Making Diabetic Eye Exams Accessible

For many physicians, a performance improvement activity can feel like one more obligation layered on top of an already full schedule. Mathew Devine, DO, a board-certified family physician practicing in upstate New York, does not see it that way. To him, the American Board of Family Medicine (ABFM) performance improvement requirement is simply a built-in invitation to simply share what he was already planning to do.

His most recent project, a Health Disparities/Equity Self-Directed Clinical Performance Improvement Activity, focused on improving access to diabetic retinal exams in his practice. He started at 60% and set his sights on 90%. By the end of the project period, he was closing in on 89 percent. But the numbers are only part of the story.

Bridging the Gap to Access

Diabetes is one of the most demanding diagnoses a patient can receive. The health maintenance checklist, eye exams, foot exams, A1C targets, kidney function, cardiovascular risk, can feel like an overwhelming inventory of things going wrong all at once. For Dr. Devine, that reality shapes how he approaches every visit with a patient who has diabetes.

Many of the patients he sees are navigating food insecurity, unstable housing, transportation gaps, and other demands that push a preventive screening down the priority list. When you are worried about keeping the heat on, a retinal scan does not always feel urgent. Understanding that distinction changed how he and his team approached outreach. Rather than treating missed exams as a compliance problem, they treated it as an access to care problem. And that shift in framing made all the difference.

“There are days that are pretty humbling when you actually take the time to ask patients where they are in their world,” he said. “I do not want to label this patient. We need to figure out why they are not doing it. And it is not because they usually do not want to. It is because they cannot, for whatever reason.”

The solution Dr. Devine landed on was rooted in reducing friction. Where he practices, a retinal camera technician was already available to come in roughly once a month and perform diabetic eye exams on site, right alongside a patient’s regular visit. No separate appointment. No additional trip across town. Just a brief scan, before or after seeing their physician.

For patients already stretched thin, that convenience is not a small thing. It is often the difference between catching a problem early or missing it entirely. His performance improvement activity focused on making sure that resource was being used consistently. He and his team worked to identify eligible patients, align their scheduling with the technician’s visits, and remove as many barriers as possible between a patient walking through the door and leaving with a completed retinal exam.

The results were immediate and meaningful. “We have picked up so many retinopathies just from this process,” he said. Patients who might have gone another year without a scan were diagnosed and referred to an ophthalmologist/optometrist before their condition progressed. For many of these patients, this was their first retinal scan. Getting it done consistently meant changes in their eye health could finally be tracked and caught early.

Dr. Devine is deliberate about how he frames diabetes with his patients. Rather than walking into a room and working through a checklist of 15 items, he sets a realistic agenda, focuses on the two or three most pressing things, and makes a plan for the rest. The goal is not to do everything at once. It is to make sure patients leave feeling cared for rather than overwhelmed.

He is also quick to remind the resident physicians he supervises that a missed exam is often a signal, not a failure. Before assuming a patient is disengaged, ask what is actually going on in their life. To him, patients usually aren’t non-compliant, their situation makes them unable to comply. His performance improvement activity set out to prove that.

Performance Improvement with Purpose

When thinking about what performance improvement to complete, Dr. Devine’s advice is straightforward: start small and do not try to do too much at once. It is a lesson he shares with residents and fellow physicians alike, and his own work has reinforced it year after year. Pick one thing, work out the process, and expand from there.

“These projects are all very manageable, very doable,” he said. “They take less time than we think, and they are not overly complicated unless you make them harder, and you do not have to.”

He also encourages physicians to lean on their health system for guidance. Understanding which quality measures your organization is already tracking, and where the gaps are, can make choosing a performance improvement activity much easier. Rather than searching for a project, you may find that the data your system already has points directly to one. He focused his own efforts in the final quarter of the calendar year, aligning his quality push with how his practice’s metrics are reported. Know your reporting cycle and work with it, not against it. “We do little quality improvement projects all the time and we just do not put it on paper,” he said. “This is a chance to put it on paper, look at it, and grow it.”

Better Numbers, Better Outcomes, Better Practice

Three years after starting this work, the impact has spread well beyond Dr. Devine’s own patient panel. Other attending physicians have joined the effort. Staff no longer needs to be reminded when the quality push begins each fall. What started as one physician trying to improve one metric has become a shared commitment to doing better for a patient population that has every reason to need it.

He has also woven performance improvement thinking into how he works with learners, giving residents the chance to design their own approaches to the problems they see. His philosophy is simple: show people the problem, then get out of the way. “They come up with something just as good, maybe better, and they are more engaged because they built it,” he said.

The performance improvement activity was the spark, but improved patient care was always the end goal. As Dr. Devine put it, the ABFM requirement gave him a framework to act on something he already knew needed to change. “I want my patients to be well taken care of,” he said. “These are the types of things that can help move that along.”

ABFM thanks Dr. Devine for taking the time to share his story. His work is a reminder of what performance improvement looks like when it is done with purpose, and of the difference it can make for the patients who depend on him every day.