Target BP: First Year in Review · PDF fileTarget BP: First Year in Review ... and American...

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Target BP: First Year in Review

Teaching Clinic Point of ViewR. Bruce Hanlin, M.D.

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Care Coordination Institute and American Medical Association

The MAP Hypertension Control QI Project

R. Bruce Hanlin, MD, FAAFPVice Chair, Medical Staff Affairs and Quality

Department of Family MedicineGreenville Health System

Greenville, SC

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• Start with the End in Mind: The Results

• The Clinical Champion

• The Practice

• The Program

• Key Points for Success

• Quality Improvement in the Real World

Outline (7 minutes)

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50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

0 1 2 3 4 5 6

Hypertension

control rate

Months after Implementation

Hypertension Control Rate Improved 22%

after Implementing MAP

22% improvement in 6

months

The Results

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Special Hypertension Training and Certifications:

The Clinical Champion: Dr. Hanlin

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Special Hypertension Training and Certifications:

• None!


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Lean Six Sigma Certifications:


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Lean Six Sigma Certifications:

• None!


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The Practice

Family Medicine Residency Clinical Staff

• 21 Residents

• 10 Faculty

• Support Staff are LPNs and MAs

Family Medicine Residency Population

• 50% Medicaid

• 45% Medicare

• 3% Self Pay

• 2% Commercial Insurance

• Approx. 4,000 Adult Patients

• Approx. 2,000 Adult Hypertensive Patients

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The Program

American Medical Association “M.A.P.” framework:

• Measure Accurately

• Act Rapidly

• Partner with Patients, Families, and Communities

Adapted to local resources by the Care Coordination Institute

(CCI)

• Gathers and reports quality data

• Initiates quality improvement projects

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AMA-CCI Model for Improving Blood Pressure Control

PRACTICE

6-month QI initiative

• Practice facilitation

• Dashboards

• Peer-to-peer exchange

MEASURE ACCURATELYObtain accurate, representative BP

ACT RAPIDLYImplement evidence-based protocol to Dx and Rx HTN and reduce clinical inertia

PARTNER WITH PATIENTS, FAMILIES & COMMUNITIES

Engage patients in healthy lifestyles and

self-management

Blood Pressure

Control:

∆ % Patients

with BP

<140/<90

Δ in SBP

Δ in DBP

OUTCOMES

Facilitating FactorsEngaged

LeadershipEffective

TeamworkConfident

ExpectationsActionable Data

Sustained ∆Committed

StaffEvidence-Based

Protocol, QI Tools

EVIDENCE-BASED STRATEGIES

CONFIRMATORY

AOBP

THERAPEUTIC

INERTIA

∆ BP after THERAPEUTIC

INTENSIFICATION

METRICSACTION STEPS

Proper Patient Prep & Position, etc.

Confirmatory AOBP Measurements

Treatment Protocol

Single-pill combinations

Visit Frequency

Evidence-Based Communication Strategy

BP Self-Monitoring

Lifestyle Change(s)

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CCI Hypertension Guideline Booklet and M.A.P. Checklists

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Measure Accurately Checklist

� Ensure patient is positioned correctly for an accurate BP reading

� Use the correct cuff size on bare arm

� Use a validated, automated device to measure when BP is elevated

and take the average of three readings

� When appropriate follow the steps to diagnosing and improve

treatment resistant hypertension

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Act Rapidly Checklist

� Use the evidence-based protocol to guide hypertension treatment

� Re-assess patient every 2-4 weeks until BP is controlled

� Whenever possible, prescribe single-pill combination therapy

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NICE Adapted Hypertension Rx

Initial Monotherapy and Add-On Therapies

Step 1

Step 2

Step 3

Non-African OriginAge <55 yrs

African Origin or Age =55 yrs

RAS Blocker

Add CCB

Add Diuretic

Add RASB

CCB1,†

See TRH GuidelinesStep 4

Among TRH patients in a community-based network, BP control is higher when ACEI-CCB-diuretic are included in regimens of ≥3 meds (Hypertension. 2013;62:691–697).

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CCI Pharmacological Treatment Algorithm

Regimen-1

(3 pills; 3 meds)

Regimen- 2

(2 pills; 3 meds)

Lisinopril 40 (Free)Benazepril / Amlodipine 40/10

($4/Mo)

Amlodipine 10 ($4/mo) Indapamide ($4/mo)

HCTZ 25 ($4/mo)

Total Cost:$8/month

Total Cost:$8/month

Regimen- 3

(3 pills; 3 meds)

Regimen- 4

(2 pills; 3 meds)

Losartan 100 ($4/mo)Valsartan / HCT 320/25

($10/mo)

Amlodipine 10 ($4/mo) Amlodipine 10 ($4/mo)

HCTZ 25 ($4/mo)

Total Cost: $12/month Total Cost: $14/month

Pharmacological Treatment algorithm (should control 80%–90% of hypertensives to <140/<90).

Note: If patients have compelling indications for specific medication classes, then begin with those. For information on inexpensive medications for use in delivery of the CCI Treatment Algorithms, visit CCIHealth.org.

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Partner with Patients, Families and

Communities Checklist

To empower patients to control their blood pressure:� Engage patients using evidence-based communication strategies

� Help patients accurately self-measure BP

� Direct patients and families to resources that support medication adherence and healthy lifestyles

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Evidence-based communication strategies

• When clinicians use evidence-based skills to communicate,

talking less and listening more, we can learn more about

patient preferred treatment approaches

• A mutually agreeable (and understood) treatment approach is

more likely to be followed

• Goals for evidence-based communication strategies:

− To understand patients, not interrogate them

− To encourage patients, not persuade them

− To support patients, not try to fix them

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Effective Quality Improvement

Requires a TEAM

A clinical champion is important,

but the whole clinical team must be involved

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A Tale of Two Clinics

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Quality Improvement in the Real World

Key Points for Success

• A Clinical Champion

• A Simple Approach

• Observation of Operational Workflows

• A Team Approach

− Cannot Succeed with a Clinical Champion Alone

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Real World Challenges

• As time permits

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What a great Quality Improvement Project!

• National Partner (American Medical Association)

• Local Partner collects data and provides beautiful

reports (CCI)

• Catchy Acronym (MAP)

What could go wrong?

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Week 1

• We have a pharmacy in the lobby of our office.

• The pharmacy has a discounted medication program

(“340b pricing”).

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Week 1




• Some of the medications on the beautiful treatment

algorithm are not carried in our pharmacy.

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Week 1




• Some of the medications on the beautiful treatment

algorithm are not carried in our pharmacy.

• Dr. Egan from CCI edited the treatment algorithm to

match our available medications.

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Week 1

• Nurses like the new automated BP machines, and have

already incorporated them into their workflow.

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Week 2 (Monday, of course)

• Nurses state that three automated BP machines are “broken.”

• Only one is “working.”

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• Nurses state that three automated BP machines are “broken.”

• Only one is “working.”

But ,some good news:

• The working device is now a pet.

• They named him “Bob.”

• They make sure he gets fed electrons every night.

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• We decide that the engagement of the nurses is at risk.

• We need to “Act Rapidly.”

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• Trouble-shooting:

One machine is no longer on the automatic pressure setting.

It is set to stop pumping at 50 mm Hg.

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Error codes on the other machines indicate patient motion

during the readings.

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− Nurses are retrained on the “Automatic” pressure setting.

Error codes on the other machines indicate patient motion

during the readings.

− Patients are given more instruction to sit still, not talk on

a cell phone, etc.

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Week 3

• Everything is working smoothly.

• No more error codes from the automated BP devices.

• No malfunctions logged.

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Week 6

• Can the providers tell the difference between a standard

blood pressure and an Automated Office Blood Pressure

(AOBP) averaged reading in the EMR?

• Quick survey of the providers.

− The entire survey is 4 questions.

− Survey return rate was 68% in 2 days.

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In the EMR, I can easily tell if the nurse has obtained the average of 3 blood pressure readings in the room or not?

0%

20%

40%

60%

80%

100%

Survey 1

Percent Who "Agree" or "Strongly Agree"

Percent Who "Agree"

or "Strongly Agree"

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Plan-Do-Study-Act Cycles (PDSA):

• After Survey 1 (3/10/2016), we:

− Discussed where to put the “Average” notation in our EMR.• Nurses

• Providers

• Data Miners

− Found a way to enter the notation outside of the BP Data Field.

− Formalized (wrote down) the process.

− Sent the process to nurses and providers.

− Did screen shots showing how the “Average” notation appears

in the EMR.

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Ideal View in the EMR

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• After Survey 1 (3/10/2016), we:

− Discussed where to put the “Average” notation in our EMR.

− Found a way to enter the notation outside of the BP Data Field.

− Formalized (wrote down) the process.

− Sent the process to nurses and providers.

− Did screen shots showing how the “Average” notation appears in the EMR.

• “Study” phase of PDSA cycle:

− Repeated the survey: Survey 2 (2 weeks after the first survey).

− Survey showed improvement!

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0%

20%

40%

60%

80%

100%

Survey 1 Survey 2


Percent Who "Agree"

or "Strongly Agree"

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• PDSA Cycle # 2:

− Interacted with a live demo of the BP field and pointed out the “Average”

notation in our EMR during an office conference.

− Discovered that providers were using several different views of the BP data.

− Some providers were not seeing the “Average” notation.

− Spent some time watching individual providers interact with the EMR during

patient care, and tried to standardize the views used by providers.

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Ideal View in the EMR

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Actual View in the EMR

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• PDSA Cycle # 2:

− Interacted with a live demo of the BP field and pointed out the “Average”

notation in our EMR during an office conference.

− Discovered that providers were using several different views of the BP data.

− Some providers were not seeing the “Average” notation.

− Spent some time watching individual providers interact with the EMR during

patient care, and tried to standardize the views used by providers.

− Repeated the survey after 2 more weeks.

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0%

20%

40%

60%

80%

100%

Survey 1 Survey 2 Survey 3


Percent Who "Agree"

or "Strongly Agree"

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Summary:• Leaders should not assume that front line staff “get it.”

− Leaders, Early Adopters, Project Champions, or whatever else you want to call them, are, by definition, more engaged than front line staff.

− The engagement of front line staff make or break the improvement process.

• Direct observation of workflows of nurses and providers is essential, especially when things are “broken.”

• Quick surveys help to guide the improvement process.

− NOT research quality.

− Just enough information to take action.

− “Perfection is the enemy of improvement.”

• Quality Improvement in the Real World is challenging but very rewarding.

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