NURS 732 Week 8 Quality Improvement Plan Part III Example

Quality Improvement Plan Part III: Implementation, Spread, Evaluation, Governance and Sustainment of a Blood Pressure Control Program

Introduction

Part I of this plan set an aim for Riverbend Community Health Center: to bring 70% of its hypertensive adults to goal within a year, against a 58% baseline, while shrinking the nine-point shortfall for Spanish-speaking patients to four points or fewer. Part II located the causes in how blood pressure was measured, how patients were followed between visits and whether they took their medicines, and planned small tests of change organized by a driver diagram. This final part describes how changes that succeed will be implemented and spread, how the program will be evaluated, how it will be governed and how its gains will be sustained.

Implementation and Spread

Sollecito and Johnson (2013) distinguish testing a change from making it part of routine work, and routine work from spreading it to new settings. The plan treats these as separate stages. A change that succeeds in its first small test is retested at a larger scale, then written into standard work for the team that tested it, and only then spread to the other care teams, with a further test in each team to catch differences in context. The timeline below shows the planned sequence.

Care team D was chosen first because it has the lowest control rate and its medical assistant leads measurement on the improvement team. Team C follows because its patient population has more Spanish-speaking patients than any other team, which tests the changes where the equity gap is widest.

Implementation will be supported by training sessions for each team before spread, short reference cards in each room and a weekly huddle in each team during its first month. The community health workers will lead the expansion of the cuff library and text check-ins, which require relationships with patients more than clinical skill.

Evaluation Plan

Measures and Analysis

The program will be evaluated with the outcome, process and balancing measures defined in Part II. Outcome and process measures will be plotted monthly on run charts annotated with the dates of each change and of any data corrections. Run charts allow the team to detect non-random change with simple rules and are well suited to the small, frequent data of a single clinic (Perla et al., 2011). In addition to the standard single-reading control measure, the team will report control using the average of home readings for patients who have them. A study of a health system hypertension program found that control based on a single last reading paralleled control based on averaged readings over time but was consistently lower, with only fair agreement between the two (Chaves et al., 2026), so reporting both will give leaders a fuller picture.

Equity

The equity gap will be charted separately each month, and every outcome and process measure will be broken down by preferred language and insurance status at the six-month review. If the overall rate improves while the gap widens, the team will treat that as a failure of the equity aim and examine whether the Spanish-language materials, text program and pharmacist calls are reaching the intended patients.

Decision Points

Decisions at the six- and twelve-month reviews will follow rules agreed in advance with the medical director. If control has risen at least six points with no adverse signal in the balancing measures, spread will continue as planned. If process measures have improved but control has not, the team will examine adherence and follow-up rather than adding new changes. If rooming time has risen by more than three minutes or side effects have increased, the relevant change will be paused and redesigned before spread continues. Setting these rules before results arrive protects the team from reading the data in whatever way favors continuing.

Governance and Organizational Responsibilities

The program will be governed through the center's existing structure. Every quarter, the board's quality committee will review each measure, the equity gap and the balancing measures among them, and only that committee may alter the aim or the scope. The medical director, as executive sponsor, will hold the team accountable between reports.

Several ethical, legal and regulatory responsibilities apply. Text messaging with patients must follow the center's privacy and security policies: messages will contain no diagnoses or medication names, patients will consent to texting and may opt out at any time, and replies will be entered in the record by authorized staff only. The cuff-lending program will use validated devices, with a signed loan agreement and cleaning between patients. The center reports hypertension control to federal funders each year, and the team will ensure that the measure definitions it uses for improvement match the reporting definitions, so that the program's results and the center's official figures do not diverge. Because the work is quality improvement rather than research, it will follow the center's improvement policy, and any plan to publish results will be reviewed by an institutional review board before data are used for that purpose. Ethically, the program's greatest risk is overtreatment in pursuit of a target, especially among older patients, which is why the side-effect measure and pharmacist follow-up are part of governance, not only of evaluation.

Sustainability Plan

Many improvement efforts in primary care fade once attention moves elsewhere. When Tiso et al. (2026) examined why a family medicine center abandoned its Lean safety program, they found staff who were not ready, leaders and staff who never owned the work and oversight scattered across committees, so coordination and commitment drained away. The plan addresses each. Readiness is built through staged spread and training. Ownership rests with named leads in each care team and with the quality committee. Governance is consolidated in one reporting line.

Sustainment also depends on the improvement becoming the normal way of working. The rest period, repeat reading and cuff sizing will be written into the medical assistants' standard work and competency checklist; nurse follow-up within two weeks will be added to the registered nurses' role descriptions; and the pharmacist adherence check will become a standing order. New staff will learn these practices in orientation. The registry, dashboard and run charts will continue to be maintained by the quality coordinator. Funding for replacement cuffs, the text platform and a portion of community health worker time will be requested in the next annual budget.

Evidence suggests sustained programs can reach high levels of control. In a large integrated health system serving Medicare beneficiaries of predominantly Hispanic origin, the adjusted odds of hypertension control were 5.7 times higher after full implementation of a multicomponent program, and control rose to high levels that were sustained over several years (Chaves et al., 2026). Lean methods also appear to help practices absorb shocks. Hung et al. (2026) surveyed physician practices nationally and found that Lean adopters described a better pandemic response and steadier finances, and that practices running rapid improvement events with live data reported staffing shortfalls hurting patients less often. For Riverbend, that argues for keeping the monthly improvement huddle and the live dashboard after the project ends, since they are the habits that let a team notice slippage early and respond before control falls. A change is sustained when it no longer needs the team that made it.

Dissemination

The team will share its results internally at an all-staff meeting and through the monthly run charts in each team room, and externally through the state primary care association's quality network, which includes other community health centers working on the same measure. The patient advisor will co-present at least one of these sessions, so that other centers hear the patient's role directly.

Christian Worldview

Jesus told of a servant who was faithful over a little and was set over much (English Standard Version Bible, 2001/2016, Matthew 25:21). The program depends on faithfulness in small, repeated acts: a rest period, a repeat reading, a phone call two weeks after a high reading. Sustaining those acts after the project's attention fades is a form of faithfulness. The equity aim also reflects the biblical concern for those at the margins, ensuring that patients with the least access share in the benefits of improvement.

Conclusion

Across its three parts, this plan defined a problem with local data, chartered an interprofessional team with a patient advisor, set a measurable aim, analyzed causes, selected evidence-based changes, defined measures and planned small tests. Part III completes the plan with staged implementation and spread, an evaluation built on run charts, equity analysis and decision rules, governance that addresses privacy, reporting and ethics, and a sustainability plan that writes the changes into standard work, roles and budgets. If carried out as written, the plan gives Riverbend a realistic path to controlling blood pressure for more of its patients, and especially for those it has served least well.

References

Chaves, P. H. M., DeSoria, M., Roque, L., & Mas, R. J. (2026). Hypertension control rates before and after implementation of a multicomponent quality improvement program in Medicare beneficiaries primarily of Hispanic origin in a large health system in South Florida, 2011-2018. The Journal of Clinical Hypertension, 28(8), Article e70297. https://doi.org/10.1111/jch.70297

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Hung, D. Y., Shortell, S. M., Morris, E., Quach, C. Y., Reponen, E., Rotter, T., Perez-Araos, A., & Schifferdecker, K. E. (2026). Lean management of crisis response and post-pandemic outcomes in US primary care practices. BMC Health Services Research, 26(1). https://doi.org/10.1186/s12913-026-14968-3

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

Sollecito, W. A., & Johnson, J. K. (Eds.). (2013). McLaughlin and Kaluzny's continuous quality improvement in health care (4th ed.). Jones & Bartlett Learning.

Tiso, A., Pozzan, C., Pamich, C., & Verbano, C. (2026). Barriers to Lean & Safety Management implementation in primary care settings: Insights from an unsuccessful case. Risk Management and Healthcare Policy, 19, Article 610926. https://doi.org/10.2147/RMHP.S610926