The implementation started with a joint planning meeting with GNCHC and ECDHD staff. The meeting started with looking at the simplified aim statement that GNCHC's QI department and ECDHD's QI staff had decided on. Both ECDHD and GNCHC use the PDSA methodology as a basis for their QI work. All the staff members were familiar with the PDSA concept, and they had all been involved in one or more PDSAs in the past. The team started the meeting by asking, “Why do some diabetic patients not achieve good glycemic control?” Individual members were asked to brainstorm, first by themselves and later as a group. A cause-and-effect/fishbone diagram was then completed to determine the root causes of the failure of diabetic patients to achieve glycemic control. This step was necessary to help the team understand what barriers were in the way of compliance with medical treatment recommendations. Once the barriers were better understood, the team members began to explore the interventions they thought would help address the root causes. The following evidence-based interventions were discussed and reviewed:
• diabetes prevention and control: self-management education—Diabetes self-management education (DSME) is the process of facilitating the knowledge and skills necessary for diabetes self-care.
• diabetes prevention and control: disease management program—This program is an organized, proactive, multicomponent approach to health care delivery for people with a specific disease, such as diabetes.
• diabetes prevention and control: case management interventions to improve glycemic control—Case management oversees all services received by the diabetic or hypertensive patients, involves a care plan for each patient, and monitors the results.
The GNCHC team members also discussed how they had implemented some changes in the clinic workflow and educational materials. The percentage of patients with good glycemic control of their A1c levels increased to 70%. Individuals directly involved in the improvement process listed what they believed were the most important factors, which are as follows:
• one-on-one education and support,
• tailored interventions directed at patient-specific issues,
• access to medications,
• multi-team approach (everyone working on the same page),
• making it hard for patients to get lost,
• having patients set self-management goals,
• changing educational materials to make them more readable and at a lower literacy level,
• bilingual staff, and
• establishing a relationship between a patient and a nurse or community health worker.
The team thought these interventions were indeed important. They then used a priority grid for selection of the interventions most likely to impact health outcomes. The top interventions were (1) medication access, (2) establishing a relationship with the patient, (3) a team approach to care, and (4) self-chosen health management goals. After planning, the team moved on to the second part of the PDSA process, which is the Do or implementation phase.
The team had a small amount of financial resources ($5,000) to implement the project. They decided that the funding should be used primarily for staff time. The focus of the process was to target patients using a bilingual community health worker who would explore medication usage and provide education focused on patient-identified needs. A bilingual staff member who had previously been a physician in Venezuela was chosen to implement the one-on-one intervention. The intervention took place in the clinical setting and included face-to-face meetings when the patient came to see the medical provider, follow-up calls, and help with self-management goal-setting and education. The one-on-one meetings included components of case management such as medication access and problem-solving, including social issues. In addition, high priority was placed on disease and nutritional education and education on medication use. The patients were not told what to choose—they chose their own goals; however, they needed orientation to this aspect of the visits, and the goals were negotiated instead of imposed. When patients chose unrealistic goals for the time frame, the goal-setting was performed collaboratively; however, the goals always belonged to the patient.
Considerable discussion occurred about what constitutes success for any one patient and for the PDSA. The team decided that any movement in the right direction would be viewed as a short-term success given the short time frame and patients' history of struggling to achieve favorable health outcomes. All 20 patients had baseline and post-intervention information recorded that included BP level, A1c level, years since diagnosis, language, comorbidity, preventive health care past and present needs, living conditions, vaccination status, activity level, and individual barriers to past outcomes. These results were analyzed and formally and informally communicated to the community health center management for dissemination.