Table 1 Quality improvement change concepts and key activities

Embed clinical evidence on ABCS into daily work to guide care for patients

▪ Review the evidence supporting the ABCS for primary and secondary prevention of cardiovascular risk

▪ Review treatment guidelines for ABCS measures

▪ Educate staff on clinical guidelines

▪ Select patient education materials for primary and secondary prevention

Utilize reliable, robust data to understand and improve ABCS measures

▪ Develop process to pull data from EMR

▪ Review data for accuracy and build confidence in data

▪ Develop process to support accurate data entry/collection

▪ Use data to identify gaps between the evidence-based guidelines and current care for all patients on panel

▪ Create population-based reports and visual data dashboards

Establish a regular QI process involving cross-functional teams

▪ Set aside regular meeting time for cross-functional QI team

▪ Select a QI methodology to structure improvement efforts

▪ Train team members on QI methodology

▪ Practice good meeting skills

▪ Regularly review data on ABCS outcome and process measures to understand areas for improvement

▪ Invite patient(s) to participate on the QI team

Identify at-risk patients for prevention outreach

▪ Understand current patient panel relative to ABCS

▪ Select actionable improvement goals based on ABCS data

▪ Recall patients overdue for care/outreach related to ABCS testing, education, counseling

Define roles and responsibilities (tasks) across the care team to identify and manage ABCS population

▪ Use workflow mapping to examine current processes and explore other approaches

▪ Introduce preventive screenings and educational materials for ABCS measures into workflow

▪ Develop/enable point of care reminders based on ABCS guidelines

▪ Scrub charts daily to flag patients needing support on ABCS

Deepen patient self-management support for action planning around ABCS

▪ Train staff in motivational interviewing

▪ Develop shared care plans with patients, emphasizing goal setting led by patient values

▪ Follow up with patient progress toward care plan goals

Develop robust linkage to smoking cessation, self-management programs, and other evidence-based community resources

▪ Create list of community resources and keep in a location accessible to all staff members

▪ Outreach to community resources to build referral pathway

▪ Provide list of resources to patients

▪ Proactively refer patients to community resources and assist in establishing patient with the resource