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. 

ii 
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. 

iii 
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

iv 
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

1 
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). 

2 
• 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—Making the Case for Diabetes Care Quality Improvement

3 
• Module 4: Action—Learning From Activities Currently Underway 

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

Staff specialists 

• Module 2: Data—Understanding the Foundation of Quality Improvement

• Module 3: Information—Interpreting State Estimates of Diabetes Quality 

• Module 5: Improvement—Developing a Strategy for Diabetes Quality Improvement

Modules 1 through 4 might be done by different individuals or groups of individuals to 

gather information. That information, however, will be assembled and organized in Module 

5 to “make the case” for quality improvement of diabetes care, help create a team of experts, 

and design a strategy to develop a diabetes care quality improvement program specific to 

your 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. 

4 
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 (ageadjusted) 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) 

 

• What was the percent range of age-standardized diabetes prevalence in your State for 

2002? (Figure 1.1, page 10) 

• 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? 

Learning Objective 

Upon completion of Module 1, the user(s) will be able to: 

1. Assess the need for diabetes care quality improvement in the State. (This section 

will pull together information to help “make the case” for improvement in diabetes 

care by showing why diabetes should be a priority.) 

5 
(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?

c. What other reasons might indicate a need for diabetes care quality improvement in 

your State? 

6 
d. What evidence from these pages would you use to convince potential partners that 

diabetes should be a priority? 

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.)? 

2) Does your State have a higher proportion of these vulnerable groups than 

other States?

7 
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? 

 

h. What other measures indicate that you may want to create a quality improvement 

program for a different condition? 

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

 

8 
j. Why or why not? If not, would you select a different condition?

9 
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)? 

Learning Objectives

Upon completion of Module 2, the user(s) will be able to: 

1. Understand the process and outcome measures for tracking the quality of 

diabetes care. (Understanding these measures will help the user identify gaps in 

recommended care, how closing these gaps can improve health status, and how the 

measures can be used as the basis for setting goals.) 

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

(Collecting and analyzing data in your State is important to making your case for 

improving care and calculating the long-term costs of diabetes and its impact on your 

State. Data also help you create baseline measures and set goals for improvement.) 

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

(An inventory will identify existing data that may be useful and collection 

mechanisms that might easily be enhanced for tracking quality improvement.)

4. Use published studies to arrive at State or local estimates. (Research helps inform

States of gaps in their data, questions that remain to be answered, and the need for 

additional research.) 

5. Calculate the direct and indirect costs of diabetes for States and State Medicaid 

programs. (Knowing the costs will help make the case for quality improvement, 

provide States with baseline measures, and help set goals.) 

10 
b. How would increasing HbA1c testing improve diabetes outcomes?

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 adults 

(in 2001) who 

received: 

Your State 

(%) 

National 

average (%)* 

Best-in-class 

average (%)* 

Healthy People 

2010 goal (%)* 

HbA1c testing 61 82 50 

Retinal eye 

examination 

67 81 75

Foot examination 65 82 75 

Flu vaccination 37 58 n/a 

*Review the Resource Guide Appendix D on page 127 for definitions of these terms. The figures are from

Table D.1, page 129.

11 
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-inclass, and Healthy People 2010 figures, and write those figures in the table below: 

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

Percent of adults 

(in 2001) who 

received: 

National average 

(%) 

Best-in-class 

average (%) 

Healthy People 2010 

goal (%) 

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 adults 

(in 2001) who 

received 

________ 

(State) 

(%) 

Percent your 

State is above 

(+) or below (-) 

this State 

_________ 

(State) 

(%) 

Percent your 

State is above 

(+) or below (-) 

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? 

12 
e. Where do you see the need for improvement?

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?

g. What are some additional questions you have about the quality of diabetes 

care in your State?

13 
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 

available on 

your State?

(Yes/No) 

Notes 

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: 

14 
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? 

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

15 
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? 

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: 

Your State Comparable

State 

Difference 

(+/-) 

Comparable 

State 

Difference 

(+/-) 

Percent of 

population with 

diabetes 

Direct cost of

diabetes 

Indirect cost of 

diabetes 

Total cost burden 

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

16 
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?

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

improvement? 

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

data in your State?

17 
Module 3: Information — Interpreting State Estimates of Diabetes 

Quality

Learning Objectives:

Upon completion of this module, the user(s) will be able to: 

1. Identify State rates benchmarks for the four major measures and assess those 

rates in relation to national averages and other States. (There are many types of 

benchmarks—national average, best-in-class performance, and national consensusbased-goal benchmarks.) 

2. Identify factors that influence a State’s position among other States. (Knowing 

these factors can help States assess how difficult it may be to change and where 

States should target their efforts.) 

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

(Any of the benchmarks listed above can be used to set goals. Aiming for the average 

is usually the least rigorous goal, while striving to be the best-in-class is usually the 

most rigorous, achievable goal. Knowing your State’s position as it relates to the full 

distribution of State rates also shows how well the State is doing among all States. A 

State that is among the lowest in the Nation on a particular dimension might want to 

focus improvement in that area.) 

4. Draft preliminary goals for specific measures. (Knowing what you want to 

achieve in the long term will help States identify the resources and tools they need to 

get there.) 

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. 

0.0 20.0 40.0 60.0 80.0 100.0

HbA1c test

Retinal exam

Foot exam

Flu vaccination

Source: Derived from data tables of NHQR (2003), based on CDC, BRFSS data

Legend:

Grey diamonds = Rates for all States

Black square = National average

Black triangle = Best-in-class State average

18 
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?

2) Significantly below the national average (indicated by a “-” sign next to the 

rate)? Which ones?

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?

4) Significantly below the best-in-class range (does not include a “‡” sign next 

to the State rate)? Which ones?

19 
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?

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/.) 

20 
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?

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? 

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.) 

 

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? 

21 
b. Write the figure in the appropriate blank below: 

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

o Increase the number of adults with diabetes who receive an HbA1c test at least 

once a year to the level of the national average – 61 percent. 

o Increase the number of adults with diabetes who receive an HbA1c test at least 

once in a year to the best-in-class average – 82 percent. 

o Increase retinal exam testing for adults with diabetes by 5 percentage points 

within the next 3 years. 

o Increase the number of adults with diabetes who receive foot examinations from

their physicians to reach the Healthy People 2010 goal – 75 percent. 

o Increase the number of adults with diabetes who receive flu vaccinations to the 

best-in-class average – 58 percent. 

o Identify the barriers to obtaining HbA1c testing or retinal exams or foot 

examinations or flu vaccinations. 

o Begin collecting data on any or all of the measures (if your State does not already 

have these data). 

22 
What are your preliminary goals for:

HbA1c testing: 

Retinal exam: 

Foot exam: 

Flu vaccination: 

Guidance for Setting Goals: 

o Consider this goal-setting exercise as preliminary to enhance your 

understanding. (Stakeholders who will become champions of the initiative 

must have a part in setting goals for the program. Only in that way will the 

goals reflect the circumstances that the community faces and be supportable 

by leaders in the health care community.)

o Note where your State falls on the chart in Module 3, question 1a: Is your 

State extremely low, close to the national averages, or within the best-in-class 

averages? (Your position on the chart will tell you how far your State must go 

to be among the best performing health care systems.) Do you want to set 

long-range and short-range goals? 

o Remember that you will have to identify and address the underlying issues 

that affect your State’s position. 

o The four measures featured here are only a subset of the meaningful goals 

and are not necessarily the most effective goals for diabetes quality 

improvement in your State. (HbA1c levels, provider and patient education, 

adherence with recommended lifestyle changes, and focus on vulnerable 

populations are some of the important goals that your planning group may 

decide to set.)

o As you move through the planning process and discover new information, you 

can come back and change your goals to reflect your new knowledge. 

o Your quality improvement program for diabetes care should ultimately be

designed to reach the goals set by the full quality improvement team. 

23 
Module 4: Action — Learning From Activities Currently Underway

Learning Objectives: 

Upon completion of Module 4, the user(s) will be able to: 

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

what resources are already available saves time and money.)

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

practices. (Many existing program models can be modified to accommodate Statespecific needs.) 

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

(You can build upon the resources and partnerships that already exist and identify 

where your State needs to develop activities.)

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?

24 
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

Ideas: 

IHI Breakthrough Series Collaborative 

• Institute for Healthcare Improvement (IHI) Breakthrough Collaboratives general 

information: 

http://www.ihi.org/IHI/Programs/CollaborativeLearning/ 

Ideas: 

• Improving care for people with chronic conditions – diabetes: 

http://www.ihi.org/IHI/Topics/ChronicConditions/Diabetes/HowToImprove/

Ideas: 

• Report from the Health Disparities Collaborative on Diabetes: 

http://www.healthdisparities.net/Diabetes_Apr2002.pdf

Ideas: 

25 
isease Management Programs 

ion of America 

D

• Disease Management Associat

http://www.dmaa.org

Ideas: 

• ouncil of State Governments 

/health/chronic+illness/default.htm

C

http://www.csg.org/CSG/Policy

Ideas: 

elf-Management Programs

gement Program at Stanford University 

S

• Chronic Disease Self-mana

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 

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

Ideas: 

26 
Health Resources and Services Administration, Bureau of Primary Health Care, 

CProgramInfo.htm

•

Health Disparities Collaboratives 

http://bphc.hrsa.gov/programs/HD and 

http://www.healthdisparities.net/

Ideas: 

• National Diabetes Education Program (NDEP) 

http://ndep.nih.gov and http://www.betterdiabetescare.org 

Ideas: 

• Centers for Medicare & Medicaid Services Quality Improvement Organizations 

http://www.medqic.org/content/nationalpriorities/topics/projectdes.jsp?topicID=4

77&showMeasures=yes&showSteps=yes

Ideas: 

27 
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? 

28 
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 Development 

State Quality Improvement Action Planning Implementation Evaluation 

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 

29 
b. Review Appendix 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 general

fund 

State in-kind Total 

Your State 

Comparable State 

Comparable State 

Comparable State 

30 
Module 5: Improvement — Developing a Strategy for Diabetes 

Quality Improvement 

Learning Objectives

Upon completion of Module 5, the user(s) will be able to: 

1. Have assembled in this document the information from Modules 1-4 above 

that presents: a) the case for diabetes quality improvement in the State; b) a 

preliminary strategy suited to the State; and c) strategic partnerships for 

diabetes quality improvement efforts. 

2. Have a preliminary “Plan” as part of the “Plan-Do-Study-Act” (PDSA) 

model of the cycle of quality improvement. Again, consider this plan 

preliminary. The full quality improvement team must be part of the creation of 

the plan to ensure its relevance, completeness, and success for obtaining support 

from stakeholders in the State health care community. 

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: 

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

o Why should improving diabetes care be a priority?

o What populations are vulnerable to gaps in diabetes care?

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

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

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

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

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

o Where do you need the most improvement?

o What is the cost of diabetes in your State? 

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

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

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

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

31 
b. Add a preliminary strategy, suited to the State, to the document you started above. 

Convene a working meeting with your internal staff. Use the information you collected 

throughout this Workbook (noted in parentheses) to fill out the outline below. 

1) Decide on topic areas related to quality improvement. 

o What do you predict as the current obstacles to quality care? (Module 1, 

question 1e) 

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

Module 3, questions 2a, 2b) 

o What questions do you have about the quality of diabetes care? (Module 2, 

question 2g; Module 3, questions 2a, 2b) 

o What does current research indicate about diabetes care in your State?

(Module 2, questions 2b, 3a, 4b, 4c) 

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

improve. 

o Why has diabetes prevalence increased? (Module 1, questions 1a, 1b, 1e; 

Module 2, question 2d; Module 3, questions 2a, 2b) 

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

Module 3, questions 1a, 1b, 2a, 2b) 

3) Develop goals for quality improvement. (Module 1, question 1g; Module 2, 

questions 1a, 1b, 2b, 2c, 4b, 4c; Module 3, questions 3a, 3b, 4a; Module 4, questions 2a, 2b) 

4) Take an inventory of current diabetes quality improvement programs in the State, 

including non-governmental, Federal, or local initiatives. Make a preliminary list of 

additional actions to take. (Module 4, questions 1a, 1b, 3a) 

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

o Do you have data for diabetes measures (Module 1, question 1f; Module 2, 

questions 2a, 3a; Module 3, question 2b) 

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

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

4a) 

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

32 
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 position Organization Role in quality 

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 

33 
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

34 
2. Have a preliminary “Plan” as part of the “Plan-Do-Study-Act” (PDSA) model 

of the cycle of quality improvement. 

 

Now that you have completed the preliminary plan, you can move from the “Plan” to the 

“Do” stage of the PDSA model. 

Read pages 92-96 of the Resource Guide on implementing the PDSA model. You cannot 

complete the next steps of the PDSA cycle alone. The partnership defined above will be 

critical. 

Do:

• Assemble a collaborative of quality improvement champions and stakeholders. 

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

• Discuss diabetes versus other conditions ripe for quality improvement and select 

a condition. 

• Work with them to set goals; to develop an intervention, plan, and evaluation 

strategy; to collect data, and to test the plan. 

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

• Keep the group on track. Keep assessments timely and do not let the perfect be 

the enemy of the good. 

• Move to the next step. 

Study:

• Pilot test the 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:

• 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. 

35 
Module 6: The Way Forward — Promoting Quality Improvement in 

the States 

Learning Objective

Upon completion of Module 6, the user(s) will be able to: 

1. Identify what the user(s) can uniquely contribute to promote quality 

improvement in health care and where help is needed. 

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 

36 
c. Assisting planning and goal setting 

d. Initiating measurement and reporting 

e. Including evaluation and accountability 

f. Enhancing infrastructure 

g. Creating incentives 

37 
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. 

38