A quality improvement initiative to improve glycemic control across four family and community medicine centers in the Armed Forces Hospitals Southern Region, Saudi Arabia

Abstract

In Q1 2023, poorly controlled T2DM (HbA1c > 9%) affected 11–20% of patients across four Family and Community Medicine (FCM) Centers of the Armed Forces Hospital Southern Region (AFHSR); two centers already exceeded the Ministry of Defense Health Services (MODHS) benchmark of < 15%. Root cause analysis using fishbone diagrams and Pareto charts identified patient awareness deficits, inadequate staff training, absent registries, weak referral coordination, and limited medication access as primary drivers. A multidisciplinary team applied the FOCUS-PDSA (Find, Organize, Clarify, Understand, Select–Plan, Do, Study, Act) framework across three sequential cycles (January 2023–December 2024), piloted at Ahad Rufaidah Center (ARC) then scaled to all centers. Interventions included physician training, formalized referral protocols, case manager assignment, a diabetes registry, patient education, formulary expansion, point-of-care equipment procurement, and MODHS guideline implementation. Outcome data were extracted quarterly from the Wipro electronic health record system. By Q4 2024, all four centers were at or below the 15% MODHS benchmark (KFMC 13%, Abha 14%, Airbase 15%, ARC 15%). Against the corrected Q1 2023 baseline, this reflects genuine improvement at ARC (20% to 15%) and KFMC (17% to 13%), but an increase in uncontrolled T2DM from an already-compliant baseline at Abha (12% to 14%) and Airbase (11% to 15%), across a cohort exceeding 35,000 patient-visits. HbA1c testing completeness exceeded 92%, with no documented increase in incidence of hypoglycemia. Following implementation of a structured FOCUS-PDSA initiative, all four AFHSR FCM Centers were at or below the MODHS < 15% benchmark by Q4 2024; however, this reflects genuine improvement from baseline at only two centers (ARC, KFMC), while the other two (Abha, Airbase) increased from an already-compliant Q1 2023 baseline. As an uncontrolled QI time series, this design cannot exclude secular trends or other contemporaneous factors as contributors, and the bundled intervention design does not permit isolating which component(s) drove the observed changes. No increase in hypoglycemia burden was observed. This project offers a starting model for primary care settings seeking to improve glycemic control, with center-level variation warranting further study. Not applicable; this was a quality improvement initiative and not a registered clinical trial.