Checklists—like the ones used to reduce central-line infections—can help physician practices improve outcomes for hypertension, one of America’s most common and dangerous conditions. But even for those committed to improving patient safety and health care quality, checklists alone won’t sustain positive changes without a shift in attitudes and beliefs.
Fortunately, a safety model proven to succeed in the acute setting can help create and sustain change in the ambulatory setting for measuring blood pressure. Participants in a pilot program, part of the AMA’s Improving Health Outcomes initiative, are currently involved in applying this model to their practice settings.
The Comprehensive Unit-Based Safety Program (CUSP) is a five-step process designed to change a practice’s workplace culture to bring about significant improvements in quality and safety. Developed by the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, a partner in the AMA’s work to improve health outcomes around hypertension, the framework aims to empower staff to drive quality improvement efforts in their clinical areas.
The five steps of the CUSP model are:
1. Train staff in the science of safety. Understanding how system factors affect care delivery is key to making lasting improvements. The program provides a 20-minute video developed by Armstrong Institute director Peter Pronovost, MD, that describes how system factors can negatively impact care and lead to preventable harm.
2. Engage staff to identify defects. In this second step, staff members identify patient safety defects in their work areas and explain how these defects may contribute to a patient’s uncontrolled hypertension. For example, the position of a wall-mounted sphygmomanometer could prohibit clinical staff from properly positioning patients to ensure accurate blood pressure measurements.
3. Partner with a senior executive or someone who has decision-making power over the practice. This step helps the practice teams bridge the gap between frontline staff and executive leadership. The active involvement of practice leaders in improvement efforts helps develop a shared understanding of issues, establishes support for implementing and evaluating the plan, and gives teams the leverage they need to create real change in their practice.
4. Learn from defects. In this phase, staff members improve care by examining a defect to understand what went wrong, why it happened, what was done to reduce risk and how they can ensure risks were reduced.
5. Implement tools to improve. The practice team then uses tools to address areas that need improvement. In the case of the Improving Health Outcomes: Blood Pressure initiative, the AMA and collaborators at Johns Hopkins are partnering with 10 pilot practices in two states to develop and test a set of evidence-based recommendations and associated tools called the “M.A.P. for achieving optimal hypertension control.”
Using CUSP enables cultural change within a practice, providing a means to shift staff’s attitudes, values and beliefs. Because all staff must use their expertise to implement CUSP, the entire team is empowered to continue the process as a new norm.
In the AMA pilot program, the practice sites also will benefit from lessons learned from Project ReDCHiP (Reducing Disparities and Controlling Hypertension in Primary Care) in their integration of quality improvement and patient-centered care principles. Lisa Cooper, MD, director of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, and her team will assist in leveraging their expertise in hypertension control improvement.
