A tale of two audits: statistical process control for improving diabetes care in primary care settings.
BACKGROUND
Diabetes constitutes a major burden of disease globally. Both primary and secondary prevention need to improve in order to face this challenge. Improving management of diabetes in primary care is therefore of fundamental importance.


OBJECTIVE
The objective of these series of audits was to find means of improving diabetes management in chronic disease mini-clinics in primary health care. In the process, we were able to study the effect and practical usefulness of different audit designs - those measuring clinical outcomes, process of care, or both.


METHODS
King Saud City Family and Community Medicine Centre, Saudi National Guard Health Affairs in Riyadh city, Saudi Arabia.


METHODS
Simple random samples of 30 files were selected every two weeks from a sampling frame of file numbers for all diabetes clients seen over the period. Information was transferred to a form, entered on the computer and an automated response was generated regarding the appropriateness of management, a criterion mutually agreed upon by care providers. The results were plotted on statistical process control charts, p charts, displayed for all employees. Data extraction, archiving, entry, analysis, plotting and design and preparation of p charts were managed by nursing staff specially trained for the purpose by physicians with relevant previous experience.


RESULTS
Audit series with mixed outcome and process measures failed to detect any changes in the proportion of non-conforming cases over a period of one year. The process measures series, on the other hand, showed improvement in care corresponding to a reduction in the proportion non-conforming by 10% within a period of 3 months. Non-conformities dropped from a mean of 5.0 to 1.4 over the year (P < 0.001).


CONCLUSIONS
It is possible to improve providers' behaviour regarding implementation of given guidelines through periodic process audits and feedbacks. Frequent process audits in the context of statistical process control should be supplemented with concurrent outcome audits, once or twice a year.
Al-Hussein
Fahad Abdullah
FA
Family and Community Medicine, King Saud Ibn AbdulAziz University for Health Sciences, Riyadh, Saudi Arabia. HusseinF@NGHA.med.sa
D000465:Algorithms; D000554:Ambulatory Care Facilities / Q000592:standards; D003920:Diabetes Mellitus / Q000628:therapy*; D006801:Humans; D008485:Medical Audit; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D011320:Primary Health Care; D011787:Quality of Health Care; D012529:Saudi Arabia