Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Ohio Practice Name: Nationwide Children’s Hospital Primary Care Red Clinic Team Members: Stephen Hersey, MD Cindy Gibson, RN Sonya Sebastian, PharmD Nicole Caldwell, MD

Progress Summary Since Learning Session 1 Entire team of 2 attendings and 20 residents are actively involved in the QI Effectively using asthma action plans and asthma education Standardization of and compliance with follow up has been improved

% of patients in which reasons for lack of asthma control is identified when asthma control is "not well controlled" or "very poorly controlled"

% of patients in which the stepwise approach is used to identify treatment therapy and adjust or maintain therapy based on asthma control

% of patients in which self-management education materials (in addition to the asthma action plan) are provided and explained to the patient and family at any visit

% of patients for whom a follow-up appointment to monitor asthma control is recommended Follow the instructions to take a picture of your graph andpaste 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'.Follow the instructions to take a picture of your graph andpaste 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'.

PDSA Cycles PDSA Title: ASTHMA CHECKS AT WELL CHILD EXAMS  Plan: incorporate CQN encounter into routine well child exams  Do: created a shortened form which the clinician addends to his/her well child exam note  Study: tested this for one week with Dr Hersey’s residents  Act: incorporated CQN encounter into routine well child exams with efficiency

PDSA Cycles PDSA Title: ASTHMA CHECKS AT SICK CHILD EXAMS NOT RELATED TO ASTHMA  Plan: incorporate CQN encounter into sick child exams not related to asthma  Do: created a shortened form which the clinician addends to his/her sick child note  Study: tested this for one week with Dr Hersey’s residents  Act: incorporated CQN encounter into sick child exams not related to asthma with efficiency

TEST 1 What: Who (population): Who (executes): Where: When: PD SA TEST 2 What: Who (population): Who (executes): Where: When: PD SA TEST 3 What: Who (population): Who (executes): Where: When: PD SA TEST 4 What: Who (population): Who (executes): Where: When: PD SA TEST 1 What: Who (population): Who (executes): Where: When: PD SA TEST 2 What: Who (population): Who (executes): Where: When: PD SA TEST 3 What: Who (population): Who (executes): Where: When: PD SA TEST 4 What: Who (population): Who (executes): Where: When: PD SA TEST 1 What: Who (population): Who (executes): Where: When: PD SA TEST 2 What: Who (population): Who (executes): Where: When: PD SA TEST 3 What: Who (population): Who (executes): Where: When: PD SA TEST 4 What: Who (population): Who (executes): Where: When: PD SA PDSA Title PDSA Ramps

Nationwide Children’s Hospital Primary Care Red Clinical Assessment Process Map – EMR System M a k e s u r e t h a t y o u r o f f i c e f l o w d o c u m e n t c o m m u n i c a t e s t h e o f f i c e f l o w w e a k p o i n t s. Y o u c a n u s e a n a r r o w t o s h o w w h e r e t h e y a r e a n d t y p e i n a s h o r t d e s c r i p t i o n. Asthma patients identified at the Nurse Station At time of pt/parent rooming,, encounter form is removed from folder in exam room, given to parent and parent is asked to fill out their part of the encounter form Once parent input is completed the form remains with family in the exam room. Patient is ready to be seen by Resident/ Attending During the visit the physician fills out the remainder of form while having Informed clinical Discussion/ Education provided Resident precepts case with the attending Physician completes the EMR note immediately after the visit NO During Office Visit Post Visit Activities Attending verifies for completeness If necessary circle back with Physician or patient family by phone to obtain missing information NO All necessary information on the form is entered into EQIPP and Registry YES Office Visit - Prework Who qualifies for the study? Lacking an effective registry

Red Clinic CQN Encounter Form ASTHMA QI CAREGIVER QUESTIONNAIRE RESPONSES (COPY ANSWERS FROM CAREGIVER QUESTIONNAIRE) 1) Days of school/daycare missed due to asthma in the past 6 months? { :10022} 2) Work days missed due to child’s asthma in the past 6 months? { :10022} 3) Has child visited the Emergency Room or Urgent Care due to asthma in the past 12 months? {YES/NO: } If yes, how many times? { :10022} 4) Has child been admitted to the hospital due to asthma in the past 12 months? {YES/NO: } If yes, how many times? { :10022}

Red Clinic CQN Encounter Form ASSESSMENT AND PLAN 1) If in active flu season (Sept-March), was flu shot given this season/recommended? {YES/NO: } -if yes, shot date: See Immunization Record -if no, reason: *** 2) If between seasons (April-Aug) was a recommendation made? {YES/NO: } 3) Does pt have an active asthma action plan? {YES/NO: } If yes, was plan updated as needed and reviewed at this visit?{YES/NO: } 4) Were asthma self management and education materials (other than asthma action plan) provided at this visit? {YES/NO: } (examples include correct medication techniques, avoiding environmental triggers, and getting help to quit smoking) 5) Were validated questions used to determine the current level of asthma control? {YES/NO: } (Asthma Clinical Guidelines Binder, Caregiver Questionnaire)) 6) What is the patient's current level of control during the past month? *** (well controlled, not well controlled, very poorly controlled) Use Asthma Clinical Guidelines Binder 7) If "not well controlled" or "very poorly controlled": Did you identify reasons? {YES/NO: } 8) Have you used the Asthma Clinical Guidelines Binder to identify treatment options or to adjust therapy based on asthma control?{YES/NO: } 9) For patients 5 years and older, is spirometry currently scheduled, or have results been obtained within the last 1 year? {YES/NO: } If yes, date: *** 10) Were lung function measures by spirometry used to establish the asthma diagnosis? (refer to Box 3-2 in physician room) {YES/NO: } 11) Were one or more Key Indicators present when considering the diagnosis of asthma (refer to Box 3-1 in physician room) {YES/NO: } 12) Follow up visit: Return in { :10022} months

Red Clinic CQN Encounter Form This template exists in a more detailed as an asthma exacerbation/medication appt template AND as CQN criteria only which can be added to another encounter note (ex. Well Child Exam)

Key Learnings  We have been effective in giving asthma action plans and asthma education to our patients from the beginning of this study  We have been able to incorporate Asthma CQN effectively into well and sick visits  With an EMR in a large institution, IT controls the speed with which changes can be made

Barriers and Successes  We have been effective in giving asthma action plans and asthma education to our patients from the beginning of this study.  Our patient population uses the ER/UC as a medical home out of convenience, making compliance and follow up difficult.  Not using PDSA cycles on a regular basis

Future Plans: Mediglyphs

Future Plans: Working with IT to develop a more effective way of tracking through registry Working with IT to develop a Flow Sheet in EMR with which to track asthma sx and rx: