Strategies for Improving Diabetes Care: Practice Based Learning

The American Diabetes Association has found that despite having available standards of care in diabetes, implementing these standards in most clinical settings has been suboptimal. Consider the following alarming statistics:

  • 37% of diagnosed diabetics have an A1C of <7%.
  • 36% of diagnosed diabetics have a blood pressure of <130/80.
  • 48% of diagnosed diabetics have a total cholesterol <200.
  • Only 7.3% of diagnosed diabetics have all three parameters at target goal.

Despite numerous scientific advances in medicine, electronic technology, and point of care assessment tools, there are many causes for these poor statistics. The largest obstacles to optimal care are a fragmented health care delivery system that lacks clinical information capabilities, often duplicates services, and is not designed for delivering chronic health care. Interdisciplinary team approaches that collaborate with patients in self-empowerment and self-management education have been found to be better suited for patients with chronic care issues. The Institute of Medicine has recommended changes to delivery systems so that they provide care that is evidence based, patient centered, systems oriented, and includes information technology that fosters continuous quality improvement (CQI).

Several large health institutions such as Kaiser Permanente, the Veteran’s Administration, regional health networks, and smaller group practices have published many continuous quality improvement (CQI) projects that incorporated clinical practice outcome assessments, patient centered approaches, system design changes, and reassessment of their clinical outcomes after interventions.

Continuous Quality Improvement (CQI)

CQI is a concept that originated from the world of business and manufacturing. The underlying principle is that there is always room for improvement. Within companies, it is the commitment to constantly improve operations, processes and activities in order to meet customer requirements in an efficient, consistent and cost effective manner. The focus is not on individuals but on processes. CQI promotes the need for objective data to analyze and improve processes, and this approach is also applicable in health care settings. Effective CQI projects have been found to directly improve health outcomes. The American Diabetes Association considers ongoing CQI vital to delivering quality diabetes care.

Continuous Quality Improvement
Core Concepts of CQI
  • Quality is defined as meeting and/or exceeding the expectations of customers (patients, families, communities). Patients and families can participate at the practice level.
  • Success is achieved through meeting the needs of those we serve.
  • Most problems are found in processes, not in people. CQI does not seek to blame, but rather to improve processes.
  • Unintended variation in processes can lead to unwanted variation in outcomes, and therefore we seek to reduce or eliminate unwanted variation.
  • It is possible to achieve continual improvement through small, incremental changes using the scientific method.
  • Continuous improvement is most effective when it becomes a natural part of the way everyday work is done and not a peripheral periodic activity.
Core Steps in Continuous Improvement
  • Define the problem before trying to solve it.
  • Understand a process before you attempt to control it.
  • Identify which problems are priorities before attempting to correct everything.
  • There is no such thing as failure because you can learn from all processes.
  • Form a team that has knowledge of the system needing improvement.
  • Understand the needs of the people who are served by the system.
  • Identify and define measures of success.
  • Brainstorm potential change strategies for producing improvement.
  • Plan, collect, and use data for facilitating effective decision making.
  • Apply the scientific method to test and refine changes.

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