Improving the Adherence of Family Doctors to Diabetic Foot Exam at Jazan Armed Forces Hospital (JAFH)

Diabetic foot is a chronic serious complication of diabetes mellitus (DM). It has a worldwide prevalence of 6.3% and accounts for hospitalization in 4-10% of diabetic patients. (1) Diabetic foot imposes a great challenge on the affected individuals, affecting both mental and physical health and well-being. (2) The American Diabetes Association (ADA) recommends routine screenings for at-risk individuals to prevent mortality; these include blood pressure screenings, eye exams, and foot assessments. Required components of an annual diabetic foot exam (ADFE) include visual inspection, assessment of peripheral pulses, and sensory assessment. (3) ADFEs are associated with early detection of peripheral artery disease and neuropathy, prevention of lower-extremity wound formation, and increased value-based reimbursements. (2) Thereby improve diabetic foot screening through increased adherence of family physicians to guidelines considered one of JAFH projects for this year. A root cause analysis (RCA) was completed at the project site to identify specific barriers unique to the family practice. The main barriers that were identified included insufficient training of medical staff, poor documentation of diabetic foot exam results in patient files, unavailability of assessment tools in clinics, and time constraints. The purpose of this quality improvement (QI)project was to increase the percentage of patients with diabetes at family clinics who receive annual foot exams from (7%) to (90 %) within 10 months starting on 1st January 2023. We successfully achieved this target by the end of the project which was maintained for 10 months (January October2023) through three main initiatives brief training sessions, provision of foot screening bundles, and decreased workload by activation of virtual medication refill clinics.
Problem Description: Diabetic foot is a chronic serious complication of diabetes mellitus. It has a worldwide prevalence of 6.3% and accounts for hospitalization in 4 -10% of diabetic patients. (1) Diabetic foot imposes a great challenge on the affected individuals, affecting both their mental and physical health and well-being. (2) In addition, it also imposes a huge financial burden on both the individual and the national levels. American Diabetes Association guidelines for the management of diabetes include a series of general recommendations for foot care. Their first recommendation is that the feet should be inspected at every visit for patients with evidence of sensory loss or prior ulceration or amputation and comprehensive foot evaluation for others at least annually to identify risk factors for ulcers and amputations. (3) Although There commendation is clear, most of family doctors have a strong awareness of the importance of a comprehensive diabetic foot examination some patients never receive a foot exam, not even a quick look at their feet. Is it difficult for patients with diabetes to fail to get a legitimate yearly comprehensive diabetic foot exam from their primary care providers? This was the main question discussed in our departmental meeting then we started our improvement project.
Measurement: The key performance indicators (KPI) selected for this improvement project are as follows: Outcome measures: The percentage of patients with diabetes at family clinics who receive annual foot exams each month.
Process measures: Total score (percentage) for doctor performance in diabetic foot exam (inspection, palpation, neurological exam) pre-post intervention balancing measure: Number of patients registered in family medicine virtual clinic each month.
Analysis: The data will be collected based on each KPI selected and analyzed by using Exell and QI macros analyzing tools. The data collected for each KPI were as follows: Outcome measure for patients with diabetes at family clinics who receive annual foot exams each month, the data collected from the ERP system are S/N, Physician Code, Patient Name, MRN, Data of the clinic visit, Type of Diabetes, Date of Diagnosis with diabetes, and Date of Receiving foot exam.
Process Measure: Total score (percentage) for doctor performance in diabetic foot exam (inspection, palpation, neurological exam) pre-post intervention, the data were collected retrospectively during auditing sessions from the sheet provided in fig (2) to ensure compliance.
Balancing Measure: Number of patients registered in family medicine virtual clinic each month, the data were collected retrospectively from the ERP system for those patients are encoded in family medicine and receive services virtually.
Implementation: Study of the interventions: Plan, Do, Study, Act change model used to address the progress of project Plan. Staff were educated on the diabetic foot screening through workshops, in field training. Diabetic foot screening bundles became available in each exam room. there are specific icons in ERP for documentation of diabetic foot exam results an easy process just by clicking on them. Do. The intervention period took place over 10 months (January -October 2023); however, data were collected and evaluated monthly during this period. Study. Every month, data were assessed to determine compliance. This assessment was done by running an ERP report for diabetic patients who were seen within the month and assessing for the completion of an ADF. Act. A root cause analysis was evaluated when compliance decreased to identify potential barriers to compliance and adjust interventions as needed (the main modification was in documentation as we converted it to be in force function as the doctor cannot close the Pfile without documentation of the foot exam results)After the 10-month intervention period, we successfully achieved the target, there was a clinically significant increase in the percentage of patients with diabetes at a family clinic who received annual foot screenings from (7%) to (100 %).
Results/Discussion Summary: Diabetic foot is a chronic serious complication of diabetes mellitus (DM). The purpose of this quality improvement project was to increase the percentage of patients with type 2 diabetes mellitus attending family medicine clinics at JAFH who receive annual foot screenings from (7%)to (90 %) within 10 months starting on 1st January 2023. We achieved the target of the project through three main initiatives; brief training sessions, provision of foot screening bundles, and decreased workload by activation of a virtual, medication refill clinic by the end of the project the number of diabetic pt who received diabetic foot exam increased from (7%) to (100 %) with sustainable improvement in last 4 months associated with improving doctor performance in all items of diabetic foot exam after intervention: inspection improved form (43.3 % to 72.1%),palpation (67% to 94.3%) and neurological exam (69% to 95 %). At the same time, the number of patients registered in the virtual clinic of family medicine increased from 18 pt/month to reach 88pt/month.