Audits | Diabetes

Diabetes cycle of care QIP: Care plans (GP version)

EA hours: 0.5

MO hours: 2

RP hours: 5

Total hours: 7.5

Practice team discussing Diabetes Care plans

Members of the whole general practice team can and should contribute care-planning in type 2 diabetes (T2D), with tasks ranging from facilitating patient recall to conducting clinical assessments and devising a written GP chronic condition management plan.¹ Review of the T2D care plan (including re-establishing care goals, reviewing overall management, and identifying any need for management change) is built into the annual diabetes cycle of care.¹

Join our diabetes experts as they provide information to help you and members of your practice to optimise overall care planning as part of the cycle of care checklist for your patients with T2D.

In this practice-wide quality improvement exercise, we guide you through a stepwise process of reviewing and enhancing your team’s performance against a range of evidence-based care planning benchmarks.

This activity program is available to GPs.

Practice managers, practice nurses and other relevant practice staff can join the program here.

How long should it take?

This education is designed to take place over multiple weeks. It does not need to be completed in one sitting. You can stop at any time, and progress will be saved. You can find education you have started on your Dashboard.

References

The Royal Australian College of General Practitioners (RACGP). Management of type 2 diabetes: A handbook for general practice. East Melbourne, Vic: RACGP, 2025.

Topic 3: Care plans

This topic is one of 4 topics that form the Diabetes cycle of care quality improvement program. Access the other 3 topics here.

Learning outcomes

On completion of this clinical audit, you will be able to:

Outline the annual diabetes cycle of care checklist for patients with type 2 diabetes (T2)

Assess targets for development and review of care planning in the annual diabetes cycle of care

Using a team-based approach, decide on quality improvement targets and actions related to the development and review of care plans for individual patients with T2D

Implement and reflect on practice-wide quality improvement initiatives targeting care planning in T2D

Presenters

A/Prof Ralph Audehm

A/Prof Audehm has over 35 years as a full time GP with interest in chronic disease management and quality improvement in general practice. He has close links to the Department of General Practice, University of Melbourne, and participates in research and teaching of medical students.

Dr Kean-Seng Lim

Dr Lim is a general practitioner and GP Principal in a small group practice in Mt Druitt. He is a past President of AMA (NSW), a Wentwest Clinical Council member and President of the Mt Druitt Medical Practitioners Association. He is co-founder of CareMonitor, a cloud-based patient provider partnership platform, and Chief Medical Advisor to PENCS. He has been heavily engaged in the Western Sydney PCMH implementation project, is a member of the Wentwest Clinical leaders group, and currently co-chairs the Western Sydney Value Based Urgent Care Subcommittee.

Diabetes Cycle of Care QIP: Care plans (GP) - Predisposing activity

Diabetes Cycle of Care QIP: Care plans (GP) - Predisposing questions

Diabetes Cycle of Care QIP: Care plans (GP) - Step 1

Diabetes Cycle of Care QIP: Care plans (GP) - Step 2

Diabetes Cycle of Care QIP: Care plans (GP) - Step 3

Diabetes Cycle of Care QIP: Care plans (GP) - Step 4

Diabetes Cycle of Care QIP: Care plans (GP) - Step 4 (Patient 1)

Diabetes Cycle of Care QIP: Care plans (GP) - Step 4 (Patient 2)

Diabetes Cycle of Care QIP: Care plans (GP) - Step 5

Diabetes Cycle of Care QIP: Care plans (GP) - Reinforcing activity

Diabetes Cycle of Care QIP: Care plans (GP) - Evaluation