Improving the use of COPD action plans for patients with COPD

What is the aim of this QI activity?

• to support people with COPD to have and use a COPD Action Plan as part of their everyday care.

• identify and review 5 patients with COPD who currently do not have a COPD action plan.

What will I need to do?

• use Primary Sense reports to identify 5 patients with COPD

• review patient files.

• recall appropriate patients to complete an action plan.

• ensure patient is well informed and comfortable with the contents of the action plan.

How will I complete this activity?

• after consultation with the patients’ usual GP, recall identified patients to book in for an appointment with the Practice Nurse to prepare an Action Plan and an appointment with their GP to finalise the Plan

• if completed in paper form, upload a copy of the Action Plan and any relevant notes to the patient’s file.

• or complete the COPD action plan using the Lung Foundation software integrated RTF template (see the Resources section below for the COPD Action Plan template and instructions).

• ensure the patient has a copy of the Action Plan and understands its content.

Where do I document my results?

• QI summary register

• Model for improvement/PDSA template

Who can I contact for support?

For support with this activity please contact the General Practice Quality Improvement team on 38647540 or email [email protected].

1. Identify patients with COPD to create a COPD register and document if they have a current COPD Action Plan.

Using Primary Sense, run the Chronic Lung Disease and Asthma report.

Using the search function, search for COPD or Chronic Obstructive Pulmonary Disease (depending on how your practice codes the condition). This will filter the report to those patients with a coded COPD diagnosis in their patient record.

If you wish you can then export this list to Excel to create a COPD register.

---

2 - Review clinical records

Using the report above, begin reviewing patient files to determine whether a COPD Action Plan has been completed. You could prioritise more active patients, such as those with upcoming appointments or those who have attended the practice recently.

---

3. Set up recalls and/or prompts for patients

For patients with COPD who do not have a current COPD Action Plan, discuss the findings with their usual GP. Confirm with the GP prior to recalling the patient to arrange an appointment to complete the COPD Action Plan

4. Document and share your results

You can document your results in the QI summary register or MFI/PDSA templates and display them in the treatment room or lunchroom so that team members can see the impact of their changes.

Suggested measures and data sources

1. Manually record the number of COPD patients identified as missing a COPD Action Plan at the start of this activity, then record the number of patients that have since completed an Action Plan.

2. If using Best Practice, you can enter the ‘Reason for visit’ when completing an Action plan as ‘COPD ACTION PLAN’, then you will be able to pull a report using the search function on this.

As a team, reflect on how the activity went.

• what were the challenges/barriers?

• what worked well?

Are there any small changes that you could implement to continue improving the number of patients with a completed COPD Action Plan?

Example PDSA - Improving the use of COPD action plans for patients with COPD