Appendix G: Index of Diabetes Quality Improvement Initiatives

Listed below are a number of national and Federal quality improvement programs related to diabetes that State leaders may find useful as templates for State initiatives or for additional resources.

Public/Private Quality Improvement Initiatives

There are a wide range of public and private quality improvement initiatives active at different stages of quality improvement. While there are numerous components of quality improvement, the examples given below illustrate the quality improvement activities aimed at measurement and incentives. While the list is by no means exhaustive of public/private quality improvement initiatives, it provides examples of what organizations are doing specific to diabetes.

Measurement

National Committee for Quality Assurance and HEDIS® Measures

The National Committee for Quality Assurance is a national, nonprofit organization founded in 1991 that is dedicated to improving the quality of health care. NCQA is well known for its accreditation of managed care organizations and performance measurement initiatives. NCQA's Health Plan Employer Data and Information Set (or HEDIS®) is used by more than 90 percent of health plans in the United States to report performance on a wide variety of quality of care indicators, ranging from child immunization rates to waiting time for appointments to member satisfaction measures. HEDIS® also includes measures for diabetes care quality. NCQA reports on health plan performance in its annual publication, the State of Health Care Quality (NCQA, 2003). In addition, NCQA's Quality Compass, a national database of HEDIS® and accreditation information from health plans, is a resource for health plans, employers, and governments to assess and compare health care quality. NCQA in collaboration with the American Diabetes Association also has a program called the Diabetes Physician Recognition Program that recognizes physicians based on the quality of diabetes care they provide using its diabetes measures. Consumers can check online for a listing of physicians who are recognized for the quality of the diabetes care they provide. More information about NCQA and its programs is available at http://www.ncqa.org/.

National Diabetes Quality Improvement Alliance

Organized by leading diabetes stakeholder groups in 1998, the Diabetes Quality Improvement Project was a voluntary coalition of public and private organizations that have cooperated to develop a national set of diabetes-specific performance and outcome measures. In 2001, the DQIP partners joined other leading organizations to form the National Diabetes Quality Improvement Alliance. The Alliance agreed to work on developing one national performance measurement set for diabetes accepted by all major stakeholders. In October 2002, the newly formed Alliance developed national, uniform consensus standards from purchaser, provider, and consumer groups. Further information is available on the Alliance Web site at http://www.nationaldiabetesalliance.org/.

Incentives

Bridges to Excellence Project

Pay-for-performance initiatives have gained momentum in recent years as health care analysts have recognized that a disincentive for quality improvement exists in the U.S. health care system because all providers receive the same reimbursement regardless of the quality of their product (Leatherman, Berwick, Iles, et al., 2003). In its report, Crossing the Quality Chasm, the IOM recommended that payments for care should be redesigned to encourage providers to make positive changes to their care processes. Ideally, this shift will begin with purchasers and insurers and filter down through the delivery system to help encourage improvements at all levels.

In response to this challenge, a group of employers, physicians, health plans and patients has come together to create Bridges to Excellence focused on realigning incentives around higher quality. The program has created incentives through two programs, Diabetes Care Link and Physicians Office Link. The Diabetes Care Link requires certification or recognition under NCQA's Diabetes Physician Recognition Program and then grants 1- or 3-year recognition through a cash bonus system for participating physicians delivering quality diabetes care. The Diabetes Care Link program also focuses on helping people with diabetes engage in their own care and achieve better outcomes. The program estimates a savings of $350 and a cost of $175 per patient per year (Bridges to Excellence, 2004). More information on the Bridges to Excellence project is available at http://www.bridgestoexcellence.org.

JCAHO Codman Award

The Joint Commission on Accreditation of Healthcare Organizations is the Nation's leading accreditor of hospitals and other health care facilities. JCAHO has established the Ernest A. Codman Award to recognize health care organizations that use process and outcomes measures to improve organization performance and, ultimately, the quality of care provided to the public. The Codman Award was created in 1996 to showcase the effective use of performance measures, and enhance knowledge and encourage the use of performance measurement to improve the quality of health care. Information on this program is available at http://www.jointcommissioncodman.org/.

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Federal Programs and Resources for Diabetes Quality Improvement

In addition to public/private quality improvement efforts, State leaders can also use Federal quality improvement programs and resources for State efforts. There are a variety of programs at the Federal level that address diabetes and quality improvement, some of which are partnering with States, and others that have useful resources for State efforts.

Quality Interagency Coordination Task Force

In addition to preparing the first annual NHQR and subsequent reports, AHRQ is also involved in diabetes care by overseeing the day-to-day operations of the Federal Quality Interagency Coordination Task Force (QuIC). The purpose of the QuIC is to ensure that all Federal agencies involved in purchasing, providing, studying, or regulating health care services are working in a coordinated manner toward the common goal of improving quality care. This group has selected diabetes and depression as the first two areas for which it will mount an effort to improve clinical quality of care. For diabetes, the work group is focusing its efforts on having all Federal programs agree to use the DQIP measures of care and then to improve health care provider performance based on these indicators. More information on this task force is available at http://www.quic.gov/.

CDC Diabetes Prevention and Control Program

The Centers for Disease Control and Prevention currently funds the Diabetes Prevention and Control Program in every State. This program is discussed extensively in Module 4: Action; for further information, see this section of the Resource Guide.

National Public Health Initiative on Diabetes and Women's Health

CDC, the American Diabetes Association, the American Public Health Association (APHA), and the Association of State and Territorial Health Officials (ASTHO) cosponsor the National Public Health Initiative on Diabetes and Women's Health. Part of a comprehensive program to improve women's health, the CDC-lead initiative has three phases. In Phase I, the CDC prepared Diabetes & Women's Health Across the Life Stages: A Public Health Perspective. Published in 2001, this report examined why diabetes is a serious public health problem for women and analyzed the various factors that affect diabetes in women. This report also explored the impact of diabetes on women's lives using the various life stages as a framework—adolescence, reproductive years, middle age, and elder years. A copy of this publication is available on CDC's Web site at http://www.cdc.gov/diabetes/projects/women.htm.

In 2001 during Phase II, CDC joined the ADA, APHA, and ASTHO to turn the report into action. The four groups convened a task force in November 2001, with representatives of over 40 organizations from the public, private, and nonprofit sectors. Proposed recommendations that emerged from this meeting were published as the Interim Report: Proposed Recommendations for Action and are also available on CDC's Web site at http://www.cdc.gov/diabetes/pubs/interim/index.htm. In Phase III, currently ongoing, multidisciplinary agencies—including government, academic, voluntary, business, community-based, and professional organizations—selected recommendations of highest priority and identified appropriate strategies for implementation. This national agenda represents the result of their deliberations for action. Additional information is available at http://www.cdc.gov/diabetes/.

Healthy People 2010

Healthy People 2010 is a national prevention program lead by the U.S. Department of Health and Human Services in partnership with other Federal agencies, States, businesses, communities, and consumers. HP2010 outlines a broad range of objectives in health care with the goal of increasing the quality and length of life and eliminating health disparities in the United States. Diabetes is one of the focus areas of HP2010.

State leaders can use HP2010 objectives to assess health care quality. Some NHQR measures that relate to the HP2010 objectives still show room for improvement. Further information on HP2010 goals related to diabetes is available at http://www.healthypeople.gov/document/HTML/Volume1/05Diabetes.htm.

HRSA's Health Disparities Collaboratives

HRSA's Bureau of Primary Heath Care and the CDC's Diabetes Prevention and Control Program sponsor Health Disparities Collaboratives, a unique partnership with community health centers across the country aimed at improving chronic illness care for underserved and minority communities. This program is discussed in Module 4: Action; for further information, go to this section of the Resource Guide.

National Diabetes Program of the Indian Health Service

The National Diabetes Program of the Indian Health Service (IHS) is a public health effort to improve the prevention and treatment of diabetes among American Indian and Alaska Native populations. This segment of the U.S. population suffers disproportionately from high rates of type 2 diabetes. The IHS uses the following to track and improve diabetes care quality among American Indian and Alaska Native populations:

• Quality measures from the Indian Health Diabetes Care and Outcomes Audit, which are similar to national (DQIP measures.
• Case management to coordinate care and provide followup.
• Information management to identify patients and assure timely and appropriate care.
• Practice teams to deliver multidisciplinary care and education.
• Systems of care that are clearly defined and close gaps in care.
• Patient education to assist patients with managing their diabetes.
• Provider training to assure continuing education and competency.
• Protocol-based practice to ensure that evidence-based guidelines are followed.
• Provision of specialty exams and services to ensure access to necessary specialist services.
• Staging of populations to manage differing needs of various ages and stages of disease progression.

More information is available at http://www.ihs.gov/MedicalPrograms/Diabetes/index.asp.

National Diabetes Education Program

The National Diabetes Education Program is a national collaboration sponsored jointly by the NIH and the CDC. This program is discussed in Module 4: Action; for further information, see this section of the Resource Guide.

CMS' Quality Improvement Organizations

Quality Improvement Organizations are designated as the guardians of quality, cost-effective care for both Medicare and Medicaid. This program is discussed in Module 4: Action; for further information, go to this section of the Resource Guide.

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