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Rewarding good practice: improving blood pressure management

Journal of Diabetes Nursing, Feb, 2005 by Linda Goulden

Introduction

With the increasing workload in primary care as part of the NHS Plan (Department of Health, 1997), the new General Medical Services contract (nGMS; British Medical Association, 2003) and clinical governance requirements, the development of practice-based programmes of care must balance patient need with financial incentives. The mix of skills within the team, along with increased use of technology, must both support and demonstrate quality care. In implementing change-management of blood pressure in diabetes, which coincided with moving to 'paper-light' status, a whole-system approach was shown to ultimately reward both patient and practice.

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As a practice nurse, my role in provision and coordination of care for our patients with diabetes has increased significantly. With an ever increasing number of people with diabetes coming under GP care, the senior partner and myself undertook further professional learning to support the development of improved coordinated, consistent care for those with diabetes best managed within our practice programme.

With the looming new General Medical Services (nGMS; British Medical Association, 2003) contract and plans to become 'paper light', the recording of information on our computer system to ease the process of audit became a priority (see Figure 1). To provide a baseline to initiate change in practice, I undertook an audit of blood pressure management in relation to whether all people with diabetes in our practice had measurements taken within a 12-month period and if target blood pressure levels had been achieved. To compare practice against what was recorded, I audited both manual and electronic records. The audit was repeated at a later date to hopefully demonstrate improvement and so complete the audit cycle.

In the initial audit, the standard for those patients having had their blood pressure measured in the previous 12 months was set at 90%. Although manual search of paper records demonstrated achievement of this standard, only 68% could be supported by electronic data. In setting the baseline standard for achieving target blood pressure, I used the nGMS maximum threshold indicator of 55% of patients achieving a target blood pressure of 145/85 mmHg or under. Again, I compared manually recorded data against electronic records. We fell short of both standards here, achieving 45% in practice, but only being able to electronically demonstrate achievement of target blood pressure control in 32% of patients.

The initial audit resulted in a number of recommendations for change in practice that would address shortfalls in both holistic hypertension management as well as accurate data recording. Key areas of work would focus on clinical protocols for diabetes care, accurate computer data recording and achieving the best 'skill mix' within the team to best use resources and improve clinical outcomes.

nGMS: bringing about change

Good chronic disease management is at the heart of the nGMS contract's Quality and Outcomes Framework. Under the Framework, practice computer systems will be examined and data extracted nationally to inform primary care trusts (PCTs) of activity. In progressing nGMS and abandoning our paper-based system, a practice project review group was established, with a core data input team. This provided a focus group for introducing and addressing planned improvements in diabetes care.

[FIGURE 1 OMITTED]

The computer system at the practice is EMIS (Egton Medical Information System), and the initial task was to look at the existing diabetes template. With support from the primary care trust information technology team we amended our own template to include all local minimum data set requirements and combined this with the EMIS nGMS templates to reflect all quality indices.

With practice nurses increasingly taking lead roles in the management of chronic disease, clinical protocols of care serve to identify the roles and responsibilities of those implementing them. Our existing diabetes care protocol needed updating in line with best practice and the available evidence base. To be effective, the protocol needed collaboration and agreement from every team member while reflecting intended changes in the delivery of our practice-based programme.

A second nurse was employed to support developments in delivering primary care-led diabetes services by freeing up the senior practice nurse to focus on delivering enhanced diabetes nursing care, with support from a nursing team. Involving patients in agreeing target blood pressures, lifestyle changes to improve blood pressure control, regular monitoring and medicine reviews was a key area of activity.

The healthcare assistant was supported with some additional training to input and view data, and weekly team meetings facilitated coordinated care in reviewing individual roles and responsibilities in blood pressure management.

Sharing diabetes and hypertension clinical protocols with our district nursing team for use with our housebound patients ensured they were offered the same level of care and that all data was recorded on to the computer template.

Health Care Industry

Rewarding good practice: improving blood pressure management

Journal of Diabetes Nursing, Feb, 2005 by Linda Goulden

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