1. INTRODUCTION

The Indian Health Service Diabetes Care and Outcomes Audit (“the Audit”) is a process for assessing diabetes care and health outcomes for American Indians and Alaska Natives with diagnosed diabetes.  IHS, Tribal, and Urban health care facilities nationwide participate in this process each year by performing a self-audit of medical records for their patients with diabetes.

Assessing the care and health of patients with diabetes on a regular basis allows health care facilities to see the strengths and weaknesses of the diabetes care they are providing.  By carefully reviewing the results of their audits, facilities can identify areas for improvement and implement strategies to work towards the goal of providing all diabetes patients with the highest quality of care, as outlined in the IHS Standards of Care for Adults with Type 2 Diabetes.

To perform an audit, data for patients with diabetes are collected at the local clinic or hospital by one of two different methods:

·     Manual chart review, where one physically examines the medical record and uses its information to complete a standard audit form.  Data from the audit forms are then typed into a computer based audit data collection tool.  This method is referred to as a “manual audit”.

·     Extracting data from an electronic health record system, primarily the Resource and Patient Management System (RPMS).  This method is referred to as an “electronic audit” or simply an “e-audit”.

Use of either of these methods results in an electronic file of the audit data, which is used locally for creating reports and for local, regional, and national quality improvement efforts. 

Once a year, facilities send their data to the IHS Division of Diabetes Treatment and Prevention (DDTP) for centralized processing and analysis.  We strongly encourage you to consider using the calendar year (Jan1 through Dec 31) as the audit period.  The data are aggregated and used to generate reports to meet the need for nationwide information for GPRA, Congress, and other IHS and Federal agencies.  Using a uniform process and standardized definitions provides consistency and allows valid comparison of your facility with other IHS, Tribal and Urban facilities.  Diabetes care, as assessed by the audit, is compared to the IHS Standards of Care for Patients with Type 2 Diabetes.

For those performing a manual audit, instructions for sample size calculations, selecting charts for the audit, and standard definitions for each item are outlined later in this document.  For electronic audits, all active diabetes patients should be included.  Additional assistance, if necessary, can be obtained from your Area Diabetes Consultant.