Quality Improvement Series Session 6- Culture and Systems Windy Stevenson lammersw@ohsu

1. Quality Improvement Series Session 6- Culture and Systems Windy Stevenson lammersw@ohsu.edu Cindy Ferrell

2. Today’s Agenda

3. Recap • Problem: The DCH ambulatory clinic problem lists are incomplete and inaccurate. • Drivers: • Improve patient care • Improve provider efficiency (reduce chart review) • Lessons Learned: • We have to narrow our scope • Just saying we fix the system is woefully inadequate • Everything is more complex than we expect • Random audits of an ill defined product are not helpful • We are still limited by our access to data

4. Last time we met… • Capture data regarding types of patients or types of problems not well documented in the clinic • Explore data capacity to compare the # of patients with asthma on a bill to the # of patients with asthma on a problem list

5. Start somewhere, anywhere… • Institutional or leadership priorities • Clinical • Fiscal • Safety risk • Most annoying (therefore most motivation to fix?) • Most easily solved • Most easily measured • Most meaningful to customers So, Why do we feel stuck???

6. Let’s say your dog keeps running into the street Changing behavior This works when there is no natural consequence (fence) This works in a system with immediate feedback (treats or shock collar)

7. Challenges (ie barriers) • Time • Culture • Ownership • Definition of accuracy • Lack of natural error identification • Lack of natural rewards • Need for manual audits

8. Project Focus Options

9. New Docflowsheet Requests for Asthma Metrics • Purpose: Capture discrete data during office visit of asthma management • Where should this show: Rows should display within the visit navigator when an asthma ICD-9 problem is added to the problem list • Does pt have active daytime symptoms ? Y/N • How frequent are daytime symptoms ? < or equal to 2 times/week, > or equal to 2 times per week, daily, always • Does the patient have active nighttime symptoms ? Y/N • How frequent are the nighttime symptoms ? < or equal to 2 times/month, > or equal to 2 times/month, >1 per week, frequent • What is the asthma classification? Mild intermittent, mild persistent, moderate persistent, severe persistent • Level of control: well controlled, not well controlled, very poorly controlled, not assessed • Today’s ACT Score ________ (free text) • Today’s Track Score ________ (free text) • Asthma action Plan: completed, reviewed, not appropriate • Stepwise approach used to identify treatment option or to adjust therapy based on asthma control? Yes, no • If this patient has persistent mild, moderate or severe asthma have they received prescription for an inhaled corticosteroid or an acceptable alternative? Y/N • If this patient has persistent mild, moderate or severe asthma and have not received a prescription for an inhaled corticosteroid or acceptable alternative document reason why. • Influenza vaccine given: yes, no • Influenza recommended but not given due to: contraindicated, too ill, younger than 6 months old patient, declined by parent/guardian, not available, already had the vaccine for this influenza season • Spirometry completed today ? Yes, No • Hospitalized since last visit ? No, acute care admission, critical care admission • ER encounter since last visit? No Yes

10. Obesity and Meaningful Use The percentage of patients 2‐17 years of age who had an outpatient visit with a PCP and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year.

11. Where do you start? Problem statement: The DCH ambulatory clinic problem lists are incomplete and inaccurate.

12. How do you create a SMART aim? • Specificwe are intentional and focused • Measurablewe can prove we’ve had an impact • Actionablethere are no known insurmountable barriers • Realisticit’s within our scope • Timelywe’ll do it within a time frame

13. Take Home Points (review) Real (sustainable) change comes from changing systems, not changing within systems Be specific about what you want to accomplish, and why; be intentional Focus on patients Start before you think you are ready; don’t get paralyzed