**Diabetes Care Quality Improvement: A Workbook for State Action**

Prepared by

Barbara Kass, M.P.H.

Department of Health and Human Services

Agency for Healthcare Research and Quality

Rockville, Maryland

*www.ahrq.gov*

AHRQ Publication No. 04-0073

September 2004

**Acknowledgment**

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

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

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

Foreword

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

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

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

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

Contents

Foreword iii

Introduction 1

Module 1: Background---Making the Case for Diabetes Care Quality
Improvement 5

Module 2: Data---Understanding the Foundation of Quality Improvement....
10

Module 3: Information---Interpreting State Estimates of Diabetes
Quality... 18

Module 4: Action---Learning From Activities Currently Underway... 24

Module 5: Improvement---Developing a Strategy for Diabetes Quality
Improvement... 31

Module 6: The Way Forward---Promoting Quality Improvement in the States
36

A Final Note\... 38

**Introduction**

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

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

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

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

**Diabetes Care Quality Improvement: Resources for State Action**

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

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

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

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

**Why Diabetes?**

About 6.3 percent of the U.S. population is estimated to have
diabetes.^1^ It is a costly medical condition, not only in dollars, but
also in physical well-being. For individuals with diabetes, the average
medical costs are \$13,000 per year compared to \$2,500 per year for the
average patient without diabetes.^2^ The death rate from diabetes makes
it the Nation's sixth leading killer.^1^ There is a long list of
complications from diabetes such as heart disease, hypertension, stroke,
leg and foot ulcers, lower-limb amputation, blindness, kidney disease,
and coma and death.^1^ Many of these complications and deaths from
diabetes can be prevented or delayed with proven interventions.

**Aim and Scope of This *Workbook***

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

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

-   Recite the factors that affect the quality of care for diabetes.

-   Understand the key issues surrounding diabetes quality improvement.

-   Assess their States' performance in providing diabetes care.

-   Identify national, public-private, Federal, State, and local
    resources and best practices in diabetes quality improvement.

-   Assemble and analyze State-specific data about diabetes and health
    care quality to begin planning a quality improvement strategy.

-   Identify opportunities to contribute to improving diabetes care
    quality.

There are several measures of health care that indicate whether or not
people with diabetes are receiving appropriate care. The scope of this
*Workbook* encompasses four of those measures which are recommended by
clinical guidelines:

-   Percent of adults with diabetes who had a hemoglobin A1c (HbA1c)
    measurement at least once in the past year. (HbA1c measures the
    average blood glucose level over the past 9-120 days and is used to
    help guide treatment so that the person with diabetes is maintaining
    a safe glucose level to prevent damage to the kidneys, heart, etc.)

-   Percent of adults with diabetes who had a retinal eye examination in
    the past year (to identify damage to blood vessels in the eye).

-   Percent of adults with diabetes who had a foot examination in the
    past year (to find sores or wounds that are not healing properly).

-   Percent of adults with diabetes who had an influenza vaccination in
    the past year (to prevent problems with diabetes control that can
    result from getting the flu).

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

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

**Who Should Use This Workbook**

This workbook is intended for multiple users:

-   State elected leaders (governors, legislators, and their staff who
    provide leadership on health policy).

-   State executive branch officials (State health departments, diabetes
    prevention and control program leaders, Medicaid officials, and
    their staff).

-   Non-governmental State and local health care leaders (professional
    societies, provider associations, quality improvement organizations,
    voluntary health organization, health plans, business coalitions,
    community organizations, and consumer groups).

**How To Use This Workbook**

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

The user should first read the Executive Summary and Introduction of the
*Resource Guide*. The Executive Summary gives an overview of the
*National Healthcare Quality Report* and the *National Healthcare
Disparities Report* and outlines the purpose and structure of the
*Resource* *Guide*. The Introduction provides information about how to
use the *Resource* *Guide*. Based on the State 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: Background]{.underline}---Making the Case for Diabetes
    Care Quality Improvement

-   [Module 4: Action]{.underline}---Learning From Activities Currently
    Underway

-   [Module 6: The Way Forward]{.underline}---Promoting Quality
    Improvement in the States

*Staff specialists*

-   [Module 2: Data]{.underline}---Understanding the Foundation of
    Quality Improvement

-   [Module 3: Information]{.underline}---Interpreting State Estimates
    of Diabetes Quality

-   [Module 5: Improvement]{.underline}---Developing a Strategy for
    Diabetes Quality Improvement

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

**References**

^1^ Centers for Disease Control and Prevention. (2003). Diabetes: A
serious public health problem. Available at:
www.cdc.gov/nccdphp/bb_diabetes/ (accessed December 17, 2003).

^2^ Hogan P, Dall T, Nikolov P. (2003). Economic costs of diabetes in
the U.S. in 2002. Diabetes Care, 26(3):917-32.

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

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

Review pages 7-19 of the *Resource Guide*.

a\. Look at Figure 1.1 on page 10. This figure shows the diabetes
prevalence range diagnosed for every 100 adults in 1994 for a standard
age distribution across the States and then again in 2002. For example,
in 1994, in Oklahoma less than 4 percent of adults (age-adjusted) had
been diagnosed with diabetes. In 2002, this prevalence was at 6 percent
or greater. If you want to know the unadjusted (actual) diabetes
prevalence for your State, look in Table 2.3, page 37 of the *Resource
Guide*.

-   What was the percent range of age-standardized diabetes prevalence
    in your State for 1994? (Figure 1.1, page 10)

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-   What was the percent range of age-standardized diabetes prevalence
    in your State for 2002? (Figure 1.1, page 10)

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

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

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

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

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

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

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

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

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

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

+-----------------------------------------------------------------------+
| 1.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| 2.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| 3.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| 4.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| 5.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+
| 6.  \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\     |
| _\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ |
+-----------------------------------------------------------------------+

g\. What measures for diabetes are below average?

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

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

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

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**Module 2: Data --- Understanding the Foundation of Quality
Improvement**

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

Read pages 21-24 and Figure 2.1 on page 25 of the *Resource* *Guide* and
answer the following questions:

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

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b\. How would increasing HbA1c testing improve diabetes outcomes?

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

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

a\. From Table 2.1 (page 28), locate the information on your State. Fill
in the blanks below:

+--------------+---------+------------+---------------+---------------+
| Percent of   | Your    | National   | Best-in-class | Healthy       |
| adults (in   | State   | average    | average (%)\* | People 2010   |
| 2001) who    | (%)     | (%)\*      |               | goal (%)\*    |
| received:    |         |            |               |               |
+--------------+---------+------------+---------------+---------------+
| HbA1c        |         | > 61       | > 82          | > 50          |
| testing      |         |            |               |               |
+--------------+---------+------------+---------------+---------------+
| Retinal eye  |         | > 67       | > 81          | > 75          |
| examination  |         |            |               |               |
+--------------+---------+------------+---------------+---------------+
| Foot         |         | > 65       | > 82          | > 75          |
| examination  |         |            |               |               |
+--------------+---------+------------+---------------+---------------+
| Flu          |         | > 37       | > 58          | > n/a         |
| vaccination  |         |            |               |               |
+--------------+---------+------------+---------------+---------------+
| \*Review the |         |            |               |               |
| *Resource    |         |            |               |               |
| Guide*       |         |            |               |               |
| Appendix D   |         |            |               |               |
| on page 127  |         |            |               |               |
| for          |         |            |               |               |
| definitions  |         |            |               |               |
| of these     |         |            |               |               |
| terms. The   |         |            |               |               |
| figures are  |         |            |               |               |
| from Table   |         |            |               |               |
| D.1, page    |         |            |               |               |
| 129.         |         |            |               |               |
+--------------+---------+------------+---------------+---------------+

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

  ---------------- ---------------- ---------------- ---------------------
                   Percent your                      
                   State is above                    
                   (+) or below (-)                  

  Percent of       National average Best-in-class    Healthy People 2010
  adults (in 2001) (%)              average (%)      goal (%)
  who received:                                      

  HbA1c testing                                      

  Retinal eye                                        
  examination                                        

  Foot examination                                   

  Flu vaccination                                    n/a
  ---------------- ---------------- ---------------- ---------------------

c\. Select two States from table 2.1 within your region or locality and
write their figures down below. Then subtract your percent from their
percents. How does your State compare?

+--------------+------------+-------------+-------------+-------------+
| Percent of   | \_\_\_     | Percent     | \_\_\_\     | Percent     |
| adults (in   | \_\_\_\_\_ | your State  | _\_\_\_\_\_ | your State  |
| 2001) who    |            | is above    |             | is above    |
| received     | (State)    | (+) or      | (State)     | (+) or      |
|              |            | below (-)   |             | below (-)   |
|              | (%)        | this State  | (%)         | this State  |
+--------------+------------+-------------+-------------+-------------+
| HbA1c        |            |             |             |             |
| testing      |            |             |             |             |
+--------------+------------+-------------+-------------+-------------+
| Retinal eye  |            |             |             |             |
| examination  |            |             |             |             |
+--------------+------------+-------------+-------------+-------------+
| Foot         |            |             |             |             |
| examination  |            |             |             |             |
+--------------+------------+-------------+-------------+-------------+
| Flu          |            |             |             |             |
| vaccination  |            |             |             |             |
+--------------+------------+-------------+-------------+-------------+

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

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e\. Where do you see the need for improvement?

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

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

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

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

  -------------------------- ----------- ---------------------------------
  Data source                Data        Notes
                             available   
                             on your     
                             State?      
                             (Yes/No)    

  BRFSS                                  

  HCUP                                   

  State vital statistics                 

  Disease registries                     

  Medicaid health provider               
  reimbursement claims                   

  State employee health                  
  benefits claims                        

  Census population data                 

  Area Resource File                     

  National Committee on                  
  Quality Assurance data                 

  State Diabetes Prevention              
  and Control Program (DPCP)             

  CDC Division of Diabetes               
  Translation                            

  Kaiser Family Foundation               

  Others:                                

                                         

                                         
  -------------------------- ----------- ---------------------------------

**4. Use published studies to arrive at State or local estimates.**

Review page 33 of the *Resource* *Guide* on using published studies.

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

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b\. Where do you see a need for further research?

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

Review pages 33-38 of the *Resource Guide*.

a\. Direct costs are expenditures associated directly with treatment of
the disease: routine services, treatment of complications, and medical
conditions attributable to diabetes. Indirect costs are the lost
opportunities or additional costs of living that affect individuals
because they have diabetes: lost wages and productivity, the cost of
dealing with impairments, premature death, etc. Do you have better
estimates for costs from your State's Department of Health or Medicaid
office than those listed in Table 2.2 on page 35?

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Your State estimates for spending on diabetes medical care would be more
accurate than these derived through national studies and generalized
assumptions.

b\. From Table 2.3 on page 37, find the figures for your State and the
two States in question 2c above and fill in the blanks:

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

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d\. What do you think the differences are related to? Can you document
any of that with data from your State's Department of Health?

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

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

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**Module 3: Information --- Interpreting State Estimates of Diabetes
Quality**

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

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

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

![](media/image1.wmf){width="6.002777777777778in" height="2.55in"}

b\. Note whether your State rates fall above or below the national
average benchmarks and where they are in relation to other States. Go
back to Table 2.1 on page 28 of the *Resource Guide* for the rates by
State. Are any of the percentages for your State:

> 1\) Significantly above the national average (indicated by a "+" sign
> next to the value for your State rate)? Which ones?

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> 2\) Significantly below the national average (indicated by a "-" sign
> next to the rate)? Which ones?

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

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> 4\) Significantly below the best-in-class range (does not include a
> "‡" sign next to the State rate)? Which ones?

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

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**2. Identify factors that influence a State's position among other
States.**

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

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

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b\. Study Figure 3.6 on page 58. Note the relationships between hospital
admissions, obesity, poverty, and diabetes prevalence.

> 1\) What inferences can you make from the data?

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

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> 3\) If your State's data are not listed in Figure 3.6, how could you
> get these data for your State? (Hint: see your response to the data
> sources question from Module 2.)

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

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

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

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

b\. Write the figure in the appropriate blank below:

  ---------------- --------------- ------------------ -------------------
                   National        Best-in-class      National HP 2010
                   average         average            goal

  HbA1c test                                          

  Retinal exam                                        

  Foot exam                                           

  Flu vaccination                                     n/a
  ---------------- --------------- ------------------ -------------------

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

  -----------------------------------------------------------------------
  HbA1c test:

  Retinal exam:

  Foot exam:

  Flu vaccination:
  -----------------------------------------------------------------------

**4. Draft preliminary goals for specific measures.**

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

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

-   Increase the number of adults with diabetes who receive an HbA1c
    test at least once a year to the level of the national average -- 61
    percent.

-   Increase the number of adults with diabetes who receive an HbA1c
    test at least once in a year to the best-in-class average -- 82
    percent.

-   Increase retinal exam testing for adults with diabetes by 5
    percentage points within the next 3 years.

-   Increase the number of adults with diabetes who receive foot
    examinations from their physicians to reach the Healthy People 2010
    goal -- 75 percent.

-   Increase the number of adults with diabetes who receive flu
    vaccinations to the best-in-class average -- 58 percent.

-   Identify the barriers to obtaining HbA1c testing or retinal exams or
    foot examinations or flu vaccinations.

-   Begin collecting data on any or all of the measures (if your State
    does not already have these data).

[What are your preliminary goals for:]{.underline}

  -----------------------------------------------------------------------
  HbA1c testing:

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  Retinal exam:

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  Foot exam:

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------
  Flu vaccination:

  -----------------------------------------------------------------------

**Module 4: Action --- Learning From Activities Currently Underway**

**1. Identify tools and resources to build a quality improvement
program.**

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

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

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

b\. If so, how well are they working?

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

> c\. Visit some Web sites listed below and jot down ideas to help you
> build, implement, and evaluate a diabetes care quality improvement
> program. (Note: additional quality improvement initiatives are located
> in Appendix G, which begins on page 148 of the *Resource Guide*.)
>
> ***National Diabetes Quality Improvement Alliance***
>
> <http://www.nationaldiabetesalliance.org/>

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

> ***Chronic Care Model***
>
> [http://www.improvingchroniccare.org](http://www.icic.org/)

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

> ***IHI Breakthrough Series Collaborative***

-   Institute for Healthcare Improvement (IHI) Breakthrough
    Collaboratives general information:

> [http://www.ihi.org/IHI/Programs/CollaborativeLearning/]{.underline}

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

-   Improving care for people with chronic conditions -- diabetes:

> [http://www.ihi.org/IHI/Topics/ChronicConditions/Diabetes/HowToImprove/]{.underline}

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

-   Report from the Health Disparities Collaborative on Diabetes:
    [http://www.healthdisparities.net/Diabetes_Apr2002.pdf](http://www.ihi.org/collaboratives/Diabetes_Apr2002.pdf)

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

> ***Disease Management Programs***

-   Disease Management Association of America

> [http://www.dmaa.org](http://www.dmaa.org/)

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

-   Council of State Governments

> [http://www.csg.org/CSG/Policy/health/chronic+illness/default.htm](http://www.csg.org/CSG/Policy/health/chronic+illness+.htm)

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

> ***Self-Management Programs***

-   Chronic Disease Self-management Program at Stanford University
    <http://patienteducation.stanford.edu/programs/>

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

> ***Federal Programs and Resources for Diabetes Quality Improvement***

-   CDC Diabetes Prevention and Control Program (the State's DPCP)
    [http://www.cdc.gov/diabetes/states/index.htm](http://www.cdc.gov/diabetes/states/index.htm#laws)

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

-   Diabetes Detection Initiative and Steps to a Healthier US Initiative

> <http://www.ndep.nih.gov/ddi> and
> [http://www.healthierus.gov/steps/index.html](http://www.healtheirus.gov/steps/index.html)

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

-   Health Resources and Services Administration, Bureau of Primary
    Health Care, Health Disparities Collaboratives

> <http://bphc.hrsa.gov/programs/HDCProgramInfo.htm> and
> <http://www.healthdisparities.net/>

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

-   National Diabetes Education Program (NDEP)

> [http://ndep.nih.gov](http://ndep.nih.gov/) and
> [http://]{.underline}[www.betterdiabetescare.org](http://www.betterdiabetescare.org/)

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

-   Centers for Medicare & Medicaid Services Quality Improvement
    Organizations

> <http://www.medqic.org/content/nationalpriorities/topics/projectdes.jsp?topicID=477&showMeasures=yes&showSteps=yes>

  -----------------------------------------------------------------------
  Ideas:

  -----------------------------------------------------------------------

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

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

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

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

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

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

c\. What partnerships should you seek?

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**3. Create an inventory of your State's quality improvement actions and
resources.**

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

+--------------------------------+---------+-------------+-----------+
| **State Diabetes Quality       |         |             |           |
| Improvement Inventory**        |         |             |           |
+--------------------------------+---------+-------------+-----------+
|                                | **Stage |             |           |
|                                | of      |             |           |
|                                | Develo  |             |           |
|                                | pment** |             |           |
+--------------------------------+---------+-------------+-----------+
| **State Quality Improvement    | **Pla   | **Imple     | **Eva     |
| Action**                       | nning** | mentation** | luation** |
+--------------------------------+---------+-------------+-----------+
| ***Partnership/Planning        |         |             |           |
| Activities***                  |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Coalition/Advisory Board** |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Collaborative**            |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Cross-Agency Initiatives** |         |             |           |
+--------------------------------+---------+-------------+-----------+
| ***Program Development         |         |             |           |
| Activities***                  |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Diabetes Care Guidelines** |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Data Measurement and       |         |             |           |
| > Reporting**                  |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Information Technology**   |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Patient Education/Self     |         |             |           |
| > Management**                 |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Provider Training**        |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Collaborative**            |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Disease Management**       |         |             |           |
+--------------------------------+---------+-------------+-----------+
| ***Dissemination Activities*** |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Raising Awareness**        |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Minority and Rural         |         |             |           |
| > Outreach**                   |         |             |           |
+--------------------------------+---------+-------------+-----------+
| **Other Quality Improvement    |         |             |           |
| Action in My State**           |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Non-Governmental           |         |             |           |
| > Initiatives**                |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Federal Initiatives**      |         |             |           |
+--------------------------------+---------+-------------+-----------+
| > **Local Initiatives**        |         |             |           |
+--------------------------------+---------+-------------+-----------+

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

  ----------------- ------------- ------------ -------------- --------------
                    CDC funding   State        State in-kind  Total
                                  general fund                

  Your State                                                  

  Comparable State                                            

  Comparable State                                            

  Comparable State                                            
  ----------------- ------------- ------------ -------------- --------------

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

1.  **Have assembled in this document the information from Modules 1-4
    above that presents: a) the case for diabetes quality improvement in
    the State; b) a preliminary strategy suited to the State; and c)
    strategic partnerships for diabetes quality improvement efforts.**

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

1\) From Module 1, questions 1a, 1b, 1c, 1d, 1e, 1f, 1g, 1h:

-   Has diabetes increased in prevalence from 1994 to 2002 in your
    State?

-   Why should improving diabetes care be a priority?

-   What populations are vulnerable to gaps in diabetes care?

-   What measures for diabetes care are below average in your State?

2\) From Module 2, questions 2a, 2b, 2c, 2e, 3a, 4a, 4b, 4c:

-   How does your State compare with national and best-in-class
    averages?

-   How close are you to the Healthy People 2010 goals?

-   How does your State compare with other States in your region or
    locality?

-   Where do you need the most improvement?

-   What is the cost of diabetes in your State?

-   How do you compare with other States in your region or locality?

3\) From Module 2, question 2d and Module 3, questions 1a, 1b, 2a, 2b:

-   Which diabetes health care measures are below the national average?

-   What factors affect the quality of diabetes care in your State?

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

1\) Decide on topic areas related to quality improvement.

-   What do you predict as the current obstacles to quality care?
    (Module 1, question 1e)

-   What factors influence diabetes care? (Module 2, questions 2d, 2e,
    3a; Module 3, questions 2a, 2b)

-   What questions do you have about the quality of diabetes care?
    (Module 2, question 2g; Module 3, questions 2a, 2b)

-   What does current research indicate about diabetes care in your
    State? (Module 2, questions 2b, 3a, 4b, 4c)

2\) Develop predictions about how the State performs, why, and how the
State could improve.

-   Why has diabetes prevalence increased? (Module 1, questions 1a, 1b,
    1e; Module 2, question 2d; Module 3, questions 2a, 2b)

-   How could your State improve? (Module 2, questions 1b, 2b, 2c, 2e,
    3a, 4b; Module 3, questions 1a, 1b, 2a, 2b)

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

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

5\) Identify data needs, including measures, benchmarks, and data
sources.

-   Do you have data for diabetes measures (Module 1, question 1f;
    Module 2, questions 2a, 3a; Module 3, question 2b)

-   What data sources does your State have? (Module 2, questions 2f, 2h,
    3a

-   What information on costs does your State have? (Module 2, questions
    3a, 4a)

-   What additional data do you need? (Module 2, questions 3b, 4d)

c\. Identify strategic partnerships for diabetes quality improvement
efforts.

Read pages 85-91 of the *Resource Guide*.

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

  ----------------------------------------------------------------------------
  **Partners**          **Name or       **Organization**   **Role in quality
                        position**                         improvement
                                                           program**
  --------------------- --------------- ------------------ -------------------
  **Experts**                                              

  Topic (diabetes)                                         

  Health services                                          
  research                                                 

  Health care                                              
  specialist                                               

  Statistician                                             

  Data collection                                          

  Quality improvement                                      

  Evaluation research                                      
  ----------------------------------------------------------------------------

  --------------------- --------------- ------------- -------------------
  **Stakeholders**                                    

  Consumers                                           

  Health care providers                               

  Purchasers                                          

  Insurers                                            

  Health plans                                        
  --------------------- --------------- ------------- -------------------

+-------------------+---------------+-------------+-------------------+
| **Elected         |               |             |                   |
| officials**       |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Governor          |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Lieutenant        |               |             |                   |
| Governor          |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Other elected     |               |             |                   |
| officials         |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Legislative       |               |             |                   |
| leaders           |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Cabinet leaders   |               |             |                   |
| and               |               |             |                   |
|                   |               |             |                   |
| State department  |               |             |                   |
| heads             |               |             |                   |
+-------------------+---------------+-------------+-------------------+
|                   |               |             |                   |
+-------------------+---------------+-------------+-------------------+
|                   |               |             |                   |
+-------------------+---------------+-------------+-------------------+
|                   |               |             |                   |
+-------------------+---------------+-------------+-------------------+

+-------------------+---------------+-------------+-------------------+
| **Staff           |               |             |                   |
| leadership**      |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| > Senior State    |               |             |                   |
| > Health          |               |             |                   |
| > Department      |               |             |                   |
| > staff           |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Senior policy     |               |             |                   |
| staff             |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Diabetes program  |               |             |                   |
| staff             |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Medicaid program  |               |             |                   |
| staff             |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Quality           |               |             |                   |
| improvement       |               |             |                   |
|                   |               |             |                   |
| staff             |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Other:            |               |             |                   |
+-------------------+---------------+-------------+-------------------+
| Other:            |               |             |                   |
+-------------------+---------------+-------------+-------------------+

  -------------------- --------------- -------------- -------------------
  **Others**                                          

                                                      

                                                      

                                                      
  -------------------- --------------- -------------- -------------------

2.  **Have a preliminary "Plan" as part of the "Plan-Do-Study-Act"
    (PDSA) model of the cycle of quality improvement.**

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

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

[Do:]{.underline}

-   Assemble a collaborative of quality improvement champions and
    stakeholders.

-   Give them a charge to improve health care quality in your State.

-   Discuss diabetes versus other conditions ripe for quality
    improvement and select a condition.

-   Work with them to set goals; to develop an intervention, plan, and
    evaluation strategy; to collect data, and to test the plan.

-   Draw on the *Resource Guide*, especially if diabetes is the topic
    selected.

-   Keep the group on track. Keep assessments timely and do not let the
    perfect be the enemy of the good.

-   Move to the next step.

[Study:]{.underline}

-   Pilot test the group's ideas.

-   Collect data---baseline and post-intervention data---even in the
    pilot stage.

-   Analyze the results and draw conclusions. Differentiate between
    solid conclusions and inconclusive findings; use this information to
    improve the tracking system.

-   Plan an effective tracking system to know if the intervention
    matters when it is rolled out statewide.

[Act:]{.underline}

-   When the group agrees, implement the quality improvement strategy
    statewide.

The PDSA model will be a resource again and again---to create this plan,
to work with your quality improvement team on goals for diabetes, to
keep the cycle going, and to attack other health care issues.

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

**1. Identify what the user(s) can uniquely contribute to promote
quality improvement in health care and where help is needed.**

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

a\. Providing leadership and vision

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

b\. Forming partnerships and collaborations

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

c\. Assisting planning and goal setting

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

d\. Initiating measurement and reporting

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

e\. Including evaluation and accountability

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

f\. Enhancing infrastructure

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

g\. Creating incentives

  -----------------------------------------------------------------------

  -----------------------------------------------------------------------

**A Final Note**

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

 

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

 

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