Clinical Audit and improvement process to

Improve diabetes care at the Ashcroft

Gold Standard

  • All patients to have all 9 diabetic cares within a 15m period
  • These consist of; HbA1c, BP, microalbuminuria, total cholesterol, serum creatinine, retinal screening, foot risk classification, smoking status and weight/BMI

Background

In 2014/15 there was a CCG initiative to improve the Dmic 9 care process across the whole CCG. The aim was to improve the percentage of pateintsrecieveing all 9 care processes from 50% (CCG ave) to 65%.

As a practice we in 2014 were achieveing 45%. We worked as a practice to chase patients and improved this to 59%. However when the initiative stopped we decided to try and continue the work to improve diabetic care within the practice.

In 2014/15 we actively chased patients who had not had cares such as foot checks ACR’s but on a long term basis this was not sustainable. So we decided to make changes to our recall system and improve the quality of Diabetic care within the practice.

Method

In June 2015 a multidisciplinary group met (Dr Elizabeth Hamblin, Dr Pardip Sandhu, Nurse Zoe Booth, Nurse Joanna Young and Pamela Brown) to review our current recall system.

The problems

The following areas were identified which may have been contributing to our achievement:-

  1. Patients new to practice do not always get added to the recall system
  2. Patients with a new diagnosis of diabetes may not receive a recall in a timely manner/may not be added to the recall system
  3. Recording of data at diabetic review was difficult because of the cumbersome QOF diabetic template.

Our solutions

  1. When Manjit summarises the notes of new patients he send a task to the Nurse admin group if the patient has a diabetic code. They will add a recall
  2. If there is a new diagnosis of diabetes on a hospital discharge summary Manjit sends a task to nurse admin. They will adda recall
  3. To review our diabetic protocol and arrange a PLT session with the clinical team to review the new diabetic protocol. ( see appendix 1)
  4. Introduce an interim review for patients not achieving target HbA1c

Over 2015/16 we used the reports produced via data quality to audit our progress. Although we used data qualities reports this audit was completely instigated by the practice.

Audit Findings

process / % of patients achieving care care at end July 2015 / % of patients achieving care at end of April 2016 / CCG ave at end of April 2016
BMI / 86 / 88 / 90
BP / 97 / 97 / 95
record of smoking / 82 / 89 / 90
HbA1c taken / 96 / 96 / 96
ACR / 76 / 76 / 76
serum creatinine / 95 / 95 / 93
total cholesterol / 85 / 90 / 90
retinal screening / 82 / 82 / 79
foot risk classification / 66 / 66 / 76
all Diabetic 9 care processes / 45 / 49 / 55

Interim Analysis

  1. Although we do not achieve all of the diabetic 9 care processes on an individual basis we achieve similar to the CCG average in nearly all the cares. This suggests that our biggest problem is not in the care we are delivering but in capturing the data.
  2. To address this we have changed the way in which we record information. Nurse Jo has highlighted a YHCS template which will make data capturing easier. The we have imported this into our local templates and nursing staff have been trained to use this.

End of year re-audit findings

process / % of patients achieving care at end July 2015 / % of patients achieving care at end of April 2016 / CCG ave at end of April 2016 / re-audit end of July 2016 / % change in 1 year period
BMI / 86 / 88 / 90 / 93 / +7
BP / 97 / 97 / 95 / 97 / 0
record of smoking / 82 / 89 / 90 / 94 / +12
HbA1c taken / 96 / 96 / 96 / 96 / 0
ACR / 76 / 76 / 76 / 79 / +3
serum creatinine / 95 / 95 / 93 / 94 / -1
total cholesterol / 85 / 90 / 90 / 92 / +7
retinal screening / 82 / 82 / 79 / 82 / 0
foot risk classification / 66 / 66 / 76 / 62 / -4
all Diabetic 9 care processes / 45 / 49 / 55 / 50 / +5

Reflection and Conclusions

Having made changes to our recall process we have seen an overall improvement in the 9 care process by 5%. We have made made significant improments in recording BMI;s smoking status TC and ACR. I think this was helped by the introduction of the YHCS diabetic template.

In addition to the recording the 9 care processes we were hoping to improve the quality of diabetic care further by achieving BP control < 140/80, cholesterol levels below 5 and HbA1c < 59 (our QOF targets)

HbA1c< 5957.5 % of our patients achieved this value ( +3.8% from May 2015.

BP < 140/8057.3 % achieved this value (+3.3% from May 2015)

TC <5.0 mmol/l 75.4 achieved this value (+1.8%)

I think the introduction of the interim review has helped to achieve targets above. We have only been doing this for approximately one year so I would expect there to be further improvement over the next 12 to 24 months.

Although we have made some improvements there is further work to do. Further plans to improve quality of care include;developing patient plans for individual targets for HbA1c and BP and empowering PN to advice on stepping up medical treatment ( all PN have a diabetes diploma). We have started this process by holding a practice PLT in July where we have reviewed our current process and are planning on developing a protocol for nurses so they can advise on stepping up treatment.

Appendix 1

What to do with raised HbA1c in a patient who does not have a diagnosis of Diabetes