PHASE 2017-2019 Initiative-Wide Goals

2017-2019 PHASE Initiative Goals

Strengthening the Capacity of Safety Net Partners in Using a Population Health Approach

Over the past decade, the PHASE program has evolved in response to changes in the healthcare environment and increased capabilities among our partners. Today’s PHASE program is based on Kaiser Permanente clinical expertise and years of the on-the-ground feedback from our partners. We are always finding new ways to improve the program, tell the story of our collective journey, and understand the broader impact of this program has on our communities. This goals statement is designed to provide greater clarity to all audiences, using a consistent voice.

Thank you for being a part of PHASE 2017-2019. We look forward to improving patient care for all people, working side-by-side with you.


Prevent heart attacks and strokes in high-risk patient populations served by the community health care safety net.


We aspire to eliminate preventable Cardiovascular Disease from our communities so that all people in our communities have controlled blood pressure, controlled Hemoglobin A1C levels and are tobacco-free.


Kaiser Permanente Northern California aims to support PHASE grantees in being nationally recognized for their excellence in providing cardiovascular disease preventative care, as measured by their performance against nationally established benchmarks. All participating community health centers, and public hospital and health systems, are:

  • Working towards implementing the successful, evidence-based PHASE protocol.
  • Adopting population health management practices to reinforce the protocol.
  • Using other quality improvement interventions to deepen their impact.


Effective deployment of the protocol’s cardioprotective medication bundles (e.g.PHASE on a Page) will be reflected in significant health improvements among the general patient population and patients with diabetes. Milestones measurements will be based on national standards, specifically HEDIS measures for blood pressure control, and Hemoglobin a1c control.


Initial improvement efforts will focus on supporting grantees to achieve or maintain the 75th percentile in one or both HTN-related HEDIS measures.

  • For organizations currently below the 75th percentile we will provide focused technical assistance, training and coaching to drive a relative 10% improvement by June 2018 (grant cycle mid-point).
  • Based on key learnings from the first mid-point, Kaiser Permanente staff and the PHASE Support Team will update targets at the mid-point of the grant to drive our work toward our shared goal.

In addition to initiative-wide goals, partners will focus performance improvement efforts based on other PHASE-related priorities identified in their Charter for Improvement. Coaches will work with individual organizations to refine and address these goals/targets.

Still have questions about what this means for you? Read the PHASE Goals FAQs.

PHASE Initiative-Wide Goals: Updated for the Second Half of the 2017 – 2019 Grant Cycle

Kaiser Permanente Northern California is investing in community health centers, consortia and public hospital and health systems in order to prevent heart attacks and strokes in patients served by the health care safety net. Significant progress has been made to enhance care processes supporting hypertension control in the first half of the PHASE grant cycle.  Yet every grantee still has substantial opportunity to prevent additional heart attacks and strokes by bringing more patients with uncontrolled hypertension under control. All grantees are asked to continue their efforts to re-engineer care processes to improve their HTN control as indicated by two key metrics: BP Control in HTN Patients and BP control in DM Patients.

Goal Update

For the remaining 18 months of the current PHASE initiative, organizations are expected to express an achievable improvement goal that gets them closer to national benchmarks for excellence across all their sites, with the following considerations:

  • Grantees only applying PHASE approaches in some of their sites should develop and implement plans to spread the PHASE capacity building and care process re-engineering activities across more – if not all – sites. The ultimate goal is that all patients managed by all care teams experience the same outstanding quality of hypertension care.
  • Grantees should set a target control rate to achieve by the end of the grant (December 31, 2019). This target control rate should be realistic, achievable and take into account how much your rate has changed in response to improvement efforts so far, and how much additional HTN care process improvement you anticipate during the remaining grant period.
  • In keeping with PHASE goal of supporting outstanding care and outcomes, we will continue to assess our performance measure impact using HEDIS 75th and 90th percentile benchmarks.


Supplemental Goal: Extending CV Risk Reduction by Attention to Other Measures

When assessing organizational capacity and improvement priorities, some grantees will determine they have the ability to address additional PHASE targets.  In this circumstance, these organizations are encouraged to identify these targets and goals in the Charter for Improvement.

  • Organizations planning to expand their PHASE improvement focus beyond HTN are welcome to choose any of the PHASE measures as areas for additional quality improvement work; however, because Kaiser Permanente’s vision for improving health in the communities it serves focuses specifically on controlling HbA1c and eliminating tobacco use, these PHASE targets are particularly encouraged when aligned with local priorities.