Background and Rationale: The increasing prevalence of type 2 diabetes, particularly in rural communities, is a major problem facing our nation. Many patients are in poor compliance with ADA guidelines for diabetes management. In addition, patients with diabetes in rural communities often face challenges that can impede management initiatives by health care providers (Utz, 2008). Quality care must be achieved to reduce the likelihood of costly, life-altering, and potentially fatal complications (American Diabetes Association, 2008). To manage chronic diseases effectively and prevent secondary complications, an organized quality review process within the practice setting should be in place to address quality indicators in an ordered and timely manner. Purpose and Aims: The purpose of this project was to develop a quality improvement initiative (electronic diabetes education flow sheet - DEFS) associated with managing type 2 diabetes in a rural, nurse practitioner-managed clinic. The specific objectives were 1) to evaluate the extent to which select type 2 diabetes quality indicators are met; 2) to develop, implement, and evaluate a diabetes education process for a rural, nurse practitioner-managed clinic; and 3) to implement a QI framework clinic personnel can use for future QI initiatives. Methods: The Plan-Do-Study-Act (PDSA) cycle was the framework used to implement the QI initiative. Process and outcome measures were collected for baseline data and the DEFS was developed. Routine evaluation by the QI committee ensured appropriate utilization of the DEFS. Patients receiving initial diabetes education were interviewed to understand their perspective of the education experience. For eight weeks, process data was reviewed to ensure improvements in diabetes education. Results: Data analysis of process measures showed inconsistent documentation of selected quality indicators. Outcome measures were controlled 62% to 70% of the time. Clinical staff successfully integrated the DEFS into patient education and expanded its use to ensure compliance. Limited numbers of patient volunteers prohibited analyzing patient feedback on the education process. Significance: This project demonstrated how QI initiatives can bring about positive changes in patient management. Based on this demonstration of how the PDSA cycle can be used to address clinical concerns, other rural nurse-managed clinics might use a similar method to implement QI initiatives to ensure quality healthcare.

MSc (Med) Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, 2009 / Abstract not included on cd

Diabetes is the 7th leading cause of death in the United States and is the main cause of chronic kidney failure, nontraumatic limb amputations, blindness, myocardial infarction, and stroke. Many patients with diabetes do not meet goals for at least 1 control measure of blood sugar, blood pressure, or cholesterol. The purpose of the project was to implement a template for documentation--a toolkit for patient care management-to improve blood glucose and blood pressure levels in a rural health clinic in central Texas for 33 patients with diabetes during a 6- to 8-week timeframe. The practice-focused question asked whether management of patients with diabetes would be improved if documentation on a standard template were used by all providers at the site. Models used in this doctoral project included the chronic care model and the Institute for Healthcare Improvement breakthrough series collaborative model. Sources of evidence included published outcomes and research from a systematic review of the literature, archival and operational data collected from the rural health clinic, and evidence from the project. Glycosalated hemoglobin levels improved from a mean of 8.9 mg to 7.6 mg in 31 of 33 participants (t = 2.684, 30 df, p = .012). Systolic and diastolic blood pressures were reduced slightly, but changes were not statistically significant. Potential implications for positive change in nursing practice include improvements in clinical management, implementation of evidence-based practice, and improved outcomes for patients with diabetes. Incorporating evidence-based practice provides scientific justification for actions that will improve clinical outcomes for patients, which leads to healthier patients, families, and communities and contributes to positive social change.