The actual improvement process is composed of three steps that respond to the following questions:
It is important to understand that improvement requires change, but not all change results in improvement. Considering all of the possible changes that can be made to health care systems, considerable effort has been dedicated to creating various quality improvement strategies providing a framework that organizes possible changes into logical categories. Frameworks for change in health care quality improvement are known as quality models and have been tested to guide change. In fact, considering that there are limited resources to dedicate to improvement, most organizations adopt one or more quality models to guide their improvement efforts. There is not a right or wrong approach, and there are many areas of overlap in quality models. Experienced quality improvement teams often use multiple strategies to overcome challenges as they progress. Two approaches often used by teams that are working to improve Hypertension Control are the Care Model approach and the Critical Pathway approach.
Changes within these domains can effectively leverage transformation of a current reactive care system to one that better supports care for preventative health measures, such as, Hypertension Control and chronic disease conditions. If an organization does not have general experience with the Care Model, reading the Care Model section before proceeding is recommended. The Care Model recognizes that care for Hypertension Control is ongoing and requires more proactive care than the health care system often provides. The Care Model is implemented to improve care by working in six domains, defined below, that transform the way care is delivered:
Community-To improve the health of the population, a health care organization reaches out to form powerful alliances and partnerships with State programs, local agencies, schools, faith organizations, businesses, and clubs.
Organization of Health Care-A health care system can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.
Self Management-Effective self management is very different from telling patients what to do. Patients have a central role in determining their care and one that fosters a sense of responsibility for their own health.
Delivery System Design-Delivery of patient care requires not only to determine what care is needed, but to clarify roles and tasks to ensure the patient receives the care; that all of the clinicians who take care of a patient have centralized, up-to-date information about the patient's status, and make follow-up a part of their standard procedures.
Decision Support-Treatment decisions need to be based on explicit, proven guidelines that are supported by at least one defining study. A health care organization integrates explicit, proven guidelines into the day-to-day practice of primary care providers in an accessible and easy-to-use manner.
Clinical Information System-A registry, that is, an information system that can track individual patients and populations of patients, is a necessity when managing chronic illness or preventive care.
Definitions above adapted from the Institute for Healthcare Improvement Web site. (16)
|Community||Organization of Health Care||Self-Management Support||Delivery System Design||Decision Support||Clinical Information Systems|
|Obtain free or discounted resources from pharmaceutical firms, service groups, and health plans for: scales, meds, BP cuffs and education programs||Appoint senior leader to identify and allocate resources and remove barriers to implementation of Care Model components||Train patient care teams on importance of patient self-management support and value of each member which may lend to improving patient outcomes||Provide comprehensive and on-going training to providers and care teams on all aspects of BP measurement and management based on their skill levels and knowledge||Develop a manual or electronic registry of patients with HTN; list can initially be limited to patients with uncontrolled BP|
|Promote non-traditional partnerships for places to exercise, monitor BP, and healthy food,i.e., parks, transportation, health clubs, schools, YMCA, faith-based organizations, restaurants, barbers, and beauty shops [link to Appendix 2A]||Develop partnerships with other health care organizations interested in patient care and outcomes||Develop culturally- and linguistically- appropriate self- management support tools with demonstrated effectiveness||Develop innovative patient flow processes to ensure the implementation of appropriate interventions to improve BP control, such as support staff to: ||Use queries and reports proactively to plan patient's care; queries can include a list of HTN patients per PCP with the last visit and BP reading|
|Use of promotoras, community health workers, and faith-based community to reach out to the community for education and screening||Board and senior leaders receive regular reports on hypertension control indicators and barriers to achieving goals||Embed sustainable self-management support process in a redesigned delivery system||Adopt and use clinical guidelines in the organization||Provide information on BP trend (and indicating target BP) from registry/EMR to patient at time of visit|
|Develop relationships with universities and their providers to place students and interns in community projects||Ensure that the Care Model is integrated into the organization's strategic plans||Provide tools for self-management support (weighing scale, BP machines, pedometer, etc.)||Provide innovative patient flow and visit types (planned and group visits, drop in visits for BP checks, etc.)||Integrate guidelines into daily clinical practice (use of flow sheets, etc.)||Use an EMR or manual registry to ensure that providers have immediate individual patient's BP trends|
|Hospital and university linkages for specialty care||Senior leader is engaged; endorses and communicates content and progress to BOD and staff||Develop culturally-appropriate self-management approaches: promotoras/community health worker; group visits/support groups; stages of change model||Consistent and appropriate follow-up, especially high-risk patients using telephone, promotoras||Develop systems and mechanisms to facilitate communication between PCP, specialist, and hospital||Obtain and share BP control compliance data from the registry with patient care teams at defined intervals and in innovative user- friendly formats|
|Reach out to the community with health fairs and community education||QI team is empowered to make changes||Patient-tailored collaborative goal setting with form and follow up; copy of goals given to patient and noted in designated area in medical record||Anticipate and plan the hypertensive intake visit to ensure timely registration and follow up with clinician||Provide feedback to providers from population data (results and compliance with guidelines and measures)||Ensure integrity of registry data by defining accountability for oversight and maintenance, e.g., cross train support staff for data entry, data validity via sampling or for data downloads for patient care teams|
|Partner with State, local and community public health programs||Incorporate training in the models into the orientation of new employees and staff||Protocols and training for staff relating to self-management support||Ensure clinical case management services for complex patients||Use standing orders and protocols when appropriate||Establish a process for obtaining records from other providers|
|Provide resources to assist an organization in continued education on cultural competency||Allocate resources and remove barriers for improving hypertensive care and access||Organize and/or provide patient support groups||Inform patients about guidelines pertinent to their care|
|Integrate attainment of hypertensive care goals into business, strategic and performance improvement plans||Create expectation that patient takes responsibility for scheduling and attending hypertensive visits|
|Use all staff interactions with patients as opportunities to assist in self-management goal setting and practices|
|Create mechanisms for patient peer support and behavior change programs, such as, group hypertensive visits|
Critical Pathway Approach: As with all critical pathways, good performance relies on many different systems and processes working together efficiently. An organization is encouraged to map its own critical pathway for Hypertension Control or refer to the schematic in Figure 4.2. Often when a QI team maps its pathways, it readily can see how complex each step is. It is common for different team members to do the same step differently. Workflow inefficiencies become clear when an organization visualizes how each step is completed and the interdependencies among the steps. Some teams are overwhelmed by the possibilities of changes that can be made in their systems; others focus only on a specific group of factors.
One way to organize the factors that have an impact on the systems is to consider that some are controlled by the patient, others are primarily controlled by the care team, and still others are inherent in the system of care delivery. All three sets of changes must be considered to improve systems of care. In general, these categories can be defined as follows:
A team should use the steps along the critical pathway to target improvements. For this measure, Hypertension Control, an organization can think through each part of the critical pathway in turn, teasing out what happens, and what could be improved. In Table 4.2, changes that have worked for other QI teams are matched with the part of the system on which they have the most impact. These ideas are not meant to be inclusive, but to start a dialogue of what may improve each part of the critical pathway in an organization, and thus improve it overall.
|Area of Critical Pathway||Patient Changes||Care Team Changes||Health System Changes|
|HTN patient presents for care|
|Patient completes intake process|
|Patient assessment and vital signs completed||Education for patients on importance of hypertension screening and treatment, including guidelines in a cultural-competent manner|
|Provider assesses hypertension and co-morbidities|
|A key decision point is provider's determination if: |
|Is there evidence of end-organ damage?||Education and self-management support for patients experiencing organ damage for setting appropriate BP guidelines|
|Further management, including lifestyle and medications addressed|
|Develop and reinforce care plan based on assessment|
|Patient is scheduled for follow up|
|Care Team member contacts patient as medically indicated||Ensure patient receives guidance about access to the practice with interim concerns|
Earlier in this module, examples are provided of changes (Critical Pathway and Care Model) that have led to improved organizational systems of care and better patient health outcomes. Because every change is not necessarily an improvement, changes must be tested and studied to determine whether the change improves the quality of care. This concept is addressed in detail in the Testing for Improvement module.
It is important that these changes be tested in the context of an organization's staff, current processes, and patients. The goal is that the change results in lasting improvements within an organization.
Organizations commonly use tools to manage change as they work to improve their systems. For a comprehensive discussion of change management, refer to the Testing for Improvement and Redesigning a System of Care to Promote QI modules. Here are a couple of tools that are worth mentioning in the context of this measure:
The Model for Improvement (17) identifies aim, measure, and change strategies by asking three questions:
These questions are followed by the use of learning cycles to plan and test changes in systems and processes. These are referred to as PDSA (Plan-Do-Study-Act) cycles. The PDSA Cycle is a test-and-learning method for discovering effective and efficient ways to change a current process. In Figure 4.3: The PDSA Cycle, the graphic provides a visual of the PDSA process:
An organization focusing its improvement efforts on Hypertension Control for its patients benefits from implementing PDSAs to test change processes that have an impact on hypertension management. Those organizational processes tested may focus on outreach, operational procedures, or patient education interventions ensuring that patients have timely care. A few examples of such processes relating to Hypertension Control are listed below:
As an organization plans to test a change, it should specify who, what, where, and when so that all staff know their roles clearly. Careful planning results in successful tests of change. Documentation of what happened – the S or study part of the PDSA – is also important. This can help a team to understand the impact of changes to a process as unanticipated consequences may occur.
Tips for Testing Changes
Process mapping is another valuable tool that an organization focused on improvement often uses. A process map provides a visual diagram of a sequence of events that result in a particular outcome. Many organizations use this tool to evaluate a current process and again when restructuring a process.
The purpose of process mapping is to use diagramming to understand the current process; i.e., how a process currently works within the organization. By looking at the steps, their sequence, who performs each step, and how efficiently the process works, a team can often visualize opportunities for improvement.
Process mapping can be used before or in conjunction with a PDSA cycle. Often, mapping out the current process uncovers unwanted variation. In other words, different staff may perform the process differently, or the process is changed on certain days or by specific providers. By looking at the process map, a team may be able to identify gaps and variation in the process that have an impact on Hypertension Control.
Process mapping, when used effectively, can identify opportunities for improvement, supporting the testing of changes in the current system of care. Additional information, including tools and resources to assist an organization in adapting process mapping as an improvement strategy within its organization, can be found in the Redesigning a System of Care to Promote QI module.
Measures and data are necessary to answer this question. Data is needed to assess and understand the impact of changes designed to meet an organization's specified aim. Measurement is essential in order to be convinced that changes are leading to improvement. Organizations that have experienced successful improvement efforts found that data, when shared with staff and patients outside the core improvement team, led to the spread of improvement strategies, in turn generating interest and excitement in the overall quality improvement process.
Measures are collected prior to beginning the improvement process and continue on a regularly scheduled basis throughout the improvement program. Once an organization reaches its specified goal, frequency of data collection may be reduced. Additional information regarding frequency of data collection, tracking, and analyzing data can be found in the Managing Data for Performance Improvement module.
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