Connecting the Dots: An Interdisciplinary Diabetes Quality Improvement Initiative

Internal Medicine Resident Clinic

The practice created a paper sheet of diabetes metrics, including A1C, eye exam, foot exam, vaccines, laboratory measures, and dental exam, to prompt rooming staff regarding needed quality metrics, which were subsequently shared with the physician so orders could be placed. The sheet included check boxes to indicate whether a specific diabetes metric was due; this prompted the resident to enter an order at the time of the visit.

The practice also obtained permission from Ophthalmology to directly schedule patients for their annual eye examinations (when they were already scheduled for a primary care appointment). This was done over a 3-month timeframe.

Women’s Health Clinic

As in the resident clinic, the practice developed a health maintenance checklist with diabetes metrics, including A1C, eye exam, foot exam, vaccines, laboratory measures, and dental exam) for the check-in nurses to complete so the physician could then place orders for needed care.

Monofilaments were provided by the nursing staff for foot exams, and feet were exposed for examination.

Family Medicine Clinic

The practice identified a high incidence of undocumented foot exams in the diabetes registry. The team collected data from seven providers and found high practice variability that was related to documentation rather than actual patient care. The first project undertaken by the clinic was a plan/do/study/act (PDSA) cycle, which included using scribes to document the foot exam in the clinic note and having nurses ask patients to remove their shoes and set out a monofilament at visits related to diabetes care. The second PDSA project was to complete A1C testing in a timely manner. The front desk staff called all patients who had not been seen in a year. The A1C interval was changed from 6 months to 3 months in the health maintenance tool for patients with an A1C >7%. The intervention started with one practitioner’s panel; once it was shown to be successful, it was spread as standard practice throughout the clinic.

Endocrinology Clinic

The clinic identified as the biggest barrier to workflow the lack of blood glucose data regularly available for review during clinic visits. Glucose meter and insulin pump downloads are time-consuming and can be affected by technical difficulties. We aimed to improve the rate of patients presenting to the clinic having already downloaded their glucose meter or insulin pump data outside of the clinic for review. Through successive PDSA cycles, the clinic was able to tailor teaching strategies and revise the clinic discharge sheet to improve patients’ engagement in diabetes self-management skills, teach the use of smartphone apps to track glucose data, improve patient comfort with reviewing glucose data, and improve patient-provider communication through the use of the patient portal that is embedded in our electronic health record (EHR).

All of the clinics participated in the development of new roles for registered nurses to participate in population work in the clinics and to use the diabetes registry.

The director of dietetic internship program worked to expand the availability of nutritionists to clinics, a resource that was not previously available.

Resident Clinic

The electronic diabetes registry was useful in determining the impact of the initiative on A1C levels and on obtaining urinary microalbumin results. To determine the outcome of the eye exam intervention, we had to manually track the scheduling of annual diabetic eye exams because we were not able to capture this electronically. The percentage of patients with an A1C >8% fell from 36% at baseline to 21% at the end of the initiative. Taking into consideration fluctuations in the clinic population, this reflected ∼93 patients whose A1C moved into the <8% range. There was a small increase in the percentage of patients for which we obtained urinary microalbumin results. There was a significant improvement in the number of patients scheduled for diabetic eye examinations. In August of 2016, 22% of patients needed an exam, and 11% of those were scheduled. In September, 40% needed exams, and 23% of those were scheduled. In October, 9% needed exams, and 5% of those were scheduled.

Women’s Health Clinic

We used the microalbumin metric from the health maintenance form to measure improvement and measured each physician’s outcome before, during, and after the PDSA cycle. A total of 22% of patients had microalbumin measurements in a timely manner before, 39% during, and 56% after the intervention.

Family Medicine Clinic

From December 2015 to December 2016, the number of patients with diabetes with a documented foot exam increased from 12 to 82% (in a patient population of 630). Having scribes document the exam correctly in the office note improved data capture of the foot exam in the health maintenance tool. The changes made to the A1C reminder in the health maintenance tool moved the measurement rates from 22 to 58% in 3 months in the pilot PDSA cycle.

Endocrinology Clinic

At baseline, none of the patients were downloading insulin pumps or glucose meters at home. By the end of 7 months, the rate had increased to 20–30% of patients per clinic session, and 60% of patients remained open to continued discussion about how to download at home.

Resident Clinic

Improving resident attention to health maintenance forms is our next area of focus. We are trying to determine whether more resident education is needed or whether a simple intervention such as changing the color of the forms will encourage their increased use. We will also be requesting that the Ophthalmology Clinic document completed diabetic eye exams in the EHR.

Women’s Health Clinic

The next step will be to address variability in physician performance, which was dependent on staff turnover and the presence of supplemental nursing staff, not catching patients at problem visits, and missed opportunities, given that the current registry does not include laboratory tests completed at non-VCU facilities.

Family Medicine Clinic

We will focus on increasing the use of a population nurse, a position created to coordinate care for patients who were identified by the QI program as needing more individualized diabetes self-management training, and a nutritionist to begin interventions in patients with an A1C >9%. We will also try to increase use of the Problem Areas in Diabetes scale, a validated tool to assess emotional functioning in diabetes (1), and referrals of patients identified for social work or psychological evaluations.

Endocrinology Clinic

The next step in this clinic will be to have diabetes educators continue to encourage patients to perform home data downloads and use the patient portal. We will also be spreading the educational toolkit to the young adult and adolescent diabetes population to encourage earlier development of and lifelong engagement in diabetes self-management skills. We are also creating a diabetes registry using the EHR so the clinic can track the same performance data now available to the other clinics.