Small changes, better numbers: Success with blood pressure
by Denise Weiss, RN and Quality Improvement lead at The Rinehart Clinic in Wheeler, Oregon.
In January 2016, I moved to the Oregon coast and joined the staff of the Rinehart Clinic in Wheeler. One of my roles as an RN is helping with Healthy Hearts Northwest, the program we’ve enrolled in to help provide better cardiovascular care to our patients.
Our clinic’s quality improvement team meets weekly to assess where we’re at with our PDSAs (“plan-do-study-act” cycles”). You can’t improve unless you know what you’re currently doing, so when we got the Healthy Hearts quality measures (the ABCS), we knew we had to start with blood pressure (BP). All of the other measures are directly impacted by that.
We started with the MA staff and we tried to make it fun. We did parody skits of what not to do when taking a patient’s blood pressure. For example, in one skit, I wore a heavy-sleeved coat, was drinking coffee, talking rapidly and had my legs crossed. All the MAs watched and pointed out what was wrong in terms of taking blood pressure. We laughed a lot while we were learning.
With help from the Healthy Hearts’ materials, we made laminated posters on taking correct BP. We put them on the walls of each exam room next to the blood pressure monitor so the patients could see. After we identified some things that were being done incorrectly, we did random skills checking with the MAs. The clinic supervisor would have each one check off what they were doing. Putting the laminated sheets in the exam rooms helped get the patients involved. If an MA was busy and not doing something correctly, the patients might say something like “Oh I have my legs crossed – it says here I’m not supposed to.” So in this way we involved the patients. They are partners in improving their health outcomes.
Our first PDSA was just getting up to speed on doing everything correctly. After this, our denominator decreased. Our next PDSA was on “second reading.” For those patients not having good BP control (a reading greater than 140 over 90), a second blood pressure was taken at the end of their visit. Before the MAs wrote the after-visit summary, they would take a second reading. The theory behind this is that maybe the patient was anxious during the first reading or they just had coffee or a cigarette. By doing the second reading we could see if the patient was truly hypertensive or if the blood pressure was within range.
After the second-reading BP PDSA, we did chart audits to discover what percentage of our patients were getting that second BP reading. We saw that one team was doing really well with it, but another team was struggling. We pulled the MAs together to talk about what was and was not going well. We did another audit two weeks later and saw the same thing. We then did an incentive, a contest, where the clinic supervisor gave out lanyards. It was a small, fun motivator! During the process of continued audits, we found an EHR glitch. Two of the MAs were entering the second reading into one field and the other MA was entering it into another field where it was replacing the first reading. In this way, we found a documentation piece that was impacting data capture.
Addressing blood pressure alone has had a ripple effect. After we started with Healthy Hearts, our blood pressure numbers began to improve. Then, without having made them a focus, our other numbers started to improve (aspirin therapy and tobacco counselling).
I’m really excited about doing this work. Our clinic has support from the administration and an overall vision that we are not just focused on our clinic patients, but on the health of our community. It is all related. If you improve the health of your community, you improve the health of your patients.
Denise Weiss is a Registered Nurse at The Rinehart Clinic in Wheeler, OR. The clinic's service area is a federally-designated Health Professional Shortage Area, meaning it has an "acute shortage of health care providers," and also is a federally-designated Medically Underserved Area, meaning the area lacks the resources "to meet the medical needs of the resident population." The Rinehart Clinic is working to meet those needs by providing high quality, complete, personalized medical care for residents and visitors.