Family Medicine · Year 3 · from Family Medicine

Case 1: Quality Improvement - Diabetes Care

Practice Setting

  • Practice: Community Family Medicine Clinic
  • Patient Panel: 4,500 patients
  • Providers: 3 physicians, 2 nurse practitioners
  • Location: Suburban area, mixed socioeconomic population

Quality Improvement Challenge

The practice has received its quarterly quality report from their accountable care organization. Their diabetes mellitus HbA1c control measure is underperforming:

Current Performance:

  • Patients with diabetes who have HbA1c <8%: 62%
  • ACO target: 75%
  • National benchmark: 70%

This performance gap affects both patient health outcomes and practice reimbursement under their value-based contract.

QI Team Formation

Team Members:

  • Lead physician (QI champion)
  • Medical assistant
  • Registered nurse (care coordinator)
  • Front desk staff member
  • Practice manager
  • Patient representative

Plan-Do-Study-Act (PDSA) Cycle 1

PLAN:

Problem Identification:

  • Reviewed diabetes registry: 485 patients with diabetes
  • 302 (62%) at goal HbA1c <8%
  • 183 (38%) not at goal

Root Cause Analysis:

  1. Many patients overdue for HbA1c (no test in >6 months): 28%
  2. Patients with elevated HbA1c not returning for follow-up: 35%
  3. Medication intensification not occurring at visits: observed in chart review
  4. Patient education and self-management support inconsistent

Aim Statement: "We will increase the percentage of patients with diabetes who have HbA1c <8% from 62% to 70% within 6 months."

Intervention Selected for First Cycle: Address the testing gap - patients overdue for HbA1c monitoring

Specific Change to Test: Pre-visit planning to identify diabetic patients due for HbA1c, with standing order for lab to be completed before the appointment.

DO:

Implementation (Small Scale Test):

  • Tested with one provider's panel for 2 weeks
  • MA reviews schedule 1 week in advance
  • Identifies patients with diabetes
  • Checks if HbA1c done in past 3 months
  • If not, sends order to lab with instruction to complete before appointment
  • Patient contacted by phone/portal with lab order

Data Collection:

  • Number of patients identified as needing HbA1c
  • Percentage who completed lab before visit
  • Provider satisfaction with process
  • Time added to MA workflow

STUDY:

Results After 2-Week Pilot:

  • 24 diabetic patients identified on provider schedule
  • 14 (58%) were overdue for HbA1c
  • 10/14 (71%) completed HbA1c before their visit
  • Average additional MA time: 5 minutes per patient identified
  • Provider reported: "This is incredibly helpful - I can make real-time treatment decisions"
  • Barrier identified: Some patients couldn't afford lab copay before visit

ACT:

Decision: ADOPT with modifications

  • Roll out to all providers
  • Add financial counseling for patients with lab cost barriers
  • Integrate into daily huddle workflow

PDSA Cycle 2

PLAN:

Next Problem: Patients with elevated HbA1c not returning for timely follow-up

Intervention: Nurse care manager outreach to patients with HbA1c >9% who have not scheduled follow-up within 2 weeks

DO:

  • Tested for 4 weeks with all patients with HbA1c >9%
  • Care manager calls within 3 days of lab result
  • Reviews medication adherence, barriers to care
  • Schedules follow-up appointment
  • Completes warm handoff to pharmacist if medication issues identified

STUDY:

  • 18 patients with HbA1c >9% identified
  • 16/18 (89%) reached by phone
  • 14/16 (88%) scheduled follow-up within 3 weeks
  • Common barriers identified: medication cost, transportation, understanding of diabetes

ACT:

  • Adopt as standard workflow
  • Expand to patients with HbA1c 8-9%
  • Create resource list for common barriers

Clinical Image

Image: The Plan-Do-Study-Act quality improvement cycle showing the iterative process of planning an intervention, testing on a small scale, analyzing results, and deciding whether to adopt, adapt, or abandon.

Image Source: Wikimedia Commons Attribution: Based on IHI Model, Educational Use URL: https://commons.wikimedia.org/wiki/File:PDSA_cycle.png

Results After 6 Months

Process Measures:

  • HbA1c testing rate within 6 months: 72% → 91%
  • Follow-up scheduling rate for HbA1c >8%: 45% → 82%
  • Pre-visit labs completed: 0% → 68%

Outcome Measures:

  • HbA1c <8%: 62% → 71% (goal was 70%)
  • HbA1c <9%: 78% → 86%

Balancing Measures:

  • Provider satisfaction improved (pre-visit data availability)
  • MA workload increased but manageable with workflow redesign
  • No increase in patient complaints

Teaching Points

  1. PDSA cycles are iterative - test small, learn, adapt, then spread
  1. Root cause analysis before intervention - understand WHY before deciding WHAT
  1. Aim statements should be specific and measurable - "improve diabetes care" is not actionable
  1. Balance measures prevent unintended consequences - improving one metric shouldn't worsen another
  1. Multidisciplinary team involvement is essential - front desk and MAs often have the best process insights
  1. Quick wins build momentum - start with achievable changes that demonstrate value

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