Better Diabetes Care - How to Make Systems Changes for Improved Care

Ensure Commitment
Quality long-term diabetes management requires a systematic, comprehensive system of care that serves the needs of both patients and health care professionals. To be effective, leaders need to:

Physicians and other health care professionals need positive incentives to make changes. Reorganization of payment structures for team 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. For more information about incentives for changing the system, click here.

Establish an Improvement Team
Implementing changes in a clinical setting requires buy-in and commitment and work from others who work in together in the setting, in other words, a team.⁴ The team should be diverse and represent people from different areas of the clinic or office. This helps when brainstorming potential solutions. This team approach also encourages a division of labor among team members during the improvement effort.

Identify Gaps in Care
Self-assessment is an essential first step toward making system changes. Self-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 click here.

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 these improvements, additional goals and objectives will be based on reducing gaps identified by the assessment of the practice or health care system.

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:

To achieve any chosen goal, a practice, health care team, or planning group needs to determine baseline measures and an achievable target, then select and implement a number of small steps or objectives that would lead to achievement of the goal over time.

For example, to increase the proportion of people with diabetes who receive diabetes education, steps might include:

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.

Table 1 provides many examples of quality improvement activities that relate to elements of the chronic care model. These activities can be introduced and tested using PDSA cycles. Examples of frequently performed interventions tested with PDSA cycles in a Midwest health disparities collaborate⁵ were:

Clinicians will find that the practice of clinical medicine is itself a series of quality improvement cycles. Table 2 shows how clinical decision-making parallels the process of quality improvement.

Establish Accountability
Medical record audit and feedback of summary data to individual physicians or physician groups can help improve quality of care and patient health outcomes.⁶ Action on key performance measures, however, is essential for success.^7,8

Example of Successful Quality Improvement Implementation
A multicomponent organizational intervention in community primary care practices increased the percentage of patients with type 2 diabetes who achieved recommended clinical outcomes.⁹

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:

Resources

Please note: Some links on this page take you outside the Better Diabetes Care website. The NDEP does not endorse or otherwise guarantee the accuracy of links that take you out of this website.

References

Table 1. Examples of PDSA Cycles for Quality Improvement Activities
to Address Elements of the Chronic Care Model

Clinical Information Systems
Examples of PDSA Cycles

Used registry to disseminate current care guidelines
Used registry reports as performance feedback for providers
Developed registry to track clinical measures and to identify patients who need increased care
Used registry to preplan visits, such as pre-scheduling blood work
Identified patients needing diabetes education

Especially innovative PDSA Cycles

Made registry accessible to physicians via the Internet
Generated preaddressed letters from the registry for patients with elevated A1C levels
Linked registry to communitywide electronic medical record

Delivery System Design
Examples of PDSA Cycles

Implemented planned visits, group visits, and/or chronic disease visits
Revised team roles using questionnaires and team meetings
Involved nurse educators in planned diabetes visits
Posted notices in exam rooms for patients with diabetes to remove shoes
Used registry monthly reports and pop-up reminders for follow-up and care planning
Implemented telephone follow-up