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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 4: Improvement Strategies: Diabetes HbA1c 

The actual improvement process is composed of three steps that respond to the following questions:

  1. What changes can an organization make?
  2. How can an organization make those changes?
  3. How can an organization know the changes caused an improvement?
What Changes Can an Organization Make?

It is important to understand that improvement requires change, but not all change results in improvement. Considering all of the possible changes that can be made to health care systems, significant effort has been dedicated to creating various quality improvement strategies providing a framework that organizes possible changes into logical categories. Frameworks for change in health care quality improvement are known as quality models and have been tested to guide change. In fact, because there may be limited resources to dedicate to improvement, most organizations adopt one or more quality models to guide their improvement efforts. There is not a right or wrong approach, and there are many areas of overlap in quality models. Experienced quality improvement teams often use multiple strategies to overcome challenges as they progress. Two approaches often used by teams that are working to improve performance on Diabetes HbA1 care are the Care Model approach and the Critical Pathway approach.

The case study continued...

Case Study: The Improvement Journey 

  1. Care Model Approach: Implementing the changes described in the Care Model is a proven method to improve care delivery. The Care Model is an organizational framework for change and is organized into six domains:
    1. Organization of Health Care
    2. Clinical Information Systems
    3. Delivery System Design
    4. Decision Support
    5. Community
    6. Self-Management Support

    Changes within these domains can effectively leverage transformation of a current reactive care system to one that better supports care for chronic disease conditions, such as diabetes. Changes within these domains can effectively leverage transformation of a current reactive care system to one that better supports proactive care. If an organization does not have general experience with this model, reading information on the Care Model Web site before proceeding is recommended. The Care Model recognizes that care for diabetes is ongoing and requires more proactive care than the health care system often provides. This model is implemented to improve care by working in six domains, defined below, that transform the way care is delivered:

    Community-To improve the health of the population, a health care organization reaches out to form powerful alliances and partnerships with state programs, local agencies, schools, faith organizations, businesses, and clubs.

    Organization of Health Care-A health care system can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish.

    Self Management-Effective self management is very different from telling patients what to do. Patients have a central role in determining their care and one that fosters a sense of responsibility for their own health.

    Delivery System Design-Delivery of patient care requires not only to determine what care is needed, but to clarify roles and tasks to ensure the patient receives the care; that all of the clinicians, who take care of a patient, have centralized, up-to-date information about the patient's status, and make follow-up a part of their standard procedures.

    Decision Support-Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study. A health care organization integrates explicit, proven guidelines into the day-to-day practice of primary care providers in an accessible and easy-to-use manner.

    Clinical Information System-A registry, that is, an information system that can track individual patients and populations of patients, is a necessity when managing chronic illness or preventive care.

    Definitions above adapted from the Institute for Healthcare Improvement web site (14)

    Figure 4.1: The Care Model.

    Figure 4.1: The Care Model

    In Table 4.1: Care Model Key Changes, key changes are presented that have been used successfully to improve diabetes care within the Care Model framework. 


    Table 4.1: Care Model Key Changes
    CommunityOrganization of Health CareSelf ManagementDelivery System DesignDecision SupportClinical Information System
    Establish linkages with organizations to develop support programs and policies for patients with diabetesMake improving chronic care a part of the organization's vision, mission, goals, performance improvement and business plansUse diabetes self-management tools that are based on evidence of effectivenessUse the registry to review care and plan visits for all diabetics, regardless of reason for visitEmbed evidence-based guidelines in the care delivery systemEstablish an EMR with registry functions or stand alone registry to track key diabetes outcomes
    Link to community resources for defrayed medication costs, education, and materialsMake sure senior leaders and staff visibly support and promote efforts to improve chronic careSet and document self-management goals with patientsAssign roles, duties, and tasks for planned visits to a multidisciplinary care team. Use cross-training to expand staff capabilityEstablish linkages with key specialists to ensure that primary care providers have access to expert support.Develop processes for use of the registry, including designating personnel for data entry, assuring data integrity, and registry maintenance
    Encourage participation in community education classes and support groupsMake sure senior leaders actively support the improvement effort by removing barriers and providing necessary resourcesTrain providers and other key staff to help patients with self-management goalsUse planned visits in individual and group settingsProvide skill-oriented interactive training programs for all staff in support of chronic illness improvementUse the registry to generate reminders and care-planning tools for individual patients
    Raise community awareness through networking, outreach, and educationAssign day-to-day leadership for continued clinical improvementFollow up and monitor self-management goals

    Use group visits to support self management
    Make designated staff responsible for follow-up by various methods, including outreach workers, telephone calls, and home visitsEducate patients about guidelinesUse the registry to provide feedback to care team and leaders


    This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.


    Note: An organization may choose to adapt and refine a tool to assist improvement for the measure, Diabetes HbA1c. Testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.

    The case study continued...

    Case Study: The QI Team 

  2. Critical Pathway Approach: As with all critical pathways, good performance relies on many different systems and processes working together efficiently. An organization is encouraged to map its own critical pathway for diabetes care - glycemic control, or refer to the schematic in Figure 4.2. Often when a QI team maps its pathways, it readily can see how complex each step is. It is common for different team members to do the same step differently. Workflow inefficiencies become clear when an organization visualizes how each step is completed and the interdependencies among the steps. Some teams are overwhelmed by the possibilities of changes that can be made in their systems; others focus only on a specific group of factors.


    Figure 4.2: Critical Pathway Approach.
    Figure 4.2: Critical Pathway Approach


  3. One way to organize the factors that have an impact on the systems is to consider that some are controlled by the patient, others are primarily controlled by the care team, and still others are inherent in the system of care delivery. All three sets of changes must be considered to improve systems of care. In general, these categories can be defined as follows:

    • Patient changes-efforts to support self-management efforts, patient engagement, and navigation of the care system
    • Care team changes-changes in job duties or workflow that assist to retain patients in care and ensure timely evidence-based diabetes care
    • Health system changes-changes that have an impact on how care is delivered, independent of who delivers it

    A team should use the steps along the critical pathway to target improvements. For this measure, Diabetes HbA1c, influences on performance begin by ensuring that HbA1c is measured at the appropriate time interval (not simply ordered), as indicated by the first step in the critical pathway, HbA1c measured at appropriate interval.

    An organization should ensure that patients are appropriately educated regarding the importance of regularly testing HbA1c values based on their level of risk. Providing education to patients also affords an organization the opportunity to assess patient barriers to testing, such as, lack of insurance or cost. Successful organizations have often aligned resources in the community for testing HbA1c at a reduced cost for patients creating a true partnership in patient care.

    An organization can think through each part of the critical pathway in turn, teasing out what happens and what could be improved. In Table 4.2, changes that have worked for other QI teams are matched with the part of the system on which they have the most impact. These ideas are not meant to be inclusive, but to start a dialogue of what may improve each part of the critical pathway in an organization, and thus improve it overall.

    Changes That Work 

    Table 4.2: Sample Changes That Work That Are Linked to the Critical Pathway for Diabetes HbA1c 

    Table 4.2: Sample Changes That Work
    Area of Critical PathwayPatient ChangesCare Team ChangesHealth System Changes
    Changes that have an impact on timely measurement of HbA1c.
    Assuming the A1C has been measured, ensure the results are viewed by someone who can make a decision about whether the value is above, below, or at target. 
    • Lab tracking systems that prompt if results not logged as expected
    • Implement standing orders for HbA1c per protocol
    • Prompts for the HbA1c are not turned off when test ordered, but rather when results received
    Results need to be acted upon using clinical guidelines in context of other issues specific to the patient.Use shared decision making with patients to agree on target values for patients considering guidelines, co-morbidities, and patient preferences.
    HbA1c target not achieved.
    • Assess current care plan, barriers to following care plan, and collaborate with patient on care plan modifications
    • Improve continuity; continuity typically improves care plan understanding and adherence
    Consider more aggressive follow up standards for high risk patients - prompts for more aggressive follow-up
    Once the target is achieved, ensure that it can be maintained at target level.
    Note: Process starts over as indicated by arrow in Figure 4.2
    • Ask about any upcoming challenges and problem solve solutions
    • Actively support ongoing self-management issues
    Patient routinely given documentation of current care plan
    Reinforce care guidelines and appropriate follow -up.
    Note: Process starts over as indicated by arrow in Figure 4.2
    Schedule self-management support between visits as indicated.Ensure patient receives guidance about access to practice with interim concerns

    This toolkit is meant as a guide to help organize ideas, but is also designed to allow flexibility for creative planning.


    Note: While an organization may choose to adapt and refine a tool to assist improvement for the measure, Diabetes HbA1c, testing the measure before fully implementing it offers a way to try something new and modify it before additional resources are spent.
How Can an Organization Make Those Changes?

Earlier in this module, examples are provided of changes (Critical Pathway and Care Model) that have led to improved organizational systems of care and better patient health outcomes. Because every change is not necessarily an improvement, changes must be tested and studied to determine whether the change improves the quality of care. This concept is addressed in detail in the Testing for Improvement module.

It is important that these changes be tested in the context of an organization's staff, current processes, and patients. The goal is that the change results in lasting improvements within an organization. Organizations commonly use tools to manage change as they work to improve their systems. For further discussion on change management, refer to the Testing for Improvement and Redesigning a System of Care to Promote QI module. Here are a couple of tools worth mentioning in the context of this measure:

  1. Small tests of change – Model for Improvement and PDSA (Plan-Do-Study-Act)
  2. Process mapping
  3. Model for Improvement

    The Model for Improvement (15) identifies aim, measure, and change strategies by asking three questions:

    Figure: AIM Measure Change.

    Figure: AIM Measure Change

    These questions are followed by the use of learning cycles to plan and test changes in systems and processes. These are referred to as PDSA (Plan-Do-Study-Act) cycles. The PDSA Cycle is a test-and-learning method for discovering effective and efficient ways to change a current process. In Figure 4.3: The PDSA Cycle, the graphic provides a visual of the PDSA process:

    Figure 4.3: The PDSA Cycle.

    Figure 4.3: The PDSA Cycle

    An organization focusing its improvement efforts on Diabetes HbA1c for its patients benefits from implementing PDSAs to test change processes that have an impact on access to care in the first trimester. Those organizational processes tested may focus on outreach, operational procedures, or patient education interventions ensuring that patients have timely access to care. A few examples of such processes relating to Diabetes HbA1c are listed below:

    • What system is in place to provide patients with timely reminders regarding HbA1c testing?
    • What are the assigned roles, duties, and tasks for planned visits to a multidisciplinary care team? Are members of the team cross-trained?
    • Does the patient population understand its specific role in managing its diabetes or is there an opportunity for education?
    • Is there an opportunity to educate the community on the importance of adequate control for diabetes in a group visit setting?
    • Are there cultural, linguistic, and literacy barriers that the organization may need to address?

    As an organization plans to test a change, it should specify the who, what, where, and when so that all staff know their roles clearly. Careful planning results in successful tests of change. Documentation of what happened – the S or study part of the PDSA – is also important. This can help a team to understand the impact of changes to a process as unanticipated consequences may occur.

    The case study continues...

    Case Study: PDSA Cycles in Action

    Tips for Testing Changes

    • Keep the changes small and continue testing
    • Involve care teams that have a strong interest in improving glycemic control
    • Study the results after each change. All changes are not improvements; do not continue testing something that does not work!
    • If stuck, involve others who do the work even if they are not on the improvement team
    • Make sure that overall aims are improving; changes in one part of a complex system sometimes have an adverse effect in another
  4. Process Mapping

    Process mapping is another valuable tool that an organization focused on improvement often uses. A process map provides a visual diagram of a sequence of events that result in a particular outcome. Many organizations use this tool to evaluate a current process and again when restructuring a process.

    The purpose of process mapping is to use diagramming to understand the current process; i.e., how a process currently works within the organization. By looking at the steps, their sequence, who performs each step, and how efficiently the process works, a team can often visualize opportunities for improvement.

    Process mapping can be used before or in conjunction with a PDSA cycle. Often, mapping out the current process uncovers unwanted variation. In other words, different staff may perform the process differently, or the process is changed on certain days or by specific providers. By looking at the process map, a team may be able to identify gaps and variation in the process that have an impact on glycemic control for diabetic patients.

    Both of these improvement strategies are illustrated in the hypothetical scenario in Example 4.1: Illustration of Improvement Strategies:

    Example 4.1: Illustration of Improvement Strategies

    Successful referral to a diabetes educator

    At a small clinic in the northeast, the organization's improvement team found that 45 percent of its diabetic patients had an HbA1c of greater than 9 percent. Further investigation revealed that approximately over half of those patients had never had an appointment with the diabetes educator. The improvement team decided to look at the process of how those appointments were scheduled. The current process mapped by the improvement team was:

    1. Diabetes educator appointment ordered by the provider at time of the patient's visit.
    2. MA schedules an appointment at the hospital and provides information to the patient.
    3. Documentation of patient visits with the diabetes educator or no-shows received by the health center.
    The team felt that Steps 2 and 3 were potential problems in the process and analyzed how they could be improved. Phone calls were made to five patients who had been referred for diabetes education to assess their experiences. Two had attended their appointments but had difficulty finding the educator's office; two had not attended because they felt that it would not be worthwhile, and one developed a schedule conflict after the appointment had been made. There was no notation that the three patients had no-showed their appointments in the patients' charts.

    The QI team considered various strategies, such as, providing clearer instructions for patients, providing education on site, and improving the feedback loop between the educator and the provider. The team investigated the option of contracting the diabetes educator for a half day per week to work on site and found that it could be reimbursed for her services. This arrangement was put in place as a three-month trial and referral completion rates were monitored monthly. Although attendance was not perfect, it was significantly better than when patients were referred off site. The team also emphasized that notes from the visit, or that the patient no-showed, was critical information that must be documented in the patient chart. The team strategy was successful. By having the diabetes educator on site, access to the service was simplified and was perceived by patients to be more integrated with their providers' care.

    Process mapping, when used effectively, can identify opportunities for improvement, and support testing changes in the current system of care. Additional information, including tools and resources to assist an organization in adapting process mapping as an improvement strategy within its organization, can be found in the Redesigning a System of Care to Promote QI module.
How Can an Organization Know That Changes Caused an Improvement?

Measures and data are necessary to answer this question. Data is needed to assess and understand the impact of changes designed to meet an organization's specified aim. Measurement is essential in order to be convinced the changes are leading to improvement. Organizations with successful improvement efforts found that data, when shared with staff and patients outside the core improvement team, led to the spread of improvement strategies, in turn generating interest and excitement in the overall quality improvement process.

Measures are collected prior to beginning the improvement process and continue on a regularly scheduled basis throughout the improvement program. Once an organization reaches its specified goal, frequency of data collection may be reduced. Additional information regarding frequency of data collection, tracking, and analyzing data can be found in Managing Data for Performance Improvement module.

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