Target BP: First Year in Review

Target BP: First Year in Review Teaching Clinic Point of View R. Bruce Hanlin, M.D.

Care Coordination Institute and American Medical Association The MAP Hypertension Control QI Project R. Bruce Hanlin, MD, FAAFP Vice Chair, Medical Staff Affairs and Quality Department of Family Medicine Greenville Health System Greenville, SC

Outline (7 minutes) 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

The Results Hypertension Control Rate Improved 22% after Implementing MAP 100% 95% 90% 85% 80% Hypertension control rate 75% 70% 65% 22%improvement in 6 months 60% 55% 50% 0 1 2 3 4 5 6 Months after Implementation

The Clinical Champion: Dr. Hanlin Special Hypertension Training and Certifications:

The Clinical Champion: Dr. Hanlin Special Hypertension Training and Certifications: None!

The Clinical Champion: Dr. Hanlin Lean Six Sigma Certifications:

The Clinical Champion: Dr. Hanlin Lean Six Sigma Certifications: None!

The Practice Family Medicine Residency Clinical Staff 21 Residents 10 Faculty Support Staff are LPNs and MAs Family Medicine Residency Population 50% Medicaid 2% Commercial Insurance 45% Medicare Approx. 4,000 Adult Patients 3% Self Pay Approx. 2,000 Adult Hypertensive Patients

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

AMA-CCI Model for Improving Blood Pressure Control PRACTICE EVIDENCE-BASED STRATEGIES ACTION STEPS METRICS OUTCOMES 6-month QI initiative MEASURE ACCURATELY Obtain accurate, representative BP Proper Patient Prep & Position, etc. Confirmatory AOBP Measurements CONFIRMATORY AOBP Blood Pressure Control: Practice facilitation Dashboards ACT RAPIDLY Implement evidence-based protocol to Dx and Rx HTN and reduce clinical inertia Treatment Protocol Single-pill combinations Visit Frequency THERAPEUTIC INERTIA % Patients with BP <140/<90 Peer-to-peer exchange PARTNER WITH PATIENTS, FAMILIES & COMMUNITIES Engage patients in healthy lifestyles and self-management Evidence-Based Communication Strategy BP Self-Monitoring Lifestyle Change(s) BP after THERAPEUTIC INTENSIFICATION Δ in SBP Δ in DBP Facilitating Factors Engaged Leadership Committed Staff Effective Teamwork Evidence-Based Protocol, QI Tools Confident Expectations Actionable Data Sustained

CCI Hypertension Guideline Booklet and M.A.P. Checklists

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

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

NICE Adapted Hypertension Rx Initial Monotherapy and Add-On Therapies Step 1 Non-African Origin Age <55 yrs RAS Blocker African Origin or Age =55 yrs CCB 1, Step 2 Step 3 Step 4 Add CCB Add Diuretic See TRH Guidelines Add RASB 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).

CCI Pharmacological Treatment Algorithm Regimen-1 Regimen- 2 Regimen- 3 Regimen- 4 (3pills;3 meds) (2pills;3meds) (3pills;3meds) (2pills;3meds) Lisinopril 40 (Free) Benazepril /Amlodipine 40/10 ($4/Mo) Losartan 100 ($4/mo) Valsartan / HCT 320/25 ($10/mo) Amlodipine 10 ($4/mo) Indapamide ($4/mo) Amlodipine 10 ($4/mo) Amlodipine 10($4/mo) HCTZ 25 ($4/mo) HCTZ 25 ($4/mo) Total Cost: $8/month Total Cost: $8/month 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.

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

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

Effective Quality Improvement Requires a TEAM A clinical champion is important, but the whole clinical team must be involved

A Tale of Two Clinics

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

Quality Improvement in the Real World Real World Challenges As time permits

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?

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 ).

Quality Improvement in the Real World

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.

Quality Improvement in the Real World Week 1 Nurses like the new automated BP machines, and have already incorporated them into their workflow.

Quality Improvement in the Real World

Quality Improvement in the Real World Week 2 (Monday, of course) Nurses state that three automated BP machines are broken. Only one is working.

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.

Quality Improvement in the Real World

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.

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.

Quality Improvement in the Real World

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.

Quality Improvement in the Real World Week 3 Everything is working smoothly. No more error codes from the automated BP devices. No malfunctions logged.

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.

In the EMR, I can easily tell if the nurse has obtained the average of 3 blood pressure readings in the room or not? 100% Percent Who "Agree" or "Strongly Agree" 80% 60% 40% Percent Who "Agree" or "Strongly Agree" 20% 0% Survey 1

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.

Quality Improvement in the Real World Ideal View in the EMR

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!

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.

Quality Improvement in the Real World Ideal View in the EMR

Quality Improvement in the Real World Actual View in the EMR

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.