NURS 732 Week 2 Exemplar on the Patient's Role in Continuous Quality Improvement Example

Exemplar: Mrs. Alvarez Joins the Hypertension Team, the Patient as Data Source, Co-Designer and Judge in Continuous Quality Improvement

Introduction

When our community health center formed a team to improve blood pressure control last spring, the first roster listed medical assistants, nurses, a pharmacist, a community health worker and providers. It did not list a patient. Three meetings later, our medical director asked whether anyone had asked the patients what got in the way of their blood pressure care, and the room went quiet. The following month, Mrs. Alvarez, a 64-year-old retired school cafeteria worker who has had hypertension for fifteen years, joined the team as a patient advisor. This exemplar describes what she did over six months and what her participation teaches about the patient's role in continuous quality improvement. Her name and some details have been changed.

For Sollecito and Johnson (2013), continuous quality improvement is a customer-focused philosophy, in which understanding the needs of those served is the starting point for improving processes. In primary care, the most important customer is the patient. Yet patients are often treated as sources of satisfaction scores rather than as participants who can see processes the clinic cannot. Mrs. Alvarez's experience shows the patient in three roles: as a source of data, as a co-designer of change and as a judge of whether change succeeded.

The Patient as Source of Data

The team's first measure was the clinic's control rate, based on the last blood pressure recorded at a visit, which stood at 58%. Mrs. Alvarez brought a notebook to her first meeting. For two years she had recorded her blood pressure at home each morning with a cuff her daughter had bought her, and her home readings averaged about 128/78, while her last three clinic readings had all been above 145/90. Her provider had added a medication after each high clinic reading, and she had stopped taking one of them because it made her dizzy.

Her notebook changed the team's understanding of its own data. Some patients counted as uncontrolled were controlled at home, and some treatment decisions based on single clinic readings were adding medications patients did not need. Home readings, when patients can take and share them, provide a more complete picture of blood pressure than a single clinic measurement. But they are not equally available to everyone. In a study of 15,937 patients in 12 clinics of an urban safety-net system, only 26% had any home blood pressure value documented in the record; patients with an activated patient portal were more likely to have one and patients experiencing homelessness less likely, and 19% of the variation lay at the clinic level rather than with patients (Luna et al., 2026). Mrs. Alvarez had a cuff, a daughter who helped her use it and the confidence to bring her notebook. Many of our patients did not. The patient's notebook did not just add data to the team's picture; it showed the team that its picture had been drawn from the wrong vantage point.

The Patient as Co-Designer

Once the team understood the value of home readings, it planned to recommend that patients buy cuffs and bring their readings to visits. Mrs. Alvarez pointed out two problems. A validated cuff cost about as much as a week's groceries for many of her neighbors, and bringing readings to visits every three months would not help a provider adjust treatment in between. She proposed two changes instead. First, a cuff-lending library, in which the clinic would loan validated cuffs for three months, taught by the medical assistants, with a simple paper log in English and Spanish. Second, a monthly evening text from the community health worker asking patients to send their average reading, since many patients worked during clinic hours and could not take calls.

Both ideas were tested in small cycles. The first cycle loaned ten cuffs to patients chosen by the providers, and the team learned that the training took longer than expected and that the log needed larger print. The second cycle expanded to thirty cuffs and added a short video in both languages. The evening texts started with fifteen patients and grew to sixty. Each change came from a patient's understanding of patients' lives that no professional on the team had.

Research describes similar contributions. A primary care redesign effort across four health systems and community organizations used a structured co-design process and found that incorporating patients' lived experiences was among the shared priorities for improving hypertension care (Patil et al., 2026). The components of a clinic program to support home monitoring in an under-resourced community, a free device, training, a paper log, reminders and help with social needs, closely resembled what Mrs. Alvarez proposed (Khatib et al., 2026). Patients, in other words, often design what researchers later test.

The Patient as Judge

At the six-month review, the team's control rate had risen to 63%. The team was pleased. Mrs. Alvarez asked a different question: how did the patients who borrowed cuffs feel about the program, and did anyone stop taking a medication because of side effects, as she had? The team had not measured either. At her suggestion, the community health worker called twenty participants and asked three questions about the program, and the pharmacist added a question about side effects to the medication review. Most participants valued the cuffs and texts, but several said the evening texts felt like being checked on rather than helped, which led the team to change the wording.

Her role as judge broadened the team's definition of success. Pandhi et al. (2025) used a modified Delphi process with patients, clinician leaders and national experts to identify 46 potential outcomes of patient engagement in primary care improvement, spread across the direct care, microsystem and clinic levels. Many of those outcomes concern experience, trust and relationships, not only clinical numbers. Mrs. Alvarez pushed our team to measure some of them.

Lessons From the Case

The case suggests four lessons. First, patients see processes from a position professionals cannot occupy, which is why Sollecito and Johnson's (2013) customer focus requires involving patients directly rather than inferring their needs. Second, patients contribute most when invited early, before solutions are chosen; Mrs. Alvarez's most valuable ideas came when she challenged a plan the team had already formed. Third, engagement has limits. One advisor cannot represent every patient, and Mrs. Alvarez, with a supportive daughter and stable housing, was not typical of the patients least likely to use home monitoring (Luna et al., 2026). The team has since added a second advisor who has experienced housing instability. Fourth, engagement takes resources. The team paid Mrs. Alvarez a small stipend for her time and held two meetings a month in the early evening so she could attend, which required adjusting staff schedules.

Christian Worldview

Paul told the Philippians to set aside selfish ambition and to value others above themselves (English Standard Version Bible, 2001/2016, Philippians 2:3-4). In quality improvement, that includes seeing the patient's interests from the patient's side. Inviting Mrs. Alvarez to the table also honored her as someone made in God's image, with wisdom to contribute, not only needs to be met.

Conclusion

Mrs. Alvarez entered the improvement team as a patient and left it as a colleague. As a source of data, she showed that the clinic's measure missed what happened at home. As a co-designer, she proposed changes that fit her neighbors' lives. As a judge, she widened the team's definition of success. Her example shows that the patient's role in continuous quality improvement is not to be satisfied but to participate.

References

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Khatib, R., Shields, M., Ozoani, O., Guzman, I., Glowacki, N., Ross, K. M., Mora, N., Lauffenburger, J. C., & Gordon, M. (2026). Feasibility of implementing a clinical integration package to support self-measured blood pressure monitoring in primary care: A qualitative study. Circulation: Population Health and Outcomes, 19(5), Article e012252. https://doi.org/10.1161/CIRCOUTCOMES.125.012252

Luna, I., Karumanchi, R., Grewal, J. S., Zhang, N. S., Rodriguez, J. A., Pletcher, M. J., Sarkar, U., & Khoong, E. C. (2026). Factors associated with evidence of self-measured blood pressure adoption in an urban safety-net health system. The Journal of Clinical Hypertension, 28(6), Article e70318. https://doi.org/10.1111/jch.70318

Pandhi, N., Jacobson, N., Crowder, M., Quanbeck, A., & Davis, S. (2025). Identifying potential outcomes of patient engagement in primary care quality improvement: A modified Delphi study. Journal of Evaluation in Clinical Practice, 31(3), Article e14199. https://doi.org/10.1111/jep.14199

Patil, S. J., Caron, A., Roach, M. J., Einstadter, D., Malone, S., Marbury, Q., Whaley, M., Sullivan, C., Kimmel, P. J., Rockamore, M., Mundorf, C., Lee, K., & Bolen, S. D. (2026). From co-design to quality improvement: Using the Double Diamond framework to develop primary care redesign priorities for hypertension care. Health Expectations, 29(2), Article e70673. https://doi.org/10.1111/hex.70673

Sollecito, W. A., & Johnson, J. K. (Eds.). (2013). McLaughlin and Kaluzny's continuous quality improvement in health care (4th ed.). Jones & Bartlett Learning.