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A Quality Collaborative for Improving Hospitalist Compliance with the AAP Bronchiolitis Guideline (B-QIP)

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A Quality Collaborative for Improving Hospitalist Compliance with the AAP Bronchiolitis Guideline (B-QIP)

The Quality Collaborative for Improving Hospitalist Compliance with the AAP Bronchiolitis Guideline (B-QIP) provided hospitalist-led teams with strategies, tools, and resources necessary to assess and improve the quality of care delivered to pediatric patients admitted with bronchiolitis. The project focused on the improvement of hospital team compliance with the 2006 AAP clinical practice guideline, "Diagnosis and Treatment of Bronchiolitis."

Pilot QI Collaborative Project for VIP Network via the AAP QuIIN Networks
The VIP Network led a Bronchiolitis Benchmarking in Hospitals project 2007-2010 which resulted in an article, Decreasing unnecessary utilization in acute bronchiolitis care: Results from the value in inpatient pediatrics network. When the VIP Network joined the AAP QuIIN in 2011, the Steering Committee decided that the first full quality improvement collaborative would build on the prior work of the Bronchiolitis Benchmarking project.

B-QIP Change Package: Strategies and Tools for Change

 

Take a look at the B-QIP Change Package that is organized by the project measures and includes helpful resources and tools for each area; 1. Clinical Pathway, 2. Respiratory Distress Score, 3. Oxygen Weaning protocol, 4. Addressing Tobacco Exposure, and other tools and resources. Participating hospital teams shared resources, tools and templates that they use or had developed via the project listserv.


Project Goals

This quality improvement project had the broad goal of exploring which tools and resources best improve the quality of care for children admitted to the hospital with bronchiolitis. Our proxy for quality of care was compliance with the AAP bronchiolitis clinical practice guideline and specific targets were overuse of bronchodilators, corticosteroids, chest physiotherapy, chest radiography and continuous pulse oximetry, as well as underuse of secondhand smoke exposure screening and intervention. 

Project Aims

The specific aims of the project included:

  1. Improve the care of children with bronchiolitis by increasing compliance with the AAP clinical practice guideline on bronchiolitis, specifically including the following goals:
    • Decrease the overall usage of bronchodilators for patients admitted with bronchiolitis by 50%
    • Decrease the overall usage of systemic corticosteroids for patients admitted with bronchiolitis by 50%
    • Decrease the overall usage of chest physiotherapy for patients admitted with bronchiolitis by 50%
    • Decrease overall usage of chest radiography for inpatients with bronchiolitis by 50%
    • Achieve 90% compliance with the usage of an "objective method of assessment" of response to bronchodilators in patients admitted with bronchiolitis. For this project, an objective method of assessment is interpreted to mean a respiratory score.
    • Achieve 90% compliance with the implementation of an institutional policy on conversion from continuous pulse oximetry to intermittent pulse oximetry when children admitted for bronchiolitis no longer require supplemental oxygen.
    • Achieve 90% compliance with screening and intervention for secondhand smoke exposure in children admitted with bronchiolitis.


Teams also worked to improve systems, workflow and team communication as it relates to bronchiolitis care in the in-patient setting.

Project Measures

Chart Review and Balancing Measures 
The data for these measures were captured through the online Quality Improvement Data Aggregator (QIDA) system.

Monthly Progress Report
Several questions on the various dynamics of the project were assessed with the monthly progress report survey.

Teams
Twenty two hospital site teams were selected to participate in this quality improvement project. The selected hospitals represented 12 states.  For selection, an emphasis was placed on including community hospitals.

We suggested that the local improvement team consist of 3 members, to be led by a physician and to include a respiratory therapist and a nurse. Click here to see a list of all of the hospital site teams

Pediatric hospital teams were responsible for:

  • Physician leader only: serve as Local Leader in the attestation process required by the American Board of Pediatrics (ABP) for Part 4 Maintenance of Certification (if approved). Includes providing each hospitalist interested in participating for MOC credit a document describing the requirements of their participation, monitoring physician participation, and attesting that they met the project's completion criteria.
  • Devote necessary resources and time to testing and implementing changes over the specified intervention period, while collecting data from 20 patient charts per month for 6 months, and working to obtain buy-in from all members in their hospital.
  • Seek necessary institutional approval for participation in the project prior to any data collection.
  • Complete pre-work activities (over one month's time) including:
    • Complete pre-survey (via SurveyMonkey)
    • Participate in an orientation conference call, as well as a call regarding chart data entry into the online Quality Improvement Data Aggregator (QIDA) for "Group Administrators."
    • Participating in at least one learning session/webinar on QI methods or on bronchiolitis background and evidence-based management depending on gaps in personal knowledge base.
  • Learn the Model for Improvement and implement Plan, Do, Study, Act (PDSA) cycles.
  • Make appropriate changes in the structure of how inpatient bronchiolitis care is delivered to patients.
  • Regularly collect and submit clinical measurements pertinent to the aims of the project.
    • One core team member (identified as the Group Administrator) will enter chart review data into QIDA retrospectively for the months January, February and March 2013 and January, February and March 2014.
  • Each month for 6 months (3 months baseline and 3 months post intervention), review charts of 20 patients (or 100% of eligible patients that month if fewer than 20 eligible patients) under 2 years of age hospitalized for bronchiolitis and collect data on project measures. Chart review will be completed using the AAP Quality Improvement Data Aggregator (QIDA).
  • Complete a narrative progress report each month via SurveyMonkey.
  • Test innovations in care delivery to improve care of children with bronchiolitis.
  • Share lessons learned and problem-solve with other participating hospitals through monthly conference calls and an e-mail listserv.
  • Use e-mail and the Internet on a regular basis for ongoing support, information, and communication among hospital site teams.
  • Participate in 2 learning session/webinar learning sessions during the action period to: 1. Introduce the change package tools and 2. To discuss the next steps in sustaining change and keeping the quality improvement gains. 
  • Complete a post-survey at the end of the project and a debriefing project summary call.

Project Design:

  • Baseline assessments: Hospital teams assessed their current level of performance with respect to the project measure (utilization and process measures) via a Pre-Project Survey and in the chart review of the January, February and March 2013 bronchiolitis season (accounted as the baseline data).
  • B-QIP Coaches: One of seven B-QIP Coaches were assigned to each hospital team based on the area of expertise and experience of the coach in hospital-based improvement projects. Coaches were matched with hospital sites that had an interest in improving their baseline data in areas that coaches have expertise and a knowledge base. The Coaches were flexible in the number of times and the method of interaction with their assigned hospital teams but were encourages to communicate on a monthly basis.
  • Webinar-based Learning Sessions: Hospital teams were oriented to the project as well at quality improvement basis and bronchiolitis evidence via webinars. The method of data collection (AAP Quality Improvement Data Aggregator) and change package tools were also outlined in webinars at the outset of the project (during the pre-work phase).  
  • 9-month testing phase: Hospital teams developed a plan to improve overutilization in some areas and increase the use of tobacco smoke exposure assessment and referrals; utilized PDSA cycles to test tools, process, measures, and introduce protocols and pathways; and reviewed run charts.
  • Monthly webinars: Hospital teams shared results of their tests with project leaders, coaches and other teams, questions were answered, and specific topics were discussed (including smoking exposure assessment and how to collaborate with ED/ER departments).
  • Sustainability and Report Out Webinar-based Learning Session: Project leaders shared the data trends from the chart review data entered for the 2013 bronchiolitis season (baseline) to the 2014 season and summarized the improvement in behaviors that were made in aggregate.  The webinar also included a presentation on how to sustain and hold the gains made during the project on certain measures. 
  • One year post-Action Period Data Entry – for Sustainability: In order to assess how the improvements were sustained, hospital teams will have the opportunity to submit chart review data for a third bronchiolitis season reflecting 2015.  This will be optional data entry for the hospital sites.
  • Qualitative Interviews: A qualitative interview consultant will perform 20-30 minute phone qualitative interviews with the hospital teams. The qualitative interviews will be optional. The data retained from the interviews will be coded; data from the interviews will inform the direction and next models for the VIP Network projects.

Project Data Collection included:

  • Chart Review | Instructions for Chart Review
    • Pre-work: Three months baseline chart review data (20 charts/month, January, February and March 2013 entered into QIDA)
    • Action Period (3 months): 20 charts entered using QIDA for each month, January, February and March 2014
  • Pre- and Post-Project Survey: At pre- and post-, teams were asked to assess existing practices, beliefs and systems in place for providing inpatient bronchiolitis care and team collaboration.
  • Monthly Progress Reports: Monthly progress reports allowed clinical teams to describe specific changes and tools they have tested. They helped faculty to monitor progress and needs of practice teams.

Resources for Hospital Site Teams

Webinar-based Learning Sessions: Power Point Presentations

Select Monthly Webinars Power Point Presentations

Results

 VIP Network Bronchiolitis QI Project Key Learnings Webinar

Special thanks to the Expert Group:

  • Shawn L. Ralston, MD, MS, FAAP (co-Chairperson)
  • Matthew D. Garber, MD, FHM, FAAP (co-Chairperson)
  • Charles G. Macias, MD, MPH, FAAP
  • Grant Mussman, MD, FAAP (Project Coach)
  • Jeanann Pardue, MD, FAAP (Project Coach)
  • Alan Schroeder, MD, FAAP
  • Susan Chu Walley, MD, FAAP (Project Coach)
  • Michael C. Weisgerber, MD, FAAP

Thank you to Project Coaches:

  • Jeffrey S. Bennett, MD, FHM, FAAP
  • Michele Lossius, MD, FAAP
  • Michele Marks, DO, FAAP
  • John A. Pope, MD, FHM, FAAP

 

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