We developed a quality metric board, ‘Healthy Planet’, in the electronic health record system to observe HEDIS measure performance in the offices. Based on the data, we set yearly goals on our Balanced Score Card to strategically identify barriers and develop countermeasures. Considering the US disease burden, we started monitoring diabetes (A1C > 9) and hypertension control (BP < 140/90 mmHg). Our quality department initially focused on outreach to patients to close gaps in care, and has evolved into a population health department to identify barriers and provide strategic solutions, along with developing best practice guidelines for clinicians.
Problem:Measurement of ambulatory quality metrics to improve care of patients with chronic disease in the healthcare delivery system.
Measurement:We measured the quality of care in 74 primary care offices for patients with diabetes and hypertension using the HEDIS definitions of control (hemoglobin A1C >9 and blood pressure control <140/90 mmHg). We also stratified the diabetes management metrics based on the patients residing in priority zip codes.
Analysis: We monitored A1c for patients with diabetes and BP on patients with hypertension over two years, with each year as a measurement period. We had qualitative interviews with the clinical and practice leaders. We had monthly dashboards with improvement goals.
Implementation: We implemented patient education and home monitoring tools and provider best practice clinical guidelines. Actionable data reports were given to the practices and providers. Once data is verified as accurate and meaningful by stakeholders, the collaboration and countermeasures came easily.
Results/Discussion: We observed year over year improvements in control of both diabetes and hypertension. Critical to our success was descriptive data and operator involvement in developing countermeasures for the identified barriers. We are now able to perform more analysis on the data and stratify to go deeper into problem solving.
