A tale of two audits: statistical process control for improving diabetes care in primary care settings

Al-Hussein, Fahad Abdullah MRCGP(UK), Assistant Professor

Family and Community Medicine, King Saud Ibn AbdulAziz University for Health Sciences, Riyadh, Saudi Arabia

FUNDING BODY

The study was conducted utilising the available resources in the primary care facility concerned.

ETHICAL APPROVAL

Permission for running audits was sought from the hospital authorities. No human intervention was involved.

CONFLICTS OF INTEREST

None. The author has no pecuniary interests outside the parent organisation, Saudi Arabian National Guard Health Affairs. There have been no involvements that might raise the question of bias in the work reported or in the conclusions, implications or opinions stated.

ADDRESS FOR CORRESPONDENCE

Dr Fahad Abdullah Al-Hussein, King AdbulAziz Medical City, National Guard Health Affairs, PO Box 22490, Riyadh 11426, Saudi Arabia. Tel: +966 2520088 extension 1514; fax: +966 2520305; email: [email protected]

Received 19 June 2007

Accepted 10 July 2007

Quality in Primary Care 16(1):p 53-60, 2008.

Background

Diabetes constitutes a major burden of disease globally. Both primary and secondary prevention need to improve in order to face this challenge. Improving management of diabetes in primary care is therefore of fundamental importance.

Objective

The objective of these series of audits was to find means of improving diabetes management in chronic disease mini-clinics in primary health care. In the process, we were able to study the effect and practical usefulness of different audit designs – those measuring clinical outcomes, process of care, or both.

Setting

King Saud City Family and Community Medicine Centre, Saudi National Guard Health Affairs in Riyadh city, Saudi Arabia.

Methods

Simple random samples of 30 files were selected every two weeks from a sampling frame of file numbers for all diabetes clients seen over the period. Information was transferred to a form, entered on the computer and an automated response was generated regarding the appropriateness of management, a criterion mutually agreed upon by care providers. The results were plotted on statistical process control charts, p charts, displayed for all employees. Data extraction, archiving, entry, analysis, plotting and design and preparation of p charts were managed by nursing staff specially trained for the purpose by physicians with relevant previous experience.

Results

Audit series with mixed outcome and process measures failed to detect any changes in the proportion of non-conforming cases over a period of one year. The process measures series, on the other hand, showed improvement in care corresponding to a reduction in the proportion nonconforming by 10% within a period of 3 months. Non-conformities dropped from a mean of 5.0 to 1.4 over the year (P < 0.001).

Conclusion

It is possible to improve providers’ behaviour regarding implementation of given guidelines through periodic process audits and feedbacks. Frequent process audits in the context of statistical process control should be supplemented with concurrent outcome audits, once or twice a year.