Module 6: The Way Forward - Promoting Quality Improvement in the States

Diabetes Care Quality Improvement: A Resource Guide for State Action

"Quality health care means doing the right thing at the right time in the right way for the right person and having the best results possible." (AHRQ, 2003c)

Health care analysts and researchers have long documented extensive gaps in the quality of care delivered to Americans. Despite unrivaled technological innovation in American health care, too much of the care that is delivered to patients does not meet the accepted standards of quality. The findings of the National Healthcare Quality Report and the National Healthcare Disparities Report provided further confirmation that, while in some areas care is improving, the health care system in America has a long way to go before it delivers care that is consistent with accepted guidelines and does not vary significantly by geography, race, ethnicity, or socioeconomic status.

There is a great deal that State leaders can do to support and encourage quality improvement, and thereby, to improve health outcomes, reduce the burden of disease, and possibly increase the efficiency of the health care system. As guardians of public health and health care innovators, States can champion quality improvement and best practices that can transform health care systems. In most cases, State government is also one of the largest health care purchasers in a State due to Medicaid and State employee health insurance programs. With States experiencing budget problems and high growth in health care costs, States cannot afford to pay for a product that does not meet accepted standards of quality. Alone or in concert with other purchasers, State governments can help steer the health care system toward the consistent delivery of high quality care.

Diabetes is one chronic condition that has a compelling case for quality improvement for States. The disease burden from diabetes is great in terms of the number of people affected, the cost of complications, its effect on quality of life, and the disparities in care between racial and ethnic groups. Despite its prevalence and cost, research has demonstrated that type 2 diabetes can be prevented, and complications from both type 1 and type 2 diabetes can be prevented or significantly delayed with appropriate treatment. Diabetes also has widely accepted, evidence-based guidelines for care and a strong case for a return on investment for purchasers and society from diabetes quality improvement efforts.

The NHQR provides an array of national and State-level data that can help States focus their quality improvement efforts. This Resource Guide has taken the data from the NHQR on diabetes and placed it within a model of quality improvement to assist States with improving diabetes care. State leaders now have the opportunity to contribute to the growing momentum to improve the quality of care in America through State initiatives.

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What Can State Leaders Contribute to Quality Improvement?

As State leaders examine how they can be involved in improving the health care quality, there are a number of essential elements that State leaders can contribute to the process. These elements include: providing leadership and shared vision, fostering partnerships and collaborations between key parties, planning and setting goals, enhancing measurement and reporting, improving the infrastructure of health care quality, assuring evaluation and accountability, and creating incentives.

  • Providing leadership and vision—Quality improvement requires leadership. It will not emerge without a champion who can provide leadership for organizations and individuals to work together to develop a shared vision and common goals for health care quality. Whether initiatives are developing locally, statewide or nationally, effective leadership is essential to quality improvement. However, health care quality cannot be accomplished by one champion, be it a person or an organization. Leadership must be a catalyst for others to become involved in developing shared vision and goals for improving health care quality.
  • Forming partnerships and collaborations—In addition to leadership and vision, partnerships and collaborations are vital to improving quality. Health care quality is the product of many different parts of the health care system but ultimately must affect what happens in the community, the patient environment, and the clinical setting. Thus, all of the groups that have an effect on patient care should participate in quality improvement efforts for an initiative to be successful, including health care professionals, providers, patients, and purchasers. Health care professionals and providers need to establish systems that deliver appropriate, quality care consistently; patients need to demand and participate in the best available care; and purchasers must demand and pay for the highest quality, most cost-effective delivery of care. Consumer groups with interest in diabetes can be powerful allies for change and a source of expertise. State health department staff and other diabetes care experts from private sector organizations can provide support and expertise for State initiatives.
  • Assisting planning and goal setting—Once partnerships and collaborations are initiated, the quality improvement group must develop an action plan with specific goals for quality improvement in the State. The action plan must include timelines for specific steps and deliverables to help ensure that all partners move together. The plan should include specific responsibilities and benefits for as many project partners as possible to ensure buy-in and continued involvement.
  • Enhancing measurement and reporting—Another essential piece for understanding quality is defining quality standards and developing measures to track how well or poorly the quality improvement intervention is working and the health care system is performing. In addition to assessing quality-improvement activities, measurement and reporting provide a mechanism for comparing how well any given health plan or provider is doing in a selected area of care. Quality measurement can involve counting the number of patients who received a needed immunization or screening or how often patients had to be hospitalized due to complications after a surgery by a given provider. Health care providers and companies must have data systems that are robust enough to estimate a given set of measures of health care quality. Results then must be made available for purchasers and consumers to be able to make meaningful comparisons of the performance of various providers. As discussed earlier in the Resource Guide, there is a well developed set of measures for diabetes care quality and many existing data collection and reporting systems that are available to States. There is a wide array of public measures and publicly available data sources reported in the NHQR, as well as other important measures that States may want to incorporate into a quality improvement and evaluation strategy.
  • Improving the health care infrastructure—Part of quality improvement is the ability to make necessary adjustments in the infrastructure of health care. Infrastructure in health care can include professional education, data systems, financing and delivery systems, research, and patient education resources, among others. Health care quality evaluation by its nature highlights areas for improvement, thus drawing attention to areas where health care professionals may need additional education or training, where providers may need to redesign systems of care, where payers need to improve financial incentives, and where purchasers need to allocate more resources to address quality concerns and reward superior performance. Evaluation of health care quality can also reveal areas for further research and ways that patients can be actively engaged in managing their care and changing behavior such as smoking cessation, nutritional improvements, or other areas that may contribute to health care problems.
  • Assuring evaluation and accountability—After establishing partnerships with solid leadership and common vision and goals, measuring and collecting data on quality, and reporting it for comparison, there also is the need for evaluation of both health system performance and accountability for health care quality. Evaluation allows partners to identify the most troublesome areas and prioritize resources and attention to those areas that most need improvement. Evaluation promotes the opportunity to celebrate areas where there is solid performance or conduct improvement over time. It may require some technical input and expertise, but it is an important component of the quality improvement process. Without evaluation, impact of the program will be unknown and future direction for the program will be haphazard.
  • Creating incentives—While reporting data on performance is often enough to spur low performers toward improvement, there is also the need to tie rewards to high performance. Currently, the American health care system essentially pays all providers the same regardless of the level of quality that they deliver. Without adequate rewards for improvement, health care quality will languish. As one of the largest health care purchasers in any given State, State governments can have a tremendous influence over incentives for quality improvement in the health care system through their payment structures.

This Resource Guide has attempted to demonstrate for State leaders the need for quality improvement in diabetes. Much has been done, but data from the NHQR show that much remains to be done to achieve quality diabetes care for all people with diabetes. The number of people newly diagnosed with diabetes and the number suffering its complications are still growing.

By reviewing and analyzing this Resource Guide, assessing their local context, and designing a diabetes quality improvement strategy, State leaders can identify opportunities to make a difference in the quality of care their constituents receive. The experiences of States that have implemented quality improvement for diabetes care provide valuable insights into what can be accomplished through innovative, visionary efforts by State leaders.

Page last reviewed August 2008
Internet Citation: Module 6: The Way Forward - Promoting Quality Improvement in the States: Diabetes Care Quality Improvement: A Resource Guide for State Action. August 2008. Agency for Healthcare Research and Quality, Rockville, MD.