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man having measured blood pressure

The Grand Island Clinic in Grand Island, Nebraska is a multi-specialty group practice with 18 providers. The team at the Grand Island Clinic set out to improve the Blood Pressure (BP) control rates of their patients.

The clinic team had been monitoring performance of BP control rates for a number of years as part of their PQRS quality measures. In 2015, the Grand Island nurses took part in a BP training, facilitated by the Nebraska Dept. of Health and Human Services (DHHS). During the training they learned current standards in BP management, including accurate BP measurement, the impact of common measurement errors and the management of high blood pressure.

The nurses learned the importance of having properly calibrated and validated equipment, correct positioning of the patient in a chair with their back supported and feet touching the ground. Other best practices learned included letting the patient rest for at least five minutes, using the correct size cuff and having the patients arm at heart level on a flat surface; each play a part in the accuracy of the BP reading. The training also emphasized putting the cuff on the bare skin and no talking during the measurement. Before the training few of the nursed knew that if the patient had a full bladder it could lead to a falsely high reading. Even with the new training, they continued to look for ways to improve the number of patients with uncontrolled blood pressure.

Wanting to learn more about quality improvement and the new payment model Pat Enck, clinic administrator took advantage of an offering by the Great Plains Quality Innovation Network and enrolled her clinic in the Clinic QAPI Collaborative.  After participating in the Clinic QAPI Collaborative, the clinic took their quality improvement work to a whole new level.

First, they focused on building a team approach to quality improvement. Utilizing a team approach improved the clinics ability to provide quality care to their patients and support BP self -monitoring. By including front line staff, they were able to identify processes that could be put into place to more effectively improve BP control rates. They implemented a BP protocol and consistently utilize it in all areas of the practice. This has helped curb clinical inertia.

Self-Measured Blood Pressure monitoring (SMBP) is a best practice intervention that the nurses decided to implement. Patients are trained by the nurses on how to take their BP on a monitor at home.  SMBP allows the nurses to review the patients self-testing results with blood pressures taken in the office. SMBP is important because it avoids mis-diagnosis due to white coat hypertension, it allows clinicians to assess whether anti-hypertensive treatment is sufficiently controlling a person’s blood pressure and helps patients take more responsibility for their own care through the use of a shared care plan.

One drawback to SMBP is that patients need to buy a blood pressure machine. The clinic BP QAPI team went a step above and beyond by investigating costs of BP self-monitoring devices throughout the community. They teamed up with a local pharmacy to provide the home monitors at cost to patients that need to do self-monitoring at home. For some patients a monitor at cost was still a barrier, the Grand Island Clinic made the decision to provide a home monitor for free to these patients. It’s too soon to tell if the Self -Measured Blood Pressure monitoring will affect their overall BP Control rates, but the practice will continue to monitor.

“Taking this challenge on as a team has fostered a collaborative approach. Staff are engaged and we are implementing true quality improvement using the QAPI process and principles.” Pat Enck, Clinic Administrator.