Improving the annual review of diabetic patients in primary care: An appreciative inquiry in the Cape Town District Health Services
Background: Diabetes is a common chronic disease in the Cape Town District Health Services and yet an audit of diabetic care demonstrated serious deficiencies in the quality of care. The Metro District Health Services (MDHS) decided to focus on improving the annual review of the diabetic patient. The MDHS provides primary care to the uninsured population of Cape Town through a network of 45 Community Health Centres (CHC). Methods: An appreciative inquiry was established amongst the staff responsible for diabetic care at the 15 CHCs that had newly appointed facility managers. The inquiry completed three cycles of action-reflection over a period of one year and included training in clinical skills as requested by the participants. At the end of the inquiry a consensus was reached on the learning of the group. Results: This consensus was expressed in the form of 11 key themes. CHCs that reported success with improving the annual review formed chronic care teams that met regularly to discuss their goals, roles and to plan improvements. These teams developed more structured and systematic approaches to care, which included the creation of special clubs, attention to the steps in patient flow and methods of summarising and accessing key information. These teams also appointed specific champions who would not rotate to other duties and who would provide continuity of leadership and organisation. These teams also supported continuity of relationships, clinical management and organisation of care. Teams involved the community and local non-profit organisations, particularly in the establishment of support groups that could disseminate medications and build health literacy and self-efficacy. Some teams emphasised the need to also care for the carers and to not just focus on workload and output indicators. More successful CHCs also grappled with balancing of the workload, quality of care and waiting times in a way that improved all three in an upward spiral. Patient satisfaction, staff satisfaction and clinical outcomes were seen as interlinked. There was a need to plan methods for empowering patients and build self-efficacy through a variety of facility- and community-based as well as individual- and group-orientated initiatives. Training in clinical skills was requested for foot and eye screening. Feedback was given to the MDHS on the need to improve referral pathways and access to preventative services such as dieticians, podiatrists and vascular surgery. Finally, the inquiry process itself together with the annual audit supported organisational learning and change at the facility level. Conclusion: Improving the annual review has more to do with the organisation of care than gaps in knowledge or skills that can be addressed through training. While such gaps do exist, as shown by the training around foot screening, the main focus was on issues of leadership, teamwork, systematic organisation, continuity, staff satisfaction, motivation and the balancing of quality care provided, quantity of care demanded and queuing required. The appreciative inquiry (AI) process supported decentralised organisational learning and, while key themes were shared, the specific solutions were localised.