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Kaiser Permanente Hawaii: Reducing High Blood Pressure by Focus on Low-risk Hypertensives

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Kaiser Permanente Hawaii (KP-HI) Evidence-Based Medicine (EBM) Hypertension (HTN) Healthcare Quality Performance Improvement Project

EBM Blood Pressure Project

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.

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.

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Project Outline

Phase I: 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.

Phase II: 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.

Phase III: Develop Project Outline
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?

Phase IV: Obtain, Evaluate & Synthesize Evidence
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.

Phase V: Create Clinical Recommendations
KP-CMI Hypertension guidelines were reviewed and accepted as the basis for management of hypertension.

Phase VI: Assess Impacts of Practice Change
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.

Phase VII: Create information, Decision & Action Aids
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

Phase VIII: Implement Guideline
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

Phase IX: Implement Measurement & Reporting Plan
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

Phase X: Continuous Improvement
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



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