Transform Practices to Improve Care
Quality long-term diabetes management requires a comprehensive system of care that serves the needs of both patients and health care professionals. To be effective, leaders need to:
- Understand the mission
- Identify the effort as important
- Translate it into clear goals reflected in policies, procedures, and the business and financial plan
- Support personnel with appropriate resources   
Positive incentives encourage physicians and other health care professionals to make changes. Reorganization of payment structures for team based care (or better payment for brief interventions such as assisting smokers to quit, encouraging exercise routines, or counseling for weight loss) could enable primary care providers or other health care professionals to undertake these behavioral interventions. Accountable care organizations and medical home initiatives are examples of some of these reform efforts. See section on Develop a Patient-Centered Medical Home.
See section on Align Payment Policies with Care.
Establish an Improvement Team
Implementing changes in a clinical setting requires buy-in, commitment, and effort from those who work together in the setting, in other words, a team.  The team should be diverse and represent people from every area of the clinic or office possible. This diverse team approach helps when brainstorming potential solutions. The team approach also encourages a division of labor among team members during the improvement effort. See section on Team Care.
Identify Gaps in Care and Set Goals
Assessment is an essential first step toward making system changes. Assessment focuses on the process of change and provides a roadmap to order priorities, plan change, and direct energies. For more information on assessment to identify gaps and prioritize an action plan, see section on Identify Needs and Priorities.
Set goals for Improvement
The overall goal of health care quality improvement is to eliminate the gap between current and optimal clinical performance in an effort to improve diabetes outcomes such as the incidence of complications. To achieve improvements, goals and objectives should be based on reducing gaps identified by the assessment.
Healthy People 2020 (see resources) lists national health goals, many of which relate to diabetes, blood pressure, cholesterol, obesity, nutrition and physical activity. For example, three goals for diabetes are to increase the proportion of:
- Adults with diabetes whose condition has been diagnosed.
- Persons with diabetes who receive formal diabetes education.
- Adults with diabetes who have an A1C measurement at least twice a year.
To achieve any chosen aim, a practice, health care team, or planning group needs to determine an achievable target, baseline measures and an appropriate timeframe, then select and implement a plan. A plan should include a number of small steps or objectives that would lead to achievement of the goal over time.
Tools such as flowcharts, cause-and effect diagrams, and registry data are used to achieve clinical improvements.
For example, to increase the proportion of people with diabetes who receive diabetes education, a couple of steps might include:
- Secure financial support for patient education services.
- Determine when and where a small group of patients could meet with a diabetes educator.
Use the Plan-Do-Study-Act (PDSA) Cycle
The Institute for Healthcare Improvement (IHI) recommends the use of rapid cycle improvement for clinical settings. PDSA rapid cycles involve small-scale local tests of change in physician offices or health care organizations. The plan-do-study-act (PDSA) cycle describes the growth of knowledge through making changes and then reflecting on the consequences of those changes. 
PDSA cycles help inform three fundamental questions.
- What are we trying to improve? (the Aim)
- How will we know that a change is an improvement? (the Measurement)
- What change can we make that will result in an improvement? (the Plan)
The method is used to test the results of the change that is being evaluated.
Plan the improvement process.
- Describe first (or next) change.
- Predict the outcome.
- List tasks needed.
- Plan for collection of data.
Do the new process and collect data.
- Implement and see plan to completion.
- Document any unforeseen problems or other unexpected observations.
Study the results of the new process.
- Review and analyze the data and compare them to the predicted results.
- Summarize and reflect on what was learned from performing the cycle.
Act to hold the gains and continue further improvement
- Choose to adopt the change, abandon it, or run the cycle again under different environmental conditions.
The downloadable document, Examples of PDSA Cycles for Quality Improvement Activities to Address Elements of the Chronic Care Model provides many examples of quality improvement activities that relate to elements of the Chronic Care Model. (The Chronic Care Model is a mid-level model widely used to classify PDSA cycles). These activities can be introduced and tested using PDSA cycles. Examples of frequently performed interventions tested in a Midwest health disparities collaborate with PDSA cycles were:
- Collaborate with community organizations.
- Use a self-management support tool or goal sheet to track a patient’s progress.
- Introduce group patient visits.
- Use a patient registry to follow-up on examination and laboratory data.
Clinicians will find that the practice of clinical medicine is itself a series of quality improvement cycles. The downloadable document Example for Improving Diabetes Management using PDSA Cycle Process shows how clinical decision-making parallels the process of quality improvement.
See also the Agency for Healthcare Research and Quality.
Audit and feedback
Medical record audit and feedback of summary data to individual physicians or physician groups can help improve quality of care and patient health outcomes. Action on key performance measures, however, is essential for success.
Example of Successful Quality Improvement Implementation
A recent study found that the introduction of a multi-component organizational intervention in community primary care practices increased the percentage of patients with type 2 diabetes who achieved recommended clinical outcomes. 
This group-randomized, controlled clinical intervention introduced:
- Electronic diabetes registries
- Visit reminders
- Patient-specific physician alerts
- Pre-visit planning
- Monthly review of performance with a local physician champion
Over 24 months, 69,965 visits from 8,405 adult patients with type 2 diabetes were recorded from 238 health care providers in 24 practices from 17 health systems.
Results showed the following significant changes in intervention groups compared with control groups.
Process measures. Net increases in:
- Foot examinations 35.0%
- Annual eye examinations 25.9%
- Renal testing 28.5%
- A1C testing 8.1%
- Blood pressure monitoring 3.5%
- LDL testing 8.6%.
Outcome measures. Significant decreases in:
- Mean A1C adjusted for age, sex, and comorbidity
- At 12 months, significantly greater improvement in achieving recommended clinical values for systolic blood pressure (<130 mmHg), A1C (<7%), and LDL cholesterol (<100 mg/dl).
For other examples of implemented improvements go to http://www.ihi.org/knowledge/Pages/ImprovementStories/
Resources and References
1. Healthy People
Healthy People provides science-based, 10-year national objectives for promoting health and preventing disease.
3. Models of care for chronic disease management
Chronic Care Model (or Planned Care Model) summarizes the basic elements for improving care in health systems at the community, organization, practice, and patient levels.
4. Support Behavior Change Resources
NDEP’s Diabetes HealthSense provides an online searchable database of research, tools and programs that address the “how to” of psychosocial issues, lifestyle, and behavior change for better diabetes management.
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- Bray P, Cummings DM, Wolf M, Massing MW, Reaves J: After the collaborative is over: what sustains quality improvement initiatives in primary care practices? Jt Comm J Qual Patient Saf 2009; 35(10): 502-8.
- Montague T: Next-generation healthcare: a strategic appraisal. Healthc Pap 2009; 9(2): 39-44; discussion 60-3.
- Grumbach K, Bodenheimer T: Can health care teams improve primary care practice? JAMA 2004; 291(10): 1246-51.
- Langley GJ, Moen RP, Nolan KM, Nolan TW, Norman CL, Provost LP: The Improvement Guide. San Francisco, California, USA: Jossey-Bass Publishers, Inc, 1996, 2009.
- Peterson KA, Radosevich DM, O'Connor PJ, et al.: Improving Diabetes Care in Practice: findings from the TRANSLATE trial. Diabetes Care 2008; 31(12): 2238-43.