Table 1

LCHC hypertension measurement plan

Measure name	Type of measure	Type of chart	Operational definition	Data source(s)	Goals
% BP at goal	Outcome	P chart	N=number of patients* with HTN and BP<140/90† D=number of patients with HTN with PC billable visit in month	Epic → DRVS‡, uploaded nightly	>80% by 31 December 2017
% Recheck BP if elevated	Process	Run chart, then P chart	N=number of patients with first BP>140/90 and second BP check in same encounter D=number of patients with first BP>140/90 in face-to-face encounter	Epic → SQL → Excel, output on Thursday before first Monday of each month	>80% by 31 December 2017
% BP in last 6 months	Process	P chart	N=number of patients with BP check in last 6 months D=number of patients with HTN	Epic → SQL → Excel, output on Thursday before first Monday of each month	>80% by 31 December 2017
% Outreach if BP not at goal	Process	Run chart, then P chart	N=(number of patients with last BP>140/90 or no BP check in last 6 months) and outreach telephone encounter in past 1 month D=number of patients with HTN and last BP>140/90	Epic → SQL → Excel, output on Thursday before first Monday of each month	>80% by 31 December 2017
% HTN encounters by RN, BH, PharmD, CHW	Process	P chart	N=number of encounters (all types) with HTN visit diagnosis and rendering provider§ D=number of encounters (all types) with HTN visit diagnosis	Epic → Excel, output on Thursday before first Monday of each month	>50% by 31 December 2017
100% Team members trained	System	Check sheet	Yes=100% of team members trained in HTN workflow No=<100% trained	Team leader self-report at weekly PC improvement meeting	100% by 1 April 2017

*All patients were empaneled to an LCHC primary care provider (PCP).
†Blood pressure goal of <140/90 defined by the Uniform Data System (UDS) for community health centres.
‡DRVS from Azara, Data Reporting and Analytics Solutions software.
§Rendering provider: RN, behavioural health, PharmD or community health worker.
BH, behavioural health; BP, blood pressure; CHW, community health worker; HTN, hypertension; LCHC, Lynn Community Health Center; PC, primary care; RN, registered nurse; SQL, Structured Query Language for data analysis.