QUALITY IMPROVEMENT AND DIABETES CARE

1. QUALITY IMPROVEMENT AND DIABETES CARE

2. Why QI Now? • Increasing demand • Increasing complexity • Increasing elderly • Pressure on resources • Improvements need to be effective, efficient and sustainable

4. THE BEGINNING

5. FACTORS RELATING TO YOUR PRACTICE Are people prepared to experiment with something new? Are you prepared/able to lead? How good are you at listening to patient’s comments? How well do your team work together? Does everyone believe they can make things better? Culture and Context Are the meetings effective? Are staff happy at work? How will new contract affect care? Will retirements make a difference? Is there enough staff to help? How good is everyone at listening to each other? Do you believe it is worth investing time to make things better?

6. TASK

8. PATIENT INVOLVEMENT • How will you involve your patients?

9. ROLE OF PATIENTS IN PROCESS Diagnosing your improvement need: • Participating in a process map of the diabetes annual review system – is it effective and efficient? • Giving feedback on the current service Helping to design an intervention • Focus group • Linking to Diabetes UK local group to share ideas Testing out your intervention • Patient survey

11. Process mapping • Start and end points • Every step recorded, who does it, time it takes • Add comment post its in different colours • Identifies waste steps

13. DATA • National Diabetes Audit • PRIMIS • Practice software systems

14. CARE PROCESSES NDA QOF Foot exam and risk assessment • Blood pressure • Creatinine • BMI • Cholesterol • Foot surveillance • Smoking • Urine albumen • HbA1C • ALL processes

15. TREATMENT TARGETS NDA QOF HbA1C < 59 HbA1C < 64 HbA1C < 75 BP < 140/80 BP < 150/90 Cholesterol < 5 • HbA1C < 48 • HbA1C < 58 • HbA1C < 86 • BP < 140/80 • Cholesterol < 4 • Cholesterol < 5 • Meeting HbA1C<58 + BP < 140/80 + chol <5

16. To uncover all the factors contributing Fishbone Diagrams

17. TASKS • Construct a process map of your call and re-call system for patients with diabetes • Look at data from your practice and identify one problem in process and one in treatment target data

21. PDSA CYCLES

22. WHAT ARE WE TRYING TO ACCOMPLISH? This needs to be specific and include ‘by how much?’ and ‘by when?’ For example: • “increase attendance for diabetes reviews” is not very specific. A more specific aim would be: • “increase attendance for those invited for diabetes review over the next 3 months by 20%”

23. IS THERE AN IMPROVEMENT? • Count the number of responding to invitation for their diabetes review every week

24. MEASUREMENT • Needs to be real time data

25. MEASUREMENT “An improvement will require change but not all change will result in an improvement” Langley et al “Seek usefulness, not perfection in the measurement” Nelson et al

26. IDEAS FOR CHANGE • No appointment time stated on review letter but patients to make their own appointment • Invitation sent out in first choice language • Invitations made by phone call • Leaflet on the importance of review sent out with each invitation • Review appointment request attached to prescription

27. PLAN • Who is responsible? • When? • Over what timescale? • Involve stakeholders • Persuade reluctant team members • Predict what will happen

28. DO • One change at a time • Small change meets less resistance • Look for unexpected consequences • Gather data • Search run every Friday at 5pm

29. STUDY Has it worked? Has anything unexpected happened? What do your measurements tell you?

30. STUDY • Displaying your data well • Helps you to make sense of it • Helps everyone to see when improvements have been made

31. STUDY • When you project involves a gradual improvement in something that does not vary from day to day, it is easy to see if you have improved.

32. AIM OF RUN CHART Some measurements are highly variable and a simple graph won’t tell you if you are improving. In care of diabetes e.g. the percentage attending for health intervention such as: • Diabetes clinic review • Foot check

33. RUN CHARTS • Line graph over time • Median plotted • Time of change annotated • Determine if change an improvement • Assess sustainability • Separates random (common cause) from non random (special cause) variation

35. DOWN LOAD CHART • Free registration on IHI • http://www.ihi.org/resources/Pages/Tools/RunChart.aspx • Guidance in section three of toolkit

36. OWN APPOINTMENT TIME

37. PHONE CALL INVITATION

38. ACT • Adopt, adapt or change • Decided to adopt phone call invitations

39. RUN CHART SUMMARY • A lot of measuring - ideally need 15 measurements prior to change, to see if process stable • Not as sensitive as statistical process control (SPC) • Does not tell the cause of the variation • Easy to create at practice level

40. TASK Take one of the problems you have identified from the previous task Ask the three questions from model for improvement Commence PDSA – Plan and Do Study – To conduct in practice Act – To conduct in practice

41. MODEL FOR IMPROVEMENT • What are we trying to accomplish? • How will we know if a change has been an improvement? • What changes can we make that will result in an improvement?

42. TASK • Interpret these run charts

44. WAYS TO EMBED CHANGE • Celebrations • Visual displays • Keep it on the ‘agenda’ • On-going data collection

45. PERFORMANCE BOARD

47. FURTHER INFORMATION • RCGP QI toolkit for diabetes care • Quality Improvement for General Practice http://www.rcgp.org.uk/qi