Making the Case for Diabetes Care Quality Improvement 5 Why Diabetes? For individuals with diabetes, the average medical costs are ,000 per year …

Making the Case for Diabetes Care Quality Improvement 5 Why Diabetes? For individuals with diabetes, the average medical costs are $13,000 per year …

Diabetes Care Quality Improvement: A Workbook for State Action

Prepared by
Barbara Kass, MPH

Department of Health and Human Services
Agency for Healthcare Research and Quality
Rockville, Maryland
wwwahrqgov

AHRQ Publication No 04-0073
September 2004
Acknowledgment

This document has been prepared to be used in conjunction with Diabetes
Care Quality Improvement: A Resource Guide for State Action The author
acknowledges the authors of that report-Rosanna M Coffey and Kelly
McDermott, The Medstat Group, and Trudi L Matthews, The Council of State
Governments-for their contributions to this Workbook

This document is in the public domain and may be used and reprinted without
permission AHRQ appreciates citation as to source, and the suggested
format is provided below:

Kass B Diabetes Care Quality Improvement: A Workbook for State Action
Rockville, MD: Agency for Healthcare Research and Quality,
Department of
Health and Human Services; September 2004 AHRQ Pub No 04-0073
Foreword

Diabetes Care Quality Improvement: A Workbook for State Action and its
complementary Resource Guide were developed by the Agency for Healthcare
Research and Quality AHRQ as learning tools for all State officials who
want to improve the quality of health care In conjunction with the
Resource Guide, which uses State-level data on diabetes care from the 2003
National Healthcare Quality Report, this Workbook is designed to help
States assess the quality of care in their States and fashion quality
improvement strategies suited to State conditions

Many people for whom these learning tools were intended-State elected and
appointed leaders as well as officials in State health departments,
Diabetes Prevention and Control Programs, Medicaid offices, and elsewhere-
provided comments and feedback throughout the development and finalization
process From this process, we learned that they intend to use the
Workbook and Resource Guide in many different ways: to assess their
current structure and status, to create new quality improvement programs,
to build upon existing programs, as an orientation for new
staff, and to
share with their partners such as the American Diabetes Association

The Workbook and Resource Guide can serve as a meeting place, where the
creative minds of those who struggle with quality improvement can share
their expertise, ideas, knowledge, and solutions The various modules are
intended for different users Senior leaders are responsible for making
the case for diabetes quality improvement and taking action Modules 1, 4,
and 6 while program staff would need to provide the information necessary
to develop and implement a quality improvement strategy Modules 2, 3, and
5 The goal, of course, is that all groups of people work on these
modules as a team It is within those discussions and sharing and working
together that we hope to achieve what we set out to do: help States
improve the quality of diabetes care

If you have any comments or questions on this Workbook or its complementary
Resource Guide, please contact AHRQs Center for Quality Improvement and
Patient Safety, 540 Gaither Road, Suite 3000, Rockville, MD 20850
Contents

Foreword iii
Introduction 1
Module 1: Background-Making the Case for Diabetes Care Quality Improvement
5
Module 2:
Data-Understanding the Foundation of Quality Improvement
10
Module 3: Information-Interpreting State Estimates of Diabetes Quality
18
Module 4: Action-Learning From Activities Currently Underway 24
Module 5: Improvement-Developing a Strategy for Diabetes Quality
Improvement 31
Module 6: The Way Forward-Promoting Quality Improvement in the States
36
A Final Note 38
Introduction

Extensive gaps in health care exist between the care that is recommended
and the care that patients actually receive Sometimes, the care that is
delivered to patients does not meet the accepted standards of quality As
a result, people suffer from medical complications that can be prevented,
hospitalizations that could be avoided, decreased quality of life,
disability, and premature death

The Agency for Healthcare Research and Quality AHRQ is the lead Federal
agency supporting research into the quality, cost effectiveness, and safety
of health care In 2003, AHRQ released the first ever National Healthcare
Quality Report NHQR and National Healthcare Disparities Report NHDR
These reports, mandated by Congress, collected and analyzed national and,
where available, State-level data from a variety of
reliable sources to
measure the state of health care quality and health disparities in the
Nation

The data in the NHQR and NHDR demonstrate that the gap between health care
research and practice is not just an occasional occurrence, but is
pervasive throughout health care It affects all patient groups, even
those with the most common medical conditions, and every State Both
reports also called for health policy leaders and health care professionals
to consider ways to improve the quality of care in the United States and
take action to deal with the persistent and costly gaps in health care
quality

Ultimately, quality improvement occurs at the frontline of health care
between professionals supplying care and consumers requesting it State
leaders can be catalysts for changes in health care by supporting and
encouraging quality improvement to improve health outcomes, reduce the
burden of disease, and increase the efficiency of the health care system
States can champion quality improvement and institute best practices that
can transform health care systems

Diabetes Care Quality Improvement: Resources for State Action

AHRQ has published two resources for diabetes care quality
improvement to
assist State policymakers and health care leaders in leading and planning
quality improvement initiatives in their States:

Diabetes Care Quality Improvement: A Resource Guide for State Action
delivers a wealth of information and details for a wide audience of
participants in a States quality improvement processes This audience
ranges from leaders of health policy at all levels to sophisticated
analysts of data and information The Resource Guide is a reference book
that for some will be consulted as needed on specific topics and for
others will be read completely for in-depth knowledge

A companion to the Resource Guide, Diabetes Care Quality Improvement: A
Workbook for State Action presents exercises for State leaders to review
to acquire the key skills and lessons from the Resource Guide for use in
instituting health care quality improvement in their State This
Workbook directs readers to specific sections of the Resource Guide and
then walks them through issues that they need to consider to determine
how to provide effective leadership for quality improvement The
exercises focus the reader on their State in
comparison to the Nation and
other State experiences

The Resource Guide and this Workbook are tools State leaders can use in
conjunction with the NHQR and NHDR to meet the challenge of improving the
quality of care in America

Why Diabetes?

About 63 percent of the US population is estimated to have diabetes1
It is a costly medical condition, not only in dollars, but also in physical
well-being For individuals with diabetes, the average medical costs are
13,000 per year compared to 2,500 per year for the average patient
without diabetes2 The death rate from diabetes makes it the Nations
sixth leading killer1 There is a long list of complications from diabetes
such as heart disease, hypertension, stroke, leg and foot ulcers, lower-
limb amputation, blindness, kidney disease, and coma and death1 Many of
these complications and deaths from diabetes can be prevented or delayed
with proven interventions

Aim and Scope of This Workbook

This Workbook aims to help State leaders develop a strategy to improve
diabetes care quality It will take users through a series of written
exercises that will help them begin to think about an effective partnership
for an initiative, assembly of
available data for their State, questions to
raise about interpretation of the data, and quality improvement techniques
to enlist to develop a strategy to improve diabetes care quality It will
also help them navigate the details of the Resource Guide

Upon completion of the Workbook, State leaders will be able to:
Recite the factors that affect the quality of care for diabetes
Understand the key issues surrounding diabetes quality improvement
Assess their States performance in providing diabetes care
Identify national, public-private, Federal, State, and local resources
and best practices in diabetes quality improvement
Assemble and analyze State-specific data about diabetes and health care
quality to begin planning a quality improvement strategy
Identify opportunities to contribute to improving diabetes care quality

There are several measures of health care that indicate whether or not
people with diabetes are receiving appropriate care The scope of this
Workbook encompasses four of those measures which are recommended by
clinical guidelines:
Percent of adults with diabetes who had a hemoglobin A1c HbA1c
measurement at least once in the past year HbA1c
measures the average
blood glucose level over the past 9-120 days and is used to help guide
treatment so that the person with diabetes is maintaining a safe glucose
level to prevent damage to the kidneys, heart, etc
Percent of adults with diabetes who had a retinal eye examination in the
past year to identify damage to blood vessels in the eye
Percent of adults with diabetes who had a foot examination in the past
year to find sores or wounds that are not healing properly
Percent of adults with diabetes who had an influenza vaccination in the
past year to prevent problems with diabetes control that can result from
getting the flu

While the list of measures in the NHQR is much longer, the major indicators
listed above have State-level measures Also, the NHQR does not encompass
all of the measures of diabetes care quality, due to limited nationwide
data or reliability concerns States can use other measures if they
choose, such as self-reports of blood glucose control or diabetes education
contained in the Behavioral Risk Factor Surveillance System BRFSS, or
they can develop new measures for their specific needs

This Workbook is a start for State leaders
interested in learning about
quality improvement for diabetes care The actual planning, implementation,
tracking, and evaluation of a diabetes care quality improvement program
will go well beyond this Workbook and its companion Resource Guide
Carrying out such a program will require a team of experts: State leaders
and agency staff, topic experts, researchers, health specialists,
statisticians, data collection experts, evaluation researchers, and
representatives from stakeholder groups

Who Should Use This Workbook

This workbook is intended for multiple users:
State elected leaders governors, legislators, and their staff who
provide leadership on health policy
State executive branch officials State health departments, diabetes
prevention and control program leaders, Medicaid officials, and their
staff
Non-governmental State and local health care leaders professional
societies, provider associations, quality improvement organizations,
voluntary health organization, health plans, business coalitions,
community organizations, and consumer groups

How To Use This Workbook

While this Workbook can be completed by one individual, it would be a
lengthy process
that few State leaders have time for or may be equipped to
answer Therefore, State leaders may want to enlist the help of staff and
others who will eventually become part of the quality improvement team who
will develop, implement, and evaluate a diabetes care quality improvement
program

The user should first read the Executive Summary and Introduction of the
Resource Guide The Executive Summary gives an overview of the National
Healthcare Quality Report and the National Healthcare Disparities Report
and outlines the purpose and structure of the Resource Guide The
Introduction provides information about how to use the Resource Guide
Based on the State leaders interests, needs, and role in developing a
quality improvement program, users will want to focus on different modules
such as:

Senior leaders
Module 1: Background-Making the Case for Diabetes Care Quality
Improvement
Module 4: Action-Learning From Activities Currently Underway
Module 6: The Way Forward-Promoting Quality Improvement in the States

Staff specialists
Module 2: Data-Understanding the Foundation of Quality Improvement
Module 3: Information-Interpreting State Estimates of Diabetes Quality
Module
5: Improvement-Developing a Strategy for Diabetes Quality
Improvement

Modules 1 through 4 might be done by different individuals or groups of
individuals to gather information That information, however, will be
assembled and organized in Module 5 to make the case for quality
improvement of diabetes care, help create a team of experts, and design a
strategy to develop a diabetes care quality improvement program specific to
your States needs Module 6 will help State leaders assess their
strengths and where they need help in instituting improvement in health
care quality

References

1 Centers for Disease Control and Prevention 2003 Diabetes: A
serious public health problem Available at:
wwwcdcgov/nccdphp/bb_diabetes/ accessed December 17, 2003

2 Hogan P, Dall T, Nikolov P 2003 Economic costs of diabetes in the
US in 2002 Diabetes Care, 263:917-32

Module 1: Background - Making the Case for Diabetes Care Quality
Improvement

1 Assess the need for diabetes care quality improvement in the State

Review pages 7-19 of the Resource Guide

a Look at Figure 11 on page 10 This figure shows the diabetes
prevalence range diagnosed for every 100 adults in 1994 for
a standard age
distribution across the States and then again in 2002 For example, in
1994, in Oklahoma less than 4 percent of adults age-adjusted had been
diagnosed with diabetes In 2002, this prevalence was at 6 percent or
greater If you want to know the unadjusted actual diabetes prevalence
for your State, look in Table 23, page 37 of the Resource Guide

What was the percent range of age-standardized diabetes prevalence in
your State for 1994? Figure 11, page 10

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What was the percent range of age-standardized diabetes prevalence in
your State for 2002? Figure 11, page 10

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Has age-standardized diabetes prevalence increased in your State since
1994?

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What was the actual diabetes prevalence not adjusted to a standard age
distribution in your State for 2002?

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If the unadjusted rate for your State is greater than the adjusted rate,
then your State has an older population than the Nation on average If
the converse is true, your State has a younger population If the two
rates are the same or very close, then the population of your State has
an age distribution typical of the
Nation

b Pages 8-15 provide evidence that improving quality in diabetes care
should be a priority because of prevalence, complications, costs, and
health care disparities in addition to the fact that diabetes interventions
work and there is a good potential for return on your investment in
diabetes care What do you envision as your States starting point? Would
you want to aim to reduce prevalence among the entire population, or among
vulnerable subgroups of the population? Would you want to promote diabetes
prevention or improvement in diabetes treatment? Would you want to focus
on early interventions for people with diabetes or on effective treatment
of complications? Would you want to select 2, 3, or 4 priority areas to
work on?

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c What other reasons might indicate a need for diabetes care quality
improvement in your State?

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d What evidence from these pages would you use to convince potential
partners that diabetes should be a priority?

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e Pages 15-18 summarize gaps that exist with respect to recommended
care for people with diabetes and the care actually received A variety
of
factors such as age, race, gender, education, employment, health insurance,
income, place of residence, and health status can influence these gaps To
find measures for some of these factors compared to other States, you can
use the Kaiser Family Foundation Web site on State health facts
http://wwwstatehealthfactsorg/

1 Who in your State might be vulnerable to gaps in diabetes care
for example, the elderly, the uninsured, minorities, etc?

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2 Does your State have a higher proportion of these vulnerable
groups than
other States?

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f Go to Appendix F, which begins on page 134 of the Resource Guide
Find any measures for any conditions that are below average in your State
Read the measure carefully If the measure reflects a positive outcome or
process eg, percent of women age 40 and over who report they had a
mammogram in the last year, then a minus - sign in the column for your
State indicates that your State is significantly below the national average
and even farther below the best performing States while a plus sign
indicates your State is significantly above the national average If a
higher value for the measure represents a negative outcome or process
eg, median time to
thrombolysis use of a blood thinner for a heart
attack victim, then a plus sign indicates that your State is significantly
above the national average and farther from the best performing States
while a minus sign indicates your State is significantly below the national
average Write down any topic and measure that shows poor processes or
outcomes for your State

|_________________________________________________________________ |
|_________________________________________________________________ |
|_________________________________________________________________ |
|_________________________________________________________________ |
|_________________________________________________________________ |
|_________________________________________________________________ |

g What measures for diabetes are below average?

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h What other measures indicate that you may want to create a quality
improvement program for a different condition?

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i Do you think your State needs diabetes care quality improvement?

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j Why or why not? If not, would you select a different condition?

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Module 2: Data - Understanding the Foundation of Quality Improvement

1 Understand the process and outcome measures used for tracking the
quality of diabetes care

Read pages 21-24 and Figure 21 on page 25 of the Resource Guide and answer
the following
questions:

a What does HbA1c testing a process measure tell you about blood
glucose levels an outcome measure?

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b How would increasing HbA1c testing improve diabetes outcomes?

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2 Compare State data with national benchmarks and identify gaps in State
data

Review pages 26-29 of the Resource Guide for a discussion of the BRFSS and
its limitations The next series of exercises are based on BRFSS data

a From Table 21 page 28, locate the information on your State
Fill in the blanks below:

|Percent of |Your |National |Best-in-class |Healthy People |
|adults in |State |average |average |2010 goal |
|2001 who | | | | |
|received: | | | | |
|HbA1c testing | |61 |82 |50 |
|Retinal eye | |67 |81 |75
|
|examination | | | | |
|Foot | |65 |82 |75 |
|examination | | | | |
|Flu | |37 |58 |n/a |
|vaccination | | | | |
|Review the Resource Guide Appendix D on page 127 for definitions of|
|these terms The figures are from Table D1, page 129 |

b How does your State compare to the national, best-in-class, and
Healthy People 2010 goal averages? Take your percent in the table above,
subtract it from the national, best-in-class, and Healthy People 2010
figures, and write those figures in the table below:

c Select two States from table 21 within your region or locality and
write their figures down below Then subtract your percent from their
percents How does your State compare?

d From your knowledge of your State demographics and health care
providers, what roles do access issues, cultural barriers, insurance
status, income, place of residence, or provider education have in your
rates? What other access issues may influence diabetes care?

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e Where do you see the need for improvement?

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f If your State does not collect the diabetes measures mentioned
in questions 2a, 2b, and 2c, would you use the Behavioral Risk Factor
Surveillance System BRFSS to collect them? Why or why not?

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g What are some additional questions you have about the quality of
diabetes care in your State?

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3 Develop an inventory of the data systems available at the State and
local levels

a Review pages 30-33 of the Resource Guide Begin an inventory
list of data sources available for your State Also note how these data
sources might be able to answer the questions you wrote down in exercises
e and g above You might also note questions you have about these data
sources - things you want to find out from your data resource experts in
the State

4 Use published studies to arrive at State or local estimates

Review page 33 of the Resource Guide on using published studies

a What studies have been or are being conducted in your State on
any of the six key areas for diabetes: complications, costs, prevalence,
disparities, interventions, and return on investment?

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b Where do you see a need for further research?

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5 Calculate the direct and indirect costs of diabetes for States and
State Medicaid programs The direct and indirect costs of diabetes for
your State population and Medicaid population have been calculated from the
literature and demographic information about your State

Review pages 33-38 of the Resource Guide

a Direct costs are expenditures associated directly with treatment of
the disease: routine services, treatment of complications, and medical
conditions attributable to diabetes Indirect costs are the lost
opportunities or additional costs of living that affect individuals because
they have diabetes: lost wages and productivity, the cost of dealing with
impairments, premature death, etc Do you have better estimates for costs
from your States Department of Health or Medicaid office than those listed
in Table 22 on page 35?
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Your State estimates for spending on diabetes medical care would be more
accurate than these derived through national studies and generalized
assumptions

c How do these figures compare with States you consider similar to your
State?

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d What do you think the differences are related to? Can you document
any of that with data from your States Department of Health?

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e Would you be able to use these figures in making the case for
diabetes care quality improvement?

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f Who would you contact in your State to get these measures calculated
from actual data in your State?

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Module 3: Information - Interpreting State Estimates of Diabetes Quality

1 Identify State rates to use as benchmarks for the four major measures
and assess those rates in relation to national averages and other States

Read pages 41-47 Note the various definitions of benchmarks on page 43

a With a colored pen or pencil, take the figures you wrote down
in question 2a, in Module 2 and mark the percentage on the appropriate line
in the chart below

b Note whether your State rates fall above or below the national
average benchmarks and where they are in relation to other States Go back
to
Table 21 on page 28 of the Resource Guide for the rates by State Are
any of the percentages for your State:

1 Significantly above the national average indicated by a
sign next to the value for your State rate? Which ones?

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2 Significantly below the national average indicated by a -
sign next to the rate? Which ones?

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3 Within the best-in-class range and, thus, not significantly
different from the
best-in-class average indicated by a sign,
which says that the State is either one of the best-performing States
or is within a margin of error of these States? Which ones?

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4 Significantly below the best-in-class range does not include a
sign next to the State rate? Which ones?

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c Read pages 47-53 to see how four States were examined in the
Resource Guide Write a similar analysis of your States data Is your
State
doing well in any areas? Where could you improve?

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2 Identify factors that influence a States position among other
States

Review pages 54-59 of the Resource Guide on the factors that affect
diabetes quality of care

a What do you know about your State, its infrastructure, and your
States population that would account for your States position on the
chart above? Does your State have a large minority or elderly population?
What resources are available for the uninsured? The Kaiser Family
Foundation maintains a Web site with State-level measures for many health
and demographic indicators; see http://wwwstatehealthfactsorg/

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b Study Figure 36 on page 58 Note the relationships between
hospital admissions, obesity, poverty, and diabetes prevalence

1 What inferences can you make from the data?

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2 What do you know about your own States infrastructure,
its population, obesity, poverty levels, the uninsured, public
education, funding, and leadership? How might those factors affect
people with diabetes?

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3 If your States data are not listed in Figure 36, how
could you get these data for your State? Hint: see your response to
the data sources question from Module 2

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3 Identify the benchmarks to be used to set goals for improving
diabetes care

Review the Resource Guide, page 43 and Appendix D, on benchmarks and your
answers to Module 2, question 2 and Module 3, question 1 Note the best
benchmarks to use and why different benchmarks might be chosen in different
circumstances

a Which benchmarks for which
measures would you select from Module
2, question 2a to strive for improving diabetes care in your State?

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b Write the figure in the appropriate blank below:

c For each measure, why did you select that type of benchmark?

4 Draft preliminary goals for specific measures

Review pages 47-53 of the Resource Guide for examples of how benchmark data
were interpreted for four States

a Consider your States data in relation to setting preliminary
goals for a diabetes care quality improvement program For each of the
four measures, set a preliminary goal to reach the benchmarks you selected
in Module 3, question 3 Some examples of goal statements are:

o Increase the number of adults with diabetes who receive an HbA1c
test at least once a year to the level of the national average - 61
percent
o Increase the number of adults with diabetes who receive an HbA1c
test at least once in a year to the best-in-class average - 82
percent
o Increase retinal exam testing for adults with diabetes by 5
percentage points within the next 3 years
o Increase the number of adults with diabetes who receive foot
examinations from their physicians to reach the Healthy People 2010
goal - 75 percent
o Increase
the number of adults with diabetes who receive flu
vaccinations to the best-in-class average - 58 percent
o Identify the barriers to obtaining HbA1c testing or retinal exams
or foot examinations or flu vaccinations
o Begin collecting data on any or all of the measures if your State
does not already have these data

What are your preliminary goals for:

Module 4: Action - Learning From Activities Currently Underway

1 Identify tools and resources to build a quality improvement program

Review pages 62-69 of the Resource Guide for selected public/private
quality improvement initiatives as well as Federal programs and resources

a Is your State currently using any of these tools and resources?

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b If so, how well are they working?

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c Visit some Web sites listed below and jot down ideas to help you
build, implement, and evaluate a diabetes care quality improvement
program Note: additional quality improvement initiatives are
located in Appendix G, which begins on page 148 of the Resource
Guide

National Diabetes Quality Improvement Alliance
http://wwwnationaldiabetesallianceorg/

Chronic Care Model
http://wwwimprovingchroniccareorg

IHI Breakthrough Series Collaborative

Institute for Healthcare Improvement IHI Breakthrough
Collaboratives general information:
http://wwwihiorg/IHI/Programs/CollaborativeLearning/

Improving care for people with chronic conditions - diabetes:
http://wwwihiorg/IHI/Topics/ChronicConditions/Diabetes/HowToImprov
e/

Report from the Health Disparities Collaborative on Diabetes:
http://wwwhealthdisparitiesnet/Diabetes_Apr2002pdf

Disease Management Programs

Disease Management Association of America
http://wwwdmaaorg

Council of State Governments
http://wwwcsgorg/CSG/Policy/health/chronicillness/defaulthtm

Self-Management Programs

Chronic Disease Self-management Program at Stanford University
http://patienteducationstanfordedu/programs/

Federal Programs and Resources for Diabetes Quality Improvement

CDC Diabetes Prevention and Control Program the States DPCP
http://wwwcdcgov/diabetes/states/indexhtm

Diabetes Detection Initiative and Steps to a Healthier US
Initiative
http://wwwndepnihgov/ddi and
http://wwwhealthierusgov/steps/indexhtml

Health Resources and Services Administration, Bureau of Primary
Health Care, Health Disparities Collaboratives
http://bphchrsagov/programs/HDCProgramInfohtm and
http://wwwhealthdisparitiesnet/

National Diabetes Education Program NDEP
http://ndepnihgov and http://wwwbetterdiabetescareorg

Centers for Medicare Medicaid Services Quality Improvement
Organizations
http://wwwmedqicorg/content/nationalpriorities/topics/projectdesj
sp?topicID477showMeasuresyesshowStepsyes

2 Identify various State approaches to diabetes quality improvement and
best practices

Read pages 69-77 of the Resource Guide on partnership/planning activities,
program development activities, and dissemination activities and pages 77-
82 for examples of State diabetes care quality improvement programs and
best practices

a What do other States leaders indicate are keys to success
ie, best practices? For example, Wisconsin, California, and Minnesota
indicate that setting up strategic partnerships was very effective for
their programs

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b What State approaches and examples do you think might be useful
in your State?

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c What partnerships should you seek?

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3 Create an inventory of your States quality improvement actions and
resources

a Inventory your own States activities Note in the chart below
the stage of development for each activity Also note if your State has
not yet begun undertaking an activity or if the activity is complete

b Review Appendix H of the Resource Guide on page 152 In the
table below, write down your States level of funding for diabetes from the
CDC, the States general fund, and State in-kind resources Compare these
levels with two or three other States in your region or locality

Module 5: Improvement - Developing a Strategy for Diabetes Quality
Improvement

a Build the case for diabetes quality improvement in the State Create
a document that assembles the information you have written down in response
to these questions:

1 From Module 1, questions 1a, 1b, 1c, 1d, 1e, 1f, 1g, 1h:
o Has diabetes increased in prevalence from 1994 to 2002 in
your State?
o Why should improving diabetes care be a priority?
o What populations are vulnerable to gaps in diabetes care?
o What measures for diabetes care are below average in your State?

2 From Module 2, questions 2a, 2b, 2c, 2e, 3a, 4a, 4b, 4c:
o How does your State compare with national and best-in-class
averages?
o How close are you to the Healthy People 2010 goals?
o How does your State compare with other States in your region or
locality?
o Where do you need the most improvement?
o What is the cost of diabetes in your State?
o How do you compare with
other States in your region or locality?

3 From Module 2, question 2d and Module 3, questions 1a, 1b, 2a,
2b:
o Which diabetes health care measures are below the national
average?
o What factors affect the quality of diabetes care in your State?

b Add a preliminary strategy, suited to the State, to the document you
started above Convene a working meeting with your internal staff Use
the information you collected throughout this Workbook noted in
parentheses to fill out the outline below

1 Decide on topic areas related to quality improvement
o What do you predict as the current obstacles to quality care?
Module 1, question 1e
o What factors influence diabetes care? Module 2, questions 2d,
2e, 3a; Module 3, questions 2a, 2b
o What questions do you have about the quality of diabetes care?
Module 2, question 2g; Module 3, questions 2a, 2b
o What does current research indicate about diabetes care in your
State? Module 2, questions 2b, 3a, 4b, 4c

2 Develop predictions about how the State performs, why, and how the
State could improve
o Why has
diabetes prevalence increased? Module 1, questions 1a,
1b, 1e; Module 2, question 2d; Module 3, questions 2a, 2b
o How could your State improve? Module 2, questions 1b, 2b, 2c,
2e, 3a, 4b; Module 3, questions 1a, 1b, 2a, 2b

3 Develop goals for quality improvement Module 1, question 1g; Module
2, questions 1a, 1b, 2b, 2c, 4b, 4c; Module 3, questions 3a, 3b, 4a; Module
4, questions 2a, 2b

4 Take an inventory of current diabetes quality improvement programs in
the State, including non-governmental, Federal, or local initiatives Make
a preliminary list of additional actions to take Module 4, questions 1a,
1b, 3a

5 Identify data needs, including measures, benchmarks, and data sources

o Do you have data for diabetes measures Module 1, question 1f;
Module 2, questions 2a, 3a; Module 3, question 2b
o What data sources does your State have? Module 2, questions 2f,
2h, 3a
o What information on costs does your State have? Module 2,
questions 3a, 4a
o What additional data do you need? Module 2, questions 3b, 4d
c Identify strategic partnerships for diabetes quality
improvement
efforts

Read pages 85-91 of the Resource Guide

Add to the document, ideas for partnerships that would be strategic for
achieving diabetes quality improvement Include the key experts and
stakeholders in quality improvement consumers, health care team members,
purchasers, health plans, and topic experts, as well as champions in
health care who will carry key messages to the front line of health care
Decide who are strategic partners of quality improvement and recruit them
to the project, such as health specialists, statisticians and data experts,
researchers, evaluation specialists, and key State leaders and agencies
Begin filling in names, organizations, and their role in the table below
Also refer to your answers in Module 4, questions 2c and 3a

2 Have a
preliminary Plan as part of the Plan-Do-Study-Act PDSA
model of the cycle of quality improvement

Now that you have completed the preliminary plan, you can move from the
Plan to the Do stage of the PDSA model

Read pages 92-96 of the Resource Guide on implementing the PDSA model You
cannot complete the next steps of the PDSA cycle alone The partnership
defined above will be critical

Do:
Assemble a collaborative of quality improvement champions and
stakeholders
Give them a charge to improve health care quality in your State
Discuss diabetes versus other conditions ripe for quality
improvement and select a condition
Work with them to set goals; to develop an intervention, plan, and
evaluation strategy; to collect data, and to test the plan
Draw on the Resource Guide, especially if diabetes is the topic
selected
Keep the group on track Keep assessments timely and do not let the
perfect be the enemy of the good
Move to the next step

Study:
Pilot test the groups ideas
Collect data-baseline and post-intervention data-even in the pilot
stage
Analyze the results
and draw conclusions Differentiate between
solid conclusions and inconclusive findings; use this information
to improve the tracking system
Plan an effective tracking system to know if the intervention
matters when it is rolled out statewide

Act:
When the group agrees, implement the quality improvement strategy
statewide

The PDSA model will be a resource again and again-to create this plan, to
work with your quality improvement team on goals for diabetes, to keep the
cycle going, and to attack other health care issues
Module 6: The Way Forward - Promoting Quality Improvement in the States

1 Identify what the users can uniquely contribute to promote quality
improvement in health care and where help is needed

Read pages 99-101 of the Resource Guide Note areas where you have
particular strengths and resources to contribute Note dimensions where
your skills and those of your staff may be weakest Devise approaches
eg, input from other agencies, new hires, grant applications, etc to
strengthen the weakest areas Some of these areas are:

a Providing leadership and vision

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b Forming partnerships and collaborations

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c Assisting planning and goal setting

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d Initiating measurement and reporting

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e Including evaluation and accountability

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f Enhancing infrastructure

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g Creating incentives

Now that you have answered the questions in this Workbook and assessed your
strengths and weakness for leading a quality improvement initiative, you
are ready to take action The goal of changing health care quality in your
State may seem overwhelming Yet, with small, smart steps, you can be
effective in making that happen

Assemble
your staff or your network of State leaders and discuss the idea
You may want them to do the exercises in this Workbook, read the Resource
Guide, and prepare some ideas for a preliminary plan even before you meet
The most important first step will be identifying and recruiting public and
private partners for health care quality improvement-other State agencies,
purchasers, provider groups, consumers, and experts who fill in the gaps in
your knowledge Find out who the change agents for health care quality are
in your community

Remember, without involving the professionals at the forefront of health
care, there can be no quality enhancement As we have noted in throughout
this Workbook as well as in the Resource Guide, the full stakeholder group
should be involved in designing the goals, the approach, the details of
implementation, and the evaluation strategy Only with an effective team
of leaders, champions, and change agents for improving health care quality
will the health care system in your State be able to change and provide
better care for your community

———————–

Learning Objectives

Upon completion of Module 2, the users will be able to:

1
Understand the process and outcome measures for tracking the quality
of diabetes care Understanding these measures will help the user
identify gaps in recommended care, how closing these gaps can improve
health status, and how the measures can be used as the basis for setting
goals
2 Compare State data with national benchmarks and identify gaps in
State data Collecting and analyzing data in your State is important to
making your case for improving care and calculating the long-term costs
of diabetes and its impact on your State Data also help you create
baseline measures and set goals for improvement
3 Develop an inventory of the data systems available at the State and
local levels An inventory will identify existing data that may be
useful and collection mechanisms that might easily be enhanced for
tracking quality improvement
4 Use published studies to arrive at State or local estimates
Research helps inform States of gaps in their data, questions that
remain to be answered, and the need for additional research
5 Calculate the direct and indirect costs of diabetes for States and
State Medicaid programs Knowing the costs
will help make the case for
quality improvement, provide States with baseline measures, and help set
goals

Learning Objective

Upon completion of Module 1, the users will be able to:

1 Assess the need for diabetes care quality improvement in the State
This section will pull together information to help make the case for
improvement in diabetes care by showing why diabetes should be a
priority

Learning Objectives:

Upon completion of this module, the users will be able to:

1 Identify State rates benchmarks for the four major measures and assess
those rates in relation to national averages and other States There are
many types of benchmarks-national average, best-in-class performance, and
national consensus-based-goal benchmarks
2 Identify factors that influence a States position among other States
Knowing these factors can help States assess how difficult it may be to
change and where States should target their efforts
3 Identify the benchmarks to be used to set goals for improving diabetes
care Any of the benchmarks listed above can be used to set goals
Aiming for the average is usually the least rigorous goal, while striving
to be the
best-in-class is usually the most rigorous, achievable goal
Knowing your States position as it relates to the full distribution of
State rates also shows how well the State is doing among all States A
State that is among the lowest in the Nation on a particular dimension
might want to focus improvement in that area
4 Draft preliminary goals for specific measures Knowing what you want to
achieve in the long term will help States identify the resources and
tools they need to get there

Guidance for Setting Goals:

o Consider this goal-setting exercise as preliminary to enhance your
understanding Stakeholders who will become champions of the
initiative must have a part in setting goals for the program Only
in that way will the goals reflect the circumstances that the
community faces and be supportable by leaders in the health care
community
o Note where your State falls on the chart in Module 3, question 1a:
Is your State extremely low, close to the national averages, or
within the best-in-class averages? Your position on the chart will
tell you how far your State must go to be among the
best performing
health care systems Do you want to set long-range and short-
range goals?
o Remember that you will have to identify and address the underlying
issues that affect your States position
o The four measures featured here are only a subset of the meaningful
goals and are not necessarily the most effective goals for diabetes
quality improvement in your State HbA1c levels, provider and
patient education, adherence with recommended lifestyle changes,
and focus on vulnerable populations are some of the important goals
that your planning group may decide to set
o As you move through the planning process and discover new
information, you can come back and change your goals to reflect
your new knowledge
o Your quality improvement program for diabetes care should
ultimately be designed to reach the goals set by the full quality
improvement team

Learning Objectives:

Upon completion of Module 4, the users will be able to:

1 Identify tools and resources to build a quality improvement program
Knowing what resources are already available saves time and
money
2 Identify various State approaches to diabetes quality improvement and
best practices Many existing program models can be modified to
accommodate State-specific needs
3 Create an inventory of your States quality improvement actions and
resources You can build upon the resources and partnerships that
already exist and identify where your State needs to develop activities

Learning Objectives

Upon completion of Module 5, the users will be able to:

1 Have assembled in this document the information from Modules 1-4 above
that presents: a the case for diabetes quality improvement in the
State; b a preliminary strategy suited to the State; and c strategic
partnerships for diabetes quality improvement efforts
2 Have a preliminary Plan as part of the Plan-Do-Study-Act PDSA
model of the cycle of quality improvement Again, consider this plan
preliminary The full quality improvement team must be part of the
creation of the plan to ensure its relevance, completeness, and
success for obtaining support from stakeholders in the State health
care community

Learning Objective

Upon completion of Module 6, the users
will be able to:

1 Identify what the users can uniquely contribute to promote quality
improvement in health care and where help is needed

Source:pnl.gov

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