1. A System for Great Asthma Care Chapter Quality Network Asthma Project Oregon AAP Chapter Learning Session 1 Keith Mandel, M.D. Vice President of Medical Affairs, Physician-Hospital Organization Cincinnati Children’s Hospital Medical Center AAP/CQN Improvement Advisor October 1, 2009

2. I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity.

3. Objective Discuss key drivers for improving system of care for children with asthma.

4. Where Change Happens Informed, Empowered Patient and Family Productive Interactions Prepared, Proactive Practice Team Improved Outcomes

5. What Does a “Productive Interaction” Look Like for Chronic Illness Care? Systematic assessment at point of care –Clinical status –Evidence-based care –Confidence –Self-management skills Tailoring clinical management to family needs and preferences Active, sustained follow-up

6. Why is this so hard to do?

7. It’s the system!

8. What will your system look like in 1-2 years? A short film by Jesse Dylan

9. Evidence that System Change Works (Cochrane Review; JAMA 2002; Diabetes 2001) 40 studies (85% RCTs) (mostly in primary care) Four categories of interventions: –Decision support –Delivery system design –Changes to information systems –Self-management 19/20 that included self-management had a positive effect The five studies that included all 4 categories had a positive effect

10. Conclusions No “magic bullet” – no single intervention made a major difference Self-management is necessary, but not sufficient More intervention categories addressed, greater impact on patient outcomes Comprehensive system changes are needed to improve outcomes

11. What is a System? “A network of interdependent components that work together to accomplish a shared aim.” (Deming) Overall aim of the CQN asthma collaborative –To achieve measurable improvement in outcomes for asthma populations by applying NHLBI guidelines and making key practice changes

12. Improving Care for Populations: Need to Work at Multiple “System” Levels Broader Environment (ABP-MOC, payors/P4P, hospitals, specialists, schools, community agencies, etc.) AAP Chapters/National AAP office (improvement collaborative/resources) Primary Care Practice (practice leadership/engagement, registry implementation) Patient-Provider Interaction (AAP/CQN asthma form)

13. Recipe for Improvement System Change Concepts (“What” + Suggestions of “How”) Evidence-Based Changes (“What”) Process Improvement Model (“How”) Network for Learning (Framework for “How”) How will we know that a change is an improvement? Plan DoStudy ActPlan DoStudy Act What are we trying to accomplish? What changes can we make that will result in improvement? What changes can we make that will result in improvement? Ed Wagner, MD, MPH: MacColl Institute; Associates in Process Improvement; Institute for Healthcare Improvement

14. Chronic Care Model (Wagner)

16. Key Drivers of Focus (in near-term) Using a planned care approach to assure reliable asthma care at time of visit (reliability). Implementing a registry to improve outcomes at patient and population level. (deferred to later presentation) Engaging QI team and practice. (deferred to breakout session)

17. Value of Highly Reliable Use of AAP/CQN Encounter Form Changes nature of patient/family-provider interaction through more active patient/parent engagement. Generates disconfirming data that surfaces issues/challenges. Triggers improvement interventions at point of care. Brings evidence-based guideline tables “forward” to point of care. Provides data for: driving improvement in population- based measures, populating registry, and engaging practice colleagues. Provides data to identify “high-risk” patients.

18. Definition of Reliability: General The measurable capacity of a process to perform intended function in required time under commonly occurring conditions. The extent of failure-free operation over time. Reliability involves industrial engineering, human factors, and reliability science.

19. Definition of Reliability: AAP/CQN Asthma Project Reducing the number of missed opportunities to capture information on, and address, key aspects of asthma care (using AAP/CQN encounter form) for practices’ total asthma population.

20. Measuring “Reliability”/ Defining “System Failure” “Reliability” = # of opportunities where form utilized ÷ total # of potential opportunities “Defect rate” = 1 minus “reliability” # of missed opportunities ÷ total # of potential opportunities Defect rate often expressed as an order of magnitude (e.g., 10 -1, 10 -2, 10 -3 ).

21. Levels of Reliability 10 -1 (Level 1) = missed opportunity occurs 1 time in 10 (90% capture rate) 10 -2 (Level 2) = missed opportunity occurs 1 time in 100 (99% capture rate) 10 -3 (Level 3) = missed opportunity occurs 1 time in 1000 (99.9% capture rate) Nearly all studies assessing reliability of applying clinical evidence conclude it is at 10 -1.

22. y = mx + b m = 30-5/12 = 2%/month At this rate, it would take another 3 years to capture data on 100% of population—need to accelerate slope Importance of Reliability

23. Level 1 (10 -1 ) Reliability: Change Concepts and Examples Vigilance (“stay alert”) and hard work (“try harder”). Examples: –Data feedback on compliance. –Training/education/awareness. –Personal reminders by “opinion leader”. Complicating factors: –“Fatigue” (at physician, nurse, staff level). –Competing demands for time/attention. –“Environmental conditions” (e.g., less time available/less focus at certain visit types).

24. Level 2 (10 -2 ) Reliability: Change Concepts and Examples Checklists/reminders built into system. –Nurse/MA checks chart of asthma patients to assure data collection form inserted and ultimately completed. –“Reminders” built into EMR. Desired action (based on the evidence) is the “default.” –“Standing orders” that all asthma patients receive written management plan, controller medications (if “persistent”) and flu shots—nurses screen patients at beginning or end of office visit. Scheduling. –Data captured at time of regular follow-up phone call to parents of asthma patients. –Data captured via regular mailing to parents of asthma patients to reassess status.

25. Level 2 (10 -2 ) Reliability: Change Concepts and Examples Redundancy (i.e., multiple opportunities to complete form). –If physician fails to complete form, nurse/MA works with family to complete prior to their leaving office. –If form not placed in chart prior to visit, staff adds form to chart at time of visit. –Parent completes form in waiting area or while in exam room. –“Hold point” to review status of form prior to departure of asthma patients from office (e.g., nurse reviews chart of asthma patients prior to departure to see if form completed, management plan provided/revised, controller medications prescribed, flu shot administered).

26. Level 2 (10 -2 ) Reliability: Change Concepts and Examples Taking advantage of habits/patterns. –Parent indicates if patient has asthma at time of check-in. –Parent completes asthma form while updating demographic data in waiting area. –Nurse asks parent if patient has asthma when taking/confirming history. Standardization of processes/essential tasks. –Process for getting forms completed is standardized across nurses/physicians/office sites (e.g., process mapping of workflow). –All patients screened for asthma, flu shot status, ED/urgent care visits, admissions at time of visit. Differentiation (e.g., color coding of patient charts). “Real-time” identification of “failures” (missed opportunities for using form at point of care).

27. Level 3 Reliability (10 -3 and greater): Change Concepts Preoccupation with failures. –Circumstances underlying each missed opportunity discussed among physicians and staff. Reluctance to simplify interpretations. Commitment to resilience. –“Contingency plan” exists if patient not identified prior to visit or patient newly diagnosed at time of visit. Deference to expertise. –Recruit improvement/design ideas from multiple stakeholders, including patient/family and office staff at all levels. High degree of cooperation, coordination, communication, and collaboration among staff/team members.

28. “Prevent-Identify-Mitigate” Framework for Designing Highly Reliable Systems Prevent: design system to prevent failure (at time of visit). –Identify population. –Flag charts. –Pre-populate charts with form. –Ask parents to self-identify at check-in that child has asthma. Identify: design processes to make failures visible so that they can be addressed (at the time of the visit). –Prior to checkout, nurse/MA checks chart to see if patient has asthma and assures that form completed. Mitigate: design processes to “mitigate harm” caused by failures when not detected/intercepted (at time of visit). –Identify missed opportunities via billing system query and mail form to parent.

29. What did you learn from testing AAP/CQN form? What challenges do you anticipate around reliably implementing form into workflow? What reliability change concepts might you test?

30. Overcoming Challenges Ask questions of Collaborative faculty Share challenges and learnings on Listserv Use tools and resources posted on Extranet Seek input from other practice teams

31. Transformation: “Being The Best At Getting Better” (Lee Carter, former Board Chair, Cincinnati Children’s)

32. Questions for Discussion What system challenges are you encountering today that will be important to address in achieving overall aim/goals? What are your biggest concerns? What’s worked well from prior quality improvement efforts that would be valuable to build on through the AAP asthma initiative? What other ideas do you have for overcoming these challenges?