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.
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.
Focus on improved hypertension control
1. Improve blood pressure technique to insure accurate blood pressure
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
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
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
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
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.
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
c. Standardization of data entry
d. Health Connect Blood Pressure alert was developed.
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
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
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
ii. Standard after visit summary for patients developed
a. CMI guidelines
b. Patient Handouts
i. Patient Hypertension
1. General information
2. Dietary guidelines for hypertension
3. How to take an appropriate blood pressure
4. Goal Setting
5. Home BP Log
ii. Medication information
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
b. Working on development of outreach process in panel management
a. Smartext set up and
b. MA-BP best practice alert developed and tested, June 2009 and implemented
region-wide in August 2009
6. Panel Support Tool-decision
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
5. Decrease in scheduled visits in providers for blood pressure check
6. Currently achieved hypertension regional goals in following areas:
a. 2nd BP on elevated first
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