**Asthma Care Quality Improvement:**

**A Workbook for State Action**

Prepared by:

Karen Ho, M.H.S.

Rosanna M. Coffey, Ph.D.

DonnaRae Castillo, M.A.

U.S. Department of Health and Human Services

Agency for Healthcare Research and Quality

Rockville, Maryland

www.ahrq.hhs.gov

AHRQ Publication No. 06-0012-2

April 2006

**Acknowledgments**

Karen Ho and Rosanna M. Coffey are with Thomson Medstat; DonnaRae
Castillo is with the Agency for Healthcare Research and Quality. The
authors acknowledge the contributions of David M. Adamson, Ph.D.,
formerly of Thomson Medstat, to the planning and development of the
initial draft and Barbara Kass-Bartelmes, M.P.H., of the Agency for
Healthcare Research and Quality, for advice and consultation on
readability and utility of this product.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

This document is in the public domain within the United States only and
may be used and reproduced without permission. AHRQ appreciates citation
as to source and the suggested format is below. Foreign countries and
users who want to distribute content on a global basis in electronic
form or print should submit specific permission requests for use to:
info@ahrq.gov

Ho K, Coffey RM, Castillo D. *Asthma Care Quality Improvement: A
Workbook for State Action.* Rockville, MD: Agency for Healthcare
Research and Quality, Department of Health and Human Services; April
2006. AHRQ Pub. No. 06-0012-2.

**Foreword**

*Asthma 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 asthma care
from the *2004* *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.

The *Workbook* and its complementary *Resource Guide* can serve as tools
for those who work on quality improvement to use in sharing their
expertise, ideas, knowledge, and solutions. The various modules are
intended for different users. Senior leaders, for example, may want to
focus on making the case for asthma quality improvement, incorporating a
State-led framework into their improvement strategy, and taking action;
program staff need to provide the measures and data necessary to
implement the quality improvement plan. The goal is that everyone work
as a team and, thereby, improve the quality of asthma care in their
State.

If you have any comments or questions on this *Workbook* or its
complementary *Resource Guide*, please contact the AHRQ Center for
Quality Improvement and Patient Safety, 540 Gaither Road, Suite 3000,
Rockville, MD 20850 (phone: 301/427-1734; email:
dwight.mcneill@ahrq.hhs.gov).

**Contents**

Introduction 1

Module 1: Making the Case for Asthma Care Quality Improvement 3

Module 2: A Framework for State-Led Quality Improvement 10

Module 3: Learning From Current State Quality Improvement Efforts 18

Module 4: Measuring Quality of Care for Asthma 21

Module 5: Moving Ahead -- Implications for State Action 32

A Final Note 35

# Introduction

## 

## The Need for Asthma Quality Improvement

As protectors of the public's health, State governments play a vital
role in preventing asthma and controlling its consequences. Most States
have some public resources invested in asthma prevention, monitoring,
and care programs, although the level of investment may vary from State
to State. As health care purchasers, States are responsible for ensuring
that the health care they pay for on behalf of State employees, Medicaid
clients, and other recipients meet standards of quality.

There are a number of reasons why States may want to take a closer look
at improving quality of care for asthma, including:

-   The increased prevalence of asthma, especially among children and
    adolescents.

-   The disparities between various racial and ethnic groups in
    diagnosis and quality of asthma care.

-   Interventions and treatment that can successfully control the
    disease and prevent attacks.

-   The high health care cost of uncontrolled asthma and the potential
    for return on investment for purchasers, including State Medicaid
    agencies, through asthma quality improvement.

See Module 1 of the *Resource Guide* for more information on these
topics.

## Aim and Scope of This Workbook

The aim of this *Workbook* is to help State leaders develop information
to support health care quality improvement. Its written exercises should
help State leaders 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. It also should help readers apply information and concepts
from the *Resource Guide* to their own States.

Upon completion of the *Workbook*, State leaders will be able to:

-   Understand the key factors that determine whether there is a need
    for an asthma care quality improvement in their State (i.e., "make
    the case").

-   Identify partners to plan, develop, and support a quality
    improvement strategy for asthma.

-   Identify national, public-private, Federal, State, and local
    resources and activities related to asthma quality improvement.

-   Identify appropriate asthma data sources and measures and develop
    estimates from data for assessing the State's performance in
    providing asthma care.

-   Identify opportunities to contribute to improving asthma care
    quality.

This *Workbook* is a start for State leaders interested in learning
about quality improvement for asthma care. The actual planning,
implementation, tracking, and evaluation of an asthma 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, program 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 and legislators (and their staffs)
    who provide leadership on health policy.

-   State executive branch officials---State health departments, asthma
    prevention and control program leaders, Medicaid officials, benefit
    managers for State employees, and their staffs.

-   Nongovernmental State and local health care leaders---professional
    societies, provider associations, hospital associations, quality
    improvement organizations, voluntary health organizations, health
    plans, business coalitions, community organizations, and consumer
    groups.

## 

## How To Use This Workbook

Although this *Workbook* can be completed by one individual, it would be
a time-consuming task. Furthermore, few State leaders may be equipped to
answer all of the questions. Therefore, State leaders may want to enlist
the help of staff and others who will eventually become part of the
quality improvement team that will develop, implement, and evaluate an
asthma care quality improvement program.

The user should first read the Executive Summary and Introduction of the
*Resource Guide* for an overview of the National Healthcare Quality
Report. This report---produced annually by the Agency for Healthcare
Research and Quality (AHRQ), along with its companion National
Healthcare Disparities Report---serves as the basis for measures and
data used in the *Resource Guide* and this *Workbook*. Modules in the
*Resource Guide* are mirrored in this *Workbook*; and, based on the
State leader's interests, needs, and role in developing a quality
improvement program, users will want to focus on different modules such
as:

*Senior leaders*

-   Module 1---Making the Case for Asthma Care Quality Improvement

-   Module 2---A Framework for State-Led Quality Improvement

-   Module 3---Learning From Current State Quality Improvement Efforts

-   Module 5---Moving Ahead -- Implications for State Action

*Staff specialists* (all of above plus the following)

-   Module 4---Measuring Quality of Care for Asthma

Modules 1, 2, and 3 might be completed by different individuals or
groups of individuals to gather and assess information to create a
quality improvement team and strategy specific to the State's needs.
Module 4 provides guidance on available measures and how to use and
interpret them in a quality improvement program. Module 5 will help
State leaders assess their strengths and weaknesses in instituting
improvement in health care quality.

**Module 1: Making the Case for Asthma Care Quality Improvement**

**1. Assess the need for asthma care quality improvement in the State.**

Read "The Need for Asthma Care Quality Improvement" and "The Quality
Improvement Opportunity (pages 5-18) in the *Resource Guide* to learn
about important reasons for addressing asthma and quality of care for
asthma---increased prevalence, high cost, racial/ethnic and income
disparities, and treatment variations---as well as the potential for
return on investment through quality improvement in asthma care.

a\. Look at Table 1.1 on page 10 to see how asthma prevalence (cases for
every 100 people) has changed from 2000 to 2003. In Maryland in 2000,
for example, 10.6 percent of the population had been diagnosed with
asthma at some point in their lifetime, similar to the national average
of 10.5 percent; in 2003, Maryland's lifetime asthma prevalence was 12.3
percent, higher than the national average of 11.7 percent. The lifetime
asthma prevalence rates in Table 1.1 are from the Centers for Disease
Control and Prevention's Behavioral Risk Factor Prevalence System
(BRFSS).

1\) What was the asthma prevalence in your State in 2000? (Table 1.1)
\_\_\_\_\_\_\_\_

2\) What was the asthma prevalence in your State in 2003? (Table 1.1)
\_\_\_\_\_\_\_\_\_

3\) Has the prevalence increased in your State since 2000?
\_\_\_\_\_\_\_\_\_\_\_\_\_

4\) How does your State compare with the national average?
\_\_\_\_\_\_\_\_\_\_\_\_

b\. Asthma prevalence may vary among subgroups of the population in your
State (such as by age, racial or ethnic group, or income). As an
example, look at Table E.3 (page 117) in Appendix E of the *Resource
Guide* to find the current prevalence of asthma by State among adults by
age group (18-64 and 65 and older) in 2003.

1\) What was the current asthma prevalence for all adults in your State
in 2003? (Table E.3) \_\_\_\_\_\_\_\_\_\_

How does your State compare with: the national average? \_\_\_\_\_\_\_
the top decile of States average? \_\_\_\_\_\_\_\_ the bottom decile of
States average? \_\_\_\_\_\_\_\_\_

*[Note]{.underline}*: The States in the "top decile" (1/10^th^) are the
States that have the lowest average of asthma prevalence. The States in
the "bottom decile" are the States with the highest average of asthma
prevalence.

2\) What was the current asthma prevalence for age 18-64 in your State
in 2003? (Table E.3)

\_\_\_\_\_\_\_\_\_

How does your State compare with: the national average? \_\_\_\_\_\_\_\_
the top decile of States average? \_\_\_\_\_\_\_\_ the bottom decile of
States average? \_\_\_\_\_\_\_\_\_

3\) What was the current asthma prevalence for age 65 and older in your
State in 2003? (Table E.3) \_\_\_\_\_\_\_\_

How does your State compare with: the national average? \_\_\_\_\_\_ the
top decile of States average? \_\_\_\_\_\_\_ the bottom decile of States
average? \_\_\_\_\_\_\_\_

4\) Are there other groups (racial, ethnic, low income, etc.) in your
State for which you have asthma prevalence data from your State health
data agency?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

c\. Look at Table 1.2 (page 11) in the *Resource Guide*. This shows the
hospitalization rate for asthma (admissions per 100,000 population) by
State for different age groups. This is an important quality improvement
measure because many hospital visits for asthma can be avoided with high
quality outpatient care. Knowing your State's rate compared to the
national average may help determine whether asthma care quality
improvement, especially as it affects the cost for asthma care, should
be a priority in your State. Find your State and write your State's rate
for each age group in the table below.

If your State is not listed in Table 1.2, or if your State collects its
own hospitalization data for asthma, contact your State health data
agency for these rates and write them in the table below.

  ------------------------------- ------------- --------------- ------------
  Hospital admissions for asthma  U.S. rate     Best-in-class   Your State's
  per 100,00 population among\--                rate            rate

  Children under age 18           188.6         72.3             

  Adults age 18-64                112.8         60.2             

  Adults age 65 and older         170.6         118.2            
  ------------------------------- ------------- --------------- ------------

> 1\) How does your State compare with the U.S. rate?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

## 2) "Best-in-class" States have lower rates of avoidable hospitalizations for asthma. How does your State compare with the best-in-class averages for the three age groups above? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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3\) What do you see as the potential for quality improvement in this
measure in your State?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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**2. Estimate the cost of asthma care statewide and for Medicaid.**

Read "Estimating the Costs of Asthma Care and Potential Savings From
Quality Improvement" (pages 18-23) in the *Resource* *Guide* to learn
about estimating direct and indirect costs of asthma statewide and for
Medicaid. *Direct* costs are expenditures associated with asthma
treatment: routine services, treatment of complications, and medical
conditions attributable to asthma. *Indirect* costs are additional costs
of living or the lost opportunities that affect individuals because they
have asthma: the cost of dealing with disability, lost wages and
productivity, premature death, and so on.

a\. Look at Table 1.3 on page 20 of the *Resource Guide*. It lists
current asthma prevalence and direct and indirect cost estimates for
asthma by State. Find your State's estimates and list here.

> Direct cost of asthma to your State = \$\_\_\_\_\_\_\_\_\_\_
>
> Indirect cost of asthma to your State = \$\_\_\_\_\_\_\_\_\_\_
>
> Total estimated asthma costs to your State = \$\_\_\_\_\_\_\_\_\_\_
>
> Asthma prevalence in your State = \_\_\_\_\_\_\_\_\_\_
>
> Average cost to your State per person with asthma =
> \$\_\_\_\_\_\_\_\_\_\_
>
> (Divide State's total costs by State's asthma prevalence)

b\. Next compare your State estimates for the total population to
estimates for neighboring States in your region. Again using Table 1.3
on page 20 of the *Resource Guide*, find the figures for your State and
the two States with similar characteristics to yours and write them in
the blanks below. How does your State compare?

+--------------------------+------------+--------------+--------------+
|                          | Your State | State A      | State B      |
+--------------------------+------------+--------------+--------------+
| Asthma prevalence        |            |              |              |
+--------------------------+------------+--------------+--------------+
| Total asthma cost        |            |              |              |
+--------------------------+------------+--------------+--------------+
| Average cost per person  |            |              |              |
|                          |            |              |              |
| (divide total cost by    |            |              |              |
| prevalence)              |            |              |              |
+--------------------------+------------+--------------+--------------+
| Cost difference (+/-)    |            |              |              |
+--------------------------+------------+--------------+--------------+

c\. Look at Table 1.4 on page 21 of the *Resource Guide.* It gives the
Medicaid population with asthma and the estimated costs to each State's
Medicaid program for three age groups: 0-17, 18-64, and 65 and older.
Find your State's Medicaid population and estimated Medicaid spending on
asthma for the three age groups and list them in the first column below.
Calculate the cost per person by dividing the estimated expense by the
estimated Medicaid population with asthma. Make the same type of
comparisons for the Medicaid population between your State and the two
States you used in question 2b above.

*[Note]{.underline}*: Do you have estimates for asthma care costs from
your State health department or Medicaid program office that are better
than those listed in Table 1.4? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

If so, use them here. Your own State estimates for spending on asthma
care would be more accurate than these derived through national studies
and more generalized assumptions.

+-----------------------+---------------+---------------+--------------+
| Medicaid population   | Your State    | State A       | State B      |
+-----------------------+---------------+---------------+--------------+
| Age 0-18              |               |               |              |
+-----------------------+---------------+---------------+--------------+
| > Population with     |               |               |              |
| > asthma              |               |               |              |
+-----------------------+---------------+---------------+--------------+
| > Estimated expense   |               |               |              |
+-----------------------+---------------+---------------+--------------+
| > Average cost per    |               |               |              |
| > person (divide      |               |               |              |
| > expense by          |               |               |              |
| > population)         |               |               |              |
+-----------------------+---------------+---------------+--------------+
| Age 19-64             |               |               |              |
+-----------------------+---------------+---------------+--------------+
| > Population with     |               |               |              |
| > asthma              |               |               |              |
+-----------------------+---------------+---------------+--------------+
| > Estimated expense   |               |               |              |
+-----------------------+---------------+---------------+--------------+
| > Average cost per    |               |               |              |
| > person (divide      |               |               |              |
| > expense by          |               |               |              |
| > population)         |               |               |              |
+-----------------------+---------------+---------------+--------------+
| Age 65 and older      |               |               |              |
+-----------------------+---------------+---------------+--------------+
| > Population with     |               |               |              |
| > asthma              |               |               |              |
+-----------------------+---------------+---------------+--------------+
| > Estimated expense   |               |               |              |
+-----------------------+---------------+---------------+--------------+
| > Average cost per    |               |               |              |
| > person (divide      |               |               |              |
| > expense by          |               |               |              |
| > population)         |               |               |              |
+-----------------------+---------------+---------------+--------------+

d\. Look at Appendix B, Tables B.1-B.6 (pages 85-90) in the *Resource*
*Guide*. These tables show estimated numbers of people in racial/ethnic
subgroups of the Medicaid population with asthma by age group and
estimated Medicaid spending for asthma for these groups. Fill in the
blanks in the following table below with figures for your State and two
comparable States.

+-----------------+----------+----------+----------+-----------------+
| Population      | Medicaid |          |          |                 |
| group           | e        |          |          |                 |
|                 | ligibles |          |          |                 |
|                 | with     |          |          |                 |
|                 | asthma   |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
|                 | Age 0-18 | Age      | Age 65   | Estimated       |
|                 |          | 19-64    |          | Medicaid        |
|                 |          |          | and      | spending        |
|                 |          |          | older    |                 |
+-----------------+----------+----------+----------+-----------------+
| Your State:     |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > White         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Black         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > American      |          |          |          |                 |
| > Indian/       |          |          |          |                 |
| >               |          |          |          |                 |
| > Alaska Native |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Asian         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Hispanic      |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Other         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
|                 |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| State A:        |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > White         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Black         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > American      |          |          |          |                 |
| > Indian/       |          |          |          |                 |
| >               |          |          |          |                 |
| > Alaska Native |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Asian         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Hispanic      |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Other         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
|                 |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| State B:        |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > White         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Black         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > American      |          |          |          |                 |
| > Indian/       |          |          |          |                 |
| >               |          |          |          |                 |
| > Alaska Native |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Asian         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Hispanic      |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
| > Other         |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+
|                 |          |          |          |                 |
+-----------------+----------+----------+----------+-----------------+

1\) Does your State have large numbers of these subgroups with asthma?
How much of your Medicaid spending is devoted to asthma care for these
groups?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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2\) Can you use the figures in Appendix Tables B.1-B.6 to help make the
case for asthma care quality improvement in your State?

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**3. Estimate a State's potential cost savings by using targeted disease
management and reducing pediatric hospitalizations for asthma.**

a\. Look at pages 22-23 of the *Resource Guide* to see the results from
a calculation of potential Medicaid savings from an asthma disease
management program based on the Virginia Health Outcomes Partnership
(VHOP) experiment.

1\) Call your Medicaid program office to find your State's spending for
emergency department visits for Medicaid (see step 1, below), the number
of Medicaid claims for emergency department visits (step 2), and the
number of physicians participating in primary care case management who
might accept training in asthma management (step 6). Use your State data
to fill in the blanks to develop a "ballpark" estimate of how much might
be saved in Medicaid costs with a similar asthma disease management
intervention.

*[Note]{.underline}*: These estimates assume that you would have results
similar to those of Virginia (see page 22 of the *Resource Guide*) and
that your State has not already implemented a training program for
physicians treating Medicaid recipients with asthma. Your results will
vary depending on the size of your Medicaid program and the scale of the
intervention your State might undertake.

Steps for Estimating Potential Medicaid Savings From an Asthma Disease
Management Program

  ------------------------------------------------------------ ----------
  Step                                                         Your State

  1\. Total annual spending for emergency department visits    
  for asthma pre-intervention for Medicaid recipients          

  2\. Total annual number of Medicaid claims for emergency     
  department visits                                            

  3\. Payment per claim: Divide step 1 by step 2               

  4\. Emergency visit reduction factor: Adjusted to four       0.06
  quarters and to exclude added costs per physician and added  
  drug prescribing (both included below; see steps 7 and 8)    

  5\. Emergency care visit annual saving after training        
  physicians: Multiply step 1 by step 4                        

  6\. Number of physicians participating in primary care case  
  management who might accept training in asthma management    

  7\. Asthma drug cost: Multiply step 6 by \$180 per physician 
  per year                                                     

  8\. Program training costs: Multiply step 6 by \$235 per     
  physician                                                    

  9\. Total drug and training costs: Add steps 7 and 8         

  10\. Total Medicaid savings: Subtract step 9 from step 5     

  11\. Savings per Medicaid claim: Divide step 10 by step 2    
  ------------------------------------------------------------ ----------

**Source**: Estimates derived from Rossiter LF, Whitehurst-Cook MY,
Small RE, et al. The impact of disease management on outcomes and cost
of care: a study of low-income asthma patients. *Inquiry*
2000;37:188-202.

**Note**: Based on the VHOP experiment, for purposes of step 6, assume
that one-third of Medicaid participating physicians in any disease
management program would accept training in asthma management. See
Rossiter et al. for further detail on derivation of the emergency visit
reduction factor, asthma drug cost, and program training cost. In
addition, percent savings per claim can be calculated by dividing step
11 by step 3.

2\) How do these potential Medicaid savings for asthma care compare with
other disease management programs in your State? Do these figures help
make a case for asthma care quality improvement for your Medicaid
program?

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b\. Look at pages 23-24 in the *Resource Guide* to see results from a
calculation of potential savings for Massachusetts from reducing
avoidable hospitalizations for pediatric asthma.

1\) Follow the steps below to develop a "ballpark" estimate of how much
your State might save by reducing excess hospitalizations for pediatric
asthma.

*[Note]{.underline}*: These estimates assume that you would have results
similar to those of Massachusetts (see page 24 of the *Resource Guide*).
Your results may vary. In addition, the cost of implementing a quality
improvement program to reduce hospitalizations is [not]{.underline}
included in the calculation below.

**Steps for Estimating Potential Savings From Reducing Excess Pediatric
Asthma Hospitalizations**

  -------------------------------------------------------------- ------------
  Step                                                           Your State

  1\. Hospital admission rate for pediatric asthma per 100,000   
  population under age 18 (Table 1.2 in the *Resource Guide*)    

  2\. Estimated population under age 18 in State (Census, 2000;  
  available at                                                   
  http://www.census.gov/popest/states/asrh/SC-est2004-02.html)   

  3\. Number of pediatric asthma hospital admissions: Multiply   
  step 1 by step 2                                               

  4\. Percent of pediatric asthma hospital admissions to be      
  reduced to achieve best-in-class (Table 1.2 in the *Resource   
  Guide*)                                                        

  5\. Number of hospital admissions for pediatric asthma to      
  reduce (excess hospitalizations): Multiply step 3 by step 4    

  6\. Mean cost for pediatric asthma hospitalization\*           \$2,590.72

  7\. Total cost of all pediatric asthma hospitalizations in     
  State: Multiply step 3 by step 6                               

  8\. Total cost of excess pediatric asthma hospitalizations in  
  State: Multiply step 5 by step 6                               

  9\. Potential cost savings from reducing excess                
  hospitalizations: Subtract step 8 from step 7                  
  -------------------------------------------------------------- ------------

**\*** Step 6 was calculated by multiplying the national mean charge per
pediatric asthma hospitalization (\$5,888) by the national
cost-to-charge ratio for these hospitalizations (0.44) using data from
the 2001 HCUP Nationwide Inpatient Sample. (Information on HCUP data and
tools is available on the HCUP Web site at http://www.hcup-us.ahrq.gov
or via email at hcup@ahrq.gov.) States may use their own State estimates
on pediatric asthma hospitalizations if available.

2\) Look at your potential cost savings from reducing excess
hospitalizations. Can these potential savings help to make a case for
asthma care quality improvement in your State?

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**Module 2: A Framework for State-Led Quality Improvement**

# 

# 

# 

# 

## 

## 1. Define the State's role in the asthma care quality improvement process and develop activities using a Plan-Do-Assess approach.

a\. Read pages 26-35 in the *Resource* *Guide*. These sections discuss
the State's role in fostering quality improvement in health care,
present existing improvement models, and a define a new framework for
asthma care quality improvement and a leadership role for States.

1\) What existing programs in your State can you use to gather
information on quality improvement? Do you have previous quality
improvement programs at the State or community level which you can use
to begin planning your asthma improvement efforts? Who in your State
might be able to provide this information (such as experts in asthma,
asthma care, and quality improvement)?
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2\) Are there ongoing provider networks already involved in quality
improvement in your State that might serve as the basis of a statewide
quality improvement initiative for asthma care?

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3\) What do you envision as the State's key leadership role in
leveraging these existing programs and networks for asthma care quality
improvement?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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b\. General and clinical models of quality improvement are described on
pages 27-31 of the *Resource Guide*. These models require collaboration
in planning, setting goals, establishing appropriate measures, designing
and implementing changes, gathering and analyzing data, and interpreting
the results. What features of these models seem particularly relevant to
your State?

Plan-Do-Study-Act
model:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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IHI model:
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Chronic Care model:
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Federal models:
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c\. "A New Framework for State-Led Quality Improvement" that uses
elements of these models is described on pages 31-35 of the *Resource
Guide* and illustrated in Figures 2.1-2.3. This framework adapts the
Plan-Do-Study-Act model into a Plan-Do-Assess improvement process
comprising three stages: (1) provide leadership; (2) work in
partnership; and (3) implement improvement. The State takes a lead role
in each stage.

1\) [Stage 1: Provide leadership]{.underline}. A key part of this stage
is championing the need for improving care and creating a quality
improvement vision.

*Plan*: Are there members of your staff with experience in quality
improvement who can help plan this effort and identify potential
partners?
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What other State officials can you call upon to collaborate in leading
the asthma care quality improvement effort? Consider the governor, other
elected officials, the Medicaid program director, health department
director, school superintendent, social services director, and others
whose programs serve large numbers of State residents with asthma.
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Can you identify ways to incorporate the case for asthma care quality
improvement that you assembled in Module 1 into your planning
efforts?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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*Do*: What is the best way to convene parties interested in improving
asthma care? Are there existing advisory bodies or workgroups? Who are
the key stakeholders that you would want to include? (These might be
community organizations, providers, health plans, employers and other
larger purchasers, as well as consumers.)
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> Can you identify resources to help develop networks that support this
> effort in your State?
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Assess*: How do you assess your planning efforts at this stage? Have
you established an environment and partnerships with stakeholders that
will foster quality improvement?
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What adjustments might be
necessary?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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\(2\) [Stage 2: Work in partnership]{.underline}. This stage relies on
the collaborative efforts of key stakeholders to develop a strategy,
plan activities, develop possible solutions, and assess the potential
pros and cons of these solutions before major implementation campaigns
are begun.

*Plan*: The Centers for Disease Control and Prevention supports asthma
programs in many States through its National Asthma Control Program.
(The CDC Web site has information and a link to these programs at
[www.cdc.gov/asthma]{.underline}.) Does your State already have an
asthma plan that identifies problems/issues to consider and goals to
address in developing a quality improvement strategy? Are there
established processes in place that you can use or adapt?

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What does the quality improvement team envision as the starting point?
For example, do you want to improve the quality of care among the entire
population or among vulnerable subgroups you have identified? Do you
want to focus on quality of care in physician practices? Do you want to
focus on reducing asthma hospitalizations? Is there more than one
priority to which the team wants to commit at this point?
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What steps need to be taken to design an initial intervention that
addresses your priority
area(s)?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Do*: How will the proposed intervention be tested? Is there existing
evidence from the literature or from your key stakeholders you can use?
Can you or other stakeholders conduct a small pilot study to get data?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Which measures will be used to determine whether the proposed
intervention is successful? What experts that you have identified can
you contact for information on these measures?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Assess*: What do the results of the test show? Who can you call on to
help interpret the results? Is there something else you might need to do
to gather more data?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Does analysis of the results seem to suggest that the quality
> improvement partnership needs to modify the intervention or find
> another solution? (Perhaps your analysis indicates that you may need
> to add measures to improve documentation of how well asthma care is
> provided in your State.) Or has another problem or critical issue
> emerged that you believe should be addressed instead?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

3\) [Stage 3: Implement improvement]{.underline}. This stage relies on
the partnership to bring about change statewide and evaluate its
outcomes.

*Plan*: What are the steps needed to implement the asthma quality
improvement intervention statewide? Specify the roles and
responsibilities that each partner in the quality improvement team has
agreed to take on to bring about this change.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Do*: What are the methods and mechanisms the quality improvement team
will use to spread the change to providers and others in the State? For
example will you use an advertising campaign, training programs,
community outreach, other vehicles, or combinations?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

##  How will you measure the impact of this effort to spread change on patients and providers? 

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

*Assess*: How will the team evaluate the outcomes of the quality
improvement effort, both successes and shortcomings? Is there a plan for
modifying the intervention, based on ongoing evaluation, to assure
continuous quality improvement?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2*.* Identify appropriate resources to help States reach their
improvement goals*. ***

Read "Information Resources for Quality Improvement (pages 35-37) in the
*Resource* *Guide* for a listing of some Federal programs and resources
on quality improvement and quality of care, including asthma care.

a\. Is your State using any of these resources? If so, how well have
they worked for you?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\. Visit the Web sites of the resources listed below. Jot down any
ideas to help you plan, implement, and evaluate an asthma care quality
improvement program.

-   Institute for Healthcare Improvement (IHI model):
    [www.ihi.org]{.underline}

Ideas:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   Improving Chronic Illness Care (Chronic Care model) :
    [www.improvingchronicare.org/]{.underline}

Ideas:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   National Healthcare Quality and Disparities Reports:
    [www.qualitytools.ahrq.gov]{.underline}

Ideas:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   State resources from the NHQR:
    [www.qualitytools.ahrq.gov/qualityreport/2005/state]{.underline}

Ideas:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   Healthcare Cost and Utilization Project databases:
    [www.hcup-us.ahrq.gov]{.underline}

Ideas:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   AHRQ evidence reports: [www.ahrq.gov/clinic/epcix.htm]{.underline}

Ideas:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Diabetes quality improvement tool:
[www.ahrq.gov/qual/diabqualoc.htm]{.underline}

Ideas:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   National Quality Measures Clearinghouse:
    [www.qualitymeasures.ahrq.gov]{.underline}

Ideas:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   Behavioral Risk Factor Surveillance System:
    [www.cdc.gov/brfss]{.underline}

Ideas:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   National Asthma Control Program:
    [www.cdc.gov/asthma/NACP.htm]{.underline}

Ideas:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   National Asthma Survey:
    [www.cdc.gov/nchs/about/major/slaits/nsa.htm]{.underline}

Ideas:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   National Asthma Education and Prevention Program:
    [www.nhlbi.nih.gov/about/naepp]{.underline}

Ideas:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

# Module 3: Learning From Current State Quality Improvement Efforts

**1.** **Use the quality improvement framework to identify various
national and State approaches to asthma care quality improvement.**

Read pages 39-47 on "Current State Efforts To Improve the Quality of
Asthma Care" in the *Resource Guide* for examples of programs that
reflect the three stages of the quality improvement framework: provide
leadership, work in partnership, and implement improvement.

a\. What *leadership* approaches of other States seem particularly
relevant to your State? These might include identifying "champions" for
asthma quality improvement as well as advisory bodies, workgroups, and
coalitions to help pull the overall effort together.
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\. What types of State practices seem to offer the best opportunities
for leveraging *partnerships* to advance asthma care quality
improvement? What can you learn from States that have worked in
partnership with others (within and outside health care settings) to
develop and implement quality improvement plans, promote guidelines, or
improve their ability to measure and monitor
quality?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

c\. Which State programs would be most useful as examples for
*implementing* an asthma quality improvement effort? Are there specific
categories of activities that seem most relevant to your State's quality
improvement initiative (such as self-management, patient/public
education, provider training, or disease management)?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2.** **Start an inventory of your State's quality improvement programs
and resources.**

Review Appendix C (pages 92-103) in the *Resource* *Guide* for a list of
over 100 asthma quality improvement programs in 12 areas and Web links
for more information on each program.

a\. Inventory your own State quality improvement activities related to
asthma. Use the categories listed in Appendix C (see page 92 of the
*Resource Guide*) to organize your inventory. In the grid that follows,
fill in what you know about groups in your State already assembled
around asthma and asthma care; place a check () if this activity is
ongoing. If you know of other asthma-related activities that might not
seem to fit within the categories listed below, jot them down in the
lines after the inventory.

**Asthma-Related Quality Improvement Programs in Your State, by Type of
Activity**

  -------------------------------------------------------------------------
  **Type of activity**                 **Name of program**     **Program
                                                               contact**
  ------------------------------- ---- ----------------------- ------------
  Advisory                                                      
  bodies/councils/workgroups                                   

  Coalitions (networks)                                         

  Collaboratives                                               

  Cross-agency work                                             

  Data measurement and reporting                               

  Developing/enforcing guidelines                              

  Disease management                                           

  Minority and rural outreach                                  

  Public service/education                                      
  efforts                                                      

  Self-management                                               

  Provider training                                             

  Use of technology                                             
  -------------------------------------------------------------------------

Other:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\. Review your answers to questions 1a, 1b, and 1c above. Are there
asthma-related activities for which you and your quality improvement
team see a need but which do not appear in your inventory? Who might you
contact to get more information on how to address this need?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**Module 4: Measuring Quality of Care for Asthma**

Read pages 49-55 in the *Resource Guide* on quality measurement and
dimensions of care for asthma, including selecting process and outcome
measures for these dimensions of care.

**1. Understand quality measures and how measures of process and outcome
can be used to track the quality of asthma care.**

a\. Look at the diagram on page 51 of the *Resource* *Guide*.

1\) What does the diagram tell you about daily use of medications by
people with asthma (a process measure) and number of hospitalizations
for asthma (an outcome measure)?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2\) How would increasing daily use of medications by people with asthma
improve asthma
outcomes?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\. Review Table 4.1 (pages 53-55) and Appendix D (pages 104-112) in the
*Resource* *Guide* to learn about additional process and outcome
measures and other dimensions of asthma care management. For many of the
measures, special surveys or data collection efforts may be required.
Does your State collect data for any of these measures?

Process measures (such as medication use, management plans,
self-management, planned care):

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Outcome measures (such as symptom burden, work or school days lost,
asthma hospitalizations):

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Other measures (such as access to care through insurance, asthma
prevalence):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**2. Inventory available data systems and other resources to use in
developing State or local estimates.**

Review pages 55-59 in Module 4 and Appendixes E and F (pages 113-131 and
132-138, respectively) in the *Resource Guide*. These sections present
information on sources of measures and data for asthma care, including
data limitations and State estimates for various measures.

a\. Begin an inventory list of the data sources available for your State
below. You may wish to write down any questions or concerns you have
about these data sources on the grid---items about which you need to
contact data resource experts in your State. Place a check () if data
are available for your State.

  ---------------------------- ----- ------------------------------------
  Data source                        Questions/notes

  Behavioral Risk Factor             
  Surveillance System - CDC          

  Healthcare Cost and                
  Utilization Project - AHRQ         

  HEDIS^®^ data from the             
  National Committee for             
  Quality Assurance (available       
  by region only)                    

  National Asthma Survey - CDC       

  Other CDC surveys                  

  State vital statistics             

  Special disease registries         

  Statewide hospital discharge       
  data                               

  Medicaid health provider           
  reimbursement claims               

  State employee health              
  benefits claims                    

  Census population data             

  Area Resource File -- HRSA         

  Kaiser Family Foundation           

  Other statewide or local           
  sources (school,                   
  occupational health,               
  environmental assessments,         
  etc.)                              

  Other setting-specific             
  sources (hospitals,                
  community health centers,          
  primary care practices,            
  etc.)                              

  State and local initiatives        
  from other States                  
  ---------------------------- ----- ------------------------------------

b\. Review your answers to questions 1.b and 2.a above. Can you identify
any gaps in information or resources that you believe are important for
assessing asthma care in your State? How will you address
them?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

**3. Define "benchmark" as a measurement tool and understand how to
identify appropriate benchmarks when developing quality improvement
goals.**

Read pages 59-66 and Appendix G (pages 139-140) in the *Resource Guide*
on benchmarks and examples of how States may use them in quality
improvement. Benchmarks are values that can be used as markers for
measuring performance. Common benchmarks are national or regional
averages, individual State rates, or best-in-class (top 10 percent of
States) averages.

a\. Review your answers to question 1c in Module 1 where you compared
your State with the national and best-in-class averages for asthma
hospitalization rates. How did you assess your State's performance
against these benchmarks?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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b\. Page 60 of the *Resource Guide* lists six measures from BRFSS for
which national and best-in-class benchmarks were calculated. These
include four asthma process measures (routine care, medication use,
advice to quit smoking, and flu shots) and two asthma outcome measures
(urgent care and emergency room visits). These benchmarks are listed in
Table 4.2 (page 56) of the *Resource Guide* and reproduced in the table
below.

1\) Go to Appendix Table E.1 (page 115) in the *Resource* *Guide*; this
table lists national and best-in-class averages for selected BRFSS
measures by State, including the six measures below. Locate the values
for your State and write them in the blanks. (If your State is not
listed in Appendix Table E.1, or if your State collects its own data for
these measures, contact your State health data agency for these
percentages and write them in the table below.) Subtract your State
average from the best-in-class average to assess how many percentage
points your State must improve to be a top performer. Note on the last
two measures, a lower value is better.

  ------------------------------------ --------- --------------- ------- ---------------
  Measure                              U.S.      Best-in-class   Your    Best-in-class
                                       average   average (%)     State   average minus
                                       (%)                       (%)     your State
                                                                         average (+/-)

  Planned/routine care for asthma (2   28.3      40.4                    
  visits in past 12 months)                                              

  Advice to quite smoking              82.2      87.9                    

  Flu shot (in past 12 months)         40.3      53.3                    

  Medication use for asthma (in past   71.1      75.3                    
  month)                                                                 

  Urgent care visit (in past 12        28.1      19.4                    
  months)                                                                

  Emergency room visit (in past 12     17.7      12.2                    
  months)                                                                
  ------------------------------------ --------- --------------- ------- ---------------

2\) How does your State compare to the national and best-in-class
averages for these measures?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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c\. Look at Figure 4.1 (page 61) in the *Resource Guide*, which
illustrates the national and best-in-class averages for these six
measures and the range of variation among States in the four regions.
Examples of how four individual States compare against benchmarks on
some of these measures are shown in Figures 4.2-4.5 (pages 62-65) in the
*Resource Guide*.

Again using Appendix Table E.1 (or your own State data), select two
States with some characteristics similar to your State and write their
values for these six measures in the following table. Subtract the
percentages for each of these others States from your percentages. Write
the differences below; check off measures for which your State is
performing better than State A and/or State B.

  ------------------ -------- ------------ -------- -------- ------------ --------
  Measure            State A  Your State   Better   State B  Your State   Better
                     (%)      minus State  than     (%)      minus State  than
                              A (points    State A           B (points    State B
                              different)                     different)   

  Planned/routine                                                         
  care for asthma (2                                                      
  visits in past 12                                                       
  months)                                                                 

  Advice to quit                                                          
  smoking                                                                 

  Flu shot (in past                                                       
  12 months)                                                              

  Medication use for                                                      
  asthma (in past                                                         
  month)                                                                  

  Urgent care visit                                                       
  (in past 12                                                             
  months)                                                                 

  Emergency room                                                          
  visit (in past 12                                                       
  months)                                                                 
  ------------------ -------- ------------ -------- -------- ------------ --------

d\. It is important to know whether a State's results are significantly
different from the benchmark from a statistical standpoint. (Refer to
Appendix H on pages 141-143 of the *Resource Guide* for further
information on statistical significance.) Look at your answers to
question 3b above; then go to Appendix Table E.1 on page 115 of the
*Resource Guide*.

1\) Are any of the percentages for your State significantly
[above]{.underline} the national average (as indicated by a + sign next
to the value for your State in Appendix Table E.1)? Which ones?

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2\) Are any of the percentages for your State significantly
[below]{.underline} the national average (as indicated by a − sign next
to the value for your State in Appendix Table E.1)? Which ones?
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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3\) Are any of the percentages for your State within the best-in-class
range and thus not significantly different from the best-in-class
average (as indicated by a † sign next to the value for your State in
Appendix Table E.1)? Which ones?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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e\. Using your answers to question 3d above, together with the
discussion of four States on pages 62-66 of the *Resource* *Guide* as
examples, write a similar analysis of your State's results. On which
measures is your State doing well? In what areas could you improve?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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**4. List various sociodemographic, behavioral, and environmental
factors that must be considered in setting quality improvement goals.**

Review pages 66-70 of the *Resource* *Guide* on the factors that affect
asthma quality of care. A State's performance on quality measures may be
affected by a number of factors, including poor access to health care,
high proportions of subgroups with no insurance, cultural attitudes
toward health care providers, etc. In addition State or employer
decisions regarding coverage policies may affect the way providers
deliver care. For example, certain asthma medications may not be
reimbursed by a patient's health plan, and so the patient may have to
pay out of pocket for certain prescribed medication and may not be able
to afford them. There are also factors over which States have little or
no control, such as asthma prevalence and population characteristics.
(To find additional information on measures for some of these factors,
such as percentage of population uninsured, you can use the Henry J.
Kaiser Family Foundation Web site on State health facts at
[http://www.statehealthfacts.org]{.underline}.)

a\. What characteristics of your State, its infrastructure, and your
State's population might help to account for your answers to questions
3d and 3e above? For example, does your State have a substantial
Medicaid population or large numbers of uninsured persons, racial or
ethnic minorities, people with less than a high school education, or
other vulnerable groups?

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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b\. What other issues or concerns might affect your State's performance
in asthma care? Are there additional factors that you and your team need
to consider in determining your starting point and setting initial goals
for quality improvement in asthma
care?\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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**5.** **Using appropriate benchmarks, draft goals for a State quality
improvement effort.**

a\. Look at your answers to question 1c in Module 1 and question 3a-3d
in Module 4 on how your State compares with benchmarks on the asthma
measures presented here. (If necessary, also review pages 59-60 and
Appendix G in the *Resource Guide* for a discussion of types of
benchmarks and why different benchmarks might be chosen in different
circumstances.)

1\) To begin your quality improvement effort, which benchmarks for the
following measures would you select for your State? Place a check () in
the blank of the measure you select. If you check "Other benchmark" for
your State, describe it (for example, a regional average).

+---------------------------------+-----------+-----------+----------+
| Measure                         | U.S.      | Best      | Other    |
|                                 | average   | -in-class | b        |
|                                 | ()        | average   | enchmark |
|                                 |           | ()        | (d       |
|                                 |           |           | escribe) |
+---------------------------------+-----------+-----------+----------+
| Planned/routine care for asthma |           |           |          |
| (2 visits in past 12 months)    |           |           |          |
+---------------------------------+-----------+-----------+----------+
| Advice to quite smoking         |           |           |          |
+---------------------------------+-----------+-----------+----------+
| Flu shot (in past 12 months)    |           |           |          |
+---------------------------------+-----------+-----------+----------+
| Medication use for asthma (in   |           |           |          |
| past month)                     |           |           |          |
+---------------------------------+-----------+-----------+----------+
| Urgent care visit (in past 12   |           |           |          |
| months)                         |           |           |          |
+---------------------------------+-----------+-----------+----------+
| Emergency room visit (in past   |           |           |          |
| 12 months)                      |           |           |          |
+---------------------------------+-----------+-----------+----------+
| Asthma hospitalization rate     |           |           |          |
| (per 100,000):                  |           |           |          |
|                                 |           |           |          |
| ◦ Children                      |           |           |          |
|                                 |           |           |          |
| ◦ Adults \<65                   |           |           |          |
|                                 |           |           |          |
| ◦ Adults 65+                    |           |           |          |
+---------------------------------+-----------+-----------+----------+

2\) For each measure, why did you select that benchmark? Write your
reasons below.

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

+-----------------------------------------------------------------------+
| Planned/routine care for asthma (2 visits in past 12 months):         |
+-----------------------------------------------------------------------+
| Advice to quit smoking:                                               |
+-----------------------------------------------------------------------+
| Flu shot (in past 12 months):                                         |
+-----------------------------------------------------------------------+
| Medication use for asthma (in past month):                            |
+-----------------------------------------------------------------------+
| Urgent care visit (in past 12 months):                                |
+-----------------------------------------------------------------------+
| Emergency room visit (in past 12 months):                             |
+-----------------------------------------------------------------------+
| Asthma hospitalization rate (per 100,000):                            |
|                                                                       |
| ◦ Children                                                            |
|                                                                       |
| ◦ Adults \<65                                                         |
|                                                                       |
| ◦ Adults 65+                                                          |
+-----------------------------------------------------------------------+

3\) Set a preliminary goal to reach the benchmark for the measures you
have selected. The following are some examples of goal statements:

-   Increase the percent of adults with asthma who receive a planned
    care visit for asthma once every 6 months to the level of the best
    in class average---40.4 percent---within 2 years. (The specifics on
    these measures (e.g., which measures and period of time to reach the
    goal) should be established by your quality improvement team).

-   Increase use of inhaled corticosteroids medication for adults with
    persistent asthma to the level of use on average across the
    Nation---71.1 percent of adults with asthma---within 2 years.

-   Increase the percent of adults with asthma who receive flu
    vaccinations to the best-in-class average---53.3 percent---within 2
    years. (An aggressive program might set an even higher goal or
    tighter time frame.)

-   Reduce the hospitalization rate for asthma to the best-in-class
    averages (for children, 72.3 per 100,000) and for adults under age
    65, 60.2 per 100,000).

-   Identify the barriers to obtaining planned/routine care visits,
    smoking cessation counseling, or flu vaccinations.

[What are the preliminary goals for the following?]{.underline}

Planned/routine care for asthma (2 visits in past 12 months):

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Advice to quit smoking:

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Flu shot (in past 12 months):

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Medication use for asthma (in past month):

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Urgent care visit (in past 12 months):

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Emergency room visit (in past 12 months):

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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Asthma hospitalization rate (per 100,000):

Children\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Adults
\<65\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Adults
65+\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

b\. You may want to go beyond the measures listed above. Refer to
Appendix E (pages 113-131) in the *Resource* *Guide* for additional
BRFSS asthma measures you may want to consider in your quality
improvement effort. Some of these measures are listed below. Are any of
these measures appropriate for your State? Note those you want to
investigate further.

Asthma attacks/episodes (in past 12 months):

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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Limited activity days (in past 12 months):

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

No sleep difficulty due to asthma (in past month):

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Doctor visit for asthma (in past 12 months):

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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Asthma symptom-free days (in past 2 weeks):

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Asthma symptoms everyday (in past 2 weeks):

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Other:

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# Module 5: Moving Ahead -- Implications for State Action

**1. Summarize the essential elements for an asthma care quality
improvement effort in your State.**

Read pages 74-76 in the *Resource Guide* which discusses the essential
elements of developing and implementing a State action plan. Note your
strengths and any needs in these areas:

a\. [Providing leadership and vision]{.underline}. Identify leaders to
champion the quality improvement effort and develop a common vision for
improving asthma care.

Strengths/needs:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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b\. [Forming partnerships and collaborations]{.underline}. Identify key
stakeholders and strategic partners in quality improvement; recruit
other groups---public and private, formal and informal---to further the
effort (such as policy staff, asthma care experts, Medicaid or other
health program staff, data and program evaluation experts, and other
networks, workgroups and coalitions).

Strengths/needs:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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c\. [Identifying measures and data sources]{.underline}. Identify data
and other information resources that will support an asthma quality
improvement effort as well as any gaps in data and measures.

Strengths/needs:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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d\. [Assisting planning and goal setting]{.underline}. Based on the
needs identified and the data resources and quality measures available,
set initial goals for asthma care quality improvement.

Strengths/needs:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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e\. [Assuring evaluation and accountability]{.underline}. Determine the
purpose, goals/objectives, and intended users of the evaluation; the
methods to be used in gathering, analyzing, and interpreting the
results; and any potential limitations of the information.

Strengths/needs:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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f\. [Creating incentives]{.underline}. Explore ways to reward providers
for delivery of high-quality care, such as financial incentives, bonus
awards, or other incentive programs.

Strengths/needs:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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g\. [Spreading the change statewide]{.underline}. Disseminate lessons
learned and best practices beyond the quality improvement team to spread
improvements in asthma care throughout the State.

Strengths/needs:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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# A Final Note

By answering the questions in this *Workbook,* you have used the
Plan-Do-Assess approach to determine your State's needs and available
resources, identify measures to be used, set initial goals, and begin
considering an evaluation strategy for quality improvement; now you are
ready to take action. The goal of improving asthma care quality in your
State may at first seem overwhelming. Yet, with small, smart steps, you
can make that happen. 

 

Assemble your staff or your network of State leaders and discuss the
idea.  Most likely you will want them to read the *Resource* *Guide*, do
the exercises in this *Workbook*, and prepare some ideas for a
preliminary plan even before you meet.  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---is critical.  Find out who the
change agents for health care quality are in your State.

Any work plan must be shared with key stakeholders who may modify it in
slight or drastic ways. A preliminary plan sets the stage for discussion
and interaction with health care providers and policymakers. Flexibility
within these interactions will be important to making progress and
implementing improvement statewide.  

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