qiCoach – Improving the Care of Patients with Diabetes


With a culture of continuous quality improvement embedded into their practice, Woodcroft Medical Centre in South Australia decided to further develop optimum ways to deliver best practice to their patients.

To gain insights on how to do this and to use data driven quality improvement processes, the team engaged the services of the Improvement Foundation’s personalised quality improvement coaching service, qiCoach. A highly structured program, qiCoach services are designed to accelerate growth and improve business and patient outcomes. The qiCoach conducted a diagnostic assessment of the practices organisational efficiency, clinical activity and financial performance. Using data extraction software and the Improvement Foundation’s secure data web portal, practice staff viewed their data in new ways, easily identifying the practice’s strengths and weaknesses. With the diagnostic assessment complete, the qiCoach worked with staff to develop a quality improvement plan focussed on developing best practice in the following areas:

  • Home medicine referrals
  • Diabetes cycle of care
  • General Practice Management Plan
  • Ausdrisk – Diabetes risk assessment questionnaire
  • Diabetic Risk Evaluations
  • 45-49 year old health checks
  • Home health assessments for over 75’s
  • CVC item UP03 – quarterly care payment for contact with Practice via Coordinated Veterans Care program

The data from the diagnostic assessment assisted the practice in identifying areas to improve health care delivery and also, associated and potential growth in claiming Medicare Benefits Schedule item numbers. The qiCoach then outlined the practical steps they needed to make to produce immediate results and long term changes, additionally the team had access to the Improvement Foundation’s online tools and resources to help with organising, measuring and tracking their activities.


With the data in hand and the tools to begin, the Practice team cleansed their database which produce the following results:

  • Enhancement of recalls and reminders system – a monthly routine that consisted of out of data and time consuming became a quick and easy process with the removal of former GP’s and allocating patients to the current roster of GPs. Additionally a review process is also in place to ensure that staff are maintaining the lists with consistent information.
  • Recording of Ethnicities – as a longstanding practice, the recording of ethnicities had only recently been introduced on the new patient registration form. With only 6033 of their 7655 patient database without ethnicity recorded, the practice staff set the challenge to improve this. Within a few weeks they had brought the figure down to 2482.

Improving Outcomes for Diabetes Patients

The following improvements were made to the treatment of diabetes patients.

  • Comparison between 2014 and 2015 data showed great improvements in patient outcomes for diabetic patients in measures including HbA1c, blood pressure, lipids recorded and eGFR recorded.
  • Improvements on item number billings equated to an approximate increase in income to the practice of $122,663 including Practice Incentive Payments (PIP) and and Service Incentive Payments (SIP) with $72,858 going to the GP’s and $49,805 staying with the practice.
  • GP medical plans identified the need to make more contact with certain patients particularly those with Diabetes.
  • Employment of more nurses and utilisation of other consulting rooms within the practice so nurses could conduct more care plans, with the ultimate aim being is to see patients with diabetes at least three times a year.
  • GPs were encouraged to focus on the specific criteria and requirements for the practice to claim chronic disease item numbers. This resulted in improved management and better quality of
    patient care, as well as a more efficient work practice.
March 10, 2016

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