QIP Implementation Resources

Practical toolkits and high reliability tables that help healthcare teams improve care for diabetes and hypertension using proven strategies, templates, and step-by-step guides

A quality improvement (QI) toolkit functions as a structured, practical resource that guides healthcare teams through the systematic process of identifying, testing, and sustaining changes that lead to better outcomes [1]. Toolkits bundle evidence-based methods with ready-to-use templates, step-by-step instructions, and real-world examples. They often include tools like key driver diagrams to map change strategies, process maps to guide best practice implementation approaches, and Plan-Do-Study-Act (PDSA) worksheets to facilitate rapid-cycle testing [1]. By providing both the methodology and the operational instruments, a QI toolkit enables teams to move from problem identification to measurable improvement in a disciplined, data-driven way, ensuring that interventions are not only implemented effectively but also embedded into routine practice for lasting impact.

The following QI toolkits can serve as a resource for QI activities related to diabetes and hypertension.

₁ _{Quality Improvement Essentials Toolkit | Institute for Healthcare Improvement}

High Reliability Interventions

The Diabetes and Hypertension Trio CoMs collaborated to identify a targeted set of interventions for their respective topics, demonstrated via Wave 1 and 2 activities as level 2 or 3 high reliability, which will be trained on, tested and implemented by all Wave 3 participating sites.

Diabetes

The Diabetes Trio CoMs found that higher reliability workflows were characterized by standardization, embedded decision support, intentional redundancy, team-based care, and visible performance feedback systems across all intervention areas. Implementation challenges were most commonly related to staffing capacity, external resource limitations, fragmented workflows, technology constraints, and variable organizational readiness.

Intervention	Rationale	Resources for Implementation
Proactive Patient Identification & Registry Use (LOR 2 and 3)	Addresses identification of patients with A1C ≥9%, overdue testing, or unresolved care gaps. Improves visibility of high-risk patient populations and supported ongoing population management.	Coming soon
Standardized Timely Follow-up within 30 days (LOR 2 and 3)	Team-based referral models involving pharmacy, nursing, behavioral health, diabetes education, care coordination, nutrition, and social work supports more comprehensive diabetes management and timely follow-up. Visual cues and EHR alerts increased visibility of follow-up needs and reinforces standardized care processes.	Coming soon
Leveraging Clear Communication and Visual Cues to Support Testing and Monitoring (LOR 2 and 3)	Data visualization boards, leadership data walks, and regular staff huddles supports continuous monitoring, shared accountability, and rapid-cycle improvement.	Coming soon
Standardizing Process Related to Continuous Glucose Monitoring (LOR 2 and 3)	Visual prompts and integrated EHR tools, including direct CGM data integration, order sets, templates, and provider tip sheets, supports workflow standardization and clinical decision-making.	Coming soon
Standardizing SDOH Screening and Resource Referral (LOR 2 and 3)	Supports more consistent identification of patient needs	Coming soon
Standardizing Multimodal Patient Outreach and Engagement (LOR 2 and 3)	Leveraging multiple outreach modalities, improves engagement across diverse patient populations Follow-up workflows with repeated outreach attempts reduced loss to follow-up.	Coming soon
Encouraging a Culture of Continuous Improvement (LOR 3)	Increases leadership support, engagement, and sustainability.	Coming soon
Optimizing Medication Regimens (LOR 2 and 3)	Clinical pharmacist collaboration supports medication titration, diabetes management, patient education, and more timely optimization of treatment regimens. Standardized medication guidance tools, including prescribing “cheat sheets,” supported more consistent prescribing workflows and reduced variation in medication selection and titration practices.	Coming soon

Hypertension

Intervention	Rationale	Resources for Implementation
Accurate and Repeat BP Measurement	Standardized two-step BP measurement and repeat BP workflows reduces variation, improves measurement accuracy, and creates a more reliable foundation for diagnosis and treatment decisions. Supports timely identification of uncontrolled hypertension and have been associated with sustained improvement in BP control across participating sites.	Coming soon
Standard AHA-Guided Treatment Escalation	Reduces variation in medication management and supports timely intensification for patients with persistent uncontrolled hypertension. Home BP monitoring, adherence support, pharmacist engagement, and clear action plans strengthen patient self-management and reinforce evidence-based care between visits.	Coming soon
Timely, Goal-Directed BP Follow-up Using a Team Based Approach	Ensures patients with elevated BP are re-engaged quickly and remain connected to care until control is achieved. Distributes work across roles and improve follow-up reliability, medication optimization, and patient education.	Coming soon
Operational Alignment	Active monitoring of hypertension processes and outcome data supports rapid-cycle improvement, accountability, and early identification of care gaps. Dashboards, run charts, provider-level reporting, and routine data review improves visibility of performance and guide coaching, workflow refinement, and spread. Clinic policies and performance standards reinforces standard work, reduces variation, and supporst consistent implementation across care teams.	Coming soon

Regional QI Hub Project Toolkits

The clinical guidance in these regional toolkits aligns with current best practices per topic, however each college of medicine has incorporated variation in resources, tools, and ideas based on the need of their region.