Form 8 Diabetes Action Plan Quarterly Report

OMB No.: 0915-0285. Expiration Date: X/XX/20XX

HEALTH CENTER DIABETES ACTION PLAN – QUARTERLY REPORT TEMPLATE

The diabetes Action Plan is used to monitor three performance improvement actions related to strengthening the health center’s performance on the UDS diabetes measure. The actions should directly tie to the root cause analysis and contributing/restricting factors discussed during the site visit. Actions should be specific, measurable, achievable, relevant and time-bound. The health center’s progress will be monitored by the Project Officer using the EHB Action Plan for roughly one year. This Progress Report template may be used by health centers to track quarterly progress on the three actions. Quarterly updates on the health center’s 2018 UDS diabetes measure will inform progress.

Health Center Name:

Person(s) Responsible for Diabetes Action Plan:

Dates for Action Plan Monitoring: (1 Year):

Instructions: Project Officer Inputs the three actions from Root Cause Analysis Discussion under the appropriate measureable action item as well as the percentages of the health center’s HbA1c >9% and sends this form to the health center as an attachment to the Prepare Action Plan task in EHB. The health center submits progress updates by uploading this form as an attachment in the Resolve Action Plan task at quarterly intervals on dates agreed upon by the health center and Project Officer. Each Action will have an identified measurable item to track for each quarter. Project Officer feedback should be submitted via the Progress Notes feature in the EHB Action Plan.

UDS Diabetes: Hemoglobin A1c Poor Control (Diabetic Patients with HbA1c >9%) or No Test During Year. The Health Center will input the total number of diabetic patients, the baseline measure, and updated measure in percentages on a quarterly basis.
Total number of diabetic patients as of: Date:	Baseline diabetes measure Date:	Report 1 measure Date:	Report 2 measure Date:	Report 3 measure Date:	Report 4 measure Date:

Action Item #1: Sample: By the end of Quarter 1, ABC Health Center will educate and implement a diabetes care plan for XX number of patients to improve and lower patients HbA1c.
	Report 1 Progress Note	Report 2 Progress Note	Report 3 Progress Note	Report 4 Progress Note
Sample Progress Note: ABC Health Center has educated and implemented a diabetes care plan for XX patients. The health center has seen a decrease in their patients with a HbA1c >9 from 40% to 38%.

Action Item #2:
	Report 1 Progress Note	Report 2 Progress Note	Report 3 Progress Note	Report 4 Progress Note

Action Item #3:
	Report 1 Progress Note	Report 2 Progress Note	Report 3 Progress Note	Report 4 Progress Note

After monitoring the Actions for one year, the health center answers the following in addition to the Q4 Progress Note:

1. Were all the action steps completed? Why or why not?

2. What had the greatest impact on improving patient diabetes, and improving the UDS diabetes measure?

Public Burden Statement: Health centers (section 330 grant funded and Federally Qualified Health Center look-alikes) deliver comprehensive, high quality, cost-effective primary health care to patients regardless of their ability to pay. The Health Center Program application forms provide essential information to HRSA staff and objective review committee panels for application evaluation; funding recommendation and approval; designation; and monitoring. The OMB control number for this information collection is 0915-0285 and it is valid until XX/XX/XXXX. This information collection is mandatory under the Health Center Program authorized by section 330 of the Public Health Service (PHS) Act (42 U.S.C. 254b). Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857 or [email protected].