1. Learning Session 2 October 31, 2016
Diabetes Collaborative
Learning Session 2 October 31, 2016

2. PHO and Facilitator: ProCare Team members:
Dr Selvakumar, Dr Hamid Al-Bahadly,
Dr Mekala Pushparajah.
Nurses: Lisa, Sunita, Gomeeta, Savita, Nancy.
Reception: Lesley, Evelyn, Tehoo, Kelleigh, Sokunna & Janine.

3. Care Bundle Data

4. Aim:
Quality Improvement in Diabetes Care
To achieve at least 10% reduction of HbA1c in all poorly controlled Diabetics by June 2017.
Strategies:
Appoint a Practice Diabetes Champion – RN Sunita.
Provide professional development in Diabetes and patient communication.
- MIT Diabetes Course, HINT (Healthy Innovative Neutral training)
Encourage patients to see the Doctor 3 monthly for scripts.

5. Change Tested
On review of monthly audit of 10 random poorly controlled diabetic patients- we identified low number of Foot Check.
We planned a PDSA focusing on improving the Diabetic foot checks done by the patients.
A Query builder was developed to identify Diabetic patients without Foot check in last 12 months.
Change idea: TXT msgs sent to patients to attend for Foot Check.
Results:
On reviewing the practice data of diabetes patients it was found that 312 patients were due for their foot check.
Audit were conducted in a span of 2 & 4 weeks post the TXT messages
66 foot checks completed in the 2 weeks. An increase of 44 foot checks compared to the 2 weeks prior. And 111 foot checks were completed in total in 4 weeks.
Foot check appts also identified patients due for HbA1c and retinal screening.

6. Resulting in improved outcomes for diabetic patients.
What does the data say?
Rate of patients treatment being reviewed within last 3 months is improved by encouraging patients to see the GP for their 3 monthly prescriptions.
This provides increased opportunity for assessment of risk and presence of diabetic complications.
Resulting in improved outcomes for diabetic patients.

7. Future:
Enhance our system to identify patients overdue for HbA1c.
Utilise DCIP monthly audit results and PHO data for poorly controlled patients to identify target areas .
Change Ideas:
What impact do you hope to have from this change?
Improved Patient Diabetes Care.
To overall reduce HbA1c in our poorly controlled Diabetic population.