NU813 Unit 10 Implementation Summary Example

Four Components as Designed, One Adapted, One Short: Closing Twelve Weeks of Rooming-Based Diabetic Foot Exams Across Two Composite Clinics in an Implementation Summary, With the Referral Gap and the Handoff List Left to the Site

[Student Name]

Purdue University Global

NU813: DNP Project Implementation

Unit 10 Implementation Summary

[Instructor Name]

[Date]

The health center, clinics, staff and every figure are composite; counts, weeks and percentages are bracketed and computed consistently.

Project Summary

For twelve weeks, the foot exam was part of rooming at both clinics of [Riverside Community Health Center]. A standing order from the medical director let trained medical assistants examine any adult with diabetes who had gone a year or more without a recorded exam: a look at both feet, a 10-gram monofilament at the tested sites and a tuning fork at the great toe, all entered in a new flowsheet. Providers then set each patient's risk category and sent high-risk patients to a partner podiatry practice. The annual exam itself rests on the diabetes standards of care (American Diabetes Association Professional Practice Committee, 2024), and the risk categories, with the follow-up interval each implies, come from the international foot group (Schaper et al., 2024). The main clinic launched in [week 3] and the satellite in [week 6], a week late because of backordered equipment. Implementation ran through [week 14].

Fidelity by Component

Fidelity was monitored with Carroll and colleagues' framework, which treats adherence as the core measure and quality of delivery, participant responsiveness and facilitation as moderators that can explain why adherence rises or falls (Carroll et al., 2007). Each component is reported with its measure, its result and a verdict.

1. Huddle flag. Measure: share of clinic days on which the morning huddle sheet listed all scheduled and walk-in patients due for the exam. Result: [89] percent of [104] clinic days. Verdict: delivered as designed; the misses were concentrated in the first two weeks, before walk-in visits were added to the report.

2. Exam at rooming. Measure: protocol coverage, the share of scheduled diabetes follow-up visits by eligible patients at which the exam was completed. Result: [84] percent at the main clinic over twelve weeks, against a threshold of [75]. Verdict: delivered as designed at the main clinic.

3. Eligibility. Measure: visits at which the exam was offered. Result: from [week 5] the exam was offered at any visit by an eligible patient, under a change ordered by the medical director and recorded in a protocol deviation memo. Expanded coverage was [73] percent at the main clinic and [63] percent at the satellite. Verdict: delivered with an adaptation, reported beside the approved rule rather than in place of it.

4. Completeness of the exam. Measure: content adherence, the share of exams with every required element recorded. Result: [84] percent in weeks 3 to 6, [93] percent from [week 7], [90] percent overall. Verdict: delivered as designed after an early gap in vibration testing was corrected at huddle.

5. Provider risk classification. Measure: share of completed exams with a risk category recorded by the provider the same day. Result: [96] percent. Verdict: delivered as designed.

6. Referral follow-up. Measure: share of high-risk patients without an existing podiatrist who were seen by podiatry within [30] days of referral. Result: [21] of [30] referrals that reached the [30]-day mark, [70] percent, against a target of [80]. Verdict: delivered below target.

Five components reached their targets, one of them in adapted form; the sixth is the one that decides whether finding a foot at risk changes anything for the patient.

At the satellite, one adaptation not anticipated in the plan ran for three weeks. After its only trained medical assistant resigned in [week 7], the new assistant performed the inspection and footwear parts of the exam while the nurse practitioner performed the monofilament and vibration tests, until the nurse educator trained the new assistant in [week 11]. The flowsheet recorded who did each part, so those exams are counted and identified.

Results

The two clinics recorded [612] exams over the twelve weeks. Fourteen of these repeated an exam already done for the same person, mostly during the float-profile weeks, so [598] individual adults were examined, about [25] percent of the cleaned registry of [2,346]. Providers classified [44] as high risk, most often for loss of protective sensation. Same-day care was given for [5] active foot problems found at the exam, including a nail infection and a heel fissure.

Weekly protocol coverage at the main clinic was plotted as a run chart against the median of [12] baseline weeks, [41] percent, calculated from provider-documented exams at diabetes visits in the quarter before launch. Every one of the [12] implementation points sits above that median; a shift needs only six in a row on the same side (Perla et al., 2011), so the signal is clear. The chart therefore supports the conclusion that coverage changed after launch rather than varying by chance. Within the implementation period, a median of [85.6] percent was calculated from weeks 3 to 14 for use in sustainment monitoring.

Across the registry, the share of patients with an exam in the past year went from [54] to [66] percent. Three streams fed that change and are kept apart here: [503] patients examined by medical assistants, [95] examined by providers who used the flowsheet themselves, and [71] whose outside podiatry visit reached the chart as a scanned report. Expirations, patients whose last exam passed twelve months during the period, offset part of the gain.

What the Results Cannot Show

The rolling rate cannot be credited to the project alone. Outreach staff made their regular quarterly reminder calls in [week 8], and scanned podiatry reports climbed in the weeks that followed. There was no comparison clinic, and the satellite's series was interrupted by a staffing gap. In-clinic exams under the standing order serve as a partial check, since no outreach call can produce an exam at rooming, and that figure alone accounts for most of the change. The project did not measure foot ulcers or amputations, which are rare events that a twelve-week project cannot observe. SQUIRE 2.0 expects an improvement report to set its findings beside the conditions and weaknesses a reader needs to weigh them (Ogrinc et al., 2016), which is why this section is as long as the results it qualifies.

Balancing Measures

Rooming took a median of [3.5] extra minutes at diabetes visits and [4.0] at acute ones, so the wider rule never reached the review trigger in the deviation memo. [Thirty-eight] exams were deferred with a recorded reason, most often acute illness or swelling, and [5] percent of patients offered the exam declined it. No complaints about the exam were logged through the patient feedback system.

Barriers Met and How They Were Handled

Three barriers shaped the period. The satellite's equipment was backordered, delaying its launch by a week. The flowsheet was not visible to float medical assistants for three and a half weeks, so [41] exams were recorded in free text, care gaps stayed open and [9] patients returned for an exam they had already had; the build was corrected for every profile, the exams were entered, and the project's coverage figures were recalculated and labeled. And the satellite lost its only trained assistant in [week 7]. The Consolidated Framework for Implementation Research places most of these in the inner setting, among the structures, systems and staffing of the organization (Damschroder et al., 2009), and none was resolved by asking individual staff to try harder.

The Weak Component: Referral Follow-Up

Referral follow-up improved after two changes adopted from the troubleshooting seminar. Before [week 11], [8] of [14] patients were seen within [30] days. From [week 11], the referral coordinator booked the podiatry visit with the patient present before they left the building, and the podiatry practice held [two] new-patient slots each Thursday for health center referrals; [13] of [16] patients were seen within [30] days. The overall figure, [70] percent, remains below target, and the post-change figure rests on only [16] patients.

Cost explains two of the misses: both patients lack insurance, and the podiatry practice charges its standard self-pay fee. Better booking cannot fix a price. The referral rate counted on the placed-referral definition, which some payers accept, was [100] percent throughout; it is reported here only for comparison and was never used to judge the component, because a referral placed but not completed leaves the patient exactly where the exam found them.

Handoff List

Each open item is proposed to a role at the site, with a date for the first review.

1. Monthly coverage report to the quality committee, using the flowsheet extract and the sustainment median: clinic manager, main clinic, from [Month].

2. Training for any new medical assistant before independent exams, with three signed-off exams: nurse educator, ongoing.

3. Podiatry access for uninsured patients, whether by a reduced fee agreement, an enabling services subsidy or a route to the county hospital's clinic: medical director, decision by [Month].

4. Review of every new rooming profile to confirm the foot exam flowsheet appears: informatics lead, at each profile build.

5. Replacement of worn monofilaments and tuning forks on a set schedule: operations manager, first check in [Month].

6. Continued reserved podiatry slots, reviewed against use after three months: referral coordinator with the practice owner, [Month].

The student's practicum hours, logs and preceptor evaluation are recorded separately through the program and are not part of this summary.

References

American Diabetes Association Professional Practice Committee. (2024). 12. Retinopathy, neuropathy, and foot care: Standards of care in diabetes 2024. Diabetes Care, 47(Suppl. 1), S231-S243. https://doi.org/10.2337/dc24-S012

Carroll, C., Patterson, M., Wood, S., Booth, A., Rick, J., & Balain, S. (2007). A conceptual framework for implementation fidelity. Implementation Science, 2, Article 40. https://doi.org/10.1186/1748-5908-2-40

Damschroder, L. J., Aron, D. C., Keith, R. E., Kirsh, S. R., Alexander, J. A., & Lowery, J. C. (2009). Fostering implementation of health services research findings into practice: A consolidated framework for advancing implementation science. Implementation Science, 4, Article 50. https://doi.org/10.1186/1748-5908-4-50

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

Schaper, N. C., van Netten, J. J., Apelqvist, J., Bus, S. A., Fitridge, R., Game, F., Monteiro-Soares, M., Senneville, E., & IWGDF Editorial Board. (2024). Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/Metabolism Research and Reviews, 40(3), Article e3657. https://doi.org/10.1002/dmrr.3657