Project # Project Name Hospital Name March 20, 2019

1. Project #Project Name Hospital Name March 20, 2019 Team Representatives: Name, Title NJ DSRIP Learning Collaborative

2. Your DSRIP Quality Project Team Insert a photo and a brief description of your DSRIP quality project team. NJ DSRIP Learning Collaborative

3. Background • Briefly state your baseline performance and describe the system (if any) that existed to address your quality project outcome when you began DSRIP. • Example: • DY1-3: no population health initiative to improve BP control; baseline performance hovered around 58% • DY4: trained primary care physicians to recommend lifestyle changes and prescribe appropriate medications to control high BP. • Performance has plateaued around 70% in DY5 and DY6. NJ DSRIP Learning Collaborative

4. Project Aim Statement Please write a clearly defined Aim Statement with an expected change in outcome and time to expected change in the outcome for one of your quality project P4P measures. This article provides tips on how to develop your aim. Example: Our hospital aims to increase the percent of NJ low-income attributed patients who had at least one outpatient visit whose blood pressure is <140/90 from 70% to 80% by December 31st, 2019 by implementing a standardized repeat BP process across all ambulatory clinics. NJ DSRIP Learning Collaborative

5. Improvement/Change Strategy Provide a brief description of your current improvement strategy related to achieving your aim. Are you testing a new strategy? Are you working to adopt a strategy that was tested and deemed effective? Are you working on spreading an adopted strategy throughout your organization? NJ DSRIP Learning Collaborative

6. Improvement/Change Strategy Example Example: Testing a change Plan: One surgeon and nurse in an ambulatory clinic agreed to test repeat BP measurements in visits for a week. Do: They successfully performed repeat BPs in 60% of appointments. Study: While evaluating their experience we learned we need to purchase more mobile BP carts and have a better reminder system to prompt the care team to measure BP twice in the appointment if the first BP is >140/90. Act: We plan to expand the test to more provider after implementing a reminder system. Example: Adopting a change We successfully tested repeat BPs with all providers/care teams in an ambulatory clinic. We installed best practice alerts in our EMR to help remind the care team of the new procedure. We also began sharing data on our rates for successful repeat BP measurement (80% successful) and rates of BP control, which increased support/participation in this new process. We obtained approval from leadership to buy more mobile BP carts. Example: Spreading a change We have engaged all specialty ambulatory clinics to test our successful repeat BP strategy. NJ DSRIP Learning Collaborative

7. Performance Insert a line chart displaying your performance over time for the measure you identified in your aim statement. Be sure to annotate the chart in PPT to identify when improvement efforts were implemented over the years. TIP: If you’re struggling to make a chart on your own, you can use the dashboard sandbox to export images or data to create a chart. NJ DSRIP Learning Collaborative

8. Performance Example Began testing new repeat BP procedure in 1 ambulatory clinic Providers trained to recommend lifestyle changes and prescribe appropriate BP meds NJ DSRIP Learning Collaborative