Prevention and Management of Diabetes QI Module

Note: Due to changes at the ABFM, the OAFP will sunset its modules at the end of 2018. Check back in early 2019 for the launch of a new initiative.

As a free benefit of membership, the Ohio Academy of Family Physicians has created the Prevention and Management of Diabetes Quality Improvement (QI) Module to assist members and their practice teams in improving the care provided to patients in preventing and managing diabetes.

The module has been approved by the American Board of Family Medicine (ABFM) as an alternative Family Medicine Certification Performance Improvement (PI) activity for 20 PI points and by the American Academy of Family Physicians for 20 continuing medical education credits.

Aligned with the American Diabetes Association’s 2016 Standards of Medical Care in Diabetes (view abridged version for primary care providers), module participants will be guided through three phases:
  • A pre-assessment phase to evaluate the current practice’s care delivery and selection of a plan for improvement using a Plan, Do, Study, Act (PDSA) cycle
  • An action phase for the practice to implement its plan for improvement for a minimum of three months
  • A post-assessment phase to analyze data, reflect on successes and challenges incurred, and evaluate the program.

For an overview on completing the module, watch the video below.

“By completing this module, I realized how often we were not completing foot exams. Now we have an updated protocol that involves all team members,” stated a module participant.


Once the module has been completed, the OAFP will report final credit of the participating member physician to the AAFP and the ABFM. View the module tutorial video for a detailed explanation on completing the module.

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

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. Term of approval is for two years that began on 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 member 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 module, including submitting the evaluation, will have a statement of credit made available immediately.

Learning Objectives

  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.

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 AAFP as 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.