QUALITY IMPROVEMENT SUCCESS STORIES
Hypertension Control in the University
of Chicago Primary Care Group
Kathryn E. Gunter, George W. Weyer, Lisa M. Vinci, Marshall H. Chin, and Monica E. Peek
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■ IN BRIEF “Quality Improvement Success Stories” are published by the
American Diabetes Association in collaboration with the American College of
Physicians, Inc., and the National Diabetes Education Program. This series is
intended to highlight best practices and strategies from programs and clinics
that have successfully improved the quality of care for people with diabetes
or related conditions. Each article in the series is reviewed and follows a
standard format developed by the editors of Clinical Diabetes. The following
article describes a successful project by faculty at the University of Chicago
to improve blood pressure control among hypertensive patients at a general
internal medicine clinic on the South Side of Chicago, Ill.
Describe your practice setting trol measure (i.e., office-based blood
and location. pressure value >140/90 or >150/90
Our practice is an urban academic mmHg for patients >60 years of age
general internal medicine clinic on the without diabetes).
South Side of Chicago, Ill. At the time
of this project, our practice became Summarize the initial data
the primary care site for a Medicare for your practice (before the
Advantage contract, whereby our in- improvement initiative).
University of Chicago, Chicago, IL
stitution accepted responsibility for Initially, only 36% (63 of 173) of
Corresponding author: Monica E. Peek, the costs and quality of care for pa- patients had controlled hyperten-
mpeek@medicine.bsd.uchicago.edu sion. Among patients with diabe-
tients enrolled in the plan.
https://doi.org/10.2337/cd17-0042 tes, 40% (19 of 47) had controlled
Describe the specific quality gap hypertension.
This series is published by the American addressed through the initiative.
Diabetes Association in collaboration
This project focused on patients with What was the timeframe
with the American College of Physicians,
Inc., and the National Diabetes Education hypertension enrolled in our Medicare from initiation of your quality
Program. The American College of Advantage health plan and aimed to improvement (QI) initiative to its
Physicians and the American College of completion?
Physicians Logos are trademarks or regis-
increase the percentage of patients
tered trademarks of American College of with adequately controlled hyperten- We summarize our efforts from
Physicians, Inc., in the United States and sion according to National Center September 2015 through December
shall not be used otherwise by any third 2016 for this ongoing project.
party without the prior express written con- for Quality Assurance standards
sent of the American College of Physicians, within their Healthcare Effectiveness Describe your core QI team. Who
Inc. Likewise, products and materials that Data and Information Set (HEDIS) served as project leader, and why
are not developed by or in partnership with
the National Diabetes Education Program measures. was this person selected? Who
are prohibited from using the National
Diabetes Education Program logo. How did you identify this quality else served on the team?
gap? In other words, where did The project champion was the
©2017 by the American Diabetes Association.
Readers may use this article as long as the work
you get your baseline data? medical director for the Medicare
is properly cited, the use is educational and not We used data initially provided by the Advantage program. The team in-
for profit, and the work is not altered. See http://
creativecommons.org/licenses/by-nc-nd/3.0
health plan for patients who did not cluded a registered nurse (RN) case
for details. meet the HEDIS hypertension con- manager, the clinic medical director, a
168 CLINICAL.DIABETESJOURNALS.ORG
gunter et al.
TABLE 1. Summary of Hypertension QI Program Outcomes
Health Plan Patients With Patients With Patients With Patients With Diabetes
Participants Hypertension* Controlled Diabetes and and Controlled
(n) (n) Hypertension Hypertension Hypertension
(n [%]) (n) (n [%])
September 2015 468 173 63 (36) 47 19 (40)
December 2015 557 186 89 (48) 52 34 (65)
December 2016 723 382 244 (64) 96 63 (66)
*Patients with an established diagnosis of hypertension are eligible for this measure if they are 18–85 years of age and
have been enrolled in the health plan for at least 12 months.
licensed practical nurse (LPN) patient 2. Nursing staff re-measured all 7. Using our registry, we identified
care coordinator, a program manager blood pressures >150/90 mmHg. patients with persistently poorly
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in the managed care office, and a re- 3. Staff documented all repeat blood controlled hypertension who
search project manager. pressure measurements in a dis- needed additional care and devel-
crete field in the electronic health oped strategies to reach patients
Describe the structural changes
record (EHR). between visits. We sent EHR mes-
you made to your practice
4. We flagged the chart for provid- sages to the RN case manager for
through this initiative.
ers if repeat blood pressure was targeted outreach to these patients
We reviewed best practices (Measure
>150/90 mmHg. (e.g., appointment reminders and
Up Pressure Down Toolkit [1] and
5. MAs verbally communicated with phone calls to inquire about side
case studies from sites with successful
providers if blood pressure was effects, medication refills, trans-
hypertension improvement [2]) for
>180/100 mmHg. portation for visits, and other care
blood pressure measurement tech-
6. Using our registry, we did pre-visit needs).
nique. Informed by these resources,
we developed a training template planning to identify patients with Summarize your final outcome
and competency assessment for elevated blood pressure. We sent data (at the end of the
blood pressure measurement. We EHR prompts to primary care improvement initiative) and
worked with a nursing professional providers (PCPs) and specialists how it compared to your
practice educator at our institution, to encourage them to address ele- baseline data.
who revised nursing protocols and vated blood pressure during the After 15 months, we found that
led training on proper blood pressure next visit. Our message prompt 64% of our patients had controlled
measurement technique to medical described the HEDIS hyper- hypertension in our overall sample
assistants (MAs), RNs, and LPNs. In tension control definition and of patients, compared with 36% at
addition, we developed and imple- reminded providers to take the baseline. Among patients with dia-
mented standard work on accurate following steps if they observed betes, 66% had controlled hyperten-
measurement of blood pressure and elevated blood pressure values: sion, compared with 40% at baseline
posted these instructions in all triage • If a patient’s triage blood pres- (Table 1).
rooms. To further enhance accurate sure is elevated, recheck blood What are your next steps?
measurement, we verified calibration pressure later in the visit and In alignment with the University of
of manual blood pressure cuffs in all document the patient’s blood Chicago’s contracting strategy, we
clinic exam rooms. Finally, we imple- pressure in the EHR flowsheet. are expanding the interventions de-
mented protocols to notify providers A manual blood pressure mea- veloped for this small population of
when a repeat blood pressure mea- sure may be more accurate. Medicare Advantage beneficiaries
surement was elevated. • If the patient’s blood pressure to the broad population of patients
Describe the most important remains elevated on recheck, receiving ambulatory care within
changes you made to your if clinically appropriate, con- the University of Chicago and our
process of care delivery. sider adjusting the patient’s Care Network. In January 2017,
1. We identified best practices in treatment. we entered into Accountable Care
blood pressure measurement, and • Contact the RN case manager, Organization agreements with both
we trained and assessed compe- who may provide timely addi- Medicare (the Medicare Shared
tency of all clinical nursing staff tional support to patients for Savings Program) and our largest
on use of proper technique. blood pressure management. commercial payer. Given the rapid
VO LU M E 3 5 , N U M B ER 3 , SU M M ER 2 017 169
QUALITY IMPROVEMENT SUCCESS STORIES
growth of the populations affected by ultimately supported wider dissem- an institution-wide QI team that
value-based contracts and operation- ination of care delivery changes to includes a physician champion, our
al advantages of having the same QI improve hypertension care through- ACO medical director, a QI special-
approach for all patients, we elected out our institution. It is now standard ist, a quality analyst, and a nursing
to focus on control of hypertension practice to train and administer educator. Cardiology, endocrinology,
across all ambulatory patients as part competency assessments for blood geriatrics, nephrology, and internal
of our institutional quality score card. pressure measurement for MAs medicine clinics currently partici-
working in all outpatient clinics in pate in hypertension improvement
What lessons did you learn our institution. Routine processes for efforts. Hypertension control data
through your QI process that hypertension care now include repeat are analyzed and reported at the indi-
you would like to share with manual blood pressure measurements vidual provider and clinic level. The
others? for any patient with an initial blood institution-wide QI team is using the
Starting with a small, well-defined pressure >150/90 mmHg, followed by interventions and strategies developed
population, we learned how to focus communication with the PCP if the in the hypertension pilot to imple-
on a defined group of patients, devel- second blood pressure measurement ment a comprehensive improvement
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op strategies and tools to understand remains elevated. program across our primary care
the population, and standardize and Buy-in from physician leaders and practice and other clinics.
implement processes (e.g., training, administrators was crucial to our
measurement, documentation, and efforts. This Medicare Advantage Duality of Interest
staff and provider communication) contract was used as a pilot program No potential conflicts of interest relevant to
to target improvements in hyperten- to develop operational capabilities to this article were reported.
sion care. We learned the feasibility support participation in value-based
of developing, monitoring, and im- care contracting. The time for the References
proving workflows for hypertension nurse care manager, LPN patient 1. American Medical Group Foundation
(2013). Measure Up Pressure Down:
care among our staff and providers. coordinator, and physician leaders provider toolkit to improve hypertension
Now that we have changed care de- to work with the health plan was set control [Internet]. Available from http://
livery processes to address hyperten- aside during the regular work day and www.measureuppressuredown.com/
HCProf/find/provtoolkit_find.asp. Accessed
sion control, we have knowledge and thus did not create an excessive bur- 8 May 2017
experience that can inform processes den of “volunteer” effort by the team. 2. Cleveland Clinic Medicine Institute. Best
for other chronic conditions. Our institutions chief quality practices in hypertension: the hypertension
Our QI project helped us oper- officer (CQO) has identified hyper- improvement project [Internet]. Available
from http://www.amga.org/research/
ationalize and standardize several tension control as an institution-wide research/Hypertension/Compendiums/
aspects of hypertension care, which quality metric. The CQO established cleveland.pdf. Accessed 8 May 2017
170 CLINICAL.DIABETESJOURNALS.ORG
