In the spring of 2017, the eighteen teams participating in PHASE completed a goals worksheet as part of their Charter for Improvement (CFI).

Grantees identified specific PHASE measures they wanted to improve – and by how much – with Kaiser Permanente’s initiative-wide focus on blood pressure control being a required target. Then, at the beginning of 2018, each team submitted a year-end reflection that included their response to the question:

Considering all your PHASE-related activities this past year, what action do you believe will have the greatest impact on improving blood pressure control (and other targeted PHASE measures you’ve identified)?

Grantees cited a wide variety of high impact actions and interventions, supporting the hypothesis that improving blood pressure control involves re-engineering a complex set of interrelated activities. In order to provide insight into what peers are doing, learning, and reflecting on, we have summarized the responses to the above question and grouped them by the Building Blocks of PHASE. For each activity, the organization(s) that have implemented the activity have been identified. By clicking on “Organization” below, you can download a list of contacts if you want to follow up with any of the other organizations about their activities.

For general questions about the year-end reflection or this table, contact Alexis Wielunski.

Table of Most Impactful Action Taken to Improve Blood Pressure Control


Building Block
Engaged and Supportive Leadership Executive support and provider champions for population health management and data driven decision making  – San Joaquin General Hospital
– San Mateo Medical Center
– Elica Health
Team-Based Care Training MAs on accurate BP measurement and correct BP documentation – Community Medical Centers, Inc.
– Elica Health
– Golden Valley
– Livingston
– Sacamento Native American Health Center
Motivational interviewing and health coaching training, empowering frontline staff to be more engaged in HTN care – Santa Clara Valley Health System
– Community Health Center Network
– Redwood Community Health Coalition
Nurse-led medication titration, nurse-led visits working under standardized work/procedures – Alameda Health System
– SF Health Network
Staff training and annual competency training, case conferences to increase knowledge about HTN care – One Community Health
– Redwood Community Health Coalition
Alternative visit types for HTN (e.g. BP check with MA or LVN and BP Management by protocol with clinical pharmacist) – Chapa-De
Increased patient education and maximizing care managers – Elica Health
Quality Improvement Culture
and Performance Improvement Methodology
CMO Individual Provider Review of Data Dashboards – Livingston
Improved depression screening process – San Mateo Medical Center
Continuous quality improvement methods and tools – Community Health Partnership
Data-Driven Decision Making Data validation for accurate QI metrics, improved data governance processes – Golden Valley
– Community Health Partnership
– SF Community Clinic Consortium
– SF Health Network
Reports highlighting gaps in care requiring attention, e.g., for use during huddles – Golden Valley
– Livingston
– Valley Health Team
– SF Community Clinic Consortium
Panel Management Focused outreach to select populations: hypertension equity focus and prioritization of care for Black/African Americans – SF Health Network
Clinical Guidelines and Protocols Following the guidelines, making sure care teams are trained – Camarena