IHP 604 Module 6 Milestone Two Example

Milestone Two: Matching Causes to Evidence for Diabetes Control at Crestline

[Student Name]

Southern New Hampshire University

IHP 604: Healthcare Quality and Improvement

Module Six Milestone Two

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Milestone Two: Matching Causes to Evidence for Diabetes Control at Crestline

Milestone One framed the problem: 31% of Crestline's adult diabetes patients fall in the poor-control group, with clinic rates spread widely and Spanish speakers faring worst. This milestone asks why the problem persists and which interventions best address those reasons. It first summarizes a cause analysis and then reviews the evidence on diabetes quality improvement strategies before selecting a set of changes to test.

How Causes Were Identified

A team of two physicians, three nurses, a medical assistant, a care manager and a front desk lead built a cause-and-effect diagram over two meetings. Each proposed cause was then checked against registry data or a review of 60 randomly chosen charts of patients above 9%. Causes stayed on the list only if the data supported them.

Cause One: Long Gaps After a High Result

In the chart review, the median time from an A1c result above 9% to the next contact of any kind was 41 days, and 23% of patients had no contact within 90 days. Results land in clinician inboxes alongside hundreds of other messages, and no one is assigned to reach out.

Cause Two: Treatment Not Intensified

Only 38% of patients with a result above 9% had a medication change or referral within 90 days. Clinicians described limited visit time, uncertainty about newer drugs and worry about cost to patients. This pattern, often called clinical inertia, was more common at clinics with higher poor-control rates.

Cause Three: Missing Tests

About 1,100 patients went twelve months without any A1c result. Half had not had any visit in twelve months; the rest had visits but no test ordered, often because the visit was for another concern and the test was not due by the clinician's reckoning.

Cause Four: Language and Education Barriers

Spanish-speaking patients had fewer completed follow-up calls, and education classes are offered only in English. Only four bilingual care staff serve 2,400 Spanish-speaking patients with diabetes. Chart notes frequently recorded misunderstanding of insulin instructions.

Cause Five: Care Manager Capacity

Crestline employs three diabetes care managers for 14,200 patients, and their caseloads are filled mostly by referrals for newly diagnosed patients rather than by those with the highest A1c. Care managers reported that they rarely see the registry list of patients above 9% and have no protocol for proactive outreach. The clinics with the lowest poor-control rates are the two where a care manager spends at least two days a week on site. Capacity and targeting, not only the number of staff, shape how much case management patients actually receive.

What the Evidence Says About Strategies

Shojania et al. (2006) pooled dozens of trials testing ways to improve type 2 diabetes care and found that, across the trials, these strategies reduced A1c by an average of about 0.4 percentage points. Team changes, such as giving nurses or pharmacists a formal role in adjusting treatment, and case management produced the largest reductions, and effects were bigger in studies where baseline A1c was higher. Strategies aimed only at clinicians, such as education or reminders, showed smaller effects.

Confirming the Pattern

Tricco et al. (2012) updated this work with a systematic review and meta-analysis of more than 140 trials. They found that quality improvement strategies overall improved A1c, as well as blood pressure and cholesterol control, and that team changes and case management were again among the most effective, alongside approaches that promote patient self-management. Effects on A1c were larger when baseline control was poorer, which fits Crestline's focus on patients above 9%.

Designing Feedback That Works

Crestline's earlier attempt to share clinic rankings did not help. Ivers et al. (2012) pooled randomized comparisons in which clinicians received summaries of their own performance; on average this yielded small to moderate improvements in professional practice on average, with wide variation. Gains tended to be larger for clinicians starting from poor performance, and for feedback that a supervisor or trusted peer delivered, that recurred rather than arriving once, that mixed spoken and written formats and that set a clear goal along with concrete next steps. Crestline's rankings had few of those features.

Selected Interventions

Four interventions were selected, each linked to one or more causes and supported by the evidence above. Together they combine a team change and case management, the strongest strategies, with redesigned feedback and a simple test-ordering change.

Table 1. Causes, Interventions and Supporting Evidence

Note. Interventions will be tested at two pilot clinics before spread.

Fit With Crestline's Resources

Each selected intervention was also judged for feasibility. Case management and titration protocols require hiring two additional nurse care managers and part of a pharmacist's time, about $310,000 a year, which the expanded health plan bonus could cover if targets are met. Standing orders require only a policy change and a record build. Spanish classes can use an existing bilingual educator for two sessions a month. Redesigned feedback adds roughly half a day each month to the quality manager's workload.

Expected Effects

If Crestline achieves reductions similar to those in the trials, about 0.4 to 0.5 points on average and more among patients starting highest, perhaps a quarter of patients now just above 9% would move below it within a year. Combined with closing about half of the missing-test gap, this would bring the rate from 31% toward the 24% aim. Trial conditions are usually more favorable than routine practice, so these estimates are optimistic and will be tested through the pilots.

Interventions Not Selected

Clinician education sessions and electronic reminders were considered but not selected as main strategies, because both reviews found smaller effects for clinician-directed approaches, and reminders already fire in the record without prompting action. Patient letters were dropped after the earlier campaign drew under 10% response.

Conclusion

The causes of poor diabetes control at Crestline, delayed follow-up, slow intensification, missing tests and language barriers, map well onto strategies with the strongest evidence: case management, team-based titration, self-management support and well-designed feedback. Milestone Three will test these changes at two clinics and report what was learned.

References

Ivers, N., Jamtvedt, G., Flottorp, S., Young, J. M., Odgaard-Jensen, J., French, S. D., O'Brien, M. A., Johansen, M., Grimshaw, J., & Oxman, A. D. (2012). Audit and feedback: Effects on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews, (6), Article CD000259. https://doi.org/10.1002/14651858.CD000259.pub3

Shojania, K. G., Ranji, S. R., McDonald, K. M., Grimshaw, J. M., Sundaram, V., Rushakoff, R. J., & Owens, D. K. (2006). Effects of quality improvement strategies for type 2 diabetes on glycemic control: A meta-regression analysis. JAMA, 296(4), 427-440. https://doi.org/10.1001/jama.296.4.427

Tricco, A. C., Ivers, N. M., Grimshaw, J. M., Moher, D., Turner, L., Galipeau, J., Halperin, I., Vachon, B., Ramsay, T., Manns, B., Tonelli, M., & Shojania, K. (2012). Effectiveness of quality improvement strategies on the management of diabetes: A systematic review and meta-analysis. The Lancet, 379(9833), 2252-2261. https://doi.org/10.1016/S0140-6736(12)60480-2