This is a quality-improvement project designed to develop and implement evidence-based algorithms to improve and standardize care, and thus impact control and confidence measures. 

• Team clinicians identified areas of focus based on learning from a “not well-controlled” failure modes analysis: tobacco, triggers, comorbidities and pathophysiology. 
• The smoking cessation algorithm has been implemented.  In the coming year, we will continue testing the triggers algorithm and continue development of the comorbidities algorithm and the pathophysiology flow diagram.

In an effort to continue with an innovative and creative learning atmosphere, the team has and will continue to devote time to learning new creativity processes.

• The team learned the Six Hats (de Bono) method of discussion to focus our efforts and to communicate more effectively in goal setting.
• The team learned and utilized the Fresh Eyes creative thinking technique to understand and think creatively about how other industries would go about increasing the percentage of our population who receive a flu vaccine.

The team ran several PDSA cycles to assess the need for, acceptability and readability of various tools. 

• A “Prescription Refill Brochure” was created to help teens understand the steps necessary to obtain a prescription refill.  This has been implemented across the Teen Health Center.
• A “Bubble Diagram” was created to help teens who have a list of issues (or were unsure what to discuss in a visit) to focus on a particular topic.  The various “bubbles” represent issues related to asthma (triggers, obesity, smoking) and allowed the teen to pick from a menu of things to discuss with his or her provider.  This has been implemented in the Asthma Innovation Lab.
• “Stage-Based Smoking Brochures”were created based on the teen’s stage of readiness to quit smoking.  The brochures offer guidelines, tips and reasons for smoking cessation.  The brochures help the provider open up the dialogue with teens about smoking cessation based on their stage of readiness.  This has been implemented across the Teen Health Center.

The team continued to maintain its high level, evidence-based medical and behavioral care. It led to the development of the Teen Health Center’s Epic asthma work. By year end 54.2% of patients had achieved good asthma control.

The efforts around this initiative were intended to understand why patients’ asthma was not well controlled and develop interventions to help improve their control. 

• Over this year, control scores improved 60% for patients, compared to 25% the prior year. 
• Interventions included vigorous contact (phone, texting, schools), tracking and coordinated delivery of available evidence-based care (trigger avoidance, skill development, treatment of co-morbidities).
• Our upcoming focus will be on failure analysis for patients that did not improve and implementing processes outside of our cohort population.

Through clinical experience and more formal research methods (User Centered Design), the team recognized the impact hardships (i.e., financial, mental health) had on asthma management. We determined from our patients and by working with social services from across the hospital that inability to obtain needed medications, transportation problems, and mental health problems were the most prevalent and serious problems affecting families’ ability to meet medical needs. Therefore, we selected three major areas to address:

• In collaboration with community agencies we clarified processes and developed algorithms and tools to enhance the success of mental health referrals. By January 2011, the Lab was implementing these processes with >95% reliability. The tools and processes were spread to the entire Teen Health Center.
• The team investigated medical transportation options available through insurance and public sources. In collaboration with families, we developed a simple brochure that explains their benefits and delivered it with 95% reliability to all eligible patients. It was then made available throughout Cincinnati Children's.
• We worked with financial counseling and the pharmacy to clarify requirements and improve processes for obtaining medication when families lacked coverage. We systematically identified patients without medication coverage and successfully obtained medication for all patients in need. In addition, Financial Counseling extended its hours to ensure availability to the end of the Clinic day.

• In previous years, we immunized >98% of patients who made any visits to the Clinic during the fall immunization window. Nearly all patients who remained unimmunized could not be contacted despite multiple attempts, mostly due to lack of current address and phone number. 
• This year we developed processes to obtain and record in Epic extended contact information (multiple numbers, email addresses, etc.). This enabled us to reach more families, and the overall rate for our population increased to 86%
• This additional information also added our ability to contact families for other follow-up and care coordination needs.