doctor’s meeting -forms placed on chart -forms placed in exam rooms

15. Spirometry scheduled Spirometry scheduled Oxford Pediatrics Asthma Project Process FAILURE MODES INTERVENTIONS CURRENT PROCESS -Front desk fails to ask parent s to sched ule -Only availa ble in one office -patients can’t cooper ate -patients don’t show up -CQN form used for visit -nurses trained for spirometry Provider completes EQUIPP portion of form. Provider completes EQUIPP portion of form. -form someti mes not placed in collecti on box -form not always fully filled out -form is on back of patient form -form collection boxes in all offices Forms reviewed by asthma nurse Forms reviewed by asthma nurse -sometimes unable to assign form to a provid er -box in each office -asthma nurse tracks down providers for incomplete forms Data entered Into EQUIPP Data entered Into EQUIPP - some times unabl e to assig n form to a provi der -form EQUIPP friendly Forms scanned Into EMR. Forms scanned Into EMR. - Some times forms don’t make it back to scan pile after data entry New patients placed on asthma list. New patients placed on asthma list. -asthma list is not updat ed -registry is costly -registry is time consu ming to maint ain -we have an asthma list -Front desk assigned to scan forms -there is a scan folder

16. Key Learning The process of measuring requires standardization. The process of measuring requires standardization. The process of coming together does open avenues for change. The process of coming together does open avenues for change. Small tests of change are important. Small tests of change are important. Spirometry may or may not be useful. Spirometry may or may not be useful.

17. Future Plans Attempt to standardize use of spirometry Attempt to standardize use of spirometry Investigate ways to improve spirometry techniques Investigate ways to improve spirometry techniques Research options for a registry Research options for a registry