Increasing Patient Caseload in Diabetes Clinic

NAME OF HEALTH DEPARTMENT: Cleveland County Health Department

PROJECT TITLE: Increasing Patient Caseload in Diabetes Clinic

DeShay Oliver
This email address is being protected from spambots. You need JavaScript enabled to view it.
704-484-5199 (p)
315 E Grover Street
Shelby, NC 28150

Project Overview

Project Aim:
Our overall aim is to increase our daily patient caseload and improve the quality of our services in the Diabetes Clinic at the Cleveland County Health Department.  We will accomplish this by December 31, 2012.  This is important because the grant funding our diabetes clinic requires that we see a minimum of 15 patients each day our clinic operates.  This increase in our current caseload will improve access to quality diabetes healthcare for underinsured and indigent populations, thereby improving the health of not only our patients, but our community-at-large.  We will achieve this by using QI methods and tools learned through the QI 101 program and the Kaizen event. 


  • Increase the average number of patients seen daily in our diabetes clinic from 9 to 20.
  • Increase the percentage of patients who rate the quality of our diabetes services as “excellent” on our customer satisfaction survey from 69% to 100%.
  • Increase our patient show rate from 78% to 85%.
  • Increase the number of weekly outreach/promotional contacts from 20 to 54 per week.
  • Increase the percentage of focus group participants who rate the overall effectiveness of our diabetes clinic marketing materials as “excellent” from 36% to 80%.

Project timeframe:
September 1, 2012-December 31, 2012

How was the need for the project determined?
The QI Coordinator scheduled a meeting with the QI Committee, Health Director, and Nursing Director to discuss any identified or potential issues that could affect the quality of services offered by the health department.  Potential issues were identified through the review of Customer and Employee Satisfaction Survey results in addition to other resources.  After identifying several potential projects, the QI Coordinator met with the member of the Management Team who was responsible for supervising the departments identified for potential QI projects to assess readiness and willingness to participate in a QI project and the QI 101 Program.  Other factors taken into consideration included the ability to be successful in accomplishing overall AIM, staff’s willingness to participate and openness to change, and the timeframe in which it would take to carry out the potential project. After speaking with Management Team members, the decision was made by the QI Coordinator, with support from the Health Director and Nursing Director, to focus the QI project on increasing patient caseload in the Diabetes Clinic.  This was important because the Diabetes Clinic was not meeting the minimum caseload necessary to continue to receive the grant that funds the clinic’s services.  Furthermore, the Diabetes Clinic staff and Immediate Supervisor were excited about the opportunity to participate in this project, as it was seen as a means to help sustain their clinic and positions.  Furthermore, we stood the opportunity to achieve a significant return on our investment. 

Does this quality improvement project link to accreditation?
Yes, we were able to use the participation in the QI project to meet Re-accreditation standards for the following benchmarks and activities:

Benchmark 21: The local health department shall lead efforts in the community to link individuals with preventive, health promotion, and other health services.

  • Activity 21.2: The local health department shall make available complete and up-to-date information about local health department programs, services and resources.
  • Our health department is using the Spanish version of the new Diabetes Clinic brochure we developed as part of our promotional efforts as evidence of linguistically and culturally appropriate information about agency programs, services and resources.

Benchmark 27: The local health department shall evaluate all services it provides for effectiveness in achieving desired outcomes.

  • Activity 27.3: The local health department shall employ a quality assurance and improvement process to assess the effectiveness of services and improve health outcomes.
  • Our health department was able to use this project as evidence that our quality improvement policy and procedures are being implemented

Areas for Improvement and Change Ideas Implemented

Improvement 1: Effectiveness of Diabetes Clinic Marketing Materials
At the start of the project, the Diabetes Clinic was using a very basic one-page, white handout as its only promotional/informational material for both the Diabetes Clinic and Diabetes Education Classes.   

  • The QI Team worked together to develop a new, more attractive and eye catching brochure and flyer to be used for promotional purposes.
  • PDSA’s were conducted with the new materials by forming focus groups comprised of Diabetes Clinic and Education Class patients who reviewed and rated the new materials in multiple categories using a media review form.  Suggestions for improvement were taken into account, revisions were made, and the materials were re-tested with focus group participants until 73% of focus group participants rated the overall effectiveness of the materials as “excellent.”

Improvement 2: Outreach Efforts
At the start of the project, Diabetes Clinic staff people were averaging approximately 20 outreach contacts (patient reminder calls, missed appointment follow-ups, conducting health fairs, outreach calls to other agencies, delivering promotional materials) per week.  The limited # of outreaches was contributed to not having effective marketing materials.  Upon the completion of the new brochures and flyers, the average # of outreach contacts increased to 54 per week. 

  • We developed a Value Stream Map to visually display the Diabetes Clinic’s current outreach efforts as well as brainstorm agencies we could potentially partner with to promote the clinic where we had not already done so. 
  • An Impact Matrix was used to prioritize where we felt we should begin distributing brochures and flyer, participating and health fairs, and further marketing our clinic (where would be get the biggest return on our efforts?)
  • Diabetes Clinic staff began tracking the referral source (how new patients heard about our clinic) to help determine which marketing efforts were being successful and warranted continued efforts

Improvement 3: Patient Show Rate
At the start of our project, our average monthly show rate was 78%.  We knew if we wanted our patient caseload to increase, it would be important to improve our show rate.   

  • We designated specific times and staff to implement appointment reminder calls on days that the clinic is not operational.  Every patient is to receive a reminder call and the call is to be recorded on the weekly outreach tracking sheet.
  • All patients who do not show for an appointment are to receive a follow-up call to help determine why they didn’t show and to reschedule their appointment.

Improvement 4: Patient Caseload 
At the start of this project, the Diabetes Clinic was averaging 9 patients per clinic day.  However, the grant that funds the clinic requires a minimum of 15 patients per operational clinic day.  Therefore, we knew we had to do something to increase patient caseload, or we risked losing our Diabetes Clinic funding.  After collecting some baseline measures, we contributed the low patient caseload to lack of marketing, a less than excellent patient show rate, and customer satisfaction scores that could certainly be improved. 

  • In addition to implementing procedures to improve patient show rate (as previously mentioned), we developed and tested a Gas Card Incentive Program in which patients who refer an eligible friend or family member to the Diabetes Clinic receive a free $10 gas card if their referral shows up for their first scheduled appointment. 
  • Before implementing this incentive program, we conducted PDSA’s to help determine the effectiveness of such a program.  During our PDSA process, patients were interviewed and asked questions concerning what they would appreciate most as an incentive, if they knew friends and/or family members who may be eligible for the clinic, and if they would be willing to refer them to our services.


Overall Improvements

  • Increased the average # of patients seen per day from 9 to 13
  • Increased the percentage of patients who rate the quality of our diabetes services as “excellent” from 69% to 75% according to customer satisfaction surveys.
  • Increased our monthly show rate from 78% to 85%
  • Increased the number of weekly outreach/promotional contacts from 20 to 42.
  • Increased the percentage of focus group participants who rate the overall effectiveness of our promotional materials as “excellent” from 36% to 73%
  • See Attachment #1 for Run Charts displaying improvements
  • Increased annual revenue by $6,672.64. (Seeing an average of 4 more patients per day=8 more patients per week=416 patients per year; the average cost per appointment =$16.04 X 416= $6,672.64)
  • Increase in patient caseload qualified diabetes clinic as a recipient of the Community Health Grant in the amount of $115,922. 
  • Total Financial Benefits: $122,594.64
  • Additional unintended benefits:
  • Improved teamwork among Diabetes Clinic staff
  • Improved feeling of job security among Diabetes Clinic staff
  • Increased knowledge of Diabetes Clinic services among QI team members who do not work in the clinic 
  • Opportunity to spread QI to other units throughout health department

 Lessons Learned

  • The first time we conducted our Focus Group Surveys with patients in the Diabetes Education Classes, the media review forms were not completed properly and thoroughly and showed very little improvement from the original promotional flyer, to the newly developed promotional materials.  While this was discouraging initially, we determined that while the results did not show us what had hoped for, it may not be because there was not significant improvement.  Rather, the survey wasn’t measuring what we needed it to because it was too complex for the patients to complete properly.  Therefore, we developed a much more simplified version of the media review form and conducted it once again with the same group and got much more positive results.  In summary, we learned that simpler can be better and sometimes, if you aren’t getting the answers you may not be asking the right questions.
  • What things do you wish you knew before tackling this specific project? For our first QI project, it would have been simpler to take on a project that was focused on a clinical process, rather than a population based issue.  It was difficult to apply some of the QI tools and methods to our project, as our overall AIM was not to address a process, but rather increase patient caseload.  While we were able to make it work, I would advise teams new to the QI process to  focus on clinical process so they have an opportunity to use and apply all of the tools and resources learned throughout the QI 101 program.  It would be helpful if the Center for Public Health Quality provided a little more guidance to QI 101 teams during the project selection process to help ensure their AIM and goals will fit nicely with the QI tools and methods taught.  After all, you want your first project to focus on the “low hanging fruit,” rather than to be so difficult that it discourages participation in future projects.  Furthermore, it would be helpful to be familiar with all of the QI tools such as the Spaghetti and Driver Diagrams and Functional Flow Chart prior to the Kaizen Event and/or 2nd QI 101 Workshop.  

Programs supported by:

BlueCross BlueShield of NC FoundatoinThe Duke Endowment

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