An RN works in a primary care clinic affiliated with the local community hospital. Using the PCMH Model, each care team manages a panel of 1,200 patients. In preparation for the weekly team meeting, the RN accesses the BP measurement data for the team’s panel of patients. While discussing the available panel data, the team notices the:

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Percentage of patients at or below their target/goal BP is 69%, while the hospital benchmark is 85%.

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Percentage of African American patients at or below their target/goal BP is 63%.

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Percentage of patients who do not attend appointments as scheduled is 28%, while the national average is 23.5%.

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One hundred eleven patients on the panel have a last recorded BP above the target/goal: 60 patients were seen more than 6 weeks ago and 51 patients were seen more than 3 months ago. The next available face-to-face provider visit is in 6 weeks.

The team decides to implement a QI initiative.

1.

In addition to the RN, what care team members will participate in the QI initiative?

2.

What interventions, including referrals and links to population-based interventions, might the QI team use to increase the number of patients on their panel of 1,200 patients who are at or below their target/goal BP?

3.

What dimensions of quality (STEEEP) are reflected in the data?