QA&CPD Category 1 activity

Rapid PDSA cycles improving

practice processes for the care of
patients with diabetes
QA&CPD Category 1 activity
Rapid PDSA cycles improving practice processes
for the care of patients with diabetes
Disclaimer
These activites have been designed for information purposes only and are
intended to assist practices to implement changes in practice systems which
improve the care of patients with type 2 diabetes.
Further clinical information should be obtained from the RACGP publication
Diabetes management in general practice: Guidelines for type 2 diabetes.
This publication was supported by funding from the Australian Government.
The publication reects the views of the authors and not necessarily reects
the views of the Australian Government.
Published by:
The Royal Australian College of General Practitioners
College House
1 Palmerston Crescent
South Melbourne, Victoria 3205
Australia
Tel 03 8699 0414
Fax 03 8699 0400
www.racgp.org.au
ISBN 978-0-86906-312-5
Published June 2010
The Royal Australian College of General Practitioners. All rights reserved.
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Rapid PDSA cycles improving practice
processes for the care of patients with diabetes
QA&CPD Category 1 activity
This activity is designed to support
general practitioners and practice teams
in undertaking a Category 1 QA&CPD
activity using the PCS Clinical Audit
Tool
TM
(CAT) to implement a rapid plan,
do, study, act (PDSA) cycle based on the
RACGP, Diabetes Australia publication
Diabetes management in general
practiceguidelines.
It is designed as a guide only, and
participants may choose to undertake the
cycles as outlined, or identify other topics
or change principles based on their own
needs or the results of the study.
In order to obtain 40 Category 1 points for
each GP involved, the following should
be completed and submitted to your state
QA&CPD unit for adjudication:
Rapid PDSA application form (at
completion of module). The PDSA
application form includes the
completion of the three PDSA cycle
forms and individual GP review form
PDSA cycle forms (minimum three)
Individual GP review form (one per
GP participant).
Please read the application guide before
commencing to ensure that you meet the
necessary requirements. Practice nurses
and practice managers participating in
the activity should contact the Australian
Practice Nurses Association or the
Australian Association of Practice
Managers regarding continuing
professional development points.
Introduction
What is quality
improvement?
Since Berwicks landmark 1989 paper on
continuous quality improvement (CQI),
as applied to the healthcare setting, there
has been awareness that the processes
within a general practice setting afect
patient outcomes. There is now an
acceptance that repeated measurement
of both process and outcomes helps to
identify current performance and areas
of concern.
Berwick describes a number of steps in a
model for quality improvement:
identifying what is to be accomplished
measuring change and recognising
whether this change constitutes
improvement
identifying potential alternatives to
current practice
the ability to test real changes on a
small scale.
This exible model recognises a number
of important elements for general
practice, including the range of diverse
practice styles and varying demographic
areas within which general practices
operate. The nonstandard practice size,
including difering numbers of GPs,
practice nurses and practice managers
and a range of other inuencing factors,
mean wholesale changes across general
practice are not possible. Each general
practice needs to be able to explore its
individual systems to nd out what
makes it tick.
One of the elements of the CQI model
that has been lacking in general practice
is the ability to measure improvement
efciently and efectively against a
number of indicators. Self assessment
of performance, while necessary, often
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overestimates performance and may be
neither accurate nor sufcient.
The current trend toward audit tools,
such as the CAT and the Canning
Division tool, are beginning to increase
practices awareness of practice
population data and its utility in CQI. By
using a PDSA cycle in conjunction with
an audit tool, practices can easily develop
reective CQI processes.
QA&CPD Category 1 activity
What is a rapid PDSA cycle?
The PDSA cycle (Figure 1) uses simple measurements to monitor the efects of change
over time. The cycle encourages starting with small changes, which can be built into
larger improvements via successive cycles. The process emphasises an unambitious
start, reecting and building as learning occurs. A PDSA cycle can be used to test
suggestions for improvement quickly and easily based on existing ideas and research,
or through practical ideas that have been proven to work elsewhere. Not requiring
wholesale change, and being able to complete cycles over relatively short periods of
time (eg. 1 month), work well within the general practice setting.
Berwick DM. Continuous improvement as an ideal in health care. New England Journal of Medicine 1989;320:5356.
Grol R. Improving practice. A systematic approach to implementation of change in patient care. Oxford: Elsevier Science, 2004.
Plan Do
Act Study
Plan
The rst step in a PDSA cycle is to gure out what you want to do. What do you wish
to improve, observe or change? Plan the test or an observation and what data you will
need to measure its impact.
State the aim of the test or observation
Predict the possible outcome
Develop a plan to test the changes.
Once you have decided on the issue you would like to explore, give some thought to:
which actions need to happen (eg. recall, reminders, practice brief, training) and in
what order?
who will be responsible for each step?
who needs to be informed or consulted?
Figure 1. The PDSA cycle
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How will you measure the change (eg. CAT, Canning Tool, ad hoc search)?
What do you expect/hope to see as a result of the change?
How will you know whether the change has worked?
Some example of research questions are:
How do I improve the rate of Pap tests among eligible female patients?
What items do I need to complete in order to claim an Service Incentive Payment
(SIP) for my patients with diabetes?
Do I have patients that would beneft from a Home Medications Review (HMR)?
Are my asthma patients who use inhalers receiving a yearly fu vaccination?
Do
Once you have planned the change, the second step is to undertake the test on a
small scale. This may be an activity with just a sole patient or one process within the
practice. It is important that the do stage is kept as short as possible, although there
will be some changes that can only be measured over a longer period of time.
This stage allows you to:
undertake the test
document the process, taking note of practice staf and patients reactions, any
problems or unexpected observations
collect all measurements, data and observations.
This minor test is undertaken to:
substantiate the probability that a change in this area is possible
decide whether the change will produce an acceptable outcome
decide on the scope of the change and if it is viable in the actual practice setting
decide if a combination of changes is required to achieve the outcome
understand the cost, resources and patient/practice staf impact of changes
enable a smooth transition to any changes implemented.
Study
The third step is to review and analyse the data and observations. You will need to:
set aside time for all persons involved in the process to discuss the outcomes of the
small scale test
review all data and observations against expected outcomes. Did the practices
expectations match what really happened?
consider what could be done diferently
refect on what has been learnt
reach a consensus on subsequent action(s).
Act
The act step is to make any necessary adaptations or improvements, and acknowledge
and celebrate successes. It allows the practice to rene the changes against any
broader knowledge achieved from the small scale test, or if further change is needed, to
use the information to enter another planning cycle.
Small promising changes are tested in a rapid series of PDSA processes. These will
rene the methodology and determine the most promising results.
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What is the PCS Clinical Audit Tool
TM
?
The PCS Clinical Audit Tool
TM
(CAT) is a population health software program that
enables general practice staf to look at the totality of their practice population. By
doing so, general practices can quickly and easily identify patient groups that may not
be getting optimal care and use this information to better direct practice activities. In
addition, practices can identify missing data or patients at risk, enabling targeted care.
For example, a practice can quickly identify how many eligible female patients are
overdue for, or have never had, a Pap test; how many patients with diabetes do not have
an HbA1c on record; or a range of other practical clinical or business administrative
questions. These patients can then be recalled and/or managed using the practices
standard procedures.
CAT works with Medical Director (2 and 3), Best Practice, Genie and Zedmed. It takes
a snapshot of patient data and allows you to view it via easy-to-read pie and line
charts, and reports.
In addition to CAT, there are a range of other population health tools on the market.
This Category 1 activity assists the practice in using CAT to complete rapid PDSA
cycles. While this activity provides a guide to using CAT, it can be also undertaken
using similar tools or adapted to your clinical software system.
Rapid PDSA cycle
This example of a rapid PDSA cycle will take the practice through some data cleansing
and administrative functions that will allow practice data to be used in a range of ways.
If the practice is particularly interested in improving diabetes care, there are a range of
other diabetes indicators that can be explored.
PDSA cycle 1
Plan
State the aim of the test or observation
To improve practice processes for the care of patients with diabetes.
What do you want to achieve, what actions need to happen and in what order?
To establish the number of people within the practices clinical database coded
with a diagnosis of diabetes and compare this to expected numbers.
This will result in, for example:
an easily accessible, accurate and current diabetes register
refection on range of coding/information recording practices of diferent
clinicalstaf
information coding changes to standardise recording of diagnoses.
Once the practice agrees on the aim and the possible outcomes, it is important to
thoroughly plan the do stage.
Install an appropriate audit tool onto the practice IT system
Ensure members of staf are trained in the use of CAT
Select patients with a diagnosis of diabetes
Does this represent all patients with a diagnosis of diabetes? Reect on the
number of patients with diabetes within the practice and compare with
population prevalence
Check diagnostic coding in the medical record for discrepancies.
Who will be responsible for each step and when will it be completed?
The practice team needs to meet to determine who is responsible for each step.
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QA&CPD Category 1 activity
What resources are required?
The practice team needs to meet to determine what resources are required.
Who else needs to be kept informed or consulted?
Consider whether there are others who need to be consulted, eg. practice nurses,
practice managers, patients, allied health staf.
How will you measure changes to practice?
For example, use of CAT, Canning Tool, ad hoc search?
Determine the system that ts within the practice prole.
What observations would be expected as a result of this change?
Using CAT, the practice is able to identify and explore details of those patients with
a correctly entered diagnosis of diabetes.
You would expect to have about 7.5% of patients with diabetes. The AusDiab study
found that the prevalence of diabetes in the Australian population aged 25 years
and over was 7.5%: 8% males, 7% females.
This may vary depending on your practice population, as some population groups
have a higher prevalence of diabetes. For example :
Aboriginal and Torres Strait Islander people are estimated to have a prevalence of
diabetes of over two times the rate of nonindigenous people
People from lower socioeconomic groups have a higher prevalence rate
Hospitalisation rates for diabetes are higher in people living in remote and very
remote areas
Diabetes increases with age. Prevalence is:
2.5% in the 3544 years age group
6.2% in the 4554 years age group
13.1% in the 5564 years age group
18.6% in the 6574 years age group
23.6% in those aged 75 years and over.
What data needs to be collected to check the outcome of the change?
Number of patients coded with diabetes on the practice clinical database.
How will it be known whether the change has worked or not?
Subsequent audits identify all patients with a diagnosis of diabetes.
Coding for diabetes remains constant.
Do
The second step is to undertake the test on a small scale using the CAT. Using CAT, the
practice will be able to address the aim of identifying the number of people within the
practices clinical database that are coded with a diagnosis of diabetes.
Note that CAT enables the practice to search their entire database, or only those that
meet the RACGP Standards for general practices denition of active, which is patients
who have visited a minimum of three times in the past 2 years. This will assist the
practice in identifying their core patients.
Dunstan D, Zimmet P, Welborn T, Sicree R, Armstrong T, Atkins R, Cameron A, Shaw J, and Chadban S on behalf of the
AusDiab Steering Committee. Diabesity & Associated Disorders in Australia 2000. The accelerating epidemic: The
Australian Diabetes, Obesity and Lifestyle Study (AusDiab). Available at www.diabetes.com.au/pdf/AusDiab_Report.pdf.
Australian Institute of Health and Welfare 2008. Diabetes: Australian facts 2008. Diabetes series No. 8. Cat. No. CVD 40.
Canberra: AIHW, 2008.
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CAT starting point
1. CAT open
2. Population extract loaded and extract pane hidden
3. Filter pane open and, under the general tab
4. OPTIONAL: active (three visits <2 years).
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Identify patients
1. In the Conditions tab select diabetes Yes
2. Click recalculate
3. Click hide lters
4. You will see the demographic breakdown for your diabetic population in the age
breakdown graph.
Document the process, taking note of any problems or unexpected observations
Collect all measurements, data and observations.
Study
Set aside time for all people involved in the process to discuss the outcomes of the
small scale test.
What were the results?
Did they difer from the groups expectations? Did you expect to see this number of
patients with diabetes? Is it higher or lower than expected?
What has the group learned from completing this cycle?
Consider what could be done diferently
Refect on what has been learnt
Reach a consensus on subsequent action(s). If the numbers are lower than
expected, this could be a coding issue. Is there a standard process for coding
patients with diabetes?
Act
What action will you take now?
Cycle 2 enables you to examine your database to identify patients with diabetes who
are not correctly coded.
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PDSA cycle 2
Plan
State the aim of the test or observation
To improve practice processes for the care of patients with diabetes.
What do you want to achieve, what actions need to happen and in what order?
To establish the number of people within the practices clinical database that have
an HbA1c recorded, but are not coded as diabetic.
This will result in, for example:
an easily accessible, accurate and current diabetes register
refection on a range of coding/information recording practices of diferent
clinical staf
practice ability to ofer appropriate care to those with diabetes
information coding changes to standardise recording of diagnoses.
Once the practice agrees on the aim and the possible outcomes, it is important to
thoroughly plan the do stage.
Select patients without a diagnosis of diabetes
Determine if any of these have had an HbA1c
Check diagnostic coding in the medical record for discrepancies.
If you do not receive pathology results in HL7 format:
select patients with a diagnosis of diabetes
compare this to a list of patients from your pathology provider who have had an
HbA1c
are the numbers the same?
check diagnostic coding in the medical record for discrepancies.
Who will be responsible for each step and when will it be completed?
The practice team needs to meet to determine who is responsible for each step.
What resources are required?
The practice team needs to meet to determine who is responsible for each step.
Who else needs to be informed or consulted?
Are there others who need to be consulted (eg. practice nurses, practice managers,
patients, allied health staf).
How will you measure the change (eg. CAT, Canning Tool, ad hoc search)?
Determine the system that ts within the practice prole.
What observations would be expected as a result of this change?
Using CAT the practice is able to identify those patients with diabetes who are not
correctly coded in their electronic health record.
Expectations will depend on the teams perception of the accuracy of their
database.
What data needs to be collected to check the outcome of the change?
Number of patients who have had an HbA1c but are not recorded as diabetic.
How will it be known whether the change has worked or not?
Subsequent audits identify all patients with a diagnosis of diabetes
Subsequent audits to ensure diabetic patients are receiving appropriate care
Coding for diabetes remains constant.
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Do
The second step is to undertake the test on a small scale using CAT. Using CAT, the
practice will be able to address the aim of identifying the number of people within the
practices clinical database that are, or are not, coded with a diagnosis of diabetes.
Note: CAT enables the practice to search either its entire database, or only those
records that meet the RACGP Standards for general practices denition of active, ie.
patients who have visited a minimum of three times in the past 2 years. This will assist
the practice in identifying its core patients.
Note: if you do not receive pathology results in HL7 format, you can ask your pathology
provider to give you a list of patients who have had an HbA1c in the past 2 years (or
whatever time period you wish to examine). You can then compare this to your list of
patients with diabetes.
CAT starting point
1. CAT open
2. Population extract loaded and extract pane hidden
3. Filter pane open and, under the general tab
4. OPTIONAL: active (three visits <2 years).
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Identify patients
5. In the conditions tab select diabetes no
6. Click recalculate
7. Click hide lters
8. After it has recalculated, in HbA1c tab select m <=7% AND >7% and <=8% AND
>8% and <10% AND >=10%
9. Select export in the top right hand corner of the graph pane.
Explore the patient list
10. Using the export list, visit the patient les in your clinical desktop system (eg.
Medical Director, Best Practice)
11. Examine the patient le, under diagnosis, results and patient history
Document the process, taking note of any problems or unexpected observations
Collect all measurements, data and observations.
Study
Set aside time for all people involved in the process to discuss the outcomes of the
small scale test.
What were the results?
Did they difer from the groups expectations? Did you expect to see this number of
patients with a HbA1c, despite having no diagnosis of diabetes? Did you expect to see
more or less? What does this tell you about your database?
When you explored patient records, could you easily identify why they were not
diagnosed? Were there accurate and relevant notes in patient les to identify them as
diabetic?
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How would you go about standardising the coding of diagnosis in your practice?
What has the group learnt from completing this cycle?
Consider what could be done diferently
Refect on what has been learnt
Reach a consensus on subsequent action(s). Is there a standard process for coding
patients with diabetes?
Act
What action will you take now?
This might involve updating the register to include patients not identied, and
developing standard procedures for coding of patients.
PDSA cycle 3
Plan
State the aim of the test or observation
To improve practice processes for the care of patients with diabetes.
What do you want to achieve, what actions need to happen and in what order?
To identify outstanding Diabetes Cycle Of Care items for each patient with
diabetes.
This will result in, for example:
an awareness of the number of Diabetes Cycle of Care items that have not been
completed
an awareness of the number of Diabetes Cycle of Care items that have been
completed but have not been claimed
an ability to recall patients to complete these items
an improvement in the practice systems for managing cycles of care
ability to claim Practice Incentives Program (PIP) payments for completed
Diabetes Annual Cycles of Care.
Once the practice agrees on the aim and the possible outcomes, it is important to
thoroughly plan the do stage.
1. Identify diabetes patients
2. Using CAT, identify SIP items that have not been completed
3. Discuss how these patients could be recalled
4. Discuss how practice would address this from a stafng and resourcing angle.
Who will be responsible for each step and when will it be completed?
The practice team needs to meet to determine who is responsible for each step.
What resources are required?
The practice team needs to meet to determine what resources are required.
Who else needs to be informed or consulted?
Are there others who need to be consulted, eg. practice nurses, practice managers,
patients, allied health staf?
How will you measure the change (eg. CAT, Canning Tool, ad hoc search)?
Determine the system that ts within the practice prole.
What observations would be expected as a result of the change?
Using CAT, the practice is able to identify and recall patients who have outstanding
Diabetes Cycle of Care items, enabling more efective patient management.
Expectations will depend on the practices perception of the status of their
patients.
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What data needs to be collected to check the outcome of the change?
Outstanding Diabetes Annual Cycle of Care items.
How will it be known whether the change has worked?
Increased number of completed cycle of care items
Increased PIP payments.
Do
The second step is to undertake the test on a small scale using CAT. Using CAT, the
practice will be able to address the aim of identifying the number of people within the
practices clinical database that are, or are not, coded with a diagnosis of diabetes.
Note: CAT enables the practice to search its entire database, or only those records that
meet the RACGP Standards for general practices denition of active, which is patients
who have visited a minimum of three times in the past 2 years. This will assist the
practice in identifying its core patients.
CAT starting point:
5. CAT open
6. Population extract loaded and extract pane hidden
7. OPTIONAL lter pane open and, under the general tab: active (three visits <2
years) selected.
Identify patients
12. In the conditions tab select diabetes yes
13. Click recalculate
14. Click hide lters
15. In the report pane, select diabetes SIP items tab
16. Select items completed per patient subtab
17. You will see the count of Diabetes SIP items completed per patient
18. Click each of the bars in the graph
19. Click worksheet
20. You will see a list of patients with diabetes including a matrix of complete and
incomplete cycle of care items
21. Export the patient list for potential patient recall.
Document the process, taking note of any problems or unexpected observations
Did you expect to see this number of incomplete items?
How will the practice manage the recall of these patients?
What systems could the practice implement to ensure these items are routinely
completed?
Collect all measurements, data and observations.
This minor test is undertaken to:
substantiate the probability that a change in this area is possible
decide on which of several proposed changes will have the best outcome
decide on the scope of the change and if it is viable in the actual practice setting
decide if a combination of changes is required to achieve the outcome
understand the cost, resources and patient impact of changes
enable a smooth transition to any changes implemented.
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Study
Set aside time for all people involved in the process to discuss the outcomes of the
small scale test.
What were the results?
Did they difer from the groups expectations?
Did you expect to see this number of incomplete items?
How will the practice manage the recall of these patients?
What systems could the practice implement to ensure these items are routinely
completed?
What has the group learnt from completing this cycle?
Consider what could be done diferently
Refect on what has been learnt
Reach a consensus on subsequent action(s). Is there a system for completing cycles
of care?
Act
What action will you take now?
This might involve developing systems and processes for ensuring cycles of care are
completed, or for recalling patients.
Where can I nd more information?
Clinical Audit Tool:
www.clinicalaudit.com.au
Australian Primary Care Collaboratives Program:
www.apcc.org.au
Diabetes Australia and the RACGP Diabetes management in general practice:
www.racgp.org.au/guidelines/diabetes
The RACGP QA&CPD information relating to PDSA:
www.racgp.org.au/QACPD
Your local division of general practice:
www.agpn.com.au/divisions-directory.
QA&CPD Category 1 activity