Abstract
Aim: This doctoral quality improvement project aimed to improve the percentage of diabetic patients receiving standardized, appropriate diabetic care to 90% and improve team engagement to 4 on a Likert scale over 90 days. (Team engagement was just one component of this doctoral QI project).
Background: Diabetic patients are at higher risk for heart disease, stroke, blindness, kidney failure, and extremity amputations (CDC 2017). Diabetes and its complications, deaths, and societal costs have a vast and rapidly growing impact on the United States (US). With an economic burden of $327 billion for 2017, demonstrating a 26% increase from 2015 arguably one of the costliest diseases facing the US (ADA, 2018a). Evidence has shown decreased mortality and improved diabetic patient outcomes when evidence-based clinical practice guidelines are followed (ADA, 2018b). The American Diabetes Association (2017) recommends providers routinely seek out processes and structures conducive to improving diabetes care.
Rationale: Prior to this project, no standard routine best practices were followed for diabetic patients at this chaotic clinic. Consequently, diabetic patients were receiving sub-optimal care. A chart audit of diabetic patients showed a significant gap in care, with 75% of patients having a Glycated Hemoglobin (HbA1C) of more than 8%, 25% having inadequate blood pressure control, and 100% had one or more preventative care measures not completed.
Methods: A rapid cycle quality improvement model was used with four two-week Plan-DoStudy-Act (PDSA) cycles. Iterative tests of change (TOC) were used to improve team confidence, patient engagement, diabetes care measures, and preventive care referrals. Test interventions of change (TOC) were introduced every two weeks for four PDSA cycles in the four areas of concentration: team engagement, patient engagement, diabetic care measure checklist, and preventative care referrals. Operational definitions were established for each TOC to prevent ambiguity. Data were collected and analyzed using run charts, chart audits, and surveys. Iterative TOC was used to improve team confidence, patient engagement, diabetes care measures, and preventive care referrals. This project utilized process measures to determine what interventions were performed as planned to affect the outcome measures.
Results: Results for PDSA cycle 1 and 2 showed a gradual improvement due to inadequate systems, lack of team confidence, and team dynamics. PDSA cycles 3 and 4 showed much improvement, with an overall mean average of 93% of diabetic patients receiving standardized, appropriate diabetic care an improvement from 27%; team confidence increasing to 4.5 on a Likert scale from 2.5; diabetic patients empowered to create goals 84% improving from 33 %, and diabetes care measures reviewed via checklist 92% of the time improving from 39%.
Conclusion: Despite the numerous challenges along the way, this QI project improved patient-centered standardized, diabetes care in this chaotic practice. The major success of this project was the process of change affecting the overall team with improved cohesiveness, confidence, and communication. With, team meetings, educational sessions, morning huddles with a white board instrumental in improving team dynamics and cohesiveness, which was demonstrated to be a key component in the success of this QI project, as well as to improved workflow efficiency for this practice. This project highlighted that a team has significant power for achieving better diabetes outcomes.