A System for Great Asthma Care

Chapter Quality Network Asthma ProjectOregon AAP Chapter Learning Session 1

Keith Mandel, M.D.Vice President of Medical Affairs, Physician-Hospital

OrganizationCincinnati Children’s Hospital Medical Center

AAP/CQN Improvement Advisor

October 1, 2009

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.

Objective

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

Where Change Happens

Informed,Empowered

Patientand Family

ProductiveInteractions

Prepared,Proactive

Practice Team

Improved Outcomes

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

Why is this so hard to do?

It’s the system!

What will your system look like in 1-2 years?

A short film by Jesse Dylan

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

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

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

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)

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?How will we know that a change is an improvement?

Plan

DoStudy

Act Plan

DoStudy

Act

What are we trying to accomplish?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

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

Chronic Care Model (Wagner)

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

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)

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.

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.

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.

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).

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.

Cumulative Percentage of Asthma Population with Data Captured

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

2003-Oct

2003-Nov

2003-Dec

2004-Jan

2004-Feb

2004-Mar

2004-Apr

2004-May

2004-Jun

2004-Jul

2004-Aug

2004-Sept

2004-Oct

2004-Nov

2004-Dec

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

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).

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.

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).

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).

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.

“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.

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?

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

Transformation:“Being The Best At

Getting Better”

(Lee Carter, former Board Chair, Cincinnati Children’s)

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?