The measures in the above table are a reasonable benchmark for us to apply to the Grafton GP Super Clinic to see

if we were achieving good diabetic health outcomes. It should also be noted that the overall aim of the APCC for diabetic care was that 50% of patients would have an HbA1c equal to or less than 7. At the time of the first data collection 7% of practices were meeting the target of 50% of patients with an HbA1c less than or equal to 7 and by the end of 17 months 15% were meeting this target.

Key APCC Measure Percentage of patients with diabetes with a last recorded HbA1C <= 7 within the last 12 months. Percentage of patients with diabetes with a low-density lipoprotein cholesterol (LDL-C) <2 mmol/litre (or Total Cholesterol <4) within the last 12 months. Percentage of patient with diabetes with a last recorded BP reading of <=130/80 within the last 12 months.

Average % achieved by the APCC 7 waves 38%

33%

22%

350 300 250 200 Patients 150 100 50 0 Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

50% 40% 30% 20% 10%

Median

Goal

Median

0% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

Patient Centred Care

One patient at a time. Micromanage patients who have poor control diabetic clinics. Ensure patient care plans. Home medication reviews. Chase those who DNA for dietitian and other AHP appointments.

Proactive Care
Develop systems for each chronic disease. Diabetic risk assessments. Early diagnosis through DRA + FM etc.

Miscellaneous
Be more vigilant and do more screening. Maintain and rejuvenate your and your patients motivation. Hard work, hard work, hard work.

Recall and Reminder Systems

Send letters for reminders for diabetic assessments. - Subsequent discussion re: best mode of communication e.g. sms, telephone, etc.

Vision

350 60% 50% 40%

60% 50% 40% 30% 20% 10% 0% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

Median

Median Goal

Recall for required HbA1c. Regular follow up. Regular screening for HbA1c. Make sure diabetics come to diabetic clinics. Diabetic clinics.

From Good to Great

Anything we do do the best we can at all times. Pride in all we do. Find out what the best in class looks like and benchmark from there. Strive to be the best.

Goal

30% 20% 10% 0% Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

Improving Data Quality

Data Cleanse. Use diabetes cycle of care area in Best Practice as routine. New patients more diligent in recording all aspects of care. Drop down box. Reception Update patient details especially the ATSI. Get patient demographics. Reception Make sure telephone numbers are recorded. Have a diabetic cycle of care sticker on desk as a prompt.

Team Work Communication

Identify quick wins and celebrate the results. Case conferences. ***Communicate. Regular liaison of practical staff. Recommendation to see allied health including dietician. Team approach rather than dependant on one individual. Working collaboratively with all health professionals. Find out who does what well, and use that person as a champion to drive change. Offer nurse time if cant see GP Check BP etc and arrange follow up with GP appointment Claim 10997. Involvement of administration in PDSA.

A common approach - Follow check list. - Regular monitoring of BP, Cholesterol and associates. - Make sure patients are given path forms. - Update and check cycle of care at every opportunity. - Attention to basics. - Attention to detail. - Check if need script. - Working on better habits.