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Improving Chronic Disease Care in the Real
World: A Step-by-Step Approach
Tag along as we follow a network of physicians on the first leg of a 13-month journey to redesign
their diabetes care one step at a time.
Brandi White
Covered in FPM Quiz
SPEEDBAR®
» Family Care Network
is involved in a 13month project to
improve its care of
patients with diabetes.
» To make the task
manageable, the network
is approaching it as a
rapid series of baby
steps.
» Diabetes can be
difficult to manage
because it requires a
proactive approach to
care and major
behavioral changes.
» The network's goals
for diabetes include
having current flow
sheets in 80 percent of
patient charts.
» The network set a
goal that 70 percent of
its patients with diabetes
would have current
HbA1c levels of 7
percent or lower.
» The typical diabetes
checkup often resembles
a trip to the principal's
office; the patient
receives a reprimand for
bad behavior.
» In patient-centered
care, the emphasis is to
get patients more
involved -- even setting
goals for their own
conditions.
» Evidence-based
clinical guidelines can
aid physicians' decision
making and encourage
them to follow best
practices.
» For evidence-based
guidelines to be
effective, physicians and
staff members must
understand and buy into
their recommendations.
» Population-based care
is an attempt to provide
proactive health care to
every patient within
your practice.
» By establishing a
patient registry,
practices can begin to
keep track of their
patients with certain
conditions.
» Quality improvement
begins by coming up
with a good idea and
then trying it, perhaps
with just one patient.
» Before you implement
a new idea throughout
your practice, test it and
make sure it isn't simply
more paperwork.
» Family Care Network
has three pilot sites
working on the diabetes
quality improvement
project.
» The pilots have been
charged with finding a
way to identify patients
within the practice who
have diabetes.
» The pilots must also
establish a system to
remind them of what
diabetic services patients
need to have done.
» "Preplanned visits"
will help physicians
have complete
information on patients
at the time of their
diabetes checkups.
» The pilot groups must
decide who will work
with patients to set selfmanagement goals and
how the goals will be
documented in the chart.
» To encourage rapid
change, each person was
asked to identify one
change they were going
to implement
immediately.
» The pilot sites will
report their answers to
the four key questions
by the end of this year.
"The journey of a thousand miles begins with a single step." -- Chinese proverb
One year ago, if you had asked Berdi Safford, MD, a family physician in northwest
Washington, whether she wanted to embark on a quality improvement (QI) project in her busy
family practice, she probably would have burst into laughter -- and then into tears.
"Anything that sounded like 'continuous quality improvement' seemed so overwhelming and
involved so much change that there was no way I could do it," she says, "and so it never got
done."
But today, quality improvement is being done in Safford's practice. In fact Family Care Network,
the group without walls for which she is medical director, is now in the throes of an ambitious
quality improvement initiative headed by the Institute for Healthcare Improvement (IHI), an
organization dedicated to using the principles of quality improvement to identify best practices in
the delivery of health care and the design of medical practices. The project is part of IHI's
"Breakthrough Series" on chronic disease care -- a 13-month quality-improvement initiative that
involves approximately 30 organizations nationwide. Half are focused on congestive heart failure;
half are focused on diabetes. By next spring, Family Care Network hopes to demonstrate that the
principles of quality improvement can change physician and staff behavior and improve
outcomes for patients with diabetes at all 17 Family Care Network sites. It's hardly a small task,
and "the goals are set so high that you can't get there by just trying harder," says Safford. "We're
talking about practice redesign. This is not business as usual."
What gives Family Care Network some hope that the group's goals are indeed achievable is one
simple idea: Big change begins with small steps. "When you break it down into tiny little pieces,
it's more workable," says Safford. And with that, the network is tackling the gargantuan task of
improving diabetes care through a rapid series of "baby steps."
Step 1: Start where you are.
KEY POINTS:

In the current health
care system, focused
When Family Care Network became part of the IHI diabetes
project earlier this year, the physicians assumed they were
starting from a better position than the average primary care
group. Many of them were already using flow sheets in their
patient charts, were familiar with the American Diabetes
Association's (ADA) clinical guidelines, and had been paying
attention to data about their diabetes care for at least one health
plan, which was collecting the data to meet HEDIS (Health
Plan Employer Data and Information Set) reporting
requirements.
But a pre-project self-assessment graded the network "in the C
range -- much to our surprise and disappointment," says
Safford. And the health plan partnering with Family Care
Network in the IHI project fared even worse: "We ended up in
the D range," says Chelle Moat, MD, MPH, medical director
for quality management for Northwest Washington Medical
Bureau, which has its history in traditional insurance, not
managed care.


primarily on acute,
reactive care, there is
much room for
improvement of
chronic disease care.
Quality improvement
can accomplish
monumental tasks
through a rapid series
of "baby steps."
Effective chronic
disease care requires
systems that can
identify patients, track
their progress and
invest them in the care
process.
The lesson? There's always room for improvement. By honestly assessing your present
performance, says Moat, "you can look at places where you might focus your energy to try to get
better."
Step 2: Understand the problem.
Diabetes affects 15.7 million people, or 5.9 percent of the U.S. population, according to data from
the Centers for Disease Control and Prevention. Roughly one-third of diabetes cases remain
undiagnosed. The disease is the leading cause of new cases of blindness in adults ages 20 to 74; it
is the leading cause of end-stage renal disease; it accounts for more than half of lower-limb
amputations in the United States; and it contributed to 193,140 deaths in 1996, making it the
seventh leading cause of death that year. In addition, diabetes accounts for an estimated 14
percent of health care costs, or $98 billion in direct and indirect costs, according to the ADA.
What makes diabetes so difficult to manage effectively, says Safford, is a set of three problems:
One, patients can "get by" for long periods of time without anyone discovering their conditions.
Two, most health care delivery systems are set up for acute, reactive care, not proactive care of
patients with chronic conditions. And three, "effective management of diabetes requires
enormous behavioral changes on the part of patients, providers and systems," says Safford.
Difficult as these obstacles may be, research has shown that significant improvements can be
achieved through four strategies:




Glycemic control,
Intensive self-management support (diet, exercise, self-monitoring of blood glucose, foot
care),
Cardiac risk reduction (smoking, aspirin, blood pressure, lipids),
Screening and management of complications (retinopathy, nephropathy, neuropathy).
For example, in the United Kingdom Prospective Diabetes Study, which involved 5,102 patients
diagnosed with type 2 diabetes, a 1 percent reduction in HbA1c levels resulted in a 17 percent
reduction in all-cause mortality, an 18 percent reduction in myocardial infarction, a 15 percent
reduction in stroke, a 35 percent reduction in microvascular complications and an 18 percent
reduction in cataract extraction.1
Step 3: Aim for something.
The adage "aim for nothing and you'll hit it every time" is apropos of quality improvement and
chronic disease care. One of the first assignments for the Family Care Network QI team, then,
was to articulate its aim, or mission, which was "to help create successful partnerships between
providers and patients in order to manage diabetes proactively and, thereby, improve clinical
outcomes." Based on that aim, the team defined its measures and goals for diabetes:




Patient-specific self-management plans are documented in 60 percent of patient charts;
A diabetes flowchart system that functions as a reminder for care is current in 80 percent
of patient charts;
Patients have improved glycemic control (90 percent of patients have two or more HbA1c
measures per year; 70 percent of patients have current HbA1c levels of 7 percent or lower;
no more than 15 percent of patients have HbA1c levels of 8.5 percent or higher);
Diabetic screening intervals and cardiac indicators are met (70 percent of patients have
had a documented retinal exam in the past 12 months; 90 percent of most recent bloodpressure readings are 130/85 or better).
By tracking these measures each month, the network can see whether its performance is
improving.
Step 4: Understand the ideal system of care.
"Every system is perfectly designed to get the results it produces," says Donald M. Berwick, MD,
IHI president.
It follows, then, that if you want to get better results, you have to create a better system -- not
overnight but through a series of "baby steps" (see Step 5). That ideal system, according to IHI,
has at least three themes:
Patient-centered care. If you were to take any family doctor off the street and ask him or her,
"Do you practice patient-centered care?" the answer would be a resounding "of course." But
according to IHI, truly patient-centered care is something most physicians haven't even
contemplated.
In the current paradigm, says Safford, a patient's visit to the doctor for diabetes care is a lot like a
trip to the principal's office. Its focus is correction, not empowerment, and "it ends up with the
physician telling the patient what needs to change -- the theme being, doctor knows best," she
says.
But patient-centered care means giving patients information and responsibility and getting them
more involved in their own care. "The reality, at least what the studies tell us, is that the old
approach, where we tell patients what to do and kind of beat up on them when they don't, doesn't
work," says Steven Alexander, MD, medical director for Lynden Family Medicine, another
Family Care Network practice. "Patients at some point have to make the connection that they are
responsible and they can change things and make their lives better."
One way physicians can encourage this is by working with patients to set self-management goals
that the patients find meaningful and doable. For example, "If you have a patient who eats five
Big Macs a day, who smokes two packs of cigarettes a day, who is disabled and sits on the couch
all day, and his goal is to walk to the mailbox three times a week, by golly that's his goal," says
Safford.
Helping the patient reach that one small goal may be the first step in helping the patient change
his life.
Evidence-based care. Numerous studies have shown that physician practice patterns vary
widely, even where highly effective, cost-efficient treatments have been identified (for example,
prescribing beta blockers after a heart attack). Implementing evidence-based clinical guidelines,
aka practice policies, clinical pathways, etc., can help. When Safford was exposed to the most
recent ADA guidelines at an IHI learning session, she discovered "some of my diabetes thinking
wasn't up to date even though I thought it was. For example, the revised goal for target blood
pressure is less than 130/85, and most of us have been using 140/90. That's a big difference," she
explains. "I also learned to be more aggressive with the presence of microalbumin in the urine. I
wasn't being aggressive enough in the [ACE
inhibitor] doses."
'You can't get there by just
Jody Fox, RN, a member of the core QI team and
triage nurse at Family Health, one of the Family Care trying harder. We're talking
Network sites, believes evidence-based clinical
about practice redesign.'
guidelines can also be useful to non-physician staff
members by giving them a good overview of the
disease and helping them understand why flow sheets, data collection and other tools for
improving care are so important.
The ADA guidelines, updated in January 1999, can be accessed online at
http://journal.diabetes.org/CareSup1Jan00.htm. In addition, the AAFP and ADA have partnered
to create a set of guidelines titled "The Benefits and Risks of Controlling Blood Glucose Levels
in Patients with Type 2 Diabetes Mellitus" (item #A928), which you can get a copy of by calling
the AAFP at 800-944-0000.
Having good clinical guidelines in your possession is only half the battle, though. You must also
translate those guidelines into practice, in part by making sure that the recommendations are well
understood by staff members and that you have physician buy-in. "The reality is that staff
members key off the physician to a great extent, and if it doesn't matter to the physician, it's not
going to matter to the staff," says Alexander. (For more information on identifying good clinical
policies and implementing them, see the reading list
on page 43.)
'The old approach, where we
tell patients what to do and
kind of beat up on them when
Population-based care. The goal of populationthey don't, doesn't work.'
based care is, very simply, to satisfy the health care
needs of all your patients, even the patient who
hasn't set foot in your office for two years. This goes against the natural tendency of most health
care systems, which is to focus only on the acute problem of the patient sitting in the exam room,
never mind the problems lurking in the shadows. What population-based care requires is that you:
1. Identify who your patients are and what conditions they have (a patient registry) and 2.
Monitor their care proactively.
For many practices, the challenge of developing a comprehensive and accurate patient registry
may seem insuperable. The gradual computerization of practice is likely to make it easier, but
even now it's possible to make a start. Family Care Network, for example, is working with its
local hospital and other providers to create an Internet-based, communitywide registry, something
they didn't think was possible just a few months ago. (In an upcoming issue of FPM, we will
examine how the group's registries have evolved.)
The second part of population-based care is being proactive and keeping patients from falling
through the cracks. Often, the problem with diabetes is that "we may think the endocrinologist is
taking care of the patients, and the endocrinologist thinks we're taking care of them," says
Alexander. One solution is the use of flow sheets to track needed services for patients. (We'll
discuss this issue, and Family Care Network's solution, in a later article in this series.)
Step 5: Think "baby steps."
Quality improvement can often seem overwhelming
to physicians and staff members because it feels like
more work. In fact, says Alexander, "it is more work.
And everybody feels like they're overworked
already. That's the dilemma."
The solution is to 'start small
with one doctor, one patient,
one something.'
The solution, says Safford, is to "start small with one doctor, one patient, one something. You
learn what works and what doesn't, and you fix the problems before you implement the solution
on a grand scale."
A common framework for quality improvement is the PDSA cycle:




Plan what change needs to be made;
Do it, preferably on a small scale;
Study it to see whether it accomplished what you had hoped;
Act on what you have learned.
According to what participants in the IHI project learned, the key is to avoid belaboring any part
of the cycle. Rapid-cycle improvement involves simply coming up with a good idea, trying it,
checking to see if it worked, and then expanding on it or coming up with a better idea. "This was
all completely new for our group, and we realized we had a lot of work to do," says Fox, "but it
was also exciting because we were setting goals, trying new things and making changes right
away."
Often, an important question to ask of a new idea is, "Does it work, or is it just more paperwork?"
says Fox. "If it's just more paperwork, we won't implement it." (For more information on the
principles of quality improvement, see the reading list.)
In the first five days after the core team attended its first IHI learning session, each member of the
team was required to complete at least one PDSA cycle. Safford's assignment was to ask one
patient about his or her diabetes goal. "So I came home, and the next patient with diabetes I saw
was a woman I've cared for for a long time, with moderate success. She still smokes," says
Safford. "But I walked in and I sat down, smiled and said, 'Hi, what is your goal for your visit
with me today?' And she didn't even think about the answer. It just spit right out: 'Get out of here
alive!'"
The patient's response not only confirmed the "principal's office" theory, but it provided Safford
with a perfect opener to patient-centered care. "The bottom line of that 15-minute visit was we
agreed we weren't even going to touch smoking because she's so full of guilt about the fact that
she hasn't quit," says Safford. "Instead, what she was going to focus on was taking a walk every
day."
That brief interaction was a simple but successful PDSA cycle. Safford tried a new technique
(asking about self-management goals), and the patient's response taught her something. "I might
ask it a little differently next time or might have more materials present when I do it again, but I
started generalizing that to other office visits, not just around diabetes, and it was very
enlightening."
Additional reading
Clinical guidelines
"Where to Look for Good
Clinical Policies." T.T. Gilbert,
J.S. Taylor. FPM. February
1999:28-32.
"How to Evaluate and Implement
Clinical Policies." T.T. Gilbert,
J.S. Taylor. FPM. March 1999:
28-33.
Patient-centered care
"Patient-Centered Care for Better
Patient Adherence." R. Lowes.
FPM. March 1998:46-57.
Population-based care
"It's Time to Start Practicing
Population-Based Health Care."
M.L. Rivo. FPM. June 1998:3746.
Quality improvement
"Quality Improvement: First
Steps." M.T. Coleman, S.
Endsley. FPM. March 1999:23-
Step 6: Commission your pilot
group.
Family Care Network has three pilot sites working
on the IHI diabetes project, with a goal of rolling out
the program to all 17 of the group's sites before the
end of the year. In most practices, the initial pilot
could be "as simple as taking one doctor in the office
and saying 'for this doctor's patients we're going to
try this and see how it works.' Get the doctor who's
most interested, and try it," says Safford.
26.
"A Team Approach to Quality
Improvement." M. Schwarz, S.E.
Landis, J. Rowe. FPM. April
1999: 25-30.
"Holding the Gains in Quality
Improvement." J.M. Giovino.
FPM. May 1999:29-32.
Disease management
"Do-It-Yourself Disease
Management." D.C. Kibbe, K.
Johnson. FPM.
November/December 1998:3442.
Once you've identified your pilot group, conduct a
training session so that individuals understand the
goals of the project and can see the big picture
(essentially, steps one through five, above). Safford and her colleagues held a mandatory training
session for all physicians, clinical staff and office managers of the three pilot sites. At the end of
the presentation, the pilots were required to have a staff meeting on the spot and begin planning.
"What always happens is you get these great ideas, and then you go back and you get swallowed
up in day-to-day practice. Nothing gets implemented," says Safford. "So we charged them with
immediately answering four questions." [Note: Each of the following questions will be addressed
in greater detail, including the pilots' answers, in upcoming issues of FPM.]
1. How are you going to identify your patients who have diabetes?
This would involve creating some type of registry, from a simple paper-based system containing
the names of a few identified patients to a communitywide, Internet-based registry. To begin
identifying patients, practices may be able to pull the data out of their own computer systems or
patient charts. Health plans can help by finding patients with diabetes based on claims or
pharmacy data.
2. How are you going to be reminded of what services your patients with diabetes need?
The answer here will probably entail the creation of a flow sheet that can be placed in patients'
charts to serve as a reminder and record results. Perhaps the most difficult part of using a flow
sheet is deciding who will own it. Can the physicians be relied on to enter the data? Can the
nurses handle the additional work? Should the task be shared by several individuals? Practices
will also need a system for reviewing flow sheets periodically and following up with patients who
have missed needed services. Some health plans may be willing to help with this task, for
example, by sending the practice quarterly reports listing which patients had eye exams, based on
claims data.
3. How are you going to "preplan" diabetic visits?
The idea behind preplanned visits is to have patients complete their lab work, eye checks, foot
checks and any other necessary services prior to their checkups so that the family physician has
full information on the patient's condition and can provide better care. Most practices can't give
patients one-stop shopping and same-day results, so the challenge will be to prompt patients to
complete those services prior to their checkups. Reminder letters or phone calls are among the
strategies, and again health plans may be able to offer assistance.
4. How are you going to handle patient selfmanagement goals?
Will the nurses be in charge of initiating this
conversation with patients, or will the physicians
handle it? Will it happen in group sessions or oneon-one? How will you document patient selfmanagement goals in the chart, and whose
responsibility is it to follow up with patients
regarding their goals?
'There has to be something
driving you to pursue [quality
improvement], or life's just too
busy and you aren't going to
get at it.'
The pilot groups had just 30 minutes to come up with their best first guess at answering these
questions. Then, to hold everyone accountable, the core team handed out two 3 x 5 cards to
everyone and asked them to write down one thing they were going to do differently when they
went back to the office. They wrote it once for themselves and once to hand in. A week and a half
later, the QI team contacted everyone to see how they had done. "Most of them agreed that the
call was helpful, kind of spurring them forward," says Safford. "And most people had really done
something. They just needed some more encouragement to keep doing it."
Your mission ...
Next steps
This is the first in a series of articles
following the progress of Family Care
Network throughout its diabetes quality
improvement project. Coming articles
will address these questions:




How do you build a registry of
your patients who have diabetes?
* How do you keep track of what
services your patients with
diabetes need to have done?
How do you "preplan" visits so
that patients with diabetes have
outside tests completed before
they come to your office?
How do you help patients set
self-management goals they will
achieve?
To improve the quality of care in your
practice, begin answering these four
questions with your staff members and
colleagues, then look for the next article
in this series in the Improving Patient
The pilot sites in Family Care Network's diabetes
project have been working at a rapid pace on the four Care department of FPM.
key questions listed above, with a goal of having
solid answers by the end of the year. "The real test," says Alexander, "is going to be whether we
can do this with the pilots and improve care, then try to expand upon that, spread the gospel and
implement it."
In the coming issues of FPM, mostly in our Improving Patient Care department, we will report on
the network's progress, including what worked and what didn't for each of the four questions. For
practices even remotely interested in quality improvement, this is the perfect opportunity to take a
baby step or two toward providing better diabetes care. Work with your staff and colleagues to
answer the first question on the list: How are we going to identify our patients who have
diabetes? Move on to questions two, three and four as you can. Then compare your answers to
what Family Care Network offers as its solutions in upcoming issues of FPM.
"I think with this kind of thing if you're not really challenged or pushed, it isn't going to happen,"
says Alexander. "There has to be something driving you to pursue it, or life's just too busy and
you aren't going to get at it."
So consider this your push and take a step toward improved patient care, then join us for the next
article in this series.
Brandi White is a senior associate editor for Family Practice Management.
This article exemplifies the AAFP 1999 Annual Clinical Focus on management and prevention of
the complications of diabetes.
REFERENCES
1. Turner R, Holman R. UK prospective diabetes study group: intensive blood-glucose control with
sulphonylureas or insulin compared with conventional treatment and risk of complications in
patients with type 2 diabetes. Lancet. 1998;352:837-853.
Copyright © 1999 by the American Academy of Family Physicians.
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