1. Emanuel Children’s Clinic Summary of Progress: Improved optimal asthma care to 72% Increased the use of a written asthma action plan to greater then 90% through the month of February. March data returned lower scores Assessing asthma control with a validated instrument and using stepwise approach 100% of the time.

2. EQIPP DATA GRAPHS Percentage of optimal asthma care. Error in entering flu vaccine data has suppressed this number. Asthma action plan. Last data cycle shows dip in asthma action plan use.

3. EQIPP DATA GRAPHS Stepwise approach Validated instrument

4. Patients 6 mos and older with a recommendation for a Flu Vaccine

5. Nurse collects form enters patient information into EMR physician fills out the remainder of form Office Visit - Prework During Office Visit Post Visit Activities Nurse Supervisor Or Administrative office assistant Collects encounter form and verifies for completeness Clinic data shared with Physician team during monthly meeting All necessary information on the form is entered into EQIPP Clinical Assessment Process Map – Emanuel Children’s Clinic Rooming nurse/MD huddle at the start of each shift to identify patients needing asthma encounter form EQIPP Data reviewed by physician leader And Nurse supervisor Form complete At time of rooming Form incomplete At time of Patient rooming Physician collects Form enters data Into EMR Nurse schedules spirometry Provides education and Handouts as ordered From MD. Administer flu shot if ordered RN gives encounter form to family MD uses stepwise Approach. Adjust medication As needed Asthma action plan Filled out Referral to spirometry As needed. Flu vaccine discussed Asthma Education Provided Completed form placed into collection folder for later data entry Concern:Data incorrectly Entered for FLU When advised but not Given Plan: Admin Assistant Will correctly enter Data into EQIPP Concern: Asthma action plan not always initiated or Updated Plan: RN staff will now place Blank asthma action plans on All charts ID with asthma PDSA Concern:Limited time for MD to provide education Plan: RN’s Will educate families and give handouts. PDSA Nurse gives front Desk staff the encounter form To be handed out To parents at check in Concern: Same day appointments Not ID with asthma During morning huddle PDSA Nurse uses Medication List to ID Asthma Pt. Changes Identified during physician meeting are tested using PDSA and implemented during next collection period Complete Incomplete Office Flow Diagram

6. PDSA Ramp Do Study Act Pla n Do Stud y Act Plan Do Stud y Act Pla n Do StudyAct Pla n Identification of asthma patients TEST 1 What: ID Asthma Patients Who: Dr. Greenlee +RN Where: Dr. Greenlee’s Office When: Morning Meeting Who executes: RN gives form to front office Results: Increased use of asthma form. TEST 2 What: ID Asthma Patients Who: All MD’s + RN Where: MD offices When: Morning Meeting Who executes: RN gives form to front desk for delivery to patients. Results:Increased use of asthma Form. Same day patients not ID during morning meeting TEST 3 What: ID asthma patients SDA Who: RN Where: exam room When: During rooming process Who executes: RN ID’s patients using medication list:--If on asthma medication form given. Results: Increased use of asthma form for same day patients. If no asthma medication listed still missed using form. TEST 4 What: ID asthma patients Who: MD Where: exam room When: during visit Who executes: MD ID patients in the room missed during morning meeting and rooming process. MD fills out asthma form with family Results: Increased the use of asthma form not previously ID

7. PDSA Ramp Do Study Act Pla n Do Stud y Act Plan Do Stud y Act Pla n Do StudyAct Pla n Increase the use of the Asthma action plan TEST 1 What: Patients ID during morning huddle will have an updated asthma action plan upon leaving clinic Who: Dr. Greenlee +RN Where: Dr. Greenlee’s Office When: Morning Meeting Who executes: MD updates or creates new action plan Results: All patients ID with asthma had new or updated form TEST 2 What: Patients ID during morning huddle will have an updated asthma action plan upon leaving clinic Who: All MD’s + RN Where: MD offices When: Morning Meeting Who executes: MD updates or creates new action plan Results: Sporadic use or asthma action plan. MD’s not always updating or creating new plan. TEST 3 What: Patients ID during morning huddle will have an updated asthma action plan upon leaving clinic Who: RN Where: Pt Check in When: upon patient arrival Who executes: RN will place a new action plan on every chart of a patient ID with asthma Results: Increased use of asthma action plan.. TEST 4 What: Patients ID during rooming process will have an updated asthma action plan upon leaving clinic Who: RN Where: exam room When: during rooming process Who executes: RN: patients missed during morning meeting but ID during rooming process with asthma. Will have asthma action form placed on front of chart for MD to fill out. Results: Increased the use of asthma action plan on patients not previously ID

8. Key Learning  Quality improvement starts with small changes.  Learned about PDSA cycles  Registry is necessary for optimal asthma management.  Takes the entire team’s buy-in to successfully make improvements.  Due to compliance would be most beneficial to complete spirometry during clinic visit.

9. Future Plans Spirometry in clinic Grant written to obtain spirometry. Grant was successful. Clinic will obtain new machine and training this spring. This will allow us to complete spirometry at the time of appointment. Increase family compliance. Registry Clinic developing new EMR “EPIC” with some registry functions? Currently working on excel spreadsheet. Education Nurses will be main asthma educator for family and patients. Developing new handouts. Providing educational in-service for RN staff with MD.