How reliable is your practice at implementing current guidelines for diagnosing and managing asthma? Several years ago, we suspected that our practice, a family medicine training site, was not performing well in this area. After a rapid chart audit confirmed this, we decided to launch a redesign effort. Our aim was to improve the quality of care provided to patients with asthma over six months through the reliable implementation of evidence-based guidelines.
This article outlines the steps we took and the decision support tools we created to help us achieve our goal.
Assessing compliance with asthma guidelines
Our first steps were developing a clear understanding of the consensus guidelines for asthma,1 distilling them to the salient points for a presentation to our medical staff and determining the ways in which our current practice deviated from these guidelines.
To accomplish the latter, our leadership team designed a simple chart audit tool, and our quality improvement project manager and a medical student we recruited for the project audited 100 charts. Though it was time consuming, this process revealed a number of important findings that informed our interventions. We learned that many of our asthma patients were frequently seen by providers other than their primary care provider due to the episodic nature of the urgent visits that are common in asthma, and the part-time status of most of our providers. Poor continuity contributed to fragmented care including inconsistent follow-up and poor adherence to recommended guidelines in terms of severity ratings, use of controller medications, annual flu shots and self-management tools such as asthma action plans and peak flow logs. It was also difficult to quickly find previous asthma visit notes and the current treatment plan in the chart. Often an interim treatment plan would be initiated, but the recommended follow-up visit would not occur. Patient education was limited as many visits were short, urgent appointments for management of acute exacerbations. The result was often poorly controlled asthma with little patient self-management.
ASTHMA MANAGEMENT FLOW SHEET
It became clear that if we wanted to increase our reliability at implementing the guidelines, we would need to devise a system that made it easy for the providers to do the right things. This would require a team effort with substantial reliance on the nursing staff and chart tools designed to stimulate the capture of essential information.
Based on our review of the literature and the guidelines plus the findings from our chart audit, we sought to do the following:
Improve the frequency with which providers determine and record asthma severity,
Increase the use of spirometry for the diagnosis of asthma,
Ensure that peak flow is measured at every visit,
Ensure that every patient with asthma is offered a flu shot each winter,
Inform and activate patients to be more involved in their asthma management through action plans and home peak-flow monitoring.
To accomplish these objectives, we implemented a variety of interventions:
Patient identification. First, we developed an asthma registry. This was simply a Micro-soft Excel computer file with a list of all our patients with asthma, which we created by mining our billing data for asthma-related ICD-9 codes. We then flagged these patients' charts by placing a blue sticker on each one. This facilitated identification of patients with asthma even when they were coming in for other reasons and made it easier to audit these charts at the end of the day.
Patient self-assessment. When our nursing staff identified patients with asthma, they asked these patients to complete a self-assessment form. This form serves multiple important purposes: First, it helps ensure that we take a more proactive role in the management of asthma by addressing it even if the patient is presenting for issues unrelated to asthma. Second, it is in keeping with the spirit of the chronic care model (http://www.improvingchroniccare.org) in that it challenges patients to be more actively involved in their own care. Third, it helps our practice identify opportunities for intervention, such as filling prescriptions, providing a peak flow meter and encouraging its use, or providing patient education.
Chart reminders. To keep our staff on track with the guideline-driven program, we developed an asthma-management flow sheet. At each visit, the nursing staff member who rooms the patient is responsible for initiating the flow sheet. She completes as much of it as possible before clipping it to the front of the chart for the provider to continue at the visit. (We print this form on blue paper, so it stands out and conveys at a glance that “this patient has asthma.”) Note that the staff are challenged at the top of the form to record the asthma severity rating, which informs the rest of the patient's care. The form also includes reminders about peak flow measurement, flu vaccination and pneumococcal polysaccharide vaccine (PPSV).2 The form is designed to be used for up to four visits so the physician can identify trends and can tell at a glance what teaching needs have already been addressed and which should be considered. On the back of the form, we print the diagnostic criteria for each severity rating and a summary of the available medications for each class with useful dosage details.
Committed nurses. The proper use of the flow sheet relies on our nursing staff being much more engaged in the care of our patients with asthma, so we decided to give them additional training. We identified a series of weekend continuing education courses and offered to pay the tuition. All of our nursing staff embraced this opportunity, using their personal time to attend the courses. Not only did this provide the nurses with much-needed continuing education units, but it also proved to be a positive team-building experience and a key step in getting our nurses committed to this work and highly motivated to drive our work flow changes and sustain this over time.
An improved diagnostic tool. Spirometry is a powerful diagnostic tool; however, for a variety of reasons, our practice had never offered the service in-house. After researching the various aspects of office spirometry,3 we learned that purchasing a hand-held device would allow us to diagnose asthma more accurately, and the return-on-investment analysis proved promising.
PATIENT SELF-ASSESSMENT FORM – ASTHMA
Internal audits. During our project, we tracked documentation of the asthma severity rating, personal best peak flow, visit peak flow results and use of controller medications. Because this audit was conducted by our nurse manager daily, she was able to provide helpful feedback to her staff in a timely way that resulted in rapid achievement of 100 percent performance on these measures. The physicians and NPs lagged a little at first, but the momentum coming from the nursing staff and other providers inspired relatively rapid change. Because we were doing a better job of identifying patients with asthma, flu vaccination rates in this population also increased.
Advice for other practice settings
Our program for improved asthma care was successfully implemented at a large residency training site staffed by many part-time physicians using paper charts. It is expected that even small practices would find this simple but systematic practice redesign intervention easy to accomplish. Likewise, this intervention could be adapted to a practice that uses an electronic health record (EHR) by creating an electronic “flag” that indicates patients who have asthma and by importing the asthma management flow sheet into the EHR.
We recognize that, given the pace of and demands on family medicine practices, practice redesign represents a formidable challenge. It takes substantial effort to overcome the inertia associated with the status quo. Many physicians will feel intimidated by this process, especially when a daunting goal is articulated. Those in small practices may feel that they have limited resources to devote to such efforts, while those in larger practices are more likely to face challenges to continuity and a lack of cohesion among many (often part-time) providers.
Regardless of practice setting, an iterative process of sequential small changes informed by plan-do-study-act cycles can produce substantial change over time. Simply asking the question “What can we do by next Tuesday?” will likely result in measurable improvement.
For example, regular measurement and documentation of peak flow could be instituted first as a trial for the patients of one physician on one day. A brief discussion at the end of the day among the physician and staff would likely reveal the extent to which this was helpful and any problems encountered. These results could be used to plan the next trial, as the process is improved and refined. Only after it is working well for one physician would the process be spread to others in the practice. This helps avoid the premature implementation of a flawed process and fosters staff buy-in and a strong sense of team.
Keys to success
We believe our asthma improvement program was successful for the following reasons:
The scope of the program was clearly defined: implementation of evidence-based guidelines for a common, chronic condition.
Physician and nurse leaders were committed to the program, and staff buy-in was achieved through peer education and commitment of a small resource (paying for nurses to attend educational workshops).
We redesigned our systems to make it easy to do the right thing; chart “flags” and “tools” helped drive the changes.
We used data to demonstrate the need for change. Evidence of our initial lack of compliance with guidelines was a potent motivator, and ongoing data reports were effective for enhancing compliance and performance.
We understood the importance of vision, planning and commitment.
Others seeking to replicate our program should consider the above factors. By adopting this approach, practices will also discover that they have adopted many of the features of the patient-centered medical home.