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Improving Outcomes for People with Diabetes in Primary CareNational Conference - Wednesday 8 February 2017
Programme
Improving Outcomes for People with Diabetes in Primary CareNational Conference - Wednesday 8 February 2017
Programme
Improving quality what works
Martin Marshall
Professor of Healthcare Improvement UCL
Improving quality for people with diabetes in primary care
8th February 2017
Challenges
1 What we do to improve patient care and health
services is insufficiently influenced by science
2 Science is insufficiently focused on the needs of
those undertaking improvement activities
6
benefit for patients
The sciences that influence patient care
Translation gap
Basic
Sciences
Clinical
Sciences
T1
implementation
T2
7
benefit for patients
The sciences that influence patient care
Translation gaps
Basic
Sciences
Clinical
Sciences
Improvement
Sciences
T1 T2 T3
Some things that we know
from theory and empirical
evidence about how to
organise and deliver high
quality health care
(but often fail to put into practice)
1 We know what lsquogoodrsquo looks like
1 Develop quality as a core strategy
2 Ensure organisational skills to support
improvement
3 Use information as a platform for change
4 Focus on learning
5 Develop leadership
High Performing Healthcare
Systems Delivering Quality by
Design
Baker GR MacIntosh-Murray A
Porcellato C Dionne L Stellmacovich K
Born K 2009
Clinical teams
Education and training
Clinical audit
Peer review collaboration
Guidelines
Health system
Performance management
Regulation
Incentivessanctions
Competition
Commissioning
Organisations
Org development
TQMCQI BPR
PDSA Lean 6 sigma
2 We know that there are many
ways of improving qualityhelliphellip
hellipbut most of them are usually
only moderately effective
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Improving Outcomes for People with Diabetes in Primary CareNational Conference - Wednesday 8 February 2017
Programme
Improving quality what works
Martin Marshall
Professor of Healthcare Improvement UCL
Improving quality for people with diabetes in primary care
8th February 2017
Challenges
1 What we do to improve patient care and health
services is insufficiently influenced by science
2 Science is insufficiently focused on the needs of
those undertaking improvement activities
6
benefit for patients
The sciences that influence patient care
Translation gap
Basic
Sciences
Clinical
Sciences
T1
implementation
T2
7
benefit for patients
The sciences that influence patient care
Translation gaps
Basic
Sciences
Clinical
Sciences
Improvement
Sciences
T1 T2 T3
Some things that we know
from theory and empirical
evidence about how to
organise and deliver high
quality health care
(but often fail to put into practice)
1 We know what lsquogoodrsquo looks like
1 Develop quality as a core strategy
2 Ensure organisational skills to support
improvement
3 Use information as a platform for change
4 Focus on learning
5 Develop leadership
High Performing Healthcare
Systems Delivering Quality by
Design
Baker GR MacIntosh-Murray A
Porcellato C Dionne L Stellmacovich K
Born K 2009
Clinical teams
Education and training
Clinical audit
Peer review collaboration
Guidelines
Health system
Performance management
Regulation
Incentivessanctions
Competition
Commissioning
Organisations
Org development
TQMCQI BPR
PDSA Lean 6 sigma
2 We know that there are many
ways of improving qualityhelliphellip
hellipbut most of them are usually
only moderately effective
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Improving quality what works
Martin Marshall
Professor of Healthcare Improvement UCL
Improving quality for people with diabetes in primary care
8th February 2017
Challenges
1 What we do to improve patient care and health
services is insufficiently influenced by science
2 Science is insufficiently focused on the needs of
those undertaking improvement activities
6
benefit for patients
The sciences that influence patient care
Translation gap
Basic
Sciences
Clinical
Sciences
T1
implementation
T2
7
benefit for patients
The sciences that influence patient care
Translation gaps
Basic
Sciences
Clinical
Sciences
Improvement
Sciences
T1 T2 T3
Some things that we know
from theory and empirical
evidence about how to
organise and deliver high
quality health care
(but often fail to put into practice)
1 We know what lsquogoodrsquo looks like
1 Develop quality as a core strategy
2 Ensure organisational skills to support
improvement
3 Use information as a platform for change
4 Focus on learning
5 Develop leadership
High Performing Healthcare
Systems Delivering Quality by
Design
Baker GR MacIntosh-Murray A
Porcellato C Dionne L Stellmacovich K
Born K 2009
Clinical teams
Education and training
Clinical audit
Peer review collaboration
Guidelines
Health system
Performance management
Regulation
Incentivessanctions
Competition
Commissioning
Organisations
Org development
TQMCQI BPR
PDSA Lean 6 sigma
2 We know that there are many
ways of improving qualityhelliphellip
hellipbut most of them are usually
only moderately effective
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Challenges
1 What we do to improve patient care and health
services is insufficiently influenced by science
2 Science is insufficiently focused on the needs of
those undertaking improvement activities
6
benefit for patients
The sciences that influence patient care
Translation gap
Basic
Sciences
Clinical
Sciences
T1
implementation
T2
7
benefit for patients
The sciences that influence patient care
Translation gaps
Basic
Sciences
Clinical
Sciences
Improvement
Sciences
T1 T2 T3
Some things that we know
from theory and empirical
evidence about how to
organise and deliver high
quality health care
(but often fail to put into practice)
1 We know what lsquogoodrsquo looks like
1 Develop quality as a core strategy
2 Ensure organisational skills to support
improvement
3 Use information as a platform for change
4 Focus on learning
5 Develop leadership
High Performing Healthcare
Systems Delivering Quality by
Design
Baker GR MacIntosh-Murray A
Porcellato C Dionne L Stellmacovich K
Born K 2009
Clinical teams
Education and training
Clinical audit
Peer review collaboration
Guidelines
Health system
Performance management
Regulation
Incentivessanctions
Competition
Commissioning
Organisations
Org development
TQMCQI BPR
PDSA Lean 6 sigma
2 We know that there are many
ways of improving qualityhelliphellip
hellipbut most of them are usually
only moderately effective
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
6
benefit for patients
The sciences that influence patient care
Translation gap
Basic
Sciences
Clinical
Sciences
T1
implementation
T2
7
benefit for patients
The sciences that influence patient care
Translation gaps
Basic
Sciences
Clinical
Sciences
Improvement
Sciences
T1 T2 T3
Some things that we know
from theory and empirical
evidence about how to
organise and deliver high
quality health care
(but often fail to put into practice)
1 We know what lsquogoodrsquo looks like
1 Develop quality as a core strategy
2 Ensure organisational skills to support
improvement
3 Use information as a platform for change
4 Focus on learning
5 Develop leadership
High Performing Healthcare
Systems Delivering Quality by
Design
Baker GR MacIntosh-Murray A
Porcellato C Dionne L Stellmacovich K
Born K 2009
Clinical teams
Education and training
Clinical audit
Peer review collaboration
Guidelines
Health system
Performance management
Regulation
Incentivessanctions
Competition
Commissioning
Organisations
Org development
TQMCQI BPR
PDSA Lean 6 sigma
2 We know that there are many
ways of improving qualityhelliphellip
hellipbut most of them are usually
only moderately effective
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
7
benefit for patients
The sciences that influence patient care
Translation gaps
Basic
Sciences
Clinical
Sciences
Improvement
Sciences
T1 T2 T3
Some things that we know
from theory and empirical
evidence about how to
organise and deliver high
quality health care
(but often fail to put into practice)
1 We know what lsquogoodrsquo looks like
1 Develop quality as a core strategy
2 Ensure organisational skills to support
improvement
3 Use information as a platform for change
4 Focus on learning
5 Develop leadership
High Performing Healthcare
Systems Delivering Quality by
Design
Baker GR MacIntosh-Murray A
Porcellato C Dionne L Stellmacovich K
Born K 2009
Clinical teams
Education and training
Clinical audit
Peer review collaboration
Guidelines
Health system
Performance management
Regulation
Incentivessanctions
Competition
Commissioning
Organisations
Org development
TQMCQI BPR
PDSA Lean 6 sigma
2 We know that there are many
ways of improving qualityhelliphellip
hellipbut most of them are usually
only moderately effective
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Some things that we know
from theory and empirical
evidence about how to
organise and deliver high
quality health care
(but often fail to put into practice)
1 We know what lsquogoodrsquo looks like
1 Develop quality as a core strategy
2 Ensure organisational skills to support
improvement
3 Use information as a platform for change
4 Focus on learning
5 Develop leadership
High Performing Healthcare
Systems Delivering Quality by
Design
Baker GR MacIntosh-Murray A
Porcellato C Dionne L Stellmacovich K
Born K 2009
Clinical teams
Education and training
Clinical audit
Peer review collaboration
Guidelines
Health system
Performance management
Regulation
Incentivessanctions
Competition
Commissioning
Organisations
Org development
TQMCQI BPR
PDSA Lean 6 sigma
2 We know that there are many
ways of improving qualityhelliphellip
hellipbut most of them are usually
only moderately effective
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
1 We know what lsquogoodrsquo looks like
1 Develop quality as a core strategy
2 Ensure organisational skills to support
improvement
3 Use information as a platform for change
4 Focus on learning
5 Develop leadership
High Performing Healthcare
Systems Delivering Quality by
Design
Baker GR MacIntosh-Murray A
Porcellato C Dionne L Stellmacovich K
Born K 2009
Clinical teams
Education and training
Clinical audit
Peer review collaboration
Guidelines
Health system
Performance management
Regulation
Incentivessanctions
Competition
Commissioning
Organisations
Org development
TQMCQI BPR
PDSA Lean 6 sigma
2 We know that there are many
ways of improving qualityhelliphellip
hellipbut most of them are usually
only moderately effective
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Clinical teams
Education and training
Clinical audit
Peer review collaboration
Guidelines
Health system
Performance management
Regulation
Incentivessanctions
Competition
Commissioning
Organisations
Org development
TQMCQI BPR
PDSA Lean 6 sigma
2 We know that there are many
ways of improving qualityhelliphellip
hellipbut most of them are usually
only moderately effective
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
hellipbut most of them are usually
only moderately effective
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
4 We know that improvement efforts
are most effective when we use
multiple interventions which combine
technical and social elements
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Intervention
5 We know that improvement requires more than an effective intervention
Implementation
Context
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Journal of Health Services Research and Policy 2007
6 We know culture is important and
changing it is difficult
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
7 We know that we need to adopt a
whole systems approach to change
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
PhysicalPsychological
Sources of behaviour
Policy categories
Intervention functions
Behaviours
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
8 We know that all efforts to improve
have unintended consequences
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
9 We know that restructuring health
services can be a distraction
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
10 We know something about different
approaches to achieving change
Stacey 2012
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
So how can we put these
lessons more effectively
into practice
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Adapted from Canadian Health Services Research Foundation 2003
Problem
Knowledge transfer
Solution
Improved dissemination of evidence to users (lsquoPushrsquo) or
demand for evidence from users (lsquoPullrsquo)
Knowledge production
Work together to define refine generate and implement evidence (lsquoCo-creationrsquo)
Nature of evidence
A product
A process
Nature of decision process
One-off event
Iterative social
process
Mobilising knowledge
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Barnsley FC
Poet-in-residence
All England Tennis
Club
Artist-in-residence
British Library
Innovator-in-residence
Researcher-in-Residence Model
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
1 The researcher is a core member of
an operational team
2 They are explicit about their expert
contribution to the team
bull the evidence base
bull theories of change
bull evaluation both formal and
informal
bull use of data
3 Their focus is on negotiation and
compromise of their expertise rather
than imposition ndash lsquoa meeting of
expertsrsquo
Researcher-in-Residence Model
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Operational Researcher-in-Residence at
Great Ormond Street Hospital for
Children
Examples
Health Service Researcher-in-
Residence in Whittington Health
Integrated Care Organisation
Anthropologist-in-Residence at
UCLH
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Political Scientist-in-Residence in Newham
general practice
Critical Discourse Social Scientist-in-
Residence in an East London integrated
care programme
Examples
Health Service Researcher-in-Residence in
Essex care homes
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
martinmarshalluclacukwwwuclacukpcphisl
MarshallProf
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
National Diabetes Audit 2015-2016Some findings and their implications
Bob Young
NDA Specialist Clinical Lead
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
National Diabetes Audit
National Diabetes Footcare
Audit
National Pregnancy in
Diabetes Audit
National Diabetes
Inpatient Audit
Insulin Pump Audit
Transition Audit
httpsdigitalnhsukfootcare
httpsdigitalnhsuknpid
httpsdigitalnhsukdiabetesinpatientaudit
National Diabetes Audit
httpsdigitalnhsuknda
httpsdigitalnhsuk
nda_trans
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
NDA Continuous Linked Data
GP and Specialist Electronic Records (Routine Records)
Core NDA (2004)
NHS number Diabetes Type Year Sex Post Code (IMD) YoB
BMI Smoking BP HbA1c TC eGFR UACR
Education Pump Data Foot (amp Eye) checks
Hospital Episode StatisticsPEDW
NHS number
Admission for
DKA Amputation
DialysisTransplant
Angina MI HF Stroke
ONS (MRIS)
NHS number
Date of death
Cause of Death
Unlinked (snapshot)
NaDIA Inpatients (2011)
NDFA Foot Ulcers
Transition NPDA
(2015)
Deliveries NNC
Foot Disease Admission
Specialist Care OPD
NPiD Antenatal
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Participation 2015-16
31
Participation 824 per cent
(2721292 PWD)
Participation lt50 in only 16 CCGs
For more information on the level of participation in
2015-16 by CCG and LHB please see the
participation report
A dashboard showing participation over the last 3
years for CCGs and LHBs can be found here
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
What this talk will cover
bull NDA 2015-16 Type 2 Diabetes core reports
bull Variation and possible explanations for
Variation in
ndash Blood Glucose Treatment Target
achievement rates (HbA1clt58mmoll
(75)
ndash Blood Pressure Treatment Target
achievement rates (BPlt14080)
32
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Characteristics of People with Type 2 Diabetes
33
Age and gender of patients with Type 2 and other diabetes
England and Wales 2015-2016
Male gt Female
Older gt Younger 36 lt
65yr
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Care Processes ndash Time Series
34
Percentage of people with diabetes receiving NICE recommended care processes by
care process diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c 931 909 931 935 948 950
Blood pressure 957 956 954 949 961 957
Cholesterol928 921 919 924 928 927
Serum creatinine935 935 932 934 945 947
Urine albumin 767 775 747 844 746 667
Foot surveillance855 864 858 862 867 867
BMI905 909 909 857 831 827
Smoking854 857 863 855 852 852
Eight care processes 4
623 621 612 676 587 537
There is a lsquohealth warningrsquo regarding the screening test for early kidney disease (Urine Albumin Creatinine Ratio UACR) prior to 2013-14 please
see the NDA Data Quality statement
34 Please see full list of footnotes in the definitions and footnote section
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Treatment Target ndash Time Series
35
Percentage of people with diabetes achieving their treatment targets by
diabetes type and audit yearEngland and Wales
Type 2 and other3
2010-11 2011-12 2012-13 2013-14 2014-15 2015-16
HbA1c
lt 58 mmolmol665 658 649 668 661 657
Blood pressure
lt 14080 614 666 686 736 742 736
Cholesterol
lt 5mmolL780 774 767 778 775 771
Meeting all three treatment
targets 351 374 373 414 410 402
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Treatment targets - Locality Variation Type 2
36
The range of CCGLHB treatment target achievements for people with Type
2 and other diabetes 2015-2016England and Wales
0 10 20 30 40 50 60 70 80 90 100
Meet all three treatment targets
Cholesterol lt5mmolL
Cholesterol lt4mmolL
BP lt=14080
HbA1c lt=86mmolmol (100)
HBA1C lt=58mmolmol (75)
HbA1c lt48mmolmol (65)
Percentage of patients
Treatmenttarget
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
T2 Treatment Targets ndash Salford Practices
37
HbA1clt58mmolmol (75)
BPlt14080
652
755
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
T2 Treatment Targets ndash Newham Practices
38
HbA1clt58mmolmol (75)
BPlt14080
634
787
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
T2 Treatment Targets ndash Barnet Practices
39
HbA1clt58mmolmol (75)
BPlt14080
674
720
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
40
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
So What Could Explain the Variation
bull Just Normal Cause Variation
bull Multivariate Statistical models show that Care Process Completion Rates
ARE appreciably explained by age sex duration and type of diabetes
ethnicity social deprivation (C statistic 08+)
bull Multivariate Statistical models show that Treatment Target Achievement
rates ARE NOT appreciably explained by age sex duration and type of
diabetes ethnicity social deprivation (C statistic 06)
bull Can that Really be True
41
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
ldquoClosing off the escape routesrdquo
I see that our diabetes treatment targets are
lower than others but we have an older
populationhelliphellip
Our practice is sitting in a deprived area
which is very different to practices
generallyhellip
Therersquos variation here because wersquore not the
same as our local CCGs ndash wersquore different with
high numbers of ethnic minoritieshellip
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
43
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
CCG average T2 DM Treatment Target Rates
lowest two
IMD Quintiles
HbA1c
lt58mmolmol
BPlt14080
England 458 659 737
Salford 718 652 755
Newham 824 634 787
Barnet 296 674 720
44
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
T2 Treatment Targets ndash Salford Practices
45
HbA1clt58mmolmol (75)
BPlt14080
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
46
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Treatment Target ndash By Age
47
Percentage of people with Type 2 diabetes achieving all three treatment targets
by age 2015-2016England and Wales
0
10
20
30
40
50
60
70
80
90
100
20 30 40 50 60 70 80
Percentage
Age of person with diabetes
Type 2 and Other
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
48
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
49
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
50
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
51
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
52
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
53
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
54
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Conclusions
bull Treatment target variation does not seem to be
explained by differences in patient characteristics
bull Some of the treatment target variation is not lsquonormal
causersquo
bull People of Working Age and younger should be a
priority for improving Treatment Target Achievement
Rates
bull Change is possible
bull Practices can use NDA results with confidence
ndash to benchmark themselves and select priorities for
improvement
ndash to measure the effectiveness of their improvement
projects
55
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
RCGP QUALITY IMPROVEMENT TOOLKIT
FOR DIABETES CARE
Roger Gadsby NDA GP Lead
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
WHY NOW
Increasing demandIncreasing complexityIncreasing elderlyPressure on resources
Improvements need to be effective efficient and sustainable
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
THE QUALITY IMPROVEMENT WHEEL
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
PILOT PROJECT
bull Betsi Cadwaladr ndash 8 practices
bull Wiltshire ndash 5 practices
bull Southport ndash 9 practices
bull Walsall ndash 7 practices
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
USEFUL QI TOOLS
bull Context
bull Process Mapping
bull Fishbone diagrams
bull Model for improvementPDSA
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
CONTEXT CHECKLIST
bull Culturebull Leadershipbull Team working bull Technological bull Capacitybull Socialdemographicsbull Capabilitybull Opportunitybull Motivation
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
CONTEXT CHECKLIST
bull Immediate solutionsndash leader
technology
bull Solutions difficultndash involve patients
time
motivate others in QI
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
PROCESS MAPPING
bull Used in process of review appointments
bull Used in first abnormal HbA1C to first appointment with diabetes nurse
bull Areas to improve ndash invitations
dealing with results
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
FISHBONE DIAGRAM
TARGET
BP NOT
MET
DOCTORPATIENT
PROCESS
Poor concordancewith therapy
Side effects
Maximum Tolerated therapy
BP not being taken
Abnormal BPs not being followed up
No search for abnormal BP
Abnormal BPs not being followed up
No prompt on computer screen
Not aware of target
Does not believe target appropriate
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
COMMON AREAS FOR IMPROVEMENT
bull Process ndash ACRs
Numbers attending for review
Responding to HbA1C results
bull Targets ndash cholesterol
HbA1C
Blood pressure
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
SATISFACTION WITH TOOLS
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
DATA
bull National Diabetes Audit
bull QOF
bull PRIMIS
bull Eclipse
bull Audit plus
bull Practice soft ware systems
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
DISPLAYING DATA
bull Line graph - HbA1C lt 58
cumulative ACRs
bull Run chart ndash foot checks
cholesterol lt 5
bull Visual display
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
QI GUIDES - GENERIC
bull Quality improvement for General Practice
bull Mini guides ndash run charts
process mapping
MFIPDSA
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
TRAINING MATERIALS
bull Presentation
bull Group work ndash context
process mapping
MFIPDSA
run charts
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
PROJECT MANAGEMENT TOOLS
bull Follow up check list
bull Multi practice plan
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
REPORT AND EVALUATION
bull As submitted to HSCIC (Now NHS Digital)
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
EVALUATION TOOLS
bull Reflection template
bull Interview template
bull Baseline questionnaire
bull Follow up questionnaire
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
EVALUATION
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
CONTEXTUAL FACTORS
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
PROCESS FACTORS
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
IMPACT
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Percentage of cholesterol results le 5mmoll 2013-2015
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
PATIENT INVOLVEMENT
Little evidence in projectWebinar
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
ENGAGEMENT
CCG or LHB involvement can have a significant impact on success
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
FURTHER INFORMATION
RCGP QI toolkit for diabetes care
httpwwwrcgporgukclinical-and-researchtoolkitsquality-improvement-toolkit-for-diabetes-careaspx
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
Diabetes care in general practice a person with diabetesrsquo experience
Marianne Littleford
Patient representative NDA Partnership Board
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399
GET IN TOUCHwwwdiabetesorguk
healthcarediabetesorguk
0345 123 2399