DNP 750 Week 5 Project Design, Setting and Stakeholders Example

A Before and After Quality Improvement Design at One Primary Care Site: Who Is Involved, Who Is Affected and Why Twelve Weeks of Baseline Come First

[Student Name]

University of Phoenix

DNP/750: DNP Applied Project I

Week 5 Assignment

[Instructor Name]

[Date]

The health center, staff and figures are composites written for a model paper.

In earlier weeks I stated the practice problem, the practice question and the evidence behind a diabetes distress screening project, and chose the Iowa Model with Plan-Do-Study-Act cycles to guide it. This paper describes the project's design, the setting where it will take place and the people who will make it work or be affected by it. Each choice is tied back to the practice question and its three outcomes: how many eligible visits include a screen, how many positive screens are followed up in time, and whether distress scores fall.

Project Design

This is a single-site quality improvement project that compares the site with itself, before the change and after it. Twelve weeks of baseline data, drawn from the electronic health record before any change, will be compared with 12 weeks of data during implementation. Process measures, the screening rate and timely follow-up, will be tracked weekly on run charts. Perla et al. (2011) present the run chart as an easy tool for seeing whether a process has shifted, using rules for shifts, trends and runs to separate real signals from random variation without complex statistics. A run chart fits a clinic pilot because it answers the question the team asks every week, whether the change is working yet, rather than waiting for one comparison at the end. The outcome measure, change in distress scores among patients who screen positive, will be compared within patients between the first scale and a repeat at 12 weeks.

Why Not Another Design

A randomized design, assigning some clinicians or patients to screening and others to usual care, would give stronger evidence of cause but is neither feasible nor appropriate here. The site has one care team that shares patients, so contamination would be likely, and withholding a recommended standard of care from some patients would be hard to justify. A retrospective chart review alone would not change practice. The before and after design with run charts matches the Iowa Model's pilot step and the purpose of the project, which is improvement at this site rather than generalizable knowledge.

Setting

The health center running the site has three primary care locations in a mid-sized Midwestern city, and this one serves about 6,400 adults each year. Sixty-eight percent are covered by Medicaid or have no insurance, 31% identify as Black, 18% as Hispanic or Latino and 46% as White, and 14% prefer Spanish for health care. Its diabetes panel numbers 820 adults, and 41% of them have a most recent A1C above 9%.

The site runs four exam pods, each with a nurse practitioner or physician and a medical assistant. Diabetes visits are scheduled every three months for 20 minutes. Medical assistants room patients, take vital signs and administer screening forms on a tablet that feeds the electronic health record. Two registered nurse care managers carry a panel of high-risk patients, including those with A1C above 9%, and see patients in clinic or by phone. A licensed clinical social worker works as the behavioral health consultant and takes same-day warm handoffs. The electronic health record can add a structured form and generate reports through the quality coordinator.

Stakeholders

Young-Hyman et al. (2016), in the American Diabetes Association position statement on psychosocial care, describe addressing distress as a team responsibility, with routine assessment by the diabetes care team and referral to mental health professionals when needed. The project's stakeholders reflect that team approach.

High influence and high interest: the medical director, who approves the project and decides on adoption; the site's nurse practitioner lead; and both care managers, who carry the follow-up pathway. These stakeholders sit on the project team and meet every two weeks.

High influence and lower interest: the chief operating officer, who controls staffing and schedules, and the electronic health record analyst, whose time is needed to build the form and report. They receive monthly updates and specific requests with deadlines.

High interest and lower influence: medical assistants, who will administer the screen and whose workload rises; the behavioral health consultant, who will receive referrals; and patients with type 2 diabetes, who will answer the questions. One medical assistant will serve as a champion, and two patients from the health center's patient advisory council will review the screening script and handouts.

Lower influence and lower interest: front desk staff and the other two sites, who will be kept informed through the monthly staff newsletter.

Resistance and Readiness

Medical assistants may see the screen as one more task in a crowded rooming process. The first PDSA cycle will measure the time the screen adds, and the champion will lead feedback sessions. Clinicians may worry about opening conversations they cannot finish in 20 minutes, which the care manager pathway is designed to answer. Organizational readiness is high: leadership has approved the project in writing and diabetes control is a grant priority.

Resources

The project needs few new resources. The screening form requires about six hours of electronic health record analyst time. Training takes one 30-minute session for medical assistants and one hour for care managers and the behavioral health consultant. Spanish versions of the two-item screen and the full scale must be obtained and checked by the health center's certified interpreters. Printed handouts on distress and coping, in English and Spanish, will cost about $200. The largest resource is care manager time for follow-up, estimated at five to six extra contacts a week, which the medical director has approved within existing hours.

Data Sources

All project data will come from records the site already keeps or will add to the electronic health record: visit and diagnosis data for eligibility, structured fields for the two screening tools, care manager encounter notes for follow-up dates and laboratory results for the exploratory A1C measure. The quality coordinator will pull a weekly report without patient names for run charts, and I will hold the linked data on the health center's secure drive.

Timeline

DNP 750 completes the precis, including problem, evidence, framework, design and methods. DNP 751 completes the full proposal, obtains the quality improvement determination and builds the form. Baseline data will be extracted at the start of DNP 752, and implementation and analysis follow in the same course.

Reporting Plans Shape the Design

Ogrinc et al. (2016) revised the SQUIRE guidelines for reporting quality improvement work through a consensus process, and the resulting checklist asks authors to report the local context, the rationale for the change, how its effects were studied and measured, how data were analyzed and how ethical questions were handled. Planning with SQUIRE 2.0 now ensures that the data collected will support the final manuscript.

Conclusion

A single-site before and after quality improvement design with run charts fits a practice question about improving screening and follow-up at one site. The setting has the staff, workflow and technology to carry the change, and stakeholders have roles matched to their influence and interest. The next paper will define the methods, measures and data collection.

References

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

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46-51. https://doi.org/10.1136/bmjqs.2009.037895

Young-Hyman, D., de Groot, M., Hill-Briggs, F., Gonzalez, J. S., Hood, K., & Peyrot, M. (2016). Psychosocial care for people with diabetes: A position statement of the American Diabetes Association. Diabetes Care, 39(12), 2126-2140. https://doi.org/10.2337/dc16-2053