From Consensus Through Prioritization: A Delphi Method, Clinical Audit, and Analytic Hierarchy Process Framework for Quality Improvement in Primary Diabetes Care

Background Type 2 diabetes mellitus (T2DM) affects approximately 17% of adults in Qatar, making improved primary care management a national health priority. Despite established guidelines, significant gaps persist between recommended care and real-world practice, particularly in preventive and patient-centered services. To address this, a structured, data-driven quality improvement (QI) framework was implemented. Methods We conducted a mixed-methods, pre-implementation QI study across 31 primary health care facilities in Qatar. The three-phase approach included: (1) a Delphi consensus with 65 primary care physicians to validate 17 key performance indicators (KPIs) for T2DM care; (2) a retrospective audit of 450 adult T2DM patient records to assess adherence to each KPI; and (3) prioritization of improvement interventions using the Analytic Hierarchy Process (AHP), based on clinical impact (50%), feasibility (30%), and urgency (20%). Results The Delphi panel reached unanimous consensus on all 17 KPIs (median importance rating 5/5), covering preventive care, metabolic monitoring, therapy management, and patient education. The audit revealed high adherence to laboratory-based indicators (∼82%) but low performance in preventive and patient-centered care: ASCVD risk assessment (19.6%), foot examinations (24.0%), and individualized HbA1c goal documentation (1.3%). KPI adherence varied widely across centers (e.g., foot exam rates ranged from 0% to 95.6%). AHP analysis identified five top-priority gaps accounting for 63% of total priority weight: ASCVD risk assessment (16%), foot examinations (16%), lifestyle education (12%), follow-up HbA1c testing (10%), and individualized HbA1c goal-setting(9%). Conclusion This study highlights critical deficits in preventive and patient-centered diabetes care in primary care facilities. By integrating expert consensus, real-world performance data, and structured prioritization through the Delphi–AHP framework, we developed a robust, evidence-based model for QI planning. Importantly, involving frontline clinicians in both KPI selection and intervention prioritization fostered ownership, contextual relevance, and alignment with clinical realities. This participatory approach enhanced the credibility and feasibility of proposed interventions and laid a strong foundation for sustainable practice change.