1. Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Alabama Practice: Charles Henderson Child Health Center Team Members: Elizabeth Dawson M.D., Tammy Ellis RN, Michelle Smith LPN, Yolanda Patterson M.D., Sheri Watkins

2. Team

4. Progress Summary Since Learning Session 1 Developed 3 encounter forms Logged over 230 patients Tremendous increase in confidence that we are doing good asthma care Started EMR and ASQ implementation and able to use QI skills for each of these

5. Optimal care 230 of 1550 asthma patients with a validated instrument used to assess asthma control 100% stepwise approach 100% of patients with a flu shot or rec 85% of patients with asthma action plan present and explained to them Will address improving optimal asthma care by using encounter forms at designated visits

6. Percent of patients with optimal asthma care

7. Percent of patients where stepwise approach is used

8. Percent of patient with a flu shot

9. Percent of patients with an action plan that was explained to them

10. PDSA Cycles PDSA Title: Electronic encounter form- intial  Plan: Make an e-form  Do: Discussed with team members that current form working well so we will use them initially and create an electronic form to cover items on encounter form.  Study: Determined that we want to keep similar age specific forms and adapt an e-form to it.  Act: will move forward with current form and adapt e- version

11. PDSA Cycles PDSA Title: engaging practice  Plan: Give entire office presentation on what QI and the asthma project are.  Do: presentations specific to support staff and doctors.  Study: excitement among coworkers about possibilities but concerns about workflow, physicians skeptical about return on time invested  Act: Initial presentation good but need updates and data and practical examples of how care is improved to get further buy in from physicians

12. TEST 1 What: CQN data form given under physician direction Who (population): 2 patients for 2 physicians Who (executes): nurses Where: in patient room When: started Tuesday after conference PD SA TEST 2 What: CQN data form to 5 total patients determined Who (population): patients Who (executes): nurses Where: patient room When: 2 weeks after initial data gathered PD SA TEST 3 What: new encounter form Who (population):patients Who (executes): for patient/parent to complete Where:in patient room When: for second data cycle PD SA TEST 4 What: new encounter form Who (population): every asthma patient Who (executes): nurse ID, doctor ID, pt completes Where: in patient room When: if haven’t done one in 1 month, started in 3 rd data cycle PD SA TEST 1 What: creating 1 new encounter form Who (population):for patients to complete 5-11 Who (executes): dr. dawson, core team, and husband Where: work and home When: started in 3 rd data cycle PD SA TEST 2 What: create 3 encounter forms Who (population): patients Who (executes): dr. dawson, core team and husband Where: office and home When: 4th data cycle PD SA TEST 3 What: use 1 encounter form Who (population): 5-11 y/o with asthma Who (executes): nurse or md distribute patient complete Where: pre workup then in patient room When: 3 rd data cycle PD SA TEST 4 What: 3 new encounter forms Who (population): 0-19 with asthma Who (executes): nurse and md distribute pt complete Where: pre workup and patient room When: 4 th data cycle PD SA TEST 1 What: adapt patient encounter form Who (population): for all ages Who (executes): Dr. P and Dr. D Where: in md office When: 5 th data cycle PD SA TEST 2 What: distribute data forms Who (population): for all asthma pts Who (executes): dr. dawson and sheri Where: records and md offcie When: 5 th data cycle PD SA TEST 3 What: create electronic encounter form Who (population): for all asthma patients Who (executes): dr. dawson and dr. patterson Where: md offices and changes at meetings When: 7 th data cycle/ during emr implementation PD SA TEST 4 What: Create flow sheet to go with encounter form Who (population): asthma patients Who (executes): dr. p and dr. d Where: md offices and meeting When: 8 th data cycle PD SA Encounter form distributionEncounter form newEncounter form 3/electronic PDSA Ramps

13. Asthma patients ID’ed by nurse on the day of visit by the work-up nurse. This is aided by pink stickers on the chart. In the room encounter form is removed from chart and given to patient and family and minimal instructions given to fill out form and physician will answer any questions Physician collects form from patient family and briefly reviews to look for possible inaccuracies Visit is completed in the room, Dr. reviews form fully in the room or outside of room & discusses w/ family Asthma teaching in appropriate areas such as smoking cessation use of controller vs. rescue, lung photos etc depending on encounter form results Asthma action plan reviewed and updated with the family Physician Form completed prior to filing chart and form placed in chart with green tab chart to ‘finished chart’ box Review workflow process and encounter form a minimum of monthly to make improvements Office Visit - Prework During Office Visit Post Visit Activities Sheri( MR) removes form and Places in physician’s encounter form folder for the month. Physician collects forms from Sheri for data entry into eqipp prior to month deadline NO Physician completes any forms that have not been completed yet Sheri keeps list of patients w/ forms completed and files completed forms for month in chart Sheri tags all asthma patients based on generated list from diagnosis codes for easier identification. CHCHC Office Flow Diagram Weak spot Physician Id patients missed by nurses, especially when needing refills and asks nurse to give form or MD gives themself Weak spot Forget to give the form- pink stickers added Forget to teach especially if doing well. Need standard times and tools to use at every visit Typically missed if pt doing well or here for non- breathing prob.

21. Barriers and Successes 2 partners not currently participating Still need spirometry Using encounter forms without a major slow down in workflow Knowledge instead of hopes and ideas that we are doing good asthma care

22. Future Plans Electronic encounter form and flow sheets to track certain things in every asthma patient and to further standardize practices. Physician in-service on 2007 guidelines and stepwise approach Identify smoking cessation info, video and other teaching tools Meet with area allergist/pulmologist for further guidance and collaboration