Getting to best practice: a practice-oriented checklist for monitoring clinic-level fidelity to hypertension interventions in a large safety-net healthcare system

Practical tools are needed to monitor and support progress toward high-fidelity implementation of evidence-based practices designed to change patients’ health behaviors and improve clinical outcomes. This article describes the development and baseline use of a clinic-level fidelity checklist for a multilevel intervention bundle of nine hypertension evidence-based practices in primary care. Collaborating with partners from a large U.S. safety-net healthcare system, we developed a checklist with categorical clinic-level fidelity ratings (“little or none,” “partial,” “complete”) for each of the nine evidence-based practices. Trained facilitators complete the checklist with clinic champions to assess fidelity and identify areas for improvement. One of five facilitators rated fidelity at baseline for each of 19 participating clinics. Feedback from facilitators and staff led to clinic fidelity checklist revisions and improvements, including standardizing ratings and documentation across clinics and facilitators, and clarifying criteria specific to an evidence-based practice (e.g., use of a hypertension registry, treatment intensification protocol with fixed-dose combination medications). Baseline clinic ratings indicated some evidence-based practices were already well-established (e.g., standardized blood pressure measurement, screening for social needs and linkage to community resources) whereas others showed areas for improvement (e.g., use of a hypertension registry, use of posters to encourage behaviors related to hypertension care), guiding facilitators’ support of clinic needs. Use of a simple fidelity monitoring checklist, completed in partnership with facilitators and clinic staff, identified opportunities to improve the implementation of evidence-based practices for hypertension care at each clinic while also refining the tool. Moving forward, quarterly checklist completion will allow monitoring of changes over time, helping facilitators tailor support to clinic needs to further drive successful EBP implementation. Our approach may be applicable for developing fidelity monitoring tools in other contexts. Clinicaltrials.gov NCT06359691 (original registration date 2024-04-08).