Background: Evidence-based blood pressure (BP) measurement is required for optimal clinical decision-making while improper measurement risks daily diagnostic and therapeutic errors.

Objective: To implement and sustain an evidence-based BP measurement protocol without extra resources and disseminate the protocol across a primary care network.

Design, Setting, and Participants: A Plan-Do-Study-Act (PDSA) framework for quality improvement was used to design a standardized BP measurement protocol including a 5-minute rest period only for patients with persistently elevated blood pressure. The protocol was developed using Goldratt’s Theory of Constraints and Layers of Resistance to ensure multidisciplinary buy-in and was implemented in 3 groups of primary care clinics. The protocol was developed in Group 1 with high leadership engagement and disseminated to Group 2 (self-selected clinics) and Group 3 (the remainder of the network). Participants included all primary care patients ≥18 years seen during the measurement period.

Measurements: BP readings and compliance with elements of the protocol.

Results: Clinic engagement within Group 1 was high with increase in protocol adherence from 30% to >90% for measurement of 2nd BP and from 21% to approximately 40% for the 3rd BP. The number of patients classified as “in control” with BP goal <140/90 increased by 10%. Protocols were implemented and sustained with high fidelity in Group#1 over 3 years and thousands of BP measurements. Protocol adherence and improvement in BP control were improved, but less so in Groups 2 and 3.

Conclusions and Relevance: A modified BP measurement protocol was actionable and accepted in a busy primary care clinic without extra resources. Implementation of the protocol was associated with a sustained 10% improvement in patients with BP <140/90, decreasing possible diagnostic and therapeutic errors. This protocol avoided the need for the 5-minute waiting period in approximately 80% of patients, while focusing the scarce resources of time and space on those patients for whom the full blood pressure measurement protocol might change clinical decision-making. Dissemination of the protocol across the wider primary care network was more variable depending on local processes and leadership engagement.

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