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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!
The Clinical Champion: Dr. Hanlin
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Lean Six Sigma Certifications:
The Clinical Champion: Dr. Hanlin
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Lean Six Sigma Certifications:
• None!
The Clinical Champion: Dr. Hanlin
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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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Quality Improvement in the Real World
Real World Challenges
• As time permits
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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?
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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”).
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Quality Improvement in the Real World
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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.
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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.
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Quality Improvement in the Real World
Week 1
• Nurses like the new automated BP machines, and have
already incorporated them into their workflow.
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Quality Improvement in the Real World
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Quality Improvement in the Real World
Week 2 (Monday, of course)
• Nurses state that three automated BP machines are “broken.”
• Only one is “working.”
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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.
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Quality Improvement in the Real World
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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.”
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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.
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Quality Improvement in the Real World
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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.
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Quality Improvement in the Real World
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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.
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Quality Improvement in the Real World
Week 3
• Everything is working smoothly.
• No more error codes from the automated BP devices.
• No malfunctions logged.
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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.
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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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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.
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Quality Improvement in the Real World
Ideal View in the EMR
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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!
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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"
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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.
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Quality Improvement in the Real World
Ideal View in the EMR
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Quality Improvement in the Real World
Ideal View in the EMR
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Quality Improvement in the Real World
Actual View in the EMR
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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.
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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 Survey 2 Survey 3
Percent Who "Agree" or "Strongly Agree"
Percent Who "Agree"
or "Strongly Agree"
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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.
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