Prevention and Management of Diabetes QI Program

The Ohio Academy of Family Physicians has created a data collection module to assist members and their practice teams in improving the prevention and management of diabetes. This module is free to OAFP members (American Board of Family Medicine (ABFM) fees still apply). By utilizing the module, you will improve practice team engagement, benchmark patient data, select a pathway for care delivery intervention, and re-measure outcome data after a three month change period. The module will systematically guide participants through a Plan, Do, Study, Act cycle to improve the care provided to female patients.

The module is accredited by the ABFM as an alternative Family Medicine Certification Performance Improvement (formerly known as MC-FP Part IV) activity and is also accredited by the American Academy of Family Physicians for Performance Improvement in Practice credits.

Learn more about completing the diabetes module and view the tutorial video below.


Learning Objectives

Participants in this module will:
  1. Understand the importance of practice team engagement on improving outcomes for patients with diabetes/prediabetes
  2. Determine the gaps in the care given to patients with diabetes, those with prediabetes, and those at risk for diabetes
  3. Put interventions into practice, work for improvement in lifestyle, medical therapy, and/or monitoring for patients with diabetes
  4. Demonstrate improvements in patient care as a result of systems changes identified through quality improvement initiatives.

Resources, References & Tools for Completing the Module

Within the module, once you complete your practice assessment and chart review, you will focus on a practice improvement strategy. Below are pathways within the module that you can choose from to improve your practices’ procedures for screening for prediabetes or your practices’ care of patients with diabetes. Within each pathway are several interventions. To complete this module, you will need to select one screening intervention and one management intervention to implement into practice.

Screening for Prediabetes and Diabetes
Management of Diabetes

Accreditation Statement

This activity has been approved by the ABFM for Performance Improvement credit toward Family Medicine Certification Requirements (formerly known as MC-FP Part IV). Term of approval will be for two years beginning Thursday, June 1, 2017, with the option for yearly renewal thereafter. Please note that once an activity is started, it must be completed within one calendar year. If the activity is not completed in that time, the activity must be restarted. In addition, for the alternate Performance Improvement activity to apply toward the Family Medicine Certification requirement, it must be completed in the stage the Diplomate wishes to receive the credit. To fully implement your practice improvement plan and analyze your results, it will take you a minimum of three months to complete the process. Please plan accordingly.

Although there is no cost to utilize this module, ABFM Diplomates who complete alternate Performance Improvement activities must submit the required Family Medicine Certification fees to the ABFM in order to receive credit for the alternate activity.

This Performance Improvement in Practice activity, Prevention and Management of Diabetes Quaility Improvement Program, has been reviewed and is acceptable for up to 20.00 Prescribed credit(s) by the AAFP. Term of approval began June 1, 2017. Term of approval is for two years from this date.

Once the module has been completed, the OAFP will report final credit of the participating physician to the AAFP and the ABFM so long as the physician’s ABFM and AAFP member numbers were accurately submitted in the profile record. Participants who successfully complete the activity, post test, and evaluation will have a statement of credit made available immediately.

Statement of Need

Family physicians care for patients of all ages and treat a variety of conditions, both acute and chronic, in numerous clinical settings. While there are many clinical guidelines to assist clinicians, the sheer number of them can be overwhelming. Guidelines meant to assure high-quality, evidence-based care for patients are complex and may contradict clinical recommendations. It is also important to note that family physicians, though woefully underrepresented in the health care system, are usually the first line of defense to screen, diagnose, and treat chronic diseases such as diabetes.

Much like primary care practices, patients are often faced with contextual barriers that prevent them from seeking treatment for their serious health conditions. Patients who have prediabetes or diabetes who are not adequately screened, who go undiagnosed, or who are diagnosed but do not adequately control their disease can experience a host of complications. As a result, diabetes has become an epidemic of mass proportions which can only be overcome through clear practice guidelines, a clinical understanding of a patient’s contextual barriers to care, and a priority to maximize the practice team to implement meaningful patient interventions.

Now more than ever, family physicians and their care teams need appropriate education and training on how to screen and diagnose patients with prediabetes and diabetes, which will help to decrease the number of patients who go undiagnosed and untreated.


  • Ryan Kauffman, MD, (Project Champion)
  • Anna McMaster, MD
  • Terry Wagner, DO
  • Douglas Harley, DO
  • Gary LeRoy, MD


  • Melinda Fritz, MD
  • Evan Howe, MD
  • Erin Jech
  • Erin Moushey, MD
  • Mary Krebs, MD
  • Kate Mahler, CAE
  • Steve Zitelli, MD

Faculty Disclosure

The OAFP adheres to the conflict of interest policy of the AAFPas well as to the guidelines of the Accreditation Council for Continuing Medical Education (ACCME) and the American Medical Association (AMA). Current guidelines state that participants in continuing medical education (CME) activities should be made aware of any affiliation or financial interest that may affect a faculty member’s participation in the activity.

The members of this expert panel have completed conflict of interest statements. Disclosures do not suggest bias but provide readers with information relevant to the evaluation of the contents of these recommendations.


This module was supported, in part, by the Cooperative Agreement Number 2 B01 OT 009042 funded by the Centers for Disease Control and Prevention (CDC). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or the Department of Health and Human Services.

If you have any questions regarding this program, please contact Director of Performance Improvement Erin Jech or call 800.742.7327.