Protocol Assignment Forum: Organizational Culture, Behavior

1. Describe the organizational and/or delivery system environment in which your intervention will take place.

My intervention will take place at the General Medical Clinic (GMC) at SFGH. GMC is an ambulatory care facility providing comprehensive primary care and specialty care for adults in a safety-net setting.

2. Based on Shortell’s 4 domains of organizational change, identify organizational barriers that could potentially impede successful implementation of your proposed intervention.

According to Shortell’s 4 domains of organizational change, here are some potential barriers that could potentially impede successful implementation of my proposed intervention:

1. Clinical Quality Performance:  The clinic does not have a registry of hypertensive patients. Therefore data on patients with uncontrolled hypertension (<140/90) is not readily available. A registry is being developed to track patients. Implementing an adapted version of the Kaiser protocol and algorithm maybe challenging as clinicians like their autonomy and don’t usually like to use algorithms. However, implementation of the protocol will lead to increased treatment intensification which in turn will lead to patients with controlled hypertension.
2. Patient Satisfaction: Patients will have to return multiple times for blood pressure checks. If scheduling is challenging then it is likely that patients will be unhappy. Also, making multiple visits for the GMC patient population can be quite challenging.
3. Organizational Learning: There has to be buy-in by the Clinic Director, Nurse Manager, Practice Manager, and Clinicians. All of these key stakeholders have been involved in adapting the Kaiser protocol and algorithm, however as the clinic is short-staffed and the patient load keeps increasing, implementing this new protocol is being viewed as additional work for clinicians. Task shifting needs to happen from physicians to nurses for implementation to reduce the burden on physicians.
4. Financial Performance: Multiple visits for blood pressure checks needs to be billable. This would then increase revenue for the clinic.

3. Using the same 4 domain model, describe how your intervention plan can take advantage of organizational strengths OR propose practical methods for addressing these barriers within your program.

1. Clinical Quality Performance: Hypertension Registry will make it easier to track hypertensive patients. Adapted algorithm will enable task shifting and nurses can take more of a leadership role in implementing the protocol.
2. Patient Satisfaction: Patient education will hopefully make multiple visits for blood pressure checks easier for patients.
3. Organizational Learning: The newly implemented EHR should make it easier to track blood pressure check visits. Also, the hypertension registry will generate regular reports for monitoring the effectiveness of the new protocol being implemented.
4. Financial Performance: Need to confirm that multiple visits for blood pressure checks are billable. If so, additional revenue will be generated for the clinic.

Past protocols

Assignments #1 and 2 (not updated but included for background information)

1) What evidence are you proposing to translate into practice?

 I propose translating Kaiser Permanente’s (KP) hypertension control protocol in a primary care practice within the Community Health Network.

 2) Justify that this evidence is “ready for translation.”

 This evidence is ready for translation as it has been highly effective at KP in reducing blood pressure in their patient population. KP nearly doubled the rate of blood pressure control in adult patients with diagnosed hypertension in 2001 to 2009 from 44% to 84%.

 3) Identify a single, key behavior change target for your translational activity.

Improve physician likelihood of treatment intensification.

 4) Conduct a “gap analysis” of your target behavior.

National data – Only 19% of patients receive treatment intensification during clinic visits with uncontrolled HTN.

5) What is the quality (performance) gap?

Nationwide BP control is near 50% whereas BP control at KP is 84%

6) What is the outcome gap? Patients with uncontrolled BP are at higher risk for future cardiovascular events.

 7) Is there evidence that changing performance will improve health (clinical outcomes)?

There is strong evidence that effective BP control reduces the incidence of cardiovascular disease.

 Assignment # 2 (not updated) 

1) Define the communities for your project and explain why each is a stakeholder for your study.

GMC Clinicians (doctors, nurses, Pas, pharmacists) – They have to be convinced that implementing an adapted version of the Kaiser blood pressure control protocol would benefit GMC patients with uncontrolled hypertension.

UCSF Faculty, staff, nurse managers, pharmacy, other leaders, and patient representatives associated with GMC.

 2) Describe your plan for approaching potential community partners to ask for their involvement.

 Buy-in has to begin at the highest level so I would first meet with the Clinic Director. Several meetings with representatives from all the various groups of stakeholders would be the next level of meetings. Baseline clinic data will be shared during these initial meetings.

 3) Identify which stages if your project you’ll incorporate community input, and describe what types of input you’ll solicit.

-        At every stage – drafting protocol, reviewing medication formulary, gathering base line data, data analyses, publication and dissemination.

 4) Name three ways you plan to share your results, beyond writing an academic articles or presenting at an academic conference.

-        GMC Meetings

-        GMC Meetings

-        Clinic, Division of General Internal Medicine, and Center for Vulnerable Populations websites

-        Social Media platforms like Twitter

ASSIGNMENT # 3 - Mapping

1. Identify a patient or community group that contributes to or is involved in the principal behavior you are attempting to improve with your intervention.

The principal behavior I am trying to improve is treatment intensification by clinicians for uncontrolled hypertension in General Medical Clinic patients at SFGH.

The target groups are physicians, residents, Nurse Practitioners, Nurses, and MEAs at the General Medical Clinic at San Francisco General Hospital.

2. Using any of the individual explanatory theories in “Theory at a Glance”, develop an explanatory model for the target behavior (above) that you will be attempting to influence with your intervention.  This can be an extension/based on expected findings (or previously published literature) from your answers to Homework #3.  Figures are always very useful... keep it simple.

As this particular protocol is planning to address clinician behavior the Theory of Planned Behavior seems most appropriate.

I didn’t have time to do the diagram.

Attitude – Clinicians attitude about treatment intensification for controlling hypertension

Behavioral Beliefs – Clinicians realize the importance of treating hypertension over 140/90. However, they may feel that I it is largely “white coat” HTN. They also tend to be reluctant to follow algorithms that they didn’t have an input in preparing. They tend to be apprehensive when they feel their autonomy will be compromised.  Studies have shown that clinicians often exhibit “therapeutic inertia”, because of unfamiliarity with clinical guidelines and clinical uncertainty.

Outcome Expectancy – Clinicans may feel that the higher HTN rates is “white coat” hypertension. Also, what if it is resistant hypertension then treatment intensification won’t help.

Subjective Norm – Are other GMC colleagues complying with the new guidelines for treatment intensitfication?

Normative Beliefs – If other GMC colleagues are implementing then I will also do the same.

Motivation to Comply – If other GMC colleagues are colleagues are following treatment intensification protocol then the clinicians will comply. If the clinic administration requires everyone to adopt the new guidelines then clinicians are more likely to comply. Also, sharing Kaiser’s success story will most likely motivate clinicians to comply.

Perceived Behavioural Control – How much control do I have in implementing the new protocol for treatment intensification?

Control Beliefs – Are the currently recorded BP measurements accurate? Are patients going to be able to ome back multiple times to get their BP read? Are there adequate staff to support the additional visit requirements? Are patients going to be able to afford the additional medications? Will they take them? How will patients deal with medication side-effects?

Perceived Power – Patients may not be able to come back multiple times for BP checks. Staffing is inadequate to support treatment intensification requirements. Not posssible to ensure patients are taking the additional meds.

External Factors

-          Clinic administration’s support is crucial for implementation of new protocol

-          Additional staffing will required for additional patient visits

-          Nursing staff can be trained to implement protocol and thereby reduce burden on doctors

-          Pharmacists should be involved in every stage to successfully implement the protocol and educate patients about side effects and importance of adherence

3. Identify how one or more of your specific interventions will target one or more of these key factors contributing to the behavior of interest.

-          Support from clinic administration

-          Involvement of clinicians in adapting the protocol for GMC

-          Education sessions for clinicians

-          Task shifting from doctors to nurses for BP checks and implementation of protocol.

4. Create a framework that draws upon a socio-ecological framework to orient your target behavior within a larger context.  ie, what are some of broader, external forces that influence the individual behavior of interest...see Figure 2 of “Theory at a Glance.”

1. Social and Economic Policies – This is where the insurance companies play a role. Will they cover additional meds? Will they cover non-generic meds?
2. Institutions – Is there buy-in from hospital and clinic administrators? Will there be any kind of recognition at the institutional level for improved hypertension treatment intensification rates in GMC.
3. Individual and Population Health –  Social marketing can be used at the community level to highlight the importance of HTN control. Social marketing can educate neighborhoods and communities on this topic thereby increasing the health literacy of the patient population. Patient living conditions are important. What are the factors that would affect behavior change in patients? Do they live in safe neighborhoods so they can go for walks? Do they have access to fresh fruits and vegetables for a healthier diet?