AMGA s Measure Up Pressure Down Campaign Plank 7: All Team Members Trained in Importance of BP Goals Elizabeth L. Ciemins, PhD, MPH, MA Barbara Holloway, RN, BSN, CDE September 19, 2013 Health Care, Education and Research
Plank 7: All Team Members Trained in Importance of BP Goals 1. Overview of philosophical approach 2. How we spread the message Health Care, Education and Research
Complexity Science-Informed Approach Health Care, Education and Research
.the next century will be the century of complexity. (Steven Hawking, 20 th Century)
5
Complexity Science Science that attempts to: Understand and explain the behavior and dynamics of systems composed of many interacting elements Uncover the principles and processes that explain how order, change and innovation emerge in these systems Health Care, Education and Research
What is a Complex Adaptive System? System implies: Multiple Agents Agents are Interdependent and Connected Complex implies: Diversity Many Elements Large Number of Connections Adaptive implies: Capacity to Alter or Change Health Care, Education and Research
Interdependent Attributes Self-Organization & Emergence Adaptable Elements Order & Disorder Embedded Systems Diversity Non-Linearity Distributed Control 8 Health Care, Education and Research
Diversity: A Complex Adaptive System, e.g., Health Care Organization, has many different elements. This enables a CAS to change. Seek it Out Health Care, Education and Research
Interdependent Attributes Self-Organization & Emergence Adaptable Elements Order & Disorder Embedded Systems Diversity Non-Linearity Distributed Control Health Care, Education and Research
Embeddedness: Each system is made up of other systems and is part of (embedded in) a larger Complex Adaptive System. Each is unique. Respect Culture City, State, National HEALTH SYSTEM Health Care Organization Clinical Department NURSE Health Care, Education and Research
Interdependent Attributes Self-Organization & Emergence Adaptable Elements Order & Disorder Embedded Systems Diversity Non-Linearity Distributed Control Health Care, Education and Research
Because Complex Adaptive Systems are nonlinear, a small change may produce a large effect, or a large change may produce a small or no effect. Inability to Predict: Outcomes are unpredictable. Think Many Small Actions The Butterfly Effect Health Care, Education and Research
Consider Type of Problem, Match Solution to Problem Technical Change Adaptive Work Health Care, Education and Research
Interdependent Attributes Self-Organization & Emergence Adaptable Elements Order & Disorder Embedded Systems Diversity Non-Linearity Distributed Control Health Care, Education and Research
Emergence: In a Complex Adaptive System outcomes emerge through a process of Self-Organization rather than through centrally planned or directed processes. Think Bottom Up Approach Health Care, Education and Research
Health Care, Education and Research 21
Conventional Change Model Complexity-informed Change Model Health Care, Education and Research
Complexity Science Tells Us.. 1. Relationships matter 2. Look for bright spots or positive deviants 3. Foster self-organization 4. Embrace uncertainty 5. Need both technical and adaptive solutions Health Care, Education and Research
Spreading the Message: Importance of BP goals Health Care, Education and Research
Who? Clinical Care Teams: Providers (MDs, DOs, NPs, PAs) Nurses (LPNs, RNs) Staff (MAs, Registration)
Where? Regularly scheduled IM and FP huddles Special sessions Face-to-face Telemedicine Other existing groups Clinical Practice Committee (Clinic RNs, LPNs) Clinic Quality Council
Why train everyone? Team-based care: every discipline plays a role in HTN management Patient part of team Project ownership (vs. buy-in)
Ownership vs. Buy-in * Ownership Invited to participate at start of project Participation a choice Helped design change Debated alternatives, contributed to decisionmaking Buy-in Invited to participate well into project Participation mandated Asked to accept change designed by others Unaware of alternatives discussed, not part of any decision-making *Henri Lipmanowicz, co-founder Plexus Institute, co-developer, Liberating Structures
Training Content
Goals of Three-Year Campaign Measurable improvements in high blood pressure prevention, detection, and control 80% of patients at goal according to NQF 0018 measure criteria 75% of AMGA membership adopt (at least one) campaign planks. Engage and empower patients to actively manage their health. 30
AMGF Chronic Care Challenge Hypertension Campaign Goal: 80% of Patients at Goal BP According to JNC 7 PRIMARY PROCESS PLANKS Process Planks for Achieving Goal Direct Care Staff Trained in Accurate BP Measurement Hypertension Guideline Used and Adherence Monitored BP Addressed for Every Hypertension Patient, Every Primary Care Visit All Patients Not at Goal and with New Rx Seen within 30 days Prevention, Engagement, and Self-Management Program in Place VALUE- ADD PROCESS PLANKS Registry Used to Identify and Track Hypertension Patients All Team Members Trained in Importance of BP Goals All Specialties Intervene with Patients Not in Control
Why Does Billings Clinic Care? Vision to be a national leader in providing the best clinical quality, patient safety, service and value. Hypertension control is an important quality metric along with prevention and control of other chronic conditions (DM, CHF, COPD, CAD, etc.) Several reimbursement mechanisms (Accountable Care Organization, Meaningful Use for HIT) require that we meet certain quality metrics (including HTN) in order to receive dollars. 32
Most Importantly. It s the right thing to do for our patients!! 33
Plank Specific Information: Importance of BP Goals Hypertension is leading risk factor for heart disease, stroke, kidney failure, diabetes complications. One of three American adults have high blood pressure Less than half of patients have their condition under control Hypertension = silent killer Often no symptoms until serious problem occurs 34
And For every 20 mm Hg systolic or 10 mm Hg diastolic: Risk for cardiovascular event doubles!! 35
THE QUIZ
Blood Pressure Measurement 1. If the cuff is applied too loosely, the pressure reading will be: a) Too low b) Too high c) Not affected 2. Which of the following can cause sounds to be heard down to zero? a) Anemia b) Vigorous exercise c) Heavy pressure on the stethoscope d) All of the above e) None of the above 3. If the nurse inflates the cuff slowly or inconsistently, which of the following may occur? a) Inaccurate reading b) Lower systolic pressure reading c) Auscultatory gap in systolic pressure d) A and B e) A and C
Importance of being at BP goal 1. Hypertension is leading risk factor for: a) Heart disease b) Stroke c) Kidney failure d) Diabetes complications e) All of the above 2. For every 20 mm Hg systolic of 10 mm Hg diastolic, risk for cardiovascular event: a) Doubles b) Triples c) Stays the same
Is there more than one answer? The Korotkoff phase used to determine diastolic pressure in adults is: a) The phase when all sounds disappear b) The phase when sounds become muffled c) The last sound heard through the stethoscope d) All of these
Other tools to spark conversation: AHA 2013 Fact Sheet Factors affecting accuracy of BP measurement Issues to consider while talking with your patient with hypertension
Purpose of Quiz & Message Sharing Techniques 1. It s not the quiz itself, but the discussion it elicits 2. The tools (quiz) provide time and space for conversations to occur 3. Within and across discipline learning regarding practices of others 4. Learning from each other, rather than the presenter
Summary 1. Examining problem/issue through lens of complexity science allowed for more effective approach 2. Recognizing health system as Complex Adaptive System permitted focus on attributes and design of appropriate interventions 3. Opportunities for teams to talk, discuss, debate ANY TOPIC will result in stronger, more cohesive teams 4. Spread through self-organization more effective than through centralized approach 5. Importance of fostering ownership versus persuading buy-in
Questions? Elizabeth Ciemins: eciemins@billingsclinic.org Barb Holloway: bholloway@billingsclinic.org
Percent with most recent bp < 130/80 Complicated HTN Patients with DM or CKD Billings Clinic Comparator 50.0 45.0 41.9 44.9 40.0 35.0 30.0 25.0 Q3 2010 Q4 Q1 2011 Q2 Q3 Q4 Q1 2012 Q2 Q3 Q4 Q1 2013 Q2 Time Period
Percent with Most Recent BP < 140/90 75.0 70.0 Billings Clinic: All Patients <=85 Billings Clinic Comparator 70.8 71.6 65.0 60.0 55.0 50.0 Q3 2010 Q4 Q1 2011 Q2 Q3 Q4 Q1 2012 Q2 Q3 Q4 Q1 2013 Q2 Time Period
Percent of Patients with ALL BP < 140/90 Stillwater Billings Clinic: All HTN Patients < 85 years 70.0 60.0 61.8 50.0 50.5 52.2 40.0 41.8 30.0 20.0 10.0.0 2010 2011 2012 2013 Year