Part 1: Introduction
Part 2: Characteristics for Success: Diabetes HbA1c
Part 3: Implementation of Clinical Quality Measure: Diabetes HbA1c
Part 4: Improvement Strategies: Diabetes HbA1c
Part 5: Holding the Gains and Spreading Improvement
Part 6: Supporting Information
Part 2: Characteristics for Success: Diabetes HbA1c
Organizations that were successful in improving Diabetes HbA1c for patients approached the issue in a systematic way, with careful attention to the factors that have an impact on patients with poor glycemic control. Although clinics may differ in specific workflow, documentation, and staffing models, organizations that experienced successful improvement efforts shared these three fundamental characteristics:
- Clear direction
- Functional infrastructure for quality improvement
- Commitment from leadership
1. Clear Direction
Successful organizations found that it is important to define clearly what they are trying to accomplish. Most often in improvement work, leadership defines an aim that guides an organization's efforts. An aim is a written, measurable, and time-sensitive statement of the accomplishments a team expects to achieve from its improvement efforts. The aim statement contains a general description of the work, the system of focus, and numerical goals. The aim statement includes a very specific indication of what success looks like and may include guidance that further frames the work, including methodologies to be used and budgetary and staffing limitations. Examples of tools used by QI teams to create their aim statements include an Aim Worksheet and Aim Statement Checklist [Word Document]. (7)
Additional information, including tools and resources to assist an organization in developing its aim statement, can be found in the Readiness Assessment and Developing Project Aims module. A completed aim statement for the measure, Diabetes HbA1c, is shown in Example 2.1: Assessing the Aim Statement for Mountain Health Care Organization (MHCO) Using the Aim Statement Checklist.
The following example provides an aim statement created by the fictional Mountain Health Care Organization's QI team and the checklist the team used to assess its completed aim statement. Using the Aim Statement Checklist to assess the QI team's aim statement provides reassurance that the team included the necessary components of the aim statement for its improvement project.
Example 2.1: Assessing the Aim Statement for Mountain Health Care Organization (MHCO) Using the Aim Statement Checklist
Aim Statement: Over the next 12 months, we will redesign the care systems of Mountain Health Care Organization to decrease the number of poorly-controlled diabetics in Dr. Billing's practice, so that less than 20 percent of these patients have a HbA1c greater than 9 percent.
- No additional staffing will be required as a result of this improvement
- A key focus will be systems for patient outreach
*Here is an example of how Mountain Health Care Organization evaluated its aim statement using the Aim Statement Checklist (7)
Aim Statement Checklist for Example 2.1: (7)
What is expected to happen?
MHCO: Fewer patients will have HbA1c of greater than 9 percent indicating poor control
Time period to achieve the aim?
MHCO: 12 months
Which system will be improved?
MHCO: Care systems that improve glycemic control
What is the target population?
MHCO: diabetic patients in Dr. Billing's practice
Specific numerical goals?
MHCO: Less than 20 percent have a HbA1c of greater than 9 percent (lower is better)
Guidance, such as, strategies for the effort and limitations?
MHCO: As noted, no new staff plus focus on patient outreach
Evaluating what others achieved provides appropriate context for choosing the numerical portion of an organization's aim. (8) While the goal of zero percent of patients with a HbA1c greater than 9 percent is optimal, an organization can set an appropriate and realistic goal based on the review of comparable data after consideration of the payer mix of the patient population served. (9) For some measures, it may be possible to find examples of benchmark data, which demonstrates the performance of a best practice. It is important to consider an organization's particular patient population when making comparisons to others' achievements. An organization may consider socioeconomic status and/or race/ethnicity of the population served, organizational size, payer mix, and other criteria in an effort to achieve an accurate comparison. Reviewing what others accomplished may help an organization to understand what is feasible to achieve. The numerical part of the aim should be obtainable, yet high enough to challenge the team to substantially and meaningfully improve. Additional guidance about setting aims can be found in the Readiness Assessment and Developing Project Aims module.
When choosing an aim or making performance comparisons for the measure, Diabetes HbA1c, the NCQA HEDIS Data Set is one source to consider. Current data is accessible from the Trending and Benchmarks section. Of note is the considerable variation among the regions, which correspond to the Health and Human Services Regions of the United States. Sources of data for additional comparisons vary regionally but may include payers, State programs, aggregate HRSA program data, and State or regional quality improvement programs.
2. Functional Infrastructure for Quality Improvement
Successful organizations found that improvement work requires a systematic approach to measuring performance, testing small changes, and tracking the impact of those changes over time. This section describes four essential components of an infrastructure to support quality improvement efforts, including:
- Quality improvement teams
- Tools and resources
- Organizing improvements
- Building on the efforts of others by using changes that worked
- There is considerable variation in how this infrastructure is created and maintained. It is important that each component is addressed in a way that fits an organization.
Quality Improvement Teams
Multidisciplinary QI teams are typically tasked to carry out this work. For improvement focused on Diabetes HbA1c, it is important to include a provider who wants to focus on decreasing the number of patients with poor glycemic control, i.e., a provider champion for improvement. (10) In addition to the provider champion, other appropriate members of a QI team may include:
It should be noted that patients can add great value to the QI process when prepared to participate in a meaningful way. The reference manual by the National Quality Center (NQC), A Guide to Consumer Involvement, has practical ideas to assist an organization on how to involve patients in its QI process. (9)
- Case managers
- Patient outreach specialist
- Patient navigator
- Scheduling staff
- Information specialist
- Other staff involved in the patient care process, such as, receptionists, diabetes educators, administrative staff, medical assistants, pharmacists, and health coaches
There are no wrong answers here. Members of a team bring expert knowledge of the work they do for diabetic patients. Together, the team learns where and how its individual actions intersect and how each can have an impact on patients' diabetic care. The ability to think from a systems perspective and the will to improve glycemic control for patients are the primary prerequisites that contribute to a successful improvement team. A more advanced discussion on forming an improvement team can be found in the Improvement Teams module.
Tools and Resources
It is important that a QI team have the tools and resources necessary to achieve its established organizational aim. Some personnel may struggle shifting from the daily work of patient care to their roles on the quality improvement team. Those challenges can be straight forward, such as, coordinating meeting times or developing content for the meetings to support the team's quality improvement efforts. Successful QI teams learned that organizing meetings efficiently is essential in their improvement efforts. Tools, such as Tips for Effective Meetings, can help a QI team to structure meetings that focus its scheduled time on improvement efforts. Another useful tool includes one that displays data in a way that makes sense to the team members. Examples of templates and tools to track progress can be found in the module Managing Data for Performance Improvement These types of tools are commonly used by improvement teams to remain focused on the work of improvement. The most important resource needs are uninterrupted time to focus on quality improvement and autonomy to test changes responsibly. Additional team resources and tools can be found in the Improvement Teams module.
Successful organizations learned that planning an approach to change is essential. Change is, by nature, unsettling for some and presenting a clear direction and methodology can be reassuring. Most organizations with quality improvement experience adopted methodologies that help them organize their improvements.
As a QI team approaches improvement of patient glycemic control, it should use quality models already embraced by its organization. For example, many organizations adopted the Care Model to organize their approaches to implementing quality improvement changes. Others successfully embraced the FOCUS PDSA approach; both of these models provide a framework for a health care organization to plan and move toward implementing its improvement efforts. There is no single model that is considered correct. Organizational alignment of methodology makes sense from the perspective of efficient training. A consistent quality improvement approach and the sharing of improvement ideas among members of a quality team can facilitate the replication of QI activities across an organization and maximize the impact of the overall QI program.
Just as organizations that are experienced in quality improvement activities adopted quality models that guide their work, many embraced a change methodology. A change methodology guides the actual change process, which involves managing how changes are made as opposed to what changes are made.
For some organizations, all changes are approved by a decision leader and then implemented. Others use a committee structure to evaluate and implement changes. Again, there is no right or wrong methodology, but one change methodology that has been found to be particularly helpful in quality improvement is called the Model for Improvement. The Model for Improvement, developed by Associates in Process Improvement, is a simple, yet powerful, tool for accelerating improvement. The model is not meant to replace a change model that an organization may already be using, but rather to accelerate improvement. This model has been used successfully by health care organizations to improve many different health care processes and outcomes.
The Model for Improvement encourages small, rapid-cycle tests of changes. In improvement, this has a distinct advantage in decreasing the time it takes for changes resulting in improvement to be implemented. This methodology also directly involves the individuals who do the work, which provides additional insights into how to rapidly improve care processes. Testing for Improvement module.
Building on the Efforts of Others by Using Changes that Worked
One hallmark that successful organizations found beneficial in advancing their quality improvement programs is that everyone across the organization uses the same tools and language to make continuous improvements. A motto of many QI training leaders is "steal shamelessly." This is not the unethical, criminal intent, but instead the sense of "Why reinvent the wheel?" What does it mean to "steal shamelessly"? It means "stealing" or using what has worked in other organizations and "shamelessly" testing and implementing it to create rapid change in one's own organization.
Specific change ideas that worked for others to successfully improve glycemic control are detailed later in this module in the Changes that Work section. Additionally, an organization that has improvement experience in another measurement area, such as, prenatal care, cancer screening, or immunizations, often adapts the successful tools to use with this measure.
3. Commitment from Leadership
For quality improvement efforts to be effective and sustained, leaders must show commitment to them. Typically, leaders may make a commitment to specific target areas for improvement once they consider the overall needs of the organization, requirements of funders, and how the proposed efforts align with the organization's mission and strategic plan. Leaders that consider quality improvement efforts as an "add-on" may be unable to maintain QI as a priority as other realities compete for the organization's attention and resources. Successful leaders in quality improvement integrate and align QI activities as part of their daily business operations.
A quality improvement team needs to have leadership commitment expressed in a tangible way. Often, it is an explicit dedication of resources, which may include team meeting time, data support, and specific planned opportunities that communicate actionable improvement suggestions to an organization's leadership. The authority of the improvement team and any constraining parameters should be clear. Detailed information highlighting the important role of leadership in a QI project can be found in the Quality Improvement module.
Here is a case study that is followed throughout the module and depicts the effort of one QI team as it focuses on improving the number of diabetic patients accessing care in its organization. The case study may be read in its entirety by clicking here.
Case Study: The Problem
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