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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Resources and Services Administration

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Hypertension Control

Part 1: Introduction

Part 2: Characteristics for Success: Hypertension Control

Part 3: Implementation of Quality Measure: Hypertension Control

Part 4: Improvement Strategies: Hypertension Control

Part 5: Holding the Gains and Spreading Improvement

Part 6: Supporting Information


Part 4: Improvement Strategies: Hypertension Control 

The actual improvement process is composed of three steps that respond to the following questions:

  1. What changes can an organization make?
  2. How can an organization make those changes?
  3. How can an organization know the changes caused an improvement?
What Changes Can an Organization Make?

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.

The case study may be read in its entirety by clicking here.

The Case Study: The Improvement Journey

  1. Care Model Approach: Implementing the changes described in the Care Model is a proven method to improve care delivery. The Care Model, as shown in Figure 4.1, is an organizational framework for change and is organized into six domains:
    1. Organization of Health Care
    2. Clinical Information Systems
    3. Delivery System Design
    4. Decision Support
    5. Community
    6. Self-Management Support
    Figure 4.1: The Care Model.
    Figure 4.1: The Care Model

    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 Exit Disclaimer. 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)

    In Table 4.1: Care Model Key Changes, key changes are presented that have been used successfully to improve Hypertension Control care within the Care Model framework.   

      
    Table 4.1: Care Model Key Changes
    CommunityOrganization of Health CareSelf-Management SupportDelivery System DesignDecision SupportClinical Information Systems
    Obtain free or discounted resources from pharmaceutical firms, service groups, and health plans for: scales, meds, BP cuffs and education programsAppoint senior leader to identify and allocate resources and remove barriers to implementation of Care Model componentsTrain patient care teams on importance of patient self-management support and value of each member which may lend to improving patient outcomesProvide comprehensive and on-going training to providers and care teams on all aspects of BP measurement and management based on their skill levels and knowledgeDevelop 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 outcomesDevelop culturally- and linguistically- appropriate self- management support tools with demonstrated effectivenessDevelop innovative patient flow processes to ensure the implementation of appropriate interventions to improve BP control, such as support staff to:
    • Flag charts of patients with uncontrolled BP on arrival
    • Review patient's medication list and compliance prior to provider's encounter
    • Assess patient's compliance with self- management activities prior to provider's encounter
    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 screeningBoard and senior leaders receive regular reports on hypertension control indicators and barriers to achieving goalsEmbed sustainable self-management support process in a redesigned delivery systemAdopt and use clinical guidelines in the organizationProvide 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 projectsEnsure that the Care Model is integrated into the organization's strategic plansProvide 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 careSenior leader is engaged; endorses and communicates content and progress to BOD and staffDevelop culturally-appropriate self-management approaches: promotoras/community health worker; group visits/support groups; stages of change modelConsistent and appropriate follow-up, especially high-risk patients using telephone, promotorasDevelop systems and mechanisms to facilitate communication between PCP, specialist, and hospitalObtain 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 educationQI team is empowered to make changesPatient-tailored collaborative goal setting with form and follow up; copy of goals given to patient and noted in designated area in medical recordAnticipate and plan the hypertensive intake visit to ensure timely registration and follow up with clinicianProvide 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 programsIncorporate training in the models into the orientation of new employees and staffProtocols and training for staff relating to self-management supportEnsure clinical case management services for complex patientsUse standing orders and protocols when appropriateEstablish a process for obtaining records from other providers
    Provide resources to assist an organization in continued education on cultural competencyAllocate resources and remove barriers for improving hypertensive care and accessOrganize 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 plansCreate 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   
    This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.

     

    Note: An organization may choose to adapt and refine a tool to assist improvement for the measure, Hypertension Control. Testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.

    The case study may be read in its entirety by clicking here.

    The Case Study: The QI Team

  2. 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:

    • Patient changes-efforts to support self-management efforts, patient engagement, and navigation of the care system
    • Care team changes-changes in job duties or work flow that assist to retain patients in care and ensure timely evidence-based hypertensive care
    • Health system changes-changes that have an impact on how care is delivered, independent of who does it

    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.

    Changes That Work 

    In Table 4.2: samplechanges that work are linked to the critical pathway for Hypertension Control. 

    Table 4.2: Sample Changes That Work
    Area of Critical PathwayPatient ChangesCare Team ChangesHealth System Changes
    HTN patient presents for care
    Patient completes intake process
    Patient assessment and vital signs completedEducation 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:
    • Patient's BP is at goal
    • Patient adheres to lifestyle modifications
    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 indicatedEnsure patient receives guidance about access to the practice with interim concerns
    This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.

     

    An organization may choose to adapt and refine a tool to assist improvement for the measure, Hypertension Control. Testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.
How Can an Organization Make Those Changes?

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:

  1. Small tests of change Model for Improvement and PDSA (Plan-Do-Study-Act)
  2. Process mapping
  3. Model for Improvement 

    The Model for Improvement (17) identifies aim, measure, and change strategies by asking three questions:

    Figure: AIM Measure Change.

    Figure: AIM Measure Change

    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:

    Figure 4.3: The PDSA Cycle.

    Figure 4.3: The PDSA Cycle

    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:

    • What system is in place to provide patients with timely reminders regarding blood pressure screening?
    • What are the assigned roles, duties, and tasks for planned visits to a multidisciplinary care team? Are members of the team cross-trained?
    • Does the patient population understand its specific role in hypertension control, or is there an opportunity for education?
    • Is there an opportunity to educate the community on the importance of hypertension control in a group visit setting?
    • Are there cultural, linguistic, and literacy barriers that the organization may need to address?

    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.

    The case study may be read in its entirety by clicking here.

    The Case Study: PDSA Cycles in Action

    Tips for Testing Changes

    • Keep the changes small and continue testing.
    • Involve care teams that have a strong interest in improving hypertensive care.
    • Study the results after each change. All changes are not improvements; do not continue testing something that does not work!
    • If stuck, involve others who do the work even if they are not on the improvement team.
    • Make sure that overall aims are improving; changes in one part of a complex system sometimes have an adverse effect in another.
  4. Process Mapping

    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.

How Can an Organization Know That Changes Caused an Improvement?

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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