Managing and preventing type 2 diabetes at Central West Medical Centre

A person with diabetes checking their blood sugar levels.
  18 June 2021  NWMPHN Primary Health Care Improvement team   

Almost five per cent of the Victorian population has type 2 diabetes and a further 5 per cent have an increased risk of developing it.

From October 2020 to March 2021, Central West Medical Centre in Braybrook participated in a type 2 diabetes intensive quality improvement (QI) project with North Western Melbourne Primary Health Network (NWMPHN).

We interviewed Practice Principal GPs Dr Emmanuel Ndukwe and Dr Vivian Ndukwe to explore their experience in the project and the outcomes their team achieved.

Central West Medical Centre was established in 2014. Their diverse patient demographic includes a wide range of ethnicities, with most of the population born overseas.

“We have two GPs, three practice nurses, four receptionists and a practice manager, and our active patient population is 2,500, although it seems more than that!” said the doctors.

Emmanuel and Vivian said they were on the lookout for an interesting QI project which would contribute to their PIP QI requirements. They had previously completed a narrower diabetes QI project with a pharmaceutical company.

When they saw the diabetes project advertised in the NWMPHN newsletter, they jumped at the chance. The project helped them “realise there were more areas of our diabetes management that we wanted to improve.”

Diabetes detectives and the Life! program

One of the activities the practice completed was looking at people with indications of diabetes but no diagnosis. One example was looking at patients with a high fasting blood glucose or on diabetes medications, but without a diagnosis of diabetes in their file.

The aim of the activity was to review the files, identify those with existing diabetes and add the correct diagnosis to their file. But in doing this review, the practice also chose to action the ‘at risk’ patients who didn’t yet have diabetes.

They started working their way through the list of patients with indications of diabetes and found lots of people who didn’t have diabetes – some with abnormal glucose results, and particularly lots of women with polycystic ovary syndrome (PCOS).

“We knew that they were at increased risk of developing type 2 diabetes so we decided to take preventative action, We learned about the Life! program through the PHN newsletter earlier in the year, so we decided to recall every person for further screening and invite them to participate in the Life! program to help them avoid type 2 diabetes in the future,” said the doctors.

Steps to complete this activity

Before the appointment

The team leader pulled the list of patients with indications of diabetes from Cleansing CAT, and called each patient, telling them the doctor would like to see them regarding their PCOS or abnormal glucose results.

With the patient

When the patients came in, the doctor talked to them about diabetes risk and the possibility that they could access free coaching sessions with a dietitian to help them lose weight and reduce their diabetes risk. The patients were open to this idea, so were offered repeat screening to ensure their eligibility for the Life! program.

After the appointment

When the results came back, the doctor called the patients to advise them of the result, and completed the AUSDRISK over the phone, getting the patient to measure their own waists. The doctor completed the referral and reception staff faxed it to the Life! program.


The practice has already referred 39 people to the Life! program. Of these, 38 people found the program beneficial, with several returning to report weight loss, and to thank the GP for their support and referral.

“One person even brought me a flower to say thank you,” Dr Vivian Ndukwe said.

The practice receives $25 for each referral and another $20 when a patient completes the six sessions.

“As the saying goes, an ounce of prevention is worth a pound of cure, so it’s nice to receive a payment for prevention activities,” said the doctors.

Being able to see the data was also really useful for the practice.

When the project started, the practice only had 36 people with a diagnosis of type 2 diabetes recorded. Emmanuel and Vivian knew this wasn’t right. This motivated the practice to fix their data – they were determined to have all their patients properly identified.

“We used to think we were doing really well with our diabetes care, but the project helped us to see where the gaps were and learn how to go about fixing them. We got to see updated data reports at the middle and end of the project, so it was great to see our improvements resulting in positive changes in our practice data.”

Emmanuel and Vivian also found the workshops to be very helpful: “Our whole practice team attended, so we all got to hear what other practices were doing and discuss ideas we could implement in our own practice.”

What would the practice do differently?

  1. Spread the activities out. “It got to the point where some patients thought we were nagging them, because we made calls about many different things -each time we did a new activity.”
  2. Allocate activity tasks across the team so they can share the load better.

Quality improvement tips for other practices

  1. Include your whole team – not just the clinicians.
  2. Start the activities straight away. “The first workshop gives you momentum to make a good start on improvement and gets the team excited to contribute to improvement activities.”

Key resources and support

Juliet, the practice’s NWMPHN quality improvement program officer, helped train the practice to use Pen CAT to look at their data – including lists of patients to improve their diabetes care.

“Our favourite resource was probably the project data reports, especially seeing the red arrows (showing negative change in the data) – those arrows were very motivating!” said the doctors.

The Life! program was a great resource for referral of patients at risk of diabetes. The three learning workshops the staff attended during the project helped inspire their activities. Visit to learn how your practice can participate.

HealthPathways Melbourne has up-to-date clinical and referral information about diabetes that is easy to access at the point of care.

Are you a GP or health professional in our region who doesn’t have access to HealthPathways Melbourne? Request access online or contact   

More information about current QI opportunities and QI reports is available on our website.