1. CQN Team Presentation State Name: OREGON Practice Name: Doernbecher General Pediatrics Team Members: Art Jaffe, Julie Johnson, Lisa Johnson, Beech Burns

3. Progress Since Learning Session 1 1.Engaging Your QI Team and Your Practice -- QI team is actively functioning -- Clinic staff, faculty, and residents participating -- Dept Chairman and hospital administrator providing financial and advocacy support -- Have had formal conferences for clinic staff -- Have had formal resident conference and ongoing continuity clinic conferences -- Regular email updates to faculty and residents

4. Progress Since Learning Session 1 2.Using A Planned Care Approach -- Have developed a triple-tiered system to ensure use of CQN form with all asthmatic patients -- Have done small-scale PDSA to evaluate use of home-made EMR template to replace CQN, and elected not to change over at this time

5. Progress Since Learning Session 1 3.Developing An Approach to Use of Protocols -- Have developed consistency in listing “asthma” on the EMR’s Problem List - may be a foundation for eventual registry -- Currently focusing on standardizing use of Asthma Action Plan -- Investigating use of a standardized assessment form, e.g., ACT, as permanent tool instead of CQN -- Requesting funds for spirometry in the new budget cycle

6. PDSA Cycles PDSA Title: Evaluate An EMR Template To Replace the Paper CQN Form  Plan: Write and load a template for a CQN form into EMR; use it for 5 days; evaluate perceptions about its utility  Do: Clinic residents only used it for 2 or 3 patients; found it was too cumbersome and time-consuming to use  Study: Electronic template was too inefficient  Act: Senior resident and QI Team decided to ADAPT the form by creating a shorter version to try during the following week

7. PDSA Cycles PDSA Title: Evaluate A Simpler EMR Template  Plan: Write and load a new and simpler form into EMR; use it for 5 days; evaluate perceptions about its utility  Do: The template’s author tried it with 1 patient; found it was still too cumbersome  Study: Electronic template was too time-consuming to use  Act: Senior resident and QI Team decided to ABANDON designing an EMR template, and to continue using CQN form

8. EQIPP Graphs: % of Patients with Optimal Care

9. EQIPP Graphs: % of patients with a validated instrument to determine level of control

10. EQIPP Graphs: % of patients with step-wise approach to identifying treatment options or adjustment of therapy

11. EQIPP Graphs: % of patients with flu shot given or recommended

12. EQIPP Graphs: % of patients with asthma action plan

13. Office Flow Document

14. Key Learnings 1.Our practice isn’t as good at providing asthma care as we would like to think we are. 2.Involvement in this project has led to a Hawthorne Effect 3.A registry is a critical component of improving care to a population. A large-scale, expensive EMR is not necessarily conducive to supporting a registry. 4.A large and very complex social structure such as an academic medical center provides both support for, and challenges to, quality improvement. 5.We need to balance process and outcome measures