Upload
hoangdan
View
217
Download
2
Embed Size (px)
Citation preview
targetbp.org
Target BP: First Year in Review
Teaching Clinic Point of ViewR. Bruce Hanlin, M.D.
targetbp.org
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
targetbp.org
• 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)
targetbp.org
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
targetbp.org
Special Hypertension Training and Certifications:
The Clinical Champion: Dr. Hanlin
targetbp.org
Special Hypertension Training and Certifications:
• None!
The Clinical Champion: Dr. Hanlin
targetbp.org
Lean Six Sigma Certifications:
The Clinical Champion: Dr. Hanlin
targetbp.org
Lean Six Sigma Certifications:
• None!
The Clinical Champion: Dr. Hanlin
targetbp.org
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
targetbp.org
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
targetbp.org
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)
targetbp.org
CCI Hypertension Guideline Booklet and M.A.P. Checklists
targetbp.org
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
targetbp.org
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
targetbp.org
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).
targetbp.org
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.
targetbp.org
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
targetbp.org
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
targetbp.org
Effective Quality Improvement
Requires a TEAM
A clinical champion is important,
but the whole clinical team must be involved
targetbp.org
A Tale of Two Clinics
targetbp.org
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
targetbp.org
Quality Improvement in the Real World
Real World Challenges
• As time permits
targetbp.org
Quality Improvement in the Real World
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?
targetbp.org
Quality Improvement in the Real World
Week 1
• We have a pharmacy in the lobby of our office.
• The pharmacy has a discounted medication program
(“340b pricing”).
targetbp.org
Quality Improvement in the Real World
targetbp.org
Quality Improvement in the Real World
Week 1
• We have a pharmacy in the lobby of our office.
• The pharmacy has a discounted medication program
(“340b pricing”).
• Some of the medications on the beautiful treatment
algorithm are not carried in our pharmacy.
targetbp.org
Quality Improvement in the Real World
Week 1
• We have a pharmacy in the lobby of our office.
• The pharmacy has a discounted medication program
(“340b pricing”).
• 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.
targetbp.org
Quality Improvement in the Real World
Week 1
• Nurses like the new automated BP machines, and have
already incorporated them into their workflow.
targetbp.org
Quality Improvement in the Real World
targetbp.org
Quality Improvement in the Real World
Week 2 (Monday, of course)
• Nurses state that three automated BP machines are “broken.”
• Only one is “working.”
targetbp.org
Quality Improvement in the Real World
Week 2 (Monday, of course)
• 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.
targetbp.org
Quality Improvement in the Real World
targetbp.org
Quality Improvement in the Real World
Week 2 (Monday, of course)
• We decide that the engagement of the nurses is at risk.
• We need to “Act Rapidly.”
targetbp.org
Quality Improvement in the Real World
Week 2 (Monday, of course)
• Trouble-shooting:
One machine is no longer on the automatic pressure setting.
It is set to stop pumping at 50 mm Hg.
targetbp.org
Quality Improvement in the Real World
targetbp.org
Quality Improvement in the Real World
Week 2 (Monday, of course)
• Trouble-shooting:
One machine is no longer on the automatic pressure setting.
It is set to stop pumping at 50 mm Hg.
Error codes on the other machines indicate patient motion
during the readings.
targetbp.org
Quality Improvement in the Real World
targetbp.org
Quality Improvement in the Real World
Week 2 (Monday, of course)
• Trouble-shooting:
One machine is no longer on the automatic pressure setting.
It is set to stop pumping at 50 mm Hg.
− 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.
targetbp.org
Quality Improvement in the Real World
Week 3
• Everything is working smoothly.
• No more error codes from the automated BP devices.
• No malfunctions logged.
targetbp.org
Quality Improvement in the Real World
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.
targetbp.org
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"
targetbp.org
Quality Improvement in the Real World
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.
targetbp.org
Quality Improvement in the Real World
Ideal View in the EMR
targetbp.org
Quality Improvement in the Real World
Plan-Do-Study-Act Cycles (PDSA):
• 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!
targetbp.org
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 Survey 2
Percent Who "Agree" or "Strongly Agree"
Percent Who "Agree"
or "Strongly Agree"
targetbp.org
Quality Improvement in the Real World
Plan-Do-Study-Act Cycles (PDSA):
• 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.
targetbp.org
Quality Improvement in the Real World
Ideal View in the EMR
targetbp.org
Quality Improvement in the Real World
Ideal View in the EMR
targetbp.org
Quality Improvement in the Real World
Actual View in the EMR
targetbp.org
Quality Improvement in the Real World
Plan-Do-Study-Act Cycles (PDSA):
• 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.
targetbp.org
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 Survey 2 Survey 3
Percent Who "Agree" or "Strongly Agree"
Percent Who "Agree"
or "Strongly Agree"
targetbp.org
Quality Improvement in the Real World
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.
targetbp.org