4 ways a clinic cut poorly controlled diabetes by a third


A small family practice created a large improvement in diabetes control by focusing on workflow efficiency teamwork and technology. In less than a year, the two-physician office posted a one-third decrease—from 31 percent to 20.5 percent—in its patients with poorly controlled diabetes, defined as HgbA1C greater than nine.  

Central to making the improvement in their clinical action plan were on-site assessment, recommendations and learning resources from the AMA STEPS Forward™ program, an open-access platform featuring more than 50 modules that offer actionable, expert-driven strategies and insights supported by practical resources and tools.  

Based on best practices from the field, STEPS Forward modules empower practices to identify areas or opportunities for improvement, set meaningful and achievable goals, and implement transformative changes designed to increase operational efficiencies, elevate clinical team engagement, and improve patient care. 

Several STEPS Forward modules have been developed from the generous grant funding of the federal Transforming Clinical Practices Initiative (TCPI), an effort designed to help clinicians achieve large-scale health transformation through TCPI’s Practice Transformation Networks. 

The AMA, in collaboration with TCPI, is providing technical assistance and peer-level support by way of STEPS Forward resources to enrolled practices. The AMA is also engaging the national physician community in health care transformation through network projects, change packages, success stories and training modules. 

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The family practice within the Midwestern University Multispecialty Clinic (MUMC) was already enrolled in TCPI when STEPS Forward consultants visited the Downers Grove, Illinois, office in early 2018, said Kim Huntington-Alfano, DO, a family physician. She practices full-time alongside a part-time physician colleague, a part-time clinical pharmacist and office staff in a multispecialty building offering dentistry, physical therapy, optometry, and other services. 

A few weeks after the visit, the consultants reported back “with their observations and recommendations for changes we might be able to make in order to improve the workflows, the efficiency and, by extension, the quality of the care we're given,” said Dr. Huntington-Alfano. 

To start, the patients with diabetes needed to be identified, and within that group, those with HgbA1C greater than 9. The clinic’s IT department took physicians part way through an automated search using ICD-10 codes. A clinical pharmacist, embedded in the practice three days a week, then put together a diabetes registry for the practice.  

“We created a searchable Excel spreadsheet, manually entered the patients and all diabetic parameters, and then we were able to identify how many of our patients were poorly controlled,” said Dr. Huntington-Alfano. 

One team member took on the role of chronic care coordinator, which included development of a pre-visit planning sheet for patients with diabetes. A formal process for tracking and performing outreach to those patients was also put into place. When the final TCPI numbers were tallied, the practice identified 39 patients with diabetes.  

A fourth-year medical student then created a patient education folder for patients newly diagnosed with diabetes and, as warranted, to those who were previously diagnosed. The materials were designed to motivate patients to become engaged with appropriate self-management of their condition.  

Dr. Huntington-Alfano and her team were provided with suggestions from the more than 50 STEPS Forward modules that would help the practice achieve its TCPI improvement goals.  

“We pulled out the pieces of various modules that were really applicable to the situation we were currently in,” said Dr. Huntington-Alfano.  

Pre-visit planning was “one of the big modules that I relied on that just helped our day to day functioning in general,” she said, adding that it played an important role in the diabetes clinical action plan. 

Elements of STEPS Forward approaches were used for other initiatives at the practice as well, such as opioid control and colon cancer screening. Both of those programs were successful. 

Looking forward, the practice is deeply engaged with upgrading its electronic health records. Their goal is to add functionality to track, treat, and engage with patients. 

“The implementation of these practice transformation strategies enhanced the effectiveness and efficiency of workflows for addressing patient care gaps—a big change from the early days of the still-growing practice when just getting through the day was the goal,” said Dr. Huntington-Alfano.