Multidisciplinary Approach to Quality Improvement Intervention to Increase Performance of Comprehensive Diabetic Foot Examinations for American Indians/Native Alaskans

Abstract

Background: Low performance rate of comprehensive diabetic foot examinations (CDFEs) causing health care disparity. Objective: Increasing performance of CDFEs at Phoenix Indian Medical Center, an Indian Health Service (IHS) facility. Design: Before-after design, convenience sample. Setting: An IHS adult ambulatory care clinic in urban Phoenix, Arizona. Target: Four primary care providers (PCPs).Interventions: Utilizing the PDSA framework, a multidisciplinary group of clinical staff developed a process to increase the performance rate of CDFEs. Brainstorming, use of the Ishikawa diagram, and root cause analysis led to identification of factors contributing to low rates of CDFEs in the clinic. The QI intervention addressed multiple aspects of activities related to the CDFE performance, including pre-visit planning, enhanced communication, making equipment for CDFEs accessible to healthcare providers, and requesting patients to remove shoes and socks. Measurement: Weekly performance rate of CDFEs. Results: The results, analyzed with a run chart, showed an upward trend in performance for some providers. The median aggregate performance rates for pre and post intervention were 82.6% and 80.2%, respectively. Limitations: This study should be replicated over a longer time frame with more participants. Two significant weaknesses were identified in this study. The required provider de-identification prevented provider feedback. The data collection method provided CDFE performance data based on provider empanelment. This method of data collection reflects composite team care rather than specific provider behaviors. Conclusions: This multidisciplinary approach to improving the performance rates of CDFEs showed an upward trend for some providers but was not statistically significant. Post intervention CDFE performance rates were not improved. Significance: This study highlights the role of the doctorally prepared advanced practice nurse (DNP) in designing, facilitating and evaluating a practice change project to address the rate of provider performance of CDFE for their AI/NA patients. An exemplar, this QI intervention can be replicated for quality improvement initiatives targeting improved healthcare outcomes, crucial to the national effort of addressing healthcare disparities.