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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Resources and Services Administration

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Diabetes HbA1c {Poor Control}

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 5: Holding the Gains and Spreading Improvement

Holding the Gains

Once an organization has redesigned the process for diabetes care regarding HbA1c, it can be tempting to move on to other issues and stop monitoring the process. Ongoing monitoring ensures that an organization holds the gains over time.

Although an organization may be able to reduce the frequency of monitoring the process, some ongoing assessment of the measure is necessary to ensure an organization continues to meet its intended goal. Processes that work well now may need to change as the environment shifts. Because all systems are dynamic, they change unless efforts are made to ensure that the improvements continue. Organizations often do a few simple things to ensure that successful changes are embedded in the daily work. Examples include:

  1. Change the procedure book to reflect the new care process.
  2. Include key tasks in the new process as part of job descriptions.
  3. Adjust the expectations for performance to include attention to quality improvement and teamwork to improve care.
  4. Re-align hiring procedures to recruit individuals who are flexible and committed to quality improvement.

The case study continued...

Case Study: Sustaining Improvements

Sustaining Improvements:
A year later...
About 15 percent of Dr. Harmon’s patients have their last HbA1 greater than 9 percent, and the team is working diligently to assist these patients. Even though the team is still working toward its aim, it has made considerable progress and learned much along the way. Because the results have been communicated at staff meetings, other providers are interested in adopting some of these changes that work and to follow the results in a registry. Confident it could make meaningful changes as a team, it expanded the team quality improvement project to include other metrics pertinent to excellent diabetes care. It used the NCQA Physician Recognition Program as a guide to choose measures and to develop appropriate aims. It remained focused on one care team to test changes to achieve its aim initially, but the organizational leadership was committed to do more; excellence in diabetes care across the organization became a strategic priority. Over the subsequent two years, the clinic made substantial improvement and is now known countywide for the excellence of its diabetes care.

Spreading Improvement

Spread can be defined differently based on an organization’s defined target population for the improvement effort. An organization often begins an improvement intervention on a smaller scale, possibly focusing on one site or one provider’s patient panel, and then increases the population of focus (POF) or the number of providers. Spread can mean spreading improvements to another area of an organization. An organization can still focus on glycemic control for diabetic patients but also include other or all providers that provide diabetes care. Ideally, others can learn from the initial improvement experience and implement the interventions of the improvement team in their own environments. Spread of this kind is often at an accelerated pace as there is experience about changes that work within the organization. Once it has successfully reached its goal for Diabetes HbA1c, an organization may choose another measure to improve other aspects of diabetes care. Good sources for diabetes measure sets include:

Another option is to target a different topic or another population of patients. An organization may evaluate organizational priorities as it did when initially choosing the Diabetes HbA1c measure and begin to plan for its next improvement effort. Additional information on Holding the Gains and Spreading Improvements, including specific resources and tools to support an organization's improvement program, can be found in the Redesigning a System of Care to Promote QI module


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