aap oregon state chapter shared vision sandra e. miller, md, faap
TRANSCRIPT
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.
Goals
• Learn about Oregon’s strategic QI plan• Understand the “gap” in care• Understand why this work is important• Become familiar with the goals for this
project
Oregon Quality Improvement Strategic Plan
• OPS QI Committee• Founded to:
– Help define “quality” of care for Oregon children
– Assist in negotiation of quality-based reimbursement
– Increase quality of care for Oregon children– Assist Pediatricians in closing the “quality gap”
in their own practices
What is the Quality Gap?
• How QI came to me….
• The gap between the care we know is best and our ability to deliver it, every time, to every patient in the way they need it.
Our Clinic’s Goals
• Know our patients and be prepared for their visit
• Use our time efficiently• Empower our patients to take charge of
their own healthcare• Work as a team and use systems to guide
our care
“Open Access” at WEMC
• Beginning access: 2-3 weeks for wellness visits
• Changes made:– Review all visits to be sure shots, wellness are
up to date– MOA vaccine prep when I am in the room– Preschedule well visits when possible– Reminder card system for wellness with phone
followup
• Current access: 1-3 days for wellness visits
Defining the Gap: Asthma
• Affecting nine million children, childhood asthma is the most common serious pediatric chronic disease. The incidence of pediatric asthma continues to grow; it accounts for 14.7 million missed school days a year and 44% of all asthma hospitalizations[1]
• During August 2007, under the auspices of the National Heart, Lung, and Blood Institute (NHLBI) the National Asthma Education and Prevention Program (NAAEP) issued the first comprehensive update in a decade of asthma guidelines for the diagnosis and management of asthma (NHLBI asthma guidelines). The guidelines emphasize the importance of asthma control and introduce new approaches for monitoring asthma. The AAP recognizes that increased exposure to the new guidelines coupled with implementation support will decrease gaps in care and help move towards optimal care for children with asthma.
[1] American Academy of Allergy, Asthma and Immunology. http://www.aaaai.org/media/resources/media_kit/ asthma_statistics.stm
Satisfaction
-Access to Care
-Positive relationship with provider
-Empowerment
-Peace of Mind
Functional
-School Attendance
-Sports and Activities
-Improved Sleep
- Family Dynamics
Costs
Hospital Costs
Medication Costs
Outpatient Costs
Caretaker’s Work Loss
Clinical
Hospitalizations
ER Visits
Use of Inhaled Steroids
- Asthma Action Plans
- Patient Education
Adherence to Guidelines
• “An intervention to enhance compliance … will need to address … barriers…” Prim Care Respir J 2007 Dec; 16(6): 369-77
• “Adherence to recommended guidelines in asthma/COPD was low.” Pharmacoepidemiol Drug Saf. 2009 May; 18(5):393-400.
• “Guideline nonadherence was widespread…” Health Serv Res 2001 Jun; 36(2): 357-71
• “Physician prescribing of asthma pharmacotherapy does not adequately comply with EPR-2 treatment guidelines.” Ann Allergy Asthma and immunology 2008 Mar; 100(3): 216-21
Oregon’s Asthma Gap
• In 2007, approximately 75,000 children were estimated to have asthma Oregon OHP
• recipients with asthma ages 4-8 years had the highest ED use
• In 2005, 70% of children with asthma received information on recognizing and treating asthma
• 32% received an asthma action plan• 47% of children on Medicaid had a low
medication ratio(All data courtesy, Oregon Asthma
Program)
Why is there a gap?
• Busyness• Low reimbursement• Absence of systems of care• Reliance on memory• Other?
Oregon’s CQN Aim
• Global Aim The Oregon Pediatric Society will establish and support a
sustainable infrastructure to facilitate pediatric practice-based quality improvement activities for its membership, to achieve measurable improvements in health outcomes, consistent with the highest quality of evidence based treatment and long term disease management for children with asthma and their families.
• Specific Aim From April 2009 to November 2010, we will recruit and lead
a collaborative of 10-15 pediatric practices within Oregon for the purpose of measurably improving outpatient asthma management and outcomes through implementation of quality improvement methods and the NHLBI/NAEPP guidelines.
Oregon Care Goals
• By September 2010, practices will achieve 75% of optimal care.
• By September 2010, practices will use a structured encounter form 90% of the time.
• By September 2010, 85% of patients with asthma will have a written asthma action plan.
• By September 2010, 70% of practices will be using an asthma registry.
• By September 2010, 80% of patients with persistent asthma will have a controller prescribed.
• By September 2010, 75% of patients will have assessment of “well controlled” asthma status documented in chart notes.
Optimal Care
>90% of patients have “optimal” asthma care (all of the following)
• assessment of asthma control using a validated instrument
• stepwise approach to identify treatment options and adjust therapy
• written asthma action plan • patients >6 mos. of age with flu shot (or
flu shot recommendation)
Change Concepts
• Engaging Your Asthma QI Team and Your Practice
*The QI team and practice is active and engaged in improving practice processes and patient outcomes
Change Concepts
• Developing an Approach to Employing Protocols * Standardize Care Processes * Practice wide asthma guidelines
implemented
Change Concepts
• Using a Planned Care Approach to Ensure Reliable Asthma Care in the Office *Care team is aware of patient needs and
work together to ensure all needed services are completed
Change Concepts
• Providing Self management Support * Realized patient and care team
relationship * Patient/Parent understand how to manage
asthma and access appropriate care
Change Concepts
• Using a Registry to Manage Your Asthma Population
*Identify each asthma patient at every visit
*Identify needed services for each patient
*Recall patients for follow-up
Key Driver Diagram
GLOBAL CQN AIMWe will build a sustainable quality improvement infrastructure within our practice to achieve measurable improvements in asthma outcomesSpecific Aim From fall 2009 to fall 2010, we will achieve measurable improvements in asthma outcomes by implementing the NHLBI guidelines and making CQN’s key practice changes
Measures/Goals
Outcome Measures: >90% of patients well controlled
Process Measures >90% of patients have “optimal” asthma care (all of the following) assessment of asthma control using a validated instrument stepwise approach to identify treatment options and adjust therapy written asthma action plan patients >6 mos. Of age with flu shot (or flu shot recommendation)
>90% of practice’s asthma patients have at least an annual assessment using a structured encounter form
Engaging Your QI Team and Your Practice*The QI team and practice is active and engaged in improving practice processes and patient outcomes
Using a Registry to Manage Your Asthma Population *Identify each asthma patient at every visit *Identify needed services for each patient *Recall patients for follow-up
Using a Planned Care Approach to Ensure Reliable Asthma Care in the Office * CQN Encounter Form * Care team is aware of patient needs and
work together to ensure all needed services are completed
Developing an Approach to Employing Protocols * Standardize Care Processes * Practice wide asthma guidelines
implemented
Providing Self management Support
* Realized patient and care team relationship
Key Drivers
Interventions
Form a 3-5 person interdisciplinary QI Team
Formally communicate to entire practice the importance and goal of this project
Meet regularly to work on improvement
All physicians and team members complete QI Basics on EQIPP
Collect and enter baseline data
Generate performance data monthly
Communicate with the state chapter and leaders within the organization
Turn in all necessary data and forms
Attend all necessary meetings and phone conferences
Select and install a registry tool
Determine staff workflow to support registry use
Populate registry with patient data
Routinely maintain registry data
Use registry to manage patient care & support population management
Select template tool from registry or create a flow sheet
Determine workflow to support use of encounter form at time of visit
Use encounter form with all asthma patients
Ensure registry updated each time encounter form used
Monitor use of encounter form
Select & customize evidence-based protocols for your office
Determine staff workflow to support protocol, including standing orders
Use protocols with all patients
Monitor use of protocols
Obtain patient education materials
Determine staff workflow to support SMS
Provide training to staff in SMS
Assess and set patient goals and degree of control collaboratively
Document & Monitor patient progress toward goals
Link with community resources
CQN Asthma Project Practice Key Driver Diagram Version 2.0
Asthma Care a Year From Now
• Easier use of the asthma guidelines by physicians and staff
• Better understanding of asthma for patients and families
• Better systems so your office members can function as an efficient team
• Knowing your patients and being ready for their visits
• The best care for every patient, every time