Toolkit for Implementing the Chronic Care Model in an Academic Environment

Diabetes Foot Exam

To meet the goal of a 90 percent foot exam rate, Vanderbilt University Medical Center developed a patient education poster and a foot-exam template to increase the number of exams they performed.

Diabetes Foot Exam

Vanderbilt University Medical Center

At the beginning of the Collaborative, Vanderbilt University Medical Center's baseline comprehensive diabetes foot exam rate was 17 percent (compared with the Academic Chronic Care Collaborative goal of greater than 90 percent). To improve the rate, the team first developed a diabetes poster that was placed in each patient room and encourages patients with diabetes to remove their shoes and socks for a foot exam.

The hypothesis underlying this initial plan-do-study-act cycle was that by placing the diabetes poster in exam rooms, the percentage of patients receiving foot exams would increase. When the team determined that the impact of the poster was marginal, they initiated a second plan-do-study-act cycle that incorporated a foot exam template developed by faculty and residents into the workflow of the visit process.

In using the template, the team determined it was used in 51 percent of foot exams. However, there were still problems, such as residents not having a monofilament to do the exam or feeling like there wasn't enough time to conduct the foot exam.

Overcoming Barriers

To address these problems and barriers, the final plan-do-study-act cycle involved a team approach to conducting foot exams.

  • Clinicians trained patient care technicians to ask patients with diabetes to remove their shoes during visits and to alert nurses the patients need an exam.
  • Nurses then conducted and documented foot exams with Chronic Disease Management staff recording data. The staff included a health systems analyst, two registered nurses, and a part-time doctorate of pharmacy.

Although some patients received more than one foot exam during the project, the team decided that performing exams three or four times increased the likelihood that more patients would receive exams.


The impact of this approach was dramatic: nearly 30 percent of exams were obtained by "Team DFE" (which stands for Team Diabetic Foot Exams). After a month of testing,

  • 57 percent of patients were ready to have their feet examined, and 78 percent of these stated that "being asked" prompted them to remove their shoes and socks versus 6 percent that were prompted by the poster.
  • After having patient care technicians and nursing staff actively identify patients with diabetes prior to visits, Vanderbilt University Medical Center's foot-exam rate rose to 80 percent.

As a result of this successful approach, the foot exam form has been automated within the electronic system. The template includes the documentation that "the patient has been advised to check their feet every visit."

In addition, the team has cataloged all of the podiatrists in the Nashville, Tennessee, area for referrals based on an abnormal exam.

Return to Document

Page last reviewed October 2014
Page originally created January 2008
Internet Citation: Diabetes Foot Exam. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.