Dire Dawa Administration Health Bureau

Goro Health Center

HTN Patients BP Control (Treatment Outcome)

Quality Improvement Project

March, 2023

Dire Dawa
Content Page
1. Content ------------------------------------------------------------------------------------------- 2
2. Introduction -------------------------------------------------------------------------------------- 3
3. Baseline Assessment ---------------------------------------------------------------------------- 4
4. Problem Identification -------------------------------------------------------------------------- 4
5. Problem Prioritization -------------------------------------------------------------------------- 5
6. Problem Statement ------------------------------------------------------------------------------ 5
7. Aim Statement ----------------------------------------------------------------------------------- 5
8. Root Cause Analysis --------------------------------------------------------------------------- 6
9. Generating Change Idea ----------------------------------------------------------------------- 7
10. Process Map ------------------------------------------------------------------------------------- 8
11. Performance Measures ------------------------------------------------------------------------- 9
12. Testing Change Idea -------------------------------------------------------------------------- 10
13. Implementation Action Plan ----------------------------------------------------------------- 11

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Introduction
Hypertension - is a serious medical condition that significantly increases the risks of heart, brain,
kidney, other organ diseases and cause of premature death worldwide. An estimated 1.13
billion people worldwide have hypertension, of which most (two-thirds) living in low- and

middle-income countries.

In Africa, WHO projections indicate death from NCDs to exceed all combined communicable,
maternal, perinatal, and nutritional diseases as the most common causes of death by 2030. This
implies that NCDs represent a leading threat to health, economies, and overall human
development in the African. Fewer than 1 in 5 people with hypertension have the problem under
control. This is primarily the result of insufficient access to care, inadequate management and the
existence of numerous financial barriers and patient factors.

In Ethiopia, almost 7.8 million adults are living with hypertension, which is about 15.8% of
adult Ethiopians have raised blood pressure. The Government of Ethiopia has adopted a
national action plan for the prevention and control of non-communicable diseases, with
specific targets to be achieved by 2025.
These include:
1. 25% relative reduction in overall mortality from cardiovascular diseases
2. 30% relative reduction in mean population intake of salt/sodium
3. 25% relative reduction in prevalence of raised BP.
Goro Health Center is providing primary health care service including non-communicable
disease care service under the roadmap of HSTP II strategic priority. The roadmap identifies and
clearly stipulates the major steps of the quality improvement project planning, communication
and implementation strategy. So this quality improvement project has been designed to improve
quality of HTN patient treatment and follows up, achieving optimum control of blood pressure in
alignment with the national commitment

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 Problems Identification
We have reviewed Simple App Database 2015 EFY six months HTN treatment and follow up
cohort report to identify major strengths and gaps; and to fix all possible problems for next
further service quality improvement at Goro Health Center in August 2015 E.C..

We have indentified the problems from the 2015 EFY six months HTN treatment and follow up
cohort report which shows so many gaps between the existing state and the desired state of a
process which need special high impact intervention for better improvement. As we understood
from the report, there were gaps in HTN patient BP control, missed appointment and defaulter
tracing, and HTN treatment drug titration. The lists of major gaps identified from the report are:

1. Low BP control of HTN patients

2. High HTN care and follow up defaulters
3. HTN drugs stock interruption
4. Poor appointment and defaulter tracing system
5. Poor HTN drug titration practice for service quality

Problem Prioritization
We select one problem using prioritization matrix, which can be fixed easily with limited
resource in a short period of time.
Priority Criteria
SN Problems need to be improved Magnitude Severity Acceptability Feasibility Total

1 High HTN care and follow up defaulters 5 4 4 3 16

2 HTN drugs stock interruption 3 5 5 2 15
3 Low BP control of HTN patients 4 5 5 3 17
4 Poor appointment and defaulter tracing system 4 3 4 3 14
5 Poor HTN drug titration practice for quality care 5 3 4 4 16

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Problem Statement

In Goro Health Center, there is poor quality of HTN care and treatment follow up delivery
system. The simple app database HTN treatment cohort report indicated that the proportion of
HTN patient blood pressure control rate were very low (54%), which might cause to increased
medical complication of hypertension, patient morbidity and mortality. The cohort report shows
that there were large number of HTN patients defaulted from treatment follow up, and poor drug
titration practice leading to inappropriate treatment. These the above mentioned problems result
in poor hypertension treatment outcome. The problem will be solved when the blood pressure, of
HTN patients who stayed in the care for three months and above, is optimum measurement or
(BP< 140/90 mm Hg).

Aim Statement

We Goro HC QI team, aims to improve HTN patients’ blood pressure (BP) control rate from
54% to 85% in the next six months, from April 2015 to August 2015 EFY

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Root Cause Analysis
We apply fishbone diagram the find out root causes of the problem which help us to generate drivers of change idea

Process

Skill gap in reporting and

information use

Figure1: Root Cause Analysis

Goro Health Center HTN Patients’ BP Control Quality Improvement Drivers Diagram

Primary

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Generating Change Ideas
1. Improve provider skill and commitment
 Provide orientation on
 Proper BP measurement technique
 Information recording and document filing
 Healthy life-style change counseling
 Select best performers & recognize
 Provide patient handover SOPs
3. Improve treatment adherence & patient
engagement
 Provide HE at facility and community
 Prepare HTN care beneficiary for experience sharing
 Conduct HTN patients forum and community
dialogue on HTN care follow up and adherence
 Conduct community mass screening
2. Provide management support and follow up
 Establish NCD specific PMT sub team for
 Cascade and communicate QI plan to providers and PMT members
 Conduct performance review audit monthly basis
 Prepare performance-based written feedback
4. Strengthen Data quality and Evidence-Based care
 Adopt and provide data recording & reporting SOP
 Conduct LQAS and RDQA regularly at NCD unit
 Conduct clinical audit and provide feedback for evidence-based
care & treatment
 Adhere treatment guidelines and protocols
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Outpatient and Chronic Care and Follow up Process Map

Goro Health Center

Triage Center
Record demographic information-age, sex Card
Check BP, RBS, PR Room
Classify & Tally

Figure2: QI Project Implementation Process Map

Performance Measures

1. Outcome Measure:

 Indicator: Percentage of HTN patients whose BP is controlled in optimum range < 130/90 mmHg

 Numerator: Number of HTN patients visited NCD unit and have controlled BP in reporting time

 Denominator: Total number of HTN patients visited NCD unit in reporting time

2. Process Measures:

 Indicator: Percentage of staffs oriented on HTN care specific topics

 Numerator: Number of staffs who got orientation on HTN care specific topics

 Denominator: Total number of staffs planned to be trained on HTN care specific topics

 Indicator: Percentage of necessary supply availability

 Numerator: Number of available supplies for HTN care and treatment

 Denominator: Total number of supplies needed for HTN care and treatment

 Indicator: Number of QI team meeting conducted per month

 Indicator: Number of written feedback prepared and provided to NCD unit

3. Balancing Measures:

 Indicator: Number of complaints received from NCD care team on additional activities and or on

extra working time

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 Change Ideas Testing Model
We apply PDSA Cycle in weekly interval rapid and multiple cycles to test HTN Bundle Adherence
driving change ideas initially on a small scale at NCD care unit during the next three months and
increase the scale of the test on the basis of learning. We also follow PDSA Cycle principles to monitor
and evaluate project implementation status by ongoing data collection, analysis and use of information
for provision of performance-based feedback.

ACTION PLAN
Define standard indicators, using feedback information or baseline from previou
Use information for planning Define activities/ procedures and Assign responsible person
Provide feedback to NCD Care Team
Standardize data collection tools
Make program changes if neededDetermine time frame and reporting frequency and the pathways for data flow

STUDY DO
Implement activities/ procedures
Calculate indicators Collect, aggregate and compile data using standard tools
Interpret what do the indicators say about the program? Check data quality
Visualize indicators (chart, graph etc.) Communicate aggregate data or indicator report

Figure3: PDSA Cycle Running Model

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 HTN Patients BP Control QI Project Implementation Action Plan to Test Change Ideas with Timeframe and Responsible Person
SN Activities to Test Change Idea Responsible Person Where to Work Time Frame
1 Improve provider skill and commitment
1.1 Provide orientation on HTN care specific topics Dr. Dagninet & QI team Goro HC 05/08/2015 E.C.
Prepare proposal and ready training materials and call for trainees Dr. Dagninet & QI team Goro HC 05/08/2015 E.C.
Conduct training using adult learning method Dr. Dagninet & Endalamaw HC meeting hall 10/08/2015 E.C.
Document training minute, participant attendance & take picture Sr. Kalkidan and Asfaw HC meeting hall 10/08/2015 E.C.
1.2 Prepare and avail HTN patient handover SOP Dr. Dagninet & Endalamaw HC meeting hall 15/08/2015 E.C.
1.3 Select best performer and recognize Management team Head Office 05/010/2015 E.C.
2 Strengthen Data Quality and Evidence-Based Care Delivery
2.1 Adopt and provide data recording & reporting SOP Dr. Dagninet & Endalamaw HF Head office 10/07/2015 E.C.
2.2 Conduct LQAS and RDQA regularly at NCD unit Dr. Dagninet & Sr. Kalkidan NCD unit Monthly
2.3 Conduct clinical audit and provide feedback for evidence-based care & QI team members HF Head Office Monthly
treatment
2.4 Adhere on treatment guidelines and protocols Dr. Dagninet, Sr. Kalkidan NCD Care Unit Always
3 Provide Management Support and Follow up
3.1 Establish NCD specific PMT sub team for HTN care follow up Endalamaw Goro HC 10/08/2015 E.C.
3.2 Cascade and communicate QI plan to providers and PMT members Dr. Dagninet & Endalamaw Goro HC 10/07/2015 E.C.
3.3 Conduct performance review audit monthly basis All QI Team Members HF Head Office Monthly
3.4 Prepare performance-based written feedback All QI Team Members HF Head Office Monthly
4 Strengthen HTN Treatment Adherence and Patient Engagement Activities
4.1 Provide HE at facility and community Dawit, Sr. Abrehet, Sr. Kalkidan Patient Waiting Area 5 days per week
4.2 Prepare HTN care beneficiary for experience sharing Dr. Dagninet, & Sr. Kalkidan Facility 12/09/2015 E.C
4.3 Conduct HTN patients forum and community dialogue on HTN care QI team & UHE-P supervisor Facility Monthly
follow up and adherence
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