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1. IMPROVING HbA1c LEVEL TO LESS THAN 6.5% AMONG TYPE 2 DIABETES MELLITUS PATIENTS IN KLINIK KESIHATAN KULIM, KULIM DISTRICT IN KEDAH DISTRICT SPECIFIC APPROACH (DSA) PEJABAT KESIHATAN DAERAH KULIM KULIM KEDAH

2. TEAM MEMBERS 01 04 02 03 Dr Anis Farhanah bt Abdul Rahim Izzati binti M Mokthar Nor Fazila binti Ibrahim Dr Cik Normadiah binti Said Fazdlizan bin Abu Hasan Dr Nazatul Asma binti Nizam Akbar 5 6

3. 5. Increasing case detection rate for PTB. 2.Increasing screening rate for diabetic retinopathy 3. Increasing of pap smear screening 4. Increasing screening rate of mammogram among high risk woman PROBLEM IDENTIFICATION 1.Improving HbA1c level ≤ 6.5% among patient type 2 Diabetes Mellitus in Klinik Kesihatan Kulim.

4. PROBLEM VERIFICATION NO PROBLEM VERIFICATION TARGET 2021 2022 1 Improving HbA1c level ≤ 6.5% among patient type 2 Diabetes Mellitus in Klinik Kesihatan Kulim. 21.85% 14.47% ≥30% 2 Increasing screening rate for diabetic retinopathy 9.42% 10.00% >90% 3 Increasing of pap smear screening 30.98% 57.0% 100% 4 Increasing screening rate of mammogram among high risk woman 59% 67% 100% 5 Increasing case detection rate for PTB. 54.9% 67.3% 100%

5. TOPIC VOTE S M A R T TOTAL Improving HbA1c level ≤ 6.5% among patient type 2 Diabetes Mellitus in Klinik Kesihatan Kulim 18 14 16 14 16 78 Increasing screening rate for diabetic retinopathy 14 14 8 8 10 54 Increasing of pap smear screening 10 11 8 7 9 45 Increasing screening rate of mammogram among high risk woman 9 9 12 14 11 55 Increasing case detection rate for PTB. 11 11 11 10 14 57 Scale: 1-Lowest Priority, 2-Medium, 3-Highest Priority No of voters: 6 PROBLEM PRIORITIZATION

6. S M A R T RATIONAL SELECTION OF PROBLEM

7. CHOSEN TOPIC Improving HbA1c level to ≤ 6.5% among patient Type 2 Diabetes Mellitus in Klinik Kesihatan Kulim.

8. VERIFICATION STUDY HbA1c level ≤ 6.5% trend among patient type 2 Diabetes Mellitus in Klinik Kesihatan Kulim (Target ≥30%) 2018 2019 2020 2021 2022 Number of patient with HbA1c level ≤ 6.5% Number of patients Type 2 Diabetes Mellitus 25/86 27/130 48/200 26/150 22/191 Percentage (%) 29.07% 24.55% 24.04 21.85% 14.47%

9. PROBLEM STATEMENT Klinik Kesihatan Kulim have a total of 1866 (the highest diabetic patient in Kulim) registered active Type II Diabetes Mellitus patients in 2022. (Data until February 2023).The key performance indicator for HbA1c level ≤ 6.5% is more than 30%. However, according to National Diabetes Registry Audit done in 2022, only 14.47% out of 191 audited patients achieved HbA1c level ≤ 6.5%. Poor HbA1c control is leading to serious complications such as stroke, heart attack, diabetic retinopathy to blindness, kidney failure that need dialysis, diabetic neuropathy until amputation and may lead to death Possible causes such as poor knowledge among patient, long appointment date and health care knowledge. This study aims to improve HbA1c level ≤ 6.5% among patient type 2 Diabetes Mellitus in Klinik Kesihatan Kulim .

10. LITERATURE REVIEW 1. A structured and coordinated effort is necessary at the basic primary care level in order to reduce the risk of diabetes complications. ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6305677/# ) 2. T2DM patients receiving treatment at the public health clinics in Kedah has been suboptimal . Only 15.6% of the patients had a HbA1C level <6.5%, while approximately 30% of them did not hAave their HbA1C levels tested over the 12-month study period. ( Management and glycemic control of patients with type 2 diabetes mellitus at primary care level in Kedah, Malaysia: A statewide evaluation | PLOS ONE )

11. 3) Determinants of glycaemic control among type 2 diabetes mellitus patients in Northern State of Kedah, Malaysia: a cross-sectional analysis of 5 years national diabetes registry 2014-2018 ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8464198/ ) 4) Glycaemic control and associated factors among patients with diabetes at public health clinics in Johor, Malaysia ( https://pubmed.ncbi.nlm.nih.gov/26976488/ ) 5)Factors that Collerate wuth Poor Glycemic Controls in Type 2 Diabetes Mellitus Patients with Complications ( https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110332/ ) LITERATURE REVIEW

12. ISHIKAWA DIAGRAM POOR GLYCAEMIC CONTROL IN TYPE 2 DM PATIENTS IN KK KULIM PATIENTS HEALTH CARE WORKER APPOINTMENT SYSTEM Comorbidities Poor attitude Poor knowledge about disease Inadequate practice for good sugar control Reluctant to start exogenous insulin Multitasking Diabetic Educator Non adherence to CPG Long appointment date

13. PROCESS OF CARE (2) TCA date given Diabetic educator Pharmacist reviewed and counselling Record Medication dispensed Maintain current treatment - Diabetic education module - Optimized treatment - Diabetic education module *SOP MANAGEMENT OF DIABETIC PATIENT IN KK KULIM 2023

14. PROCESS OF CARE Arrival at Klinik Kesihatan Kulim Registration Screening Doctor reviewed and Diabetic education HbA1c value Optimized treatment Diabetic education module Maintain current treatment Diabetic education module > 6.5% ≤ 6.5%

15. MODEL OF GOOD CARE(MOGC) NO PROCESS CRITERIA STANDARD 1 Registration All diabetic patients which fulfill inclusion criteria will be registered. 100% (from Registry Diabetic Book KK Kulim) 2 Screening Staff Nurse measured vitals signs and DXT 100% 3 Diabetic education Mode of Diabetic education - slides - flip chart - white board - SMBG pamphlet 100% 4 Optimization of care/ treatment Monitoring of blood glucose and HbA1c Adjusting the current medication dose Diabetic education module given Initiation of insulin Virtual session ( personal and group ) 100%

16. MODEL OF GOOD CARE(MOGC) (2) NO PROCESS CRITERIA STANDARD 5 Pharmacist review and counselling All dedicated patients was given counselling regarding indication, dose, frequency, side effect and duration of treatment. Advice on good compliances and management of hypoglycaemia and hyperglycaemia . 100% 6 Appointment date V irtual appointment given to review SMBG and continues diabetic education. If HbA1c >6.5%, appointment within 3 to 4 months to repeat HbA1c. if HbA1c < 6.5%, appointment within 4 months to review dxt /compliances. 100%

17. QA STUDY

18. DEFINITION HbA1c level: The quality of care of patients with diabetes in MOH KKs is monitored using the HbA1c level as a proxy. The Quality Assurance (QA) indicator is measured as the proportion of T2DM patients with HbA1c ≤6.5% and is set at the optimum achievable standard, 30%. (National Diabetes Registry)

19. GENERAL OBJECTIVE To improve HbA1c level ≤ 6.5% among patient Type 2 Diabetes Mellitus in Klinik Kesihatan Kulim.

20. SPECIFIC OBJECTIVES To verify the magnitude of poor glycemic control among Type 2 Diabetes Mellitus in Klinik Kesihatan Kulim. To identify factors that contribute to poor glycaemic control among Type 2 Diabetes Mellitus in Klinik Kesihatan Kulim. To formulate remedial measures and plan to improve HbA1c level ≤ 6.5% among patient type 2 Diabetic Mellitus in Klinik Kesihatan Kulim. To evaluate the effectiveness of the remedial measures and plan.

21. METHODOLOGY 100 randomized patients Cohort study Age < 60 years old Year 2023 INTERVENTION Diabetic Education slides Virtual personal and grouping care SMBG booklet Trial Diabetic Clinic HbA1c ≤ 6.5% HbA1c > 6.5%

22. INCLUSION & EXCLUSION CRITERIA Inclusion Criteria Active T2DM patients : Patients with Type 2 Diabetes Mellitus with at least one visit to KK Kulim and availability of HbA1c results within 2022 . Registry patients : Patients diagnosed with diabetes and registered at KK Kulim in 2022. Exclusion Criteria Patient T2DM which loss follow up, HbA1c results not available within 2022. Patient transfer out, other than T2DM patients registered at KK Kulim in 2022.

23. KEY MEASURE FOR IMPROVEMENT Indicator The Quality Assurance (QA) indicator is measured as the proportion of p ercentage of Type 2 DM patients with HbA1c ≤6.5% Formula Number of patient with HbA1c level ≤ 6.5% x100 Number of patients Type 2 Diabetes Mellitus Standard 30%

24. PROCESS GATHERING INFORMATION (DATA COLLECTION TOOLS)

25. Factors Variable Method of Collection Data Source Sample Unit Sample Size Results Patients Comorbidities NDR data NDR data Registered diabetic patient attending virtual clinic from 1st Jan 202 to December 2023 100 Dyslipidemia: 18 patients Hypertension: 19 patients Both: 54 Poor knowledge about disease Interview patients Questionnaire administered via google form 100 Poor:14% Fair:12% Good:74% 14% Poor attitude Interview patients Questionnaire administered via google form 100 Negative:2% Positive attitude:98% 2% Inadequate practice for good sugar control Interview patients Questionnaire administered via google form 100 Inadequate:6% Adequate: 19% Good: 74% 6%

26. Factors Variable Method of Collection Data Source Sample Unit Sample Size Results Appointment Date Long appointment date Previous last TCA from 2022 up to January 2023 Diabetic green book Registered diabetic patient attending virtual clinic from 1st Jan 202 to December 2023 100 26% (Patient appointment date 3-4 months) 74% more than 4 months 74%

27. ANALYSIS & INTERPRETATION

28. PROBLEM ANALYSIS What : Poor diabetic control among type 2 Diabetic Mellitus among patient Klinik Kesihatan Kulim. Where : Klinik Kesihatan Kulim, Kulim District. When : All the time throughout management period. Who : Doctors, Pharmacist, Paramedics. Who are affected : Patients in Klinik Kesihatan Kulim. How : Multiple factors identified as possible contributors.

29. MODEL OF GOOD CARE(MOGC) NO PROCESS CRITERIA STANDARD PRE- INTERVENTION POST-INTERVENTION 1 Registration All diabetic patients which fulfill inclusion criteria will be registered. 100% (from Registry Diabetic Book KK Kulim) 100% 100% 2 Screening Staff Nurse measured vitals signs and DXT 100% 100% 100% 3 Diabetic education Mode of Diabetic education - slides - flip chart - white board - SMBG pamphlet 100% 30% 100% 4 Optimization of care/ treatment Monitoring of blood glucose and HbA1c Adjusting the current medication dose Diabetic education module given Initiation of insulin Virtual session ( personal and group ) 100% 45% 100%

30. MODEL OF GOOD CARE(MOGC) (2) NO PROCESS CRITERIA STANDARD PRE- INTERVENTION POST-INTERVENTION 5 Pharmacist review and counselling All dedicated patients was given counselling regarding indication, dose, frequency, side effect and duration of treatment. Advice on good compliances and management of hypoglycaemia and hyperglycaemia . 100% 100% 100% 6 Appointment date V irtual appointment given to review SMBG and continues diabetic education. If HbA1c >6.5%, appointment within 3 to 4 months to repeat HbA1c. if HbA1c < 6.5%, appointment within 4 months to review dxt /compliances. 100% 26% 100%

31. STICKER ACHIEVEMENT OF HbA1C Patient’s small green book was tagged according to HbA1c level.

32. THERE WERE INCREMENT OF PATIENT WITH HBA1C level ≤ 6.5% FROM 27% TO 32.3% . THERE WERE DECREMENT OF PATIENTS WITH HBAIC ≥ 10% FROM 13% TO 5.1 % SUMMARY PRE INTERVENTION POST INTERVENTION

33. PRE-INTERVENTION KNOWLEDGE Score Knowledge <60 Poor 60-70 Fair >70 Good Score (%) Knowledge <60 7 60-70 6 >70 37

34. POST-INTERVENTION KNOWLEDGE Score Knowledge <60 Poor 60-70 Fair >70 Good Score (%) No Of Patients <60 5 60-70 10 >70 32

35. THERE WERE DECREMENT OF PATIENTS WITH POOR KNOWLEDGE FROM 14% TO 11% SUMMARY

36. PRE-INTERVENTION ATTITUDE Score Knowledge <60 Negative 60-70 Neutral >70 Positive Score (%) NO OF PATIENTS <60 (NEGATIVE ATTITUDE) 10 60-70 (NEUTRAL ATTITUDE) >70 (POSITIVE ATTITUDE) 40

37. POST-INTERVENTION ATTITUDE Score Knowledge <60 Negative 60-70 Neutral >70 Positive Score (%) NO OF PATIENTS <60 (NEGATIVE ATTITUDE) 1 60-70 (NEUTRAL ATTITUDE) >70 (POSITIVE ATTITUDE) 46

38. THERE WERE DECREMENT OF PATIENT WITH POOR ATTITUDE SUMMARY

39. PRE-INTERVENTION PRACTICE Score Knowledge <60 INADEQUATE 60-70 ADEQUATE >70 GOOD Score (%) NO OF PATIENTS <60 (NEGATIVE ATTITUDE) 6 60-70 (NEUTRAL ATTITUDE) 13 >70 (POSITIVE ATTITUDE) 31

40. POST-INTERVENTION PRACTICE Score Knowledge <60 INADEQUATE 60-70 ADEQUATE >70 GOOD Score (%) NO OF PATIENTS <60 (NEGATIVE ATTITUDE) 3 60-70 (NEUTRAL ATTITUDE) 9 >70 (POSITIVE ATTITUDE) 35

41. THERE WERE DECREMENT OF PATIENT WITH POOR ATTITUDE SUMMARY

42. STRATEGY FOR CHANGES

43. https://drive.google.com/file/d/1Vj8ykTK4ZL2GWk57u50PfnnGNajhuz8H/view?usp=sharing FLIP CHART DIABETES MELLITUS

44. VIDEO CONSULTATION WITH DSA PATIENTS

45. HEALTH EDUCATION USING FLIPCHART HYPERLINK VIA VIDEO CALL CONSULTATION

46. The innovation using hyperlink slides with virtual clinic one to one approach showed increment of HbA1c level ≤6.5% from 27% to 32.3% EFFECT OF CHANGE

47. GANTT CHART

48. VIRTUAL CLINIC SHOULD APPLY TO ALL CLINIC S IN KULIM DISTRICT AND WHOLE KEDAH AS WE ARE MOVING TOWARD VIRTUALIZED BY 2030 NEXT STEP

49. THANKS