Mrs. Jones, a 54-year-old established patient, comes to see you about her seasonal allergies. You haven't seen Mrs. Jones recently, but you remember that she also has diabetes. You examine Mrs. Jones, prescribe a medication for her allergies and, in the last few minutes of the visit, ask her about her diabetes. She says she's taking care of herself, so you end the visit with brief counseling on the importance of diabetes care. You then leave the room, and Mrs. Jones leaves your office. What you don't know is that Mrs. Jones hasn't had an HbA_1ctest in over a year and you won't see her for another six months.

It was situations such as the one described above that led the physicians and staff members of Family Care Network to embark on a 13-month quality improvement project aimed at redesigning the way they care for their patients with diabetes. The problem wasn't that the physicians didn't know how to treat diabetes clinically. Instead, it was largely a process problem: The practices didn't know how to keep track of those patients and make sure they were receiving the care they needed. Their solution was to develop and put into practice a diabetes flow sheet. (For information on other strategies the group implemented, see the series overview.)

What is a flow sheet?

A flow sheet is simply a one- or two-page form that gathers all the important data regarding a patient's condition, in this case diabetes. The flow sheet is housed in the patient's chart and serves as a reminder of care and a record of whether care expectations have been met.

“The goal is that every time a patient darkens the door of the practice, the doctor will look at the flow sheet and address diabetes in addition to the sore throat, cough or whatever the patient is in for at that visit,” explains Steven Alexander, MD, medical director for Lynden Family Medicine, one of the Family Care Network pilot sites. “Every time an appropriate piece of lab work or test result comes through, you load the data in its slot in the flow sheet so that at a glance you can see where you're at.”

Tips for making it work

At the outset of their quality improvement project, most of the Family Care Network sites were already using flow sheets for their patients with diabetes, but their systems weren't optimal. In many cases, the flow sheets weren't being filled out consistently or they weren't designed in a way that was helpful. Using the “plan-do-study-act” (PDSA) cycle of improvement, the groups experimented with their flow sheets and finally found systems that would work. The following tips are based on their experience.

1. Design a flow sheet that is comprehensive. The flow sheet should list all services or measures relevant to diabetes, from patients' lab values to blood pressure readings to self-management goals to foot checks. (See the flow sheet example.) The flow sheet won't be effective if key elements are missing and overlooked, so don't hesitate to revise it.

2. Make abnormalities easy to spot. The patient data listed on the flow sheet will be more useful if you also list the target measures or expectations so that you can immediately know whether a patient is progressing toward the ideal. “We put the parameters for normal labs right on the flow sheet so we don't have to wonder whether a lab result is abnormal,” explains Jody Fox, RN, triage nurse at Family Health Associates, another Family Care Network pilot site. Targets listed on a diabetes flow sheet might include the following: two or more HbA_1c checks per year, with the most current result at 7 percent or lower; a retinal exam every 12 months; and blood-pressure readings at 130/85 mm Hg or lower.

3. Don't trust doctors to fill in the flow sheets on their own. Perhaps the most difficult aspect of any flow-sheet system is getting people to use it consistently. Early in the project, Family Care Network's medical director, Berdi Safford, MD, was trying to gauge the success of the flow sheet system and discovered that out of 42 doctors, only three were filling in the flow sheets. “In my opinion, many doctors are terrible at this,” says Safford. “We come of all different ilks. Some of us are obsessive-compulsive, but even those types are so overwhelmed that they're obsessing about something else and not about the flow sheets. So it's helpful to get someone other than the doctor to do it.”

But absolving physicians from flow-sheet duties and placing it squarely on the shoulders of nurses may not be the answer either. Instead, flow sheets seem to work best when several people share the responsibility, says Safford. For example, the person who files the lab results in the chart can enter the lab results on the flow sheet. The nurse can be responsible for inputting clinical data from the visit into the flow sheet. And the physician can write in elements such as the patient's self-management goal.

4. Make sure the flow sheet cannot be overlooked in the chart. Once you've decided who will be responsible for filling in the flow sheet, you can help them fulfill that responsibility by making the flow sheet easy to find. Fox accomplished this by printing Family Health's flow sheets on bright pink, heavyweight paper.

5. Develop a system for reviewing the flow sheets periodically. Then follow up with patients who have missed needed services. If you have a diabetes patient registry (i.e., a list of your patients who have diabetes), this process can be fairly simple because you'll know exactly which charts to pull. And since the information you'll need to review will now be organized into a single page, the task is manageable. You may even be able to get help from your health plans. For example, an insurer might be willing to forward you quarterly reports listing which of your patients have had eye exams or other needed services. You can then use that information to update your patients' flow sheets and send reminder postcards to those who need them.

6. Computerize your flow sheet, if possible. While flow sheets can be easy and effective tools even in their simplest form (paper), they become infinitely more valuable when combined with computerized data. Computerized programs offer automatic reminders when patients need certain services and provide an easy way to track patient data over time.

For Family Care Network's pilot sites, computerized flow sheets are now a reality. The local hospital has initiated a communitywide, computer-based registry that houses clinical data as well, doing away with the need for paper flow sheets. For example, because the hospital's laboratory is linked into the system, lab values are automatically loaded into the patient's file as they become available. Other providers in the community also share in entering their patient data, which Family Care Network's pilot sites are then able to view.

7. Don't expect results overnight. Changing your system of care isn't easy. It will take time for physicians and staff members to experiment with the flow sheets and to find what works best for them. Don't expect your flow sheet to be perfect the first time, but keep at it. The more you use them and load them with data, the more useful they will become in ensuring that patients receive the care they need.

8. Set a goal. The point of having a goal for flow sheets, or any other aspect of practice, is simply to spur action and encourage your practice team to work together. Family Care Network set an initial goal for its pilot sites of having up-to-date diabetes flow sheets in 80 percent of patients' charts. As of May 2000, they had reached a rate of well over 90 percent and are working toward expanding their efforts into the other 14 sites.

That spirit of continuous improvement is perhaps one of the biggest successes of the project. What once seemed an impossible task, that of changing diabetes care, is now being done one step, one patient, one flow sheet at a time.