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Table 1 Quality improvement change concepts and key activities

From: Study protocol for “Healthy Hearts Northwest”: a 2 × 2 randomized factorial trial to build quality improvement capacity in primary care

Change concept Description of practice 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
  1. ABCS aspirin, blood pressure, cholesterol, smoking, EMR electronic medical record, QI quality improvement