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Delfini
Project
Showcase: Hypertension Management
Project
Critical
Appraisal Intensive & Evidence-based Clinical Guideline Review and
Healthcare Quality Improvement Project for Reducing High Blood Pressure
by Focus on Low-risk Hypertensives
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Background
Approximately
one third of the US population is hypertensive (BP = or >140/90), but
only one third have their blood pressure controlled. Nearly 50% of individuals
with hypertension are not receiving treatment. It is estimated that starting
with BP of 115/75 mm Hg, the risk of cardiovascular disease doubles with
every 20/10 mm Hg increase in blood pressure. In short, there is a very
big gap between current and optimal care for elevated blood pressure,
and the KPHI Hypertension Project was formed to improve hypertension care
and outcomes for Hawaii’s population.
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Kaiser
Permanente Hawaii (KP-HI) Evidence-Based Medicine (EBM) Hypertension (HTN)
Healthcare Quality Performance Improvement Project
Mission: Help
advance evidence- and value-based medicine in an organization that has
already proved a demonstrated commitment to evidence based medicine (EBM),
evidence based practice (EBP) and health care quality using a patient
centered approach by dedicating resources to EBM training and support
and that now seeks to progress to an even higher level in skill, depth,
application and cultural transformation.
Concept: Identify
a clinical group that has ideas for a successful evidence-based healthcare
quality improvement project and provide them with critical appraisal training
and support by facilitating the development of clinical guidelines through
scientific review of the medical literature. Learnings will be applicable
to other projects, plus team members will be able to facilitate similar
projects with other clinical groups within the care system. Quality in
healthcare will be enhanced through evidence based care and improved patient
safety.
Delfini
Role: Provide training, facilitation and support to the team to conduct
the project and to effect both clinical and evidence-based process change. |
Success
Stories:
Clinical Guideline
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| KPHI
Hypertension Project Outline |
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Phase
1: Identify Team |
.........
Leaders from KP-HI Medical Education and the Evidence Based Medicine (EBM)
Working Group solicited interest among the Hawaii region clinical staff.
With Delfini Group’s guidance, a multidisciplinary team was formed
including primary care physicians, nephrology, pharmacy, hospitalists,
nursing, dietician and a working group leader. |
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Phase
2: Select Project |
.........
The team selected low-risk hypertension (HTN) as the population to focus
on — an area with a large gap between current and optimal care. |
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Phase
3: Develop Project Outline
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Focus statement: 4/9/2007
The Kaiser Permanente Hawaii EBM Hypertension (HTN) Quality Improvement
Team will help establish guidelines, based on the Kaiser Permanente Care
Management Institute (CMI) recommendations, to help improve hypertension
care to Hawaii’s population. The use of the guidelines will help
improve management and clinical outcomes of hypertension through local
innovations. The focus will be initially on clinical implementation of
guidelines on low risk hypertensive patients.
Key issues
Focus on improved hypertension control
1. Improve blood pressure technique to insure accurate blood pressure
readings
2. Improve clinic workflow
3. Establish a work flow that can reduce unnecessary medical assistant
(MA)/ Registered Nurse (RN)/ physician visits
4. Develop an in-reach and outreach process targeting HTN patients not
at goal
5. Update providers with HTN guidelines
6. Reduction in the over-treatment of HTN
7. Create HTN handouts for clinicians, staff and patients
8. Need to improve overall outcomes with large scale NNT rates for strokes
and MI
Key Questions
Clinical Questions Addressed in this QI Project
1. What is the appropriate technique for taking blood pressure measurements?
2. How can we improve clinic workflow?
3. Are the staff and physicians appropriately trained in blood pressure
techniques?
4. What system is in place to insure accountability and training?
5. Are there appropriate monitors available in the clinic?
6. What are the new EBM HTN guidelines available via Kaiser Permanente
National CMI team, and can we apply them to Hawaii Kaiser Permanente’s
population?
7. Are the handouts currently in the system, updated and uniform? If not,
will the team work on editing and creating new ones?
8. Are group classes available for patients to have HTN education sessions?
9. What role can Panel Support Service (PSS) play in this initiative?
10. What role can How Are We Doing (HAWD) program play in this initiative?
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Phase
4: Obtain, Evaluate & Synthesize Evidence |
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Training was provided by Delfini in critical appraisal of all sources
including guidelines and other secondary sources, evidence synthesis,
creating clinical recommendations, impact assessment, creating decision
support, implementation and measurement.
Existing guidelines
were reviewed for applicability, validity, appropriateness and currency.
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Phase 5: Create
Clinical Recommendations
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KP-CMI Hypertension guidelines were reviewed and accepted as the basis
for management of hypertension. |
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Phase
6: Assess Impacts of Practice Change |
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Before implementation KP-HI Region wide control of HTN was at 50%; as
of July 2009 the rate was approximately 70% control (unofficial). HTN
control rate will be available in August 2009. |
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Phase
7: Create information, Decision & Action Aids |
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Hawaii Kaiser Permanente Region Hypertension Playbook was developed. This
playbook included —
1. Project Focus Statement
2. Updated CMI HTN Guidelines
3. Blood pressure reading
technique standardization process
a. Poster demonstrating
appropriate technique — to be placed by work-up stations
b. Video created demonstrating appropriate technique — for staff
training
c. Standardization of data entry
d. Health Connect Blood Pressure alert was developed.
[Note:
HealthConnect is part of Kaiser Permanente’s electronic medical
record system and allows registration, scheduling, billing, but also
clinical information systems — both inpatient and outpatient,
laboratory and X-ray information, pharmacy records, the ability to create
annotations and messages for individualized care, as well as decision-support,
alert and flagging features.]
4. Panel Support Service
(PSS) Team
a. Created a group class
for patients – to be presented by PSS
i. Education regarding,
diet and exercise, medications, definition of blood pressure, and
appropriate home blood pressure monitoring techniques
b. PSS Outreach process
5. Development of MA standardization
process
a. Development of MA work
flow process for hypertension
b. Outreach process
i. Development of phone
script for MA
ii. Development of reminder letters to be sent to patients
c. MA BP checks
i. Standard nursing note
template developed
ii. Standard after visit summary for patients developed
6. Handouts
a. CMI guidelines
b. Patient Handouts
i. Patient Hypertension
Booklet
1. General information
about hypertension
2. Dietary guidelines for hypertension
3. How to take an appropriate blood pressure
4. Goal Setting
5. Home BP Log
ii. Medication information
booklet
7. Specialty Care workflow
8. All information included
on Clinical Library web site and also disseminated by DVD
9. Instructional Power Point
video made with narration of slides to aid those not at meetings or new
at Hawaii Kaiser Permanente |
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Phase
8: Implement Guideline |
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The following implementation strategies were planned:
1. Hawaii Kaiser Permanente Leadership Presentations: December 2008 and
January 2009 introduce rollout of MA BP program region-wide
2. Grand rounds: Family medicine
and Internal Medicine, 1st in 2007, and updates to be done in late 2009
3. Clinic Presentations-
geared toward staff, started January 2009-July 2009
a. Each clinic had a presentation
of the MA BP standardization process
b. Establishing timeline and goals for each clinic in the roll out phase
4. PSS patient Hypertension
classes started in 2008
a. Re-introduce again in
2009
b. Working on development of outreach process in panel management
5. HealthConnect
a. Smartext set up and
implemented
b. MA-BP best practice alert developed and tested, June 2009 and implemented
region-wide in August 2009
6. Panel Support Tool-decision
support
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Phase
9: Implement Measurement & Reporting Plan |
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1. Increase in vital signs appointments on MA schedule
2. Increase in 2nd BPs done by staff during both routine intake and during
vital signs check
3. Increase in blood pressure control in patients with hypertension
4. Increase in blood pressure control in patients with hypertension and
diabetes
5. Decrease in scheduled visits in providers for blood pressure check
office visits
6. Currently achieved hypertension regional goals in following areas:
a. 2nd BP on elevated first
blood pressure
b. Overall HTN control
c. HTN control in patients with diabetes
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Phase
10: Continuous Improvement |
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1. Reviewing updates in 2009 CMI HTN guidelines
2. Improving Panel Support Services integration in program
3. Patient education classes
4. Regional rollout of MA BP alert
5. Increasing home blood pressure monitoring in patients
6. Improving maintenance phase of project |
| Message
from
Delfini
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Kaiser
Permanente: KPHI Hypertension Project
Several years ago, we were
invited to work with Kaiser Permanente Hawaii to help advance EBM within
their organization. KP Hawaii has a strong commitment to evidence- and
value-based care. Their leaders are committed to supporting EBM. They
frequently sponsor outstanding EBM conferences and retreats which are
very well attended, and they have an impressive and active EBM working
group. They were desirous
of taking EBM to a new level and expanding and embedding evidence-based
clinical improvement skills and techniques more solidly and more broadly
into their culture. We came up with an idea for a working project that
would provide just-in-time practical training, advance clinical care and
help further "seed" cultural change. Since that time, several
projects have resulted from this goal including the KPHI EBM
Hypertension Performance Improvement Project.
From Kaiser Permanente Hawaii
leadership to team members to support staff, Delfini is impressed with
the level of enthusiasm and commitment for the principles of evidence-based
medicine and for this project. The group is dedicated, responsive and
delightful to work with. We, in particular, want to recognize the incredible
leadership of Cherie Shehata MD. Cherie has been an inspiring leader,
incredibly effective and hard-working. We applaud her and her entire wonderful
team.
Mahalo,
 &
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