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U.S. Department of Health and Human Services
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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 3: Implementation: Hypertension Control 

Before following the steps in Part 3, an organization should first make a commitment to improve Hypertension Control and complete the initial steps outlined in the previous section that include:

  • Developing an aim statement
  • Creating an infrastructure for improvement
  • Obtaining commitment from leadership

Performance on this measure indicates how effectively all the steps of the processes used to deliver care work together to achieve optimum blood pressure for patients. Since there are so many factors that can have an impact on blood pressure control, it helps to visualize how these steps are mapped. The next section defines Critical Pathway and illustrates the application of this concept to implement Hypertension Control.

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

The Case Study: The Approach

Critical Pathway for HIV Screening for Pregnant Women

A critical pathway, also known as a clinical pathway, is a visual depiction of the process steps that result in a particular service or care. The sequence and relationship among the steps are displayed, which reveals a map of the care process. Additional information, including tools and resources regarding the mapping of care processes, can be found in the Redesigning a System of Care to Promote QI module. In an ideal world, the care process is reflective of evidence-based medical guidelines. Evidence-based medicine aims to apply the best available evidence gained from the scientific method for medical decision making. (13)

A map of the care process steps that incorporates all of the known evidence and follows respected evidence-based medical guidelines can be considered the idealized critical pathway. While the needs of individual patients should always be considered, clinical guidelines synthesize the best evidence into a pragmatic set of action steps that strive to provide the optimum health care delivery system. It is important to emphasize that clinical evidence and guidelines will evolve as knowledge progresses; therefore, the idealized critical pathway may evolve over time and not meet the needs of every individual.

Note: Please consider the following regarding critical pathways:
  • It is important to note that there can be more than one way to depict the idealized critical pathway.
  • Authorities vary on critical issues that have an impact on important decisions in medicine, and there is latitude within guidelines for variation related to less critical matters.
  • It is important that an organization agrees on the guidelines with which to align. There are no specific guidelines that address processes to promote early access for hypertensive care, but a number of references provide available evidence. An organization may interpret the evidence that has an impact on early hypertensive care differently than illustrated in Figure 3.1. If so, creation of a different schematic that reflects its interpretation of the best evidence is encouraged. References are located in Part 6: Supporting Information at the end of this module.
In Figure 3.1, the schematic incorporates available evidence and represents an idealized critical pathway for Hypertension Control. The boxes represent typical steps in care delivery. If these steps happen reliably and well, effective care is delivered.
Figure 3.1: Critical Pathway forHypertension Control.
Figure 3.1: Critical Pathway forHypertension Control

Walkthrough of the Idealized Critical Pathway

This critical pathway exists both inside the clinic and beyond the clinic walls. Each of these steps is important to effective blood pressure management and emphasizes the importance of all members of the care team in achieving hypertension control:

1. The patient presents for care as a result of any of the following:

  1. A scheduled appointment from the previous visit
  2. A scheduled appointment following a contact by a member of the care team after the previous visit
  3. An unscheduled appointment (walk in) for elevated blood pressure, medication refill, etc.

2. The patient is identified as being hypertensive based on alerts in the management information system or flags in the HIPAA-compliant paper chart. Each patient is given an education handout on blood pressure control to read while waiting to be seen. The staff emphasizes the importance of reading the material and noting any questions that may need to be discussed with the provider.

3. During the patient assessment and prior to the provider's encounter, the staff:
  1. Informs the patient of the blood pressure reading and the target blood pressure
  2. Asks about the patient's current medications and compliance with his or her medications and lifestyle changes
  3. Commences the process of self-management goal setting, for example, reviewing key factors that have the most impact on a patient's blood pressure using a patient-friendly self-management tool to facilitate the discussion
  4. Reviews health maintenance requirements for a hypertensive, including the need for an annual eye doctor visit, cholesterol and blood sugar screening, etc.
  5. Initiates referral requests and lab test orders
  6. Informs the patient about in-house and community resources available to assist with blood pressure control, including group visits, nutrition counseling, safe local parks and discounted gym memberships for exercising
  7. Documents all of the information above in the patients record
  8. Flags the record if the patient has a blood pressure more than140 mm Hg systolic or more than 90 mm Hg diastolic
4. Provider sees the patient and completes the appropriate assessment. Key areas include:
  1. Reviewing the support staff's patient assessment and documentation
  2. Assessing co-morbidities
  3. Reviewing the patient's self-management goals and addressing any potential barriers to achievement, for example, homelessness, unemployment, depression, and medication costs
5. Key decision points are when the provider determines if the patient's BP is at target and the patient complies with lifestyle modifications and medications. The responses to these questions influence a patient's care plan:

5a. If the patient has an appropriate blood pressure and is compliant with lifestyle modifications and medications, the provider then needs to determine if there is any evidence of end-organ damage, for example, a fundoscopy to look for retinal damage, electrocardiogram for heart damage, and creatinine and urine protein for renal damage. Evidence of end-organ damage requires a different blood pressure target, additional therapeutic options to minimize progression, and may trigger a follow-up with an appropriate specialist, such as a nephrologist or cardiologist.

5b. Provider focuses on different self-management goals even when target blood pressure is attained and the patient is compliant with life style modifications and medications, or steps up the care plan when:
  1. Blood pressure is not at target
  2. Patient is not compliant with necessary lifestyle changes
  3. There is evidence of end-organ damage
5c. Provider develops or reinforces the care plan based on the assessment. The plan includes:
  1. Necessary medication changes
  2. New or revised self-management goals
  3. Referral and lab test orders
  4. Patient linkage to helpful resources, such as an invitation to group medical visits for hypertension
  5. Scheduling a follow-up as necessary

6. Patient is discharged and scheduled for follow up as medically indicated. Support staff emphasizes key education points and hypertension management changes. A current medication list is printed for the patient.

7. A member of the care team contacts the patient a few days after the visit to emphasize key points in the education provided and to ensure that barriers to achieving the blood pressure target are addressed, such as medication refills. Patient is advised of the importance regarding follow-up care and the need for monitoring as medically indicated (at minimum annually).

A few important notes:

  • The idealized critical pathway for Hypertension Control may be developed based on key staff contacts and functions performed at each step, or based on critical decision points in blood pressure control regardless of the type and qualification of staff performing that function. Either type of pathway chosen by an organization may be used in its improvement effort.
  • An organization may adopt additional hypertensive guidelines that include important care parameters. The Institute for Clinical Systems Improvement by the National Guidelines Clearinghouse describes guidelines for Hypertension Control.
  • A critical pathway can also be constructed to illustrate how care is currently provided within an organization (the existing pathway). Understanding the gap between an organization's existing critical pathway (how you provide care now), and the idealized critical pathway (how to provide reliable, evidence-based care aligned with current guidelines), form the basis for improvement efforts
Factors That Impact the Critical Pathway

In addition to understanding the steps for providing Hypertension Control, factors that interfere with optimal care should be understood. As there may be several of these factors, a QI team may find it helpful to focus its attention on factors that interfere with ideal outcomes. This becomes especially useful as plans are developed to mitigate these factors.

Factors that have an impact on Hypertension Control can be organized into those that are patient-related, relative to the care team, and a result of the health system. Overlaps exist in these categorizations, but it is useful to consider factors that have an impact on care processes from each perspective to avoid overlooking important ones.

Patient factors are characteristics that patients possess, or have control over, that have an impact on care. Examples of patient factors are age, race, diet, and lifestyle choices. Common patient factors may need to be addressed more systematically, such as, a targeted approach to address low health literacy, or a systematic approach to educate staff on the cultural norms of a particular ethnic group. Examples of how patient factors may influence blood pressure control include:

  • Age-hypertension worsens with age and becomes more difficult to control
  • Cultural differences-these may influence perceptions of causation, diet choices, and level of concern about weight gain
  • Health literacy-affects ability to understand education provided and to ask appropriate questions
  • Work status-may influence income, health insurance, and ability to access health care
  • Co-morbid diagnosis-complicates treatment choices, increases cost of care (medications, lab tests, etc.), and ability to follow the care plan
  • Socioeconomic status-may have an impact on access to medications and food choices

Care team factors are controlled by the care team. These types of factors may include care processes, workflows, how staff follows procedures, and how effectively the team works together. Care team factors that may influence Hypertension Control include:

  • Staff education, training, and skill set
  • Cultural competence
  • Appreciation of value of each individual's work effort to the collective ability to improve care outcomes

Health system factors are controlled at the high level of an organization and often involve finance and operational issues. Health system factors that may influence care for hypertensive patients include:

  • Cost- co-pays for medical visits and lab tests, and medications
  • Scheduling systems -availability of evening, weekend and same-day appointments, and wait time may have an impact on access
  • Location-no transportation or an unsafe location may present barriers

These factors, when added to the critical pathway, create another dimension to the map as shown in Figure 3.2:

Figure 3.2: Critical Pathway for HIV Screening for Hypertension Control.
Figure 3.2: Critical Pathway for HIV Screening for Hypertension Control


Next, a team may identify specific factors that pertain to the way care is provided for its patients as in Example 3.1:

Example 3.1: A Team's Brainstorming Session

The task force brainstorms on factors that have an impact on the arrow (or opportunity) between Steps 6, 7 and 1 of the Critical Pathway for Hypertension Control (from Figure 3.2).
Example 3.1: A Team's Brainstorming Session.

Factor CategoryFactors pertinent to our organization - Steps 6, 7 and 1
PatientLimited appreciation of the gravity of the disease and the importance of regular follow-up with patient's Primary Care Provider (PCP), cultural norms and myths about blood pressure and medications, financial limitations to seeking care, and transportation barriers
Care TeamNo consistency in appointment-reminder process for patients; inefficient workflow with prolonged patient waiting times causing high no-show rates; no consistent process to follow-up on missed appointments; available educational materials are not culturally appropriate for the population
Health SystemHigh cost of medical visits; next available appointment for a patient is in four weeks; patients needing medication refills are required to schedule an appointment to see a provider; policy of organization for all patients to have a follow-up appointment regardless of reason for visit is “clogging” schedules and limiting access for those patients needing appointments

The team continues to look at different parts of the pathway to identify relevant impacts for each part. Once it is able to evaluate where there are potential opportunities for improvement, it can use this information to target its efforts. Additional examples of strategies to improve care for the measure, Hypertension Control, are described in the Improvement Strategies section of this module.

Once the team visualizes the pathway and identifies opportunities for improved care, the next step is to collect and track data to test and document them. First, a QI team needs to determine how to collect data to support its improvement work. This step is essential for understanding the performance of its current care processes, before improvements are applied, and then monitoring its performance over time.

Data Infrastructure: Hypertension Control
T his section begins to address the important role of data throughout the improvement process. It is important to recognize that different types of data are collected during the improvement project. First, data to calculate and monitor the Hypertension Control performance measure results is needed. Monitoring a performance measure involves calculating the measure over time and is used to track progress toward a numerical aim. This section provides an overview of what is needed. A detailed and stepwise approach follows to explain the types of infrastructure elements needed to gather data to support improvement. Second, changes an organization is making to improve care processes and their effects must be tracked. Tracking the impact of changes reassures the team that the changes caused their intended effects.
Data Infrastructure to Monitor the Performance Measure-An Overview

There are three major purposes for maintaining a data infrastructure for quality improvement work:

  • To know the starting baseline
  • To track and monitor performance as changes are implemented
  • To perform systematic analysis and interpretation of data in preparation for action

The first step to creating a data infrastructure for monitoring the performance measure is to determine the baseline. A baseline is the calculation of a measure before a quality improvement project is initiated. It is later used as the basis for comparison as changes are made throughout the improvement process. For the Hypertension Control measure, an organization can determine the percentage of hypertensive patients with a blood pressure less than 140/90 mm Hg. Systems of care reflect the current organizational infrastructure and the patient's interactions with existing care processes and the care team.

Baseline data is compared to subsequent data calculated similarly to monitor the impact of quality improvement efforts. The details of how to calculate the data must be determined to ensure that the calculation is accurate and reproducible. The difference between how an organization provides care now (baseline) and how it wants to provide care (aim) is the gap that must be closed by the improvement work.

The next step of data infrastructure development involves a process in place to calculate the measure over time as improvements are tested. A QI team's work is to make changes, and it is prudent to monitor that those changes result in achieving the stated aim. This involves deciding how often to calculate the measure and adhering to the calculation methodology.

Finally, an organization's data infrastructure must include systematic processes that allow analysis, interpretation, and action on the data collected. Knowledge of performance is insufficient for improvement. It is important for an organization to understand why performance is measured and to predict which changes will improve Hypertension Control based on an organization's specific situation. Collecting data related to specific changes and overall progress related to achieving an organization's specified aim are important to improvement work. The next section describes in more detail how to develop a data infrastructure to support improvement.

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