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Using Flow Sheets to Improve Diabetes Care
Has Mrs. Jones had a recent eye exam? Are her HbA1c levels improving? A diabetes flow sheet
will let you know at a glance.
Covered in FPM Quiz
Tool inside
Brandi White
Mrs. Jones, a 54-year-old established patient, comes to see you about her seasonal allergies.
You haven't seen Mrs. Jones recently, but you remember that she also has diabetes. You examine
Mrs. Jones, prescribe a medication for her allergies and, in the last few minutes of the visit, ask
her about her diabetes. She says she's taking care of herself, so you end the visit with brief
counseling on the importance of diabetes care. You then leave the room, and Mrs. Jones leaves
your office. What you don't know is that Mrs. Jones hasn't had an HbA1c test in over a year and
you won't see her for another six months.
It was situations such as the one described above that
led the physicians and staff members of Family Care
Network to embark on a 13-month quality
improvement project aimed at redesigning the way
they care for their patients with diabetes. The
problem wasn't that the physicians didn't know how
to treat diabetes clinically. Instead, it was largely a
process problem: The practices didn't know how to
keep track of those patients and make sure they were receiving the care they needed. Their
solution was to develop and put into practice a diabetes flow sheet. (For information on other
strategies the group implemented, see the series overview, below.)
The problem wasn't that the
physicians didn't know how to
treat diabetes clinically.
Instead, it was largely a
process problem.
What is a flow sheet?
A flow sheet is simply a one- or two-page form that gathers all the important data regarding a
patient's condition, in this case diabetes. The flow sheet is housed in the patient's chart and serves
as a reminder of care and a record of whether care expectations have been met.
"The goal is that every time a patient darkens the door of the practice, the doctor will look at the
flow sheet and address diabetes in addition to the sore throat, cough or whatever the patient is in
for at that visit," explains Steven Alexander, MD, medical director for Lynden Family Medicine,
one of the Family Care Network pilot sites. "Every time an appropriate piece of lab work or test
result comes through, you load the data in its slot in the flow sheet so that at a glance you can see
where you're at."
Series overview
This article is the fourth in an FPM series that follows Family Care Network, a
northwest Washington state group without walls, as it tackles a 13-month quality
improvement project focused on chronic disease care. The project is headed by the
Institute for Healthcare Improvement and involves approximately 30 organizations
nationwide.
Previous articles in the series are:



"Improving Chronic Disease Care in the Real World: A Step-by-Step
Approach," October 1999, page 38.
"Building a Patient Registry From the Ground Up," November/December 1999,
page 43.
"Helping Patients Take Charge of Their Chronic Illnesses," March 2000, page
47.
The final articles in the series will explore how to "preplan" diabetes visits and whether
the principles of quality improvement can really bring about change in a busy medical
practice.
Tips for making it work
At the outset of their quality improvement project, most of the Family Care Network sites were
already using flow sheets for their patients with diabetes, but their systems weren't optimal. In
many cases, the flow sheets weren't being filled out consistently or they weren't designed in a way
that was helpful. Using the "plan-do-study-act" (PDSA) cycle of improvement, the groups
experimented with their flow sheets and finally found systems that would work. The following
tips are based on their experience.
A sample flow sheet
The flow sheet shown here is based on
one developed by Family Health
Associates, one of three Family Care
Network pilot sites participating in a
diabetes quality improvement project.
The flow sheet can be downloaded as a
Microsoft Word file or a PDF file. To
access the PDF files, you will need
1. Design a flow sheet that is comprehensive. The
flow sheet should list all services or measures
relevant to diabetes, from patients' lab values to
blood pressure readings to self-management goals to
foot checks. (See the example on the next page.) The flow sheet won't be effective if key
elements are missing and overlooked, so don't hesitate to revise it.
Adobe Acrobat Reader, which you may
download free of charge.
2. Make abnormalities easy to spot. The patient data listed on the flow sheet will be more useful
if you also list the target measures or expectations so that you can immediately know whether a
patient is progressing toward the ideal. "We put the parameters for normal labs right on the flow
sheet so we don't have to wonder whether a lab result is abnormal," explains Jody Fox, RN, triage
nurse at Family Health Associates, another Family Care Network pilot site. Targets listed on a
diabetes flow sheet might include the following: two or more HbA1c checks per year, with the
most current result at 7 percent or lower; a retinal exam every 12 months; and blood-pressure
readings at 130/85 mm Hg or lower.
3. Don't trust doctors to fill in the flow sheets on their own. Perhaps the most difficult aspect
of any flow-sheet system is getting people to use it consistently. Early in the project, Family Care
Network's medical director, Berdi Safford, MD, was trying to gauge the success of the flow sheet
system and discovered that out of 42 doctors, only three were filling in the flow sheets. "In my
opinion, many doctors are terrible at this," says Safford. "We come of all different ilks. Some of
us are obsessive-compulsive, but even those types are so overwhelmed that they're obsessing
about something else and not about the flow sheets. So it's helpful to get someone other than the
doctor to do it."
But absolving physicians from flow-sheet duties and placing it squarely on the shoulders of
nurses may not be the answer either. Instead, flow sheets seem to work best when several people
share the responsibility, says Safford. For example, the person who files the lab results in the
chart can enter the lab results on the flow sheet. The nurse can be responsible for inputting
clinical data from the visit into the flow sheet. And the physician can write in elements such as
the patient's self-management goal.
4. Make sure the flow sheet cannot be overlooked in the chart. Once you've decided who will
be responsible for filling in the flow sheet, you can help them fulfill that responsibility by making
the flow sheet easy to find. Fox accomplished this by printing Family Health's flow sheets on
bright pink, heavyweight paper.
5. Develop a system for reviewing the flow sheets periodically. Then follow up with patients
who have missed needed services. If you have a diabetes patient registry (i.e., a list of your
patients who have diabetes), this process can be fairly simple because you'll know exactly which
charts to pull. And since the information you'll need to review will now be organized into a single
page, the task is manageable. You may even be able to get help from your health plans. For
example, an insurer might be willing to forward you quarterly reports listing which of your
patients have had eye exams or other needed services. You can then use that information to
update your patients' flow sheets and send reminder postcards to those who need them.
6. Computerize your flow sheet, if possible. While flow sheets can be easy and effective tools
even in their simplest form (paper), they become infinitely more valuable when combined with
computerized data. Computerized programs offer automatic reminders when patients need certain
services and provide an easy way to track patient data over time.
For Family Care Network's pilot sites, computerized flow sheets are now a reality. The local
hospital has initiated a communitywide, computer-based registry that houses clinical data as well,
doing away with the need for paper flow sheets. For example, because the hospital's laboratory is
linked into the system, lab values are automatically loaded into the patient's file as they become
available. Other providers in the community also share in entering their patient data, which
Family Care Network's pilot sites are then able to view.
7. Don't expect results overnight. Changing your system of care isn't easy. It will take time for
physicians and staff members to experiment with the flow sheets and to find what works best for
them. Don't expect your flow sheet to be perfect the first time, but keep at it. The more you use
them and load them with data, the more useful they will become in ensuring that patients receive
the care they need.
8. Set a goal. The point of having a goal for flow
What once seemed an
sheets, or any other aspect of practice, is simply to
spur action and encourage your practice team to
impossible task, that of
work together. Family Care Network set an initial
changing diabetes care,
goal for its pilot sites of having up-to-date diabetes
now being done.
flow sheets in 80 percent of patients' charts. As of
May 2000, they had reached a rate of well over 90
percent and are working toward expanding their efforts into the other 14 sites.
is
That spirit of continuous improvement is perhaps one of the biggest successes of the project.
What once seemed an impossible task, that of changing diabetes care, is now being done one step,
one patient, one flow sheet at a time.
Brandi White is a senior associate editor for Family Practice Management.
Copyright © 2000 by the American Academy of Family Physicians.
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