IHP 604 Module 9 Final Project Example

Final Report: Improving Diabetes Control Across Crestline Medical Group

[Student Name]

Southern New Hampshire University

IHP 604: Healthcare Quality and Improvement

Module Nine Final Project

[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.

Final Report: Improving Diabetes Control Across Crestline Medical Group

This report describes a twelve-month effort to improve diabetes control at Crestline Medical Group. It is written for the group's physician owners and quality committee and is organized so that another organization could understand what was done, why, with what results and under what conditions.

How the Report Is Organized

Ogrinc et al. (2016) published SQUIRE 2.0, revised guidelines for reporting quality improvement work, developed through a consensus process. SQUIRE asks a report to explain what was already known, why the chosen changes were expected to help, where the work happened and what exactly was done, then how effects were judged, what happened, including surprises, and what it all means. This report follows that structure in condensed form.

Problem and Available Knowledge

At baseline, 31% of Crestline's roughly 14,200 adults with diabetes had an A1c above 9% or no test in a year, a level unchanged for three years. Clinic rates ranged from 19% to 44%, and Spanish-speaking patients' rate was 39% against 29% for English speakers. Tricco et al. (2012) had shown across a large set of trials that diabetes quality improvement strategies lower A1c, with team changes and case management among the most effective and larger effects in patients with poorer starting control, which made Crestline's population a promising target.

Aim and Rationale

The aim was to reduce the poor-control rate from 31% to 24% in eighteen months, narrow the language gap to 4 points or less and avoid any increase in hypoglycemia visits. The rationale linked each intervention to a verified cause: long gaps after high results, slow medication changes, missing tests and language barriers.

Context

Crestline is a physician-owned group with 18 primary care clinics, three care managers at baseline and no dedicated improvement staff. About a third of revenue comes from contracts tied to quality measures, including a health plan bonus for diabetes control. Leadership support was strong at the group level, but clinic leadership, physician engagement and staffing varied widely.

Interventions

Four changes were introduced after testing at two pilot clinics: nurse outreach by text and call within 14 days of an A1c above 9%; a physician-approved protocol letting nurses and a pharmacist adjust diabetes medicines; standing A1c orders at any visit when the last test was over six months old; and bilingual self-management classes held in the evening. Clinics also received monthly feedback on their own control charts with targets and action plans. Changes spread to the remaining clinics in waves of four.

How the Interventions Were Tested

Each change was first tested at Eastside through linked Plan-Do-Study-Act cycles, starting with five patients or one clinician and growing only after a prediction held. The first outreach test failed because of wrong phone numbers, which led to verifying numbers at check-in. The titration protocol revealed that patients could not afford some drugs, which brought a pharmacist into the process. The Spanish classes moved to evenings with childcare after attendance fell. These adaptations, not the original designs, are what spread to the other clinics.

Study of the Interventions and Measures

Effects were studied through time-series analysis. Mohammed et al. (2008) explain that control chart limits should come from a stable baseline and that the chart type must match the data. Crestline used p charts for monthly proportions, with limits from eighteen baseline months, and a c chart for monthly hypoglycemia counts. Process measures, outreach timing and prompt medication changes, were charted weekly during each wave's first three months.

Results

After twelve months, the group-level poor-control rate had fallen from 31% to 26%, with the last seven monthly points below the baseline lower limit, a clear special-cause shift. The pilot clinic Eastside reached 27%. Contact within 14 days rose from 29% to 78% group-wide, and intensification within 90 days from 38% to 66%. The rate for Spanish-speaking patients fell from 39% to 31%, narrowing the language gap from 10 points to 5. Monthly hypoglycemia visits stayed within control limits.

Table 1. Key Measures at Baseline and Twelve Months

Note. Composite registry data; the aim period runs to eighteen months.

Unintended Consequences

Two unplanned effects appeared. Nurse workload rose sharply in clinics that joined early before the new care managers were hired, and two nurses asked to leave the outreach role. Positively, standing orders also raised kidney screening rates, since staff began ordering urine albumin tests alongside A1c.

Costs

The effort cost about $340,000 in its first year, mostly salaries for two new nurse care managers plus a share of one pharmacist. Crestline earned $1.4 million of the possible $2.2 million health plan bonus in the same year, having crossed the improvement threshold the plan agreed to add. Savings from avoided complications are not yet measurable.

Why Progress Varied

Six clinics reached 24% or below; four barely moved. Kaplan et al. (2010) identified contextual factors associated with improvement success, among them senior leadership, a supportive culture, physician involvement and data capability. The four slow clinics shared weak physician participation in huddles and at least one staffing vacancy during their wave. The interventions were the same; the conditions for using them were not.

Interpretation and Limitations

The shift is consistent with the interventions working, given its timing, the process measure changes and the absence of other major changes. The design, however, cannot rule out all other explanations, and part of the fall reflects more testing rather than better control; about 40% of the improvement came from closing missing tests. Twelve months is short, and the eighteen-month aim has not yet been reached.

Sustaining the Gains

Outreach, titration and standing orders are now written into clinic policies and the care manager job description. The three new care manager positions are funded in next year's budget. Monthly control charts will continue at every clinic, and the quality committee will review the four slow clinics quarterly, pairing each with a high-performing peer.

Conclusion

In twelve months, Crestline moved from a stable 31% to 26% poor diabetes control, narrowed its language gap by half and avoided harm, using interventions chosen from evidence, tested on a small scale and spread in waves. Reaching the 24% aim will depend less on new ideas than on giving the slowest clinics the leadership and staffing the others had.

References

Kaplan, H. C., Brady, P. W., Dritz, M. C., Hooper, D. K., Linam, W. M., Froehle, C. M., & Margolis, P. (2010). The influence of context on quality improvement success in health care: A systematic review of the literature. The Milbank Quarterly, 88(4), 500-559. https://doi.org/10.1111/j.1468-0009.2010.00611.x

Mohammed, M. A., Worthington, P., & Woodall, W. H. (2008). Plotting basic control charts: Tutorial notes for healthcare practitioners. Quality and Safety in Health Care, 17(2), 137-145. https://doi.org/10.1136/qshc.2004.012047

Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986-992. https://doi.org/10.1136/bmjqs-2015-004411

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