CONCLUSIONS FROM THE INITIAL QUALITY ASSESSMENT
45% of all the hypertensive patients had PDC > 80% from baseline assessment. Of the 45%, 84% of them have controlled Blood pressure below 140/90mmHg, this suggests a strong correlation between blood pressure control and medication adherence. The interesting finding is that 95% of the patients with PDC>80% had documentation of patient education about Hypertension, medications, and the need for adherence. And Patient records with no patient education was 98% with PDC<80% leading us to conclude that there is strong correlation between standardized patient education and medication adherence.
| BP <140/90mmHg | BP >140/90 mmHg | Incomplete BP record | |
|---|---|---|---|
|
PDC >80 |
84% |
12% |
4% |
|
PDC<80 |
11% |
81% |
8% |
| Factors affecting medication adherence | PDC > 80 | PDC<80 | Incomplete records |
|---|---|---|---|
|
Patient Education done and documented |
95% |
5% |
|
|
Patient Education not done |
2% |
98% |
|
|
Single dosing daily regimen |
78% |
20% |
2% |
|
Multiple Dosing Daily Regimen |
22% |
76% |
4% |
DESCRIBE YOUR SELECTED QUALITY IMPROVEMENT GOALS TARGETED FOR IMPROVEMENT BASED ON YOUR ASSESSMENT RESULTS
- Ensure we get 70% for all hypertensive patients to have PDC of >80% over the next one year.
- Improving the provision of a standardized patient education on medication adherence
- Improving the population of our hypertensive patients on Single daily dosing regimen
HIGHLIGHT POTENTIAL WAYS TO MEET THIS GOAL (MAY BE EVIDENCED BASED FROM LITERATUREAS WELL)
The following are literature based potential ways to achieve the goal of improving medication adherence amongst hypertensive patients
- Nurse driven patient education with educational materials on hypertension and medications
- Integration of pharmacists in monitoring patients for medication adherence
- Involvement of patients in shared decision making for prescription with the physician 1-3
- Behavioral counselling on need for medication adherence
- Nurse driven patient follow up call
- Encouraging the use of punch cards for medication usage monitoring for patients
- Technology mediated medication reminder apps for patients
SELECT QUALITY IMPROVEMENT INTERVENTIONS & WHY YOU CHOSE THOSE INTERVENTIONS
The following interventions are selected to address the two-priority problem of patients’ awareness and the complexity of the dosing regimen which were found at assessment to be linked to poor medication adherence:
- Pharmacist counsel on medication adherence with feedback system for managing side effects
- Patients involvement in decisions on having single daily dosing regimen by the physicians during consultations.
The pharmacist has the double advantage of being able to counsel patients well, monitor their drug fill and refill records and provide feedback in cases of adverse event to medications. While patient’s involvement in decisions making makes them get empowered to want to improve medication adherence.
Root cause analysis reveals that the major factor in medication adherence is patients’ poor knowledge on the need to take medications to control blood pressure and inadequate awareness of the long-term complications of poor adherence. Secondly, Patients favour single daily dosing options and feels empowered when involved in the choice of their medications.
The selection process starts with using a flow diagram to breakdown all the process that patient’s goes through from the patient’s community to the clinic, and all processes from the receptionists, to the Nurses, to the Physician consulting room, the pharmacist and then back home.
Using this 2 X 2 table analysis for prioritization of all possible intervention steps or points found during the flow diagram analysis,
| Prioritizing Interventions | |||
|---|---|---|---|
|
High Impact
|
Content |
||
THE INTERVENTION’S SELECTED
- Pharmacist counsel on medication adherence with feedback system for managing side effects
- Patients’ involvement in decisions on having single daily dosing regimen by the physicians during consultations.
The interventions at the Pharmacy will be a well standardized checklist driven knowledge transmission on hypertension as a disease, the long-term complications and the advantages of medication adherence. Educational materials are provided for patients to take home. Educational videos are also made available to answer frequently asked questions about hypertension and medication adherence while they are waiting to pick up their medications. During medication pick up, the pharmacist will interact with the patients and answer any pending concerns on medication adherence.
Patients are enlightened about getting involved in the selection of the choice of their medications during their consultation time with physicians. Every time this is done, it is documented in the patient medical records for tracking in the Pharmacy Dispensing records.
Secondly, checklist driven physicians counselling for patients. This will be policy driven. Ensure medication regimen choices are made with patients favoring single daily choices titrated against their blood pressure findings. The medical assistants or Nurses who had taken their vitals would have informed all patients prior to consultation of the new policy and that patient should get engaged in the process of medication selection.
INTERVENTIONAL STUDY DESIGN
The intervention will be tested over a period of 12 months. There will be 4 rapid PDSA cycles. The first two interventions above will be tested. Analysis of patients’ medical records will be done quarterly to study the percentage of patients who had in their medical records physician counselling and single dosing regimen. Secondly, the number of patients with counselling at the pharmacy unit, feedback reports and management in their pharmacy dispensing records. This figure will then be correlated with the records of %PDC calculated at the Pharmacy Unit quarterly to evaluate improvement in the percentage of patients with more than 80% adherence to medication from their fill/refill records. Ultimately, the percentage of patient will be correlated with controlled blood pressure records from the medical records.
After two PDSA cycles making 6 months, if we have not achieved increasing % patients with 80% or more PDC of about 60%, (Note: we are currently at 45% aiming for 70% within one year) we will have to introduce Nurse driven monthly patient education follow up phone call on hypertension and medication adherence as the third intervention. This will be added and tested in the third cycle and fourth cycle alongside the initial two interventions. The nurses will have a final checklist for standardized educational program on MA in hypertension. At least, two phone conversation within the quarter will be marked as done in the patient’s records.
At the end of 9 and 12 months, re-evaluation of the % of patients with more than 80% PDC, is calculated from the pharmacy dispensing data. To achieve our goal of 70%, it means 105 of our 150 hypertensive patients in our community clinic must have PDC of greater than or equal to 80%.
IMPLEMENTATION OF INTERVENTION
The first two intervention to be introduced is a policy to ensure physicians allow for patients’ decisions in drug regimen choices and this choice should favor a single daily dosing. The second intervention is a pharmacy driven educational counselling on hypertension and the need for medication adherence. Checklists are created on the Hospital Records – both at physician portal and pharmacy dispensing interface – to include the sequence of patients’ engagement and education – this will be checked once it is done. All patients who had at least two exposures to the intervention within the cycle will be counted as effective intervention. Hence, the need to go two cycles with the first set of interventions.
Patients are introduced to the new policy during their clinic visits by the medical assistants while their vital data is being taken. The target goal of medication adherence is also made known to the patients. The physicians are to ensure patients are told the policy and encourage patients during their consultation time to ask questions and freely make decisions that will improve adherence to their antihypertensive. The checklist is ticked once this is done.
EFFECTIVE ENGAGMENT OF LEADERSHIP AND STAFF
For change in policy for physicians to be effective, the Medical Director has to be engaged. The medical director or any senior physician will be given the responsibility to champion the policy development. The Pharmacy leadership structure must be engaged to ensure counselling, and quarterly data sets are made available. A senior pharmacy staff must also be engaged to champion the intervention. Support from the Medical Assistant and Nurses will be needed; therefore, their leadership structure should be primed, then informed of the policy, and the goal for the clinic.
DEFINING THE POTENTIAL BARRIERS AND FACILITATORS OF IMPROVEMENT
Basically, organizational readiness for change has to be managed effectively. This is the major reason the first PDSA intervention cycle will run twice before an additional intervention. Resistance from physician to engage patients in care decisions is a major potential barrier. This will be managed with open communication in meetings and discussions with the physicians from the medical director. The waiting time at the hospital may increase, looking into time taken for decision making by each patient for their care, noting that several patients have many different conditions associated with their hypertensions. The pharmacy unit may become overwhelmed as well. The time taken to counsel and gather data with the current staff structure. ICT support will be explored to see how to improve their processes. For the nurse driven calls, challenges of patients not picking up calls and having to call back severally.
Facilitators for improvement will include the goal. The motivation of achieving more than 70% of patients with at least 80% adherence to medication and seeing more patients with controlled BP figures. The strong buy in from the medical director is a major facilitator for improvement. Financial incentives from contracts with Insurance Companies are facilitator for improvement. Meeting the benchmarks for Regulators and Accreditation organizations will drive us to achieve the goal.
REASSESSMENT MEASURE SELECTION
| After first PDSA quarterly cycle, 3months of the two-intervention data | |||
|---|---|---|---|
|
% Of patients counselled by physicians (more than once) |
% of patients counselled by pharmacist and given individualized educational materials (more than once) |
% Number of patients called more than once in the quarter |
% Of patients with PDC 80% and above |
|
05 |
10 |
Not Yet Done |
48 |
|
After Second PDSA quarterly cycle, with the two-intervention making 6 months of intervention
|
|||
|
25 |
40 |
Not yet Done |
55 |
|
By the Third PDSA cycle, with the introduction of Nurse driven monthly patient education follow up phone call on hypertension and medication adherence |
|||
|
56 |
65 |
50 |
62 |
|
By the end of the Year, 4th cycle of PDSA, running the three interventions |
|||
|
60 |
75 |
66 |
67 |
COMPARISON
Since we have a sister practice with similar patients’ behavioral profile and care setting few miles away, the practice will be our control group. We also share similar baseline data on percentage of medication adherence and patients with control of blood pressure. We will compare data at the end of the 12 months intervention. Spread through other provider setting will happen when we match our goal in the first test center.
Summarized By Dr.Joshua Kolawole
(MD, MBA, MASc., FISQua, CPHQ, PMP)
Agile Program Manager & Transformational Leadership Expert, Valdymas Intelligence LLC, Grand Prairie, Texas, USA.
valdymas@valdymasintelligence.org