Quality Improvement Techniques to Improve Blood Pressure Readings

Transcription

1 June 7, 2016 Quality Improvement Techniques to Improve Blood Pressure Readings Rebecca Durham, HealthInsight Utah Susan Yelton, HealthInsight New Mexico

2 HealthInsight Quality Innovation Network (QIN) Quality Improvement Organization (QIO) CMS Quality Strategy: Eliminating disparities Strengthening infrastructure and data systems Enabling innovation Fostering learning organizations Quality Improvement Organizations About QIN-QIOs. Retrieved at: QIO Program Fact Sheet Handout. 2

3 We want to hear from you! Type questions into the Questions Pane at any time during this presentation

4 Speakers Rebecca Durham Project Manager HealthInsight (UT) Susan Yelton Project Manager HealthInsight (NM)

5 Speakers Amber Buchert Chronic Disease Program Coordinator Nevada Health Centers Jenni Wilson Business Intelligence Manager Nevada Health Centers

6 Learning Objectives Recall at least one quality improvement (QI) method to use in your work setting Articulate blood pressure (BP) measurement guidelines Explore ways to improve current blood pressure measurement process to improve the Million Hearts blood pressure control measures Create an action plan to improve and monitor change in blood pressure measurements

7 Agenda Introduction Review Blood Pressure (BP) Guidelines Walk through BP Assessment & EHR Guide Success Story: Nevada Health Centers Introduction to a few common QI tools Create an action plan Q&A

8 AHA Blood Pressure Categories AHA recommendation for healthy blood pressure: Systolic mm Hg less than 120 AND Diastolic mm Hg less than 80 AHA recommendation for prehypertension: Systolic mm Hg OR Diastolic mm Hg AHA recommended categorization for High Blood Pressure (Hypertension) Stage 1: Systolic mm Hg OR Diastolic mm Hg AHA recommended categorization for High Blood Pressure (Hypertension) Stage 2: Systolic mm Hg 160 or higher OR Diastolic mm Hg 100 or higher American Heart Association. (2016).

9 Measuring Blood Pressure the Right Way For patients: Limit physical activity 30 min before measurement No caffeine, alcohol or smoking 30 min before measurement Use restroom before Sit calmly for 5 min before For providers: Make sure device is calibrated according to manufacturers specifications Wash hands Choose proper cuff size for patient For both: Have patient sit in chair with back support and both feet on floor Rest arm at heart level No talking! Keep upper arm bare Check out clinical practice guidelines, tools and sample protocols on the MillionHearts.org website. New York City Health and Hospitals Corporation. (n.d).

10 Blood Pressure Assessment Created with local Million Hearts coalition members in Utah

11 Blood Pressure Assessment Designed to be an improvement tool Incorporates best practices in three categories Accuracy of Blood Pressure Readings Office Policies and Procedures Documentation, Alerts, EHR Clinics self-assess and create an action plan

12 Blood Pressure Assessment

13 Blood Pressure Assessment

14 Blood Pressure Assessment Corresponding resources are available Data drives change Use data from your EHR to inform and guide your efforts EHR Guide

15 EHR Guide Helps you run cardiacspecific reports Features screenshots and tutorials for commonly used EHRs: eclinicalworks, Greenway, emds Troubleshooting Quality measure selection PDSA support

16 SUCCESS STORY: NEVADA HEALTH CENTERS

17 Team Based Care: Addressing Hypertension Amber Buchert Chronic Disease Program Coordinator

18 Team Based Care: Addressing Hypertension Empowering Patients through Patient Centered Clinical Care

19 Nevada Health Center s Sierra Nevada Health Center, Virginia City Community Health Center, Carson City School Based Health Center 349 potential Patients 240 blood pressure cuffs for distribution A Community Health Worker completes the patient enrollment and training Patient Criteria: Males and females age 18 and above Diagnosed with hypertension Exhibited high blood pressure at least 2 of the last 3 appointments New patients that displayed high blood pressure at first 2 appointments

20 The Measures Being Collected The number of patients participating The number of patients with improved pressures (controlled) The number of patients whose pressure remained the same (difference is not statistically significant) The number of patients who reported worsening pressures The number of patients who followed their medication regimen The number of patient appointments needed when control gained

21 Implementation of this Program CHW calls identified patients to discuss the opportunity with them and, if they are interested, to schedule patients to receive the blood pressure monitor and training in the clinic

22 Patients Learn: To avoid bathing, drinking alcohol or caffeine, smoking, exercising and eating for 30 minutes before taking a measurement. Measurements should be taken in a quiet place. Stress raises blood pressure. To avoid taking measurements during stressful times. To remove tight fitting clothing from arm. The cuff should go around bare arm. To remain still and not talk during the measurement. To sit on a chair with their feet flat on the floor. To rest their arm on a table so that the arm cuff is at the same level as their heart.

23 Patients Learn: How to fill out the self-monitoring blood pressure logs that we provide to them. How often to report their blood pressure logs (weekly). The different options for reporting available to them, including: By telephone or voic , Stopping by the clinic to have a copy of their log saved for the CHW By fax, By mail, or by , By using the free app included with their blood pressure monitor to

24 Patients Learn: How to operate their new Omron BP786 Blood Pressure Monitor, including: How to set the date and time Battery installation Applying the arm cuff Taking a measurement Using the memory function Error messages and troubleshooting

25 Patients are given materials and the opportunity to discuss the following: Definition of both systolic and diastolic Blood pressure numbers by category according to the American Heart Association

26 Patients are given materials and the opportunity to discuss the following: Risk factors that can be controlled, and those that can t: Risk Factors You Can Control: Stress Diabetes Too little Potassium Smoking Not being physically active Drinking too much alcohol Eating too much salt Risk Factors You Cannot Control: Age Race/ethnicity Gender Family history Being over a healthy body weight Natural ways to control blood pressure, such as enjoying a healthy diet, a low sodium diet, keeping weight down, physical activity, limiting alcohol, not smoking, and managing stress

27 What happens after the blood pressure logs are received from a patient? We enter the date, time, systolic measurement, diastolic measurement, and pulse for each patient into a database for data collection. We enter the range of dates, the systolic range, diastolic range, and heart rate range for each patient into the patient s electronic health record, so their provider has access to it. Providers may release patients from this program once the patient has shown consistent blood pressure measurements for a thirty day period that are in control. Thank you

28 June Updates 99 Patients Enrolled Enrollment Period of January 27 June 3, % Compliance Rate Patients who submit their blood pressure readings on a regular basis 8 Patients have reached control and have been released from the program, but encouraged to continue daily monitoring.

29 Questions?

30 QUALITY IMPROVEMENT TOOLS

31 Root Cause Analysis: 5 Whys Define problem, ask why five times, leads to root cause Problem statement Why is that? Why is that? Why is that? Why is that? Why is that? (this is root cause) Solution is:

32 5 Whys Example Problem statement: Uncontrolled hypertension is not addressed during visits Why is that? Providers overlook blood pressure reading Why is that? Focus is on specific symptoms leading to visit Why is that? Not enough time during visits to review all information Why is that? No way to quickly identify patients with uncontrolled hypertension Why is that? No system in place to flag these patients Solution is: Medical assistant will place a red flag on file when blood pressure reading is > 140/90

33 Fishbone Diagram

34 Fishbone Diagram Example

35 IHI Model for Improvement and PDSA Cycle The Institute for Healthcare Improvement (IHI) Model for Improvement consists of two parts: 1. Three fundamental questions, which can be addressed in any order. 2. The Plan-Do-Study-Act (PDSA) cycle to test changes in real work settings. The PDSA cycle guides the test of a change to determine if the change is an improvement. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study." [See Deming WE. The New Economics for Industry, Government, and Education. Cambridge, MA: The MIT Press; 2000.]

36 Steps in Change Action 1. Form the Team 2. Plan: Set Aim, Establish Measures, Select Change 3. Do: Test Change 4. Study: Check Measures 5. Act: Implement Change, Spread Change and/or Try a Different Change

37 Action Plan What are you trying to accomplish? Who will be involved? What will be your measures? What will you change? When will you re-measure? How will you know if you ve succeeded?

38 PDSA Aim: Plan: Task 1 Task 2 Task 3 Prediction Process measures: Outcome measures:

39 Type questions into the Questions Pane at any time during this presentation QUESTIONS? COMMENTS? REFLECTIONS?

40 Thank You! Please complete post-webinar survey Next webinar: Cardiac Care Highlights Huddle Thursday, July 14, p.m. MT Noon 1 p.m. PT This material was prepared by HealthInsight, the Medicare Quality Innovation Network Quality Improvement Organization for Nevada, New Mexico, Oregon and Utah, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-B

41 References American Heart Association. (2016). Understanding Blood Pressure Readings. Retrieved from American Heart Association webpage at: nderstanding-blood-pressure-readings_ucm_301764_article.jsp#.v1xlivkrjd8 Deming WE. The New Economics for Industry, Government, and Education. Cambridge, MA: The MIT Press; Institute for Healthcare Improvement. (2016.) Plan-Do-Study-Act (PDSA) Worksheet. Retrieved from IHI Tools webpage at: Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; Million Hearts Website: New York City Health and Hospitals Corporation. (n.d). Adult hypertension clinical practice guidelines: Managing high blood pressure. Retrieved from Million Hearts Tools & Protocols page at: