1

Bishwajit Mazumder
Nursing Instructor
Dhaka Nursing College, Dhaka
E. mail mbishwa@rocketmail.com
Continuous Quality Improvement Project on Diabetes Care among
Diabetes retinopathy Patients on National Institute of
Ophthalmology & Hospital (NIO&H).

Background:
Diabetes is a complex long-term condition that leads to
increasedcardiovascular risk and complications including damage to eyes, kidneys
andnerves. Multiple vascular risk factors associated with diabetes and wide-ranging
complications mean that managing diabetes draws on many areas of healthcare. This
quality standard describes markers of high-quality, cost-effective care that, when
delivered collectively, should improve the effectiveness, safety and experience of care
for adults with diabetes.The concept of quality measurement, available diabetesrelated measures in theNational Health Care Quality Report (NHQR), and the
importance of using multi-dimensional measure sets.Quality measures of processes of
care that are linked to increases or decreases in deaths or other medical outcomes help
medical staff know how to change care in order to improve patient outcomes. There is
a distinction between quality measures and guidelines for quality care. The health care
quality measures used in the NHQR and used for State, regional, or local planning for
quality improvement initiatives relate to populations. Such measures are often rates
(e.g., percentages) which indicate the number achieving a goal (e.g., glycemic
control) relative to a population base (e.g., all people with diabetes in the Nation). By
contrast, guidelines for quality care are recommendations devised via consensus
processes of clinical experts that describe standards of care for individual patients. In
general, guidelines for quality care of individual patients are used as the theoretical
underpinning to develop population-based quality measures.

Most quality improvement efforts focus on process and outcome measures.

Process measures often reflect evidenced-based guidelines of care for specific
conditions. Outcome measures often relate to patient health status. Ideally,
improvement in a particular process measure yields improvement in the associated
outcome measure. Structural measures of the health care infrastructure are a third type
of quality measure, less directly related to quality of care.

What is Diabetes?

Diabetes is a common, controllable, life-long condition. Diabetes is a group

of diseases characterized by the presence of too much glucose in the blood. In type 1
diabetes, the body does not produce enough insulin. In type 2 diabetes, the body may
not produce enough insulin or not use insulin properly. Insulin is a hormone produced
by the pancreas to move glucose from the blood into the cells. Glucose (also known
more commonly as blood sugar) provides energy for cells.
Type 1 diabetes usually begins in childhood and occurs when the cells that produce
insulin are destroyed; this type of diabetes accounts for 5 percent to 10 percent of all
diagnosed cases.
Type 2 diabetes occurs as the body develops insulin resistance or the
pancreas loses the ability to produce insulin. Type 2 diabetes is associated with both
genetic and behavioral factors including age, obesity, physical inactivity, family
history of diabetes, among other factors. Certain racial and ethnic groups are
particularly at risk for diabetes.
Normally seen in adults, type 2 diabetes is on the rise in children and
young adults. This type of diabetes accounts for 90 percent to 95 percent of all
diagnosed cases of diabetes.
Gestational diabetes is caused by glucose intolerance that develops in some women
during pregnancy. Women with gestational diabetes are at increased risk of
developing type 2 diabetes after pregnancy.
Source: CDC National Diabetes Fact Sheet (CDC, 2003b).

Quality of Diabetes Care:

Over the past few years, increasing national attention has been focused on
improving diabetes care in the outpatient setting through the implementation of
evidenced-based guidelines and promotion of chronic care approaches that emphasize
prevention and improving outcomes. The value of tight glycemic control is now
widely accepted for outpatient management of diabetes. However, little direction has
been provided on useful approaches to improve inpatient diabetes care delivery, even
though the national burden for inpatient diabetes care is significant. Recently the
American College of Endocrinology (ACE), along with the American Diabetes
Association (ADA) released a joint consensus statement with recommendations for
improving inpatient diabetes and glycemic control. The statement referred to major
studies that showed a strong association between hyperglycemia and poor clinical
outcomes among hospitalized patients and concluded that multiple institutional and
attitudinal barriers still exist to improved care that have created a significant and
growing gap between what we know and what we do. Their consensus statement
identifies strategies for implementing improved diabetes management in hospitalized
patients.

Types of Quality Measures:

1. Process measures:
Process measures often are based on guidelines of care for a specific
condition. Process measures are generally considered to be within the control of the
provider and, therefore, are considered performance indicators. They also are more
likely to reveal actions that can be taken to improve quality (for example, whether a
necessary test or medication is given).
2. Outcome measures:
Outcome measures generally are based on patient health status. They are
considered to be the ultimate objective of quality improvement improving the
patients health (for example, mortality rates, hospitalization rates, and test results)

3. Structural measures:
Structural measuresreflect aspects of health care infrastructure that generally
are broad in scope, system wide, and difficult to link to short-term quality
improvement (for example, the staff-to-bed ratioin a hospital.

Diabetes-Related Quality Measures:

Although many process measures exist for diabetes care, those listed below
survived an extensive consensus process developed and could be estimated from
existing databases. The five process measures and seven outcome measures; the
outcome measures are of two typestest results and avoidable hospitalizations.

Process Measures:
HbA1c testPercent of adults with diabetes who had a hemoglobin A1c
measurement at least once in the past year.
Lipid profilePercent of patients with diabetes who had a lipid profile in the
past 2 years.
Eye examPercent of adults with diabetes who had a retinal eye examination
in the past year.
Foot examPercent of adults with diabetes who had a foot examination in the
past year.
Flu vaccinationPercent of adults with diabetes who had an influenza
immunization in the past year.

Outcome Measures:
Test resultsThere are three measures listed below:
HbA1c levelsPercent of adults with diagnosed diabetes with HbA1c levels
> 9.5 percent(poor control); < 9.0 percent (needs improvement); and < 7.0
percent (optimal control)
Cholesterol levels Percent of adults with diagnosed diabetes with most
recent LDL-C level< 130 mg/dL (needs improvement); <100 (optimal)
Blood pressurePercent of adults with diagnosed diabetes with most recent
blood pressure<140/90 mm/Hg

Identify problem/ Needs for improvement:

Diabetes Care Quality Improvement provides an overview of diabetes and
quality improvement. It helps to answer the question of why States should care about
these issues. State leaders should care because of the following:
a. Increasing prevalence of diabetes and its link to obesity.Seriousness of diabetes
complications and their effect on quality of life and productivity such as
i.
Heart disease, hypertension, heart attacks and stroke
ii.
Leg and foot ulcers and lower-limb amputation
iii.
Eye problems and blindness
iv.
Kidney disease and kidney failure
v.
Coma and death
vi.
Other complicationssusceptibility to infection; dental disease; skin
b.
c.
d.
e.

problems; sexual dysfunction; and

Increased risk for birth defects if pregnancy.
High health care cost of diabetes complications.
Problems with health care disparities for different groups.
Proven effectiveness of interventions to prevent type 2 diabetes and delay

complications for all types of diabetes.

f. Potential for a significant return from investments in improving diabetes quality of
care.
g. Significant gaps in quality that exist for diabetes care

Choosing this area/ Literature review:

According to my institutional perspective, diabetic retinopathy is more
common. Diabetic retinopathy is a major cause of ocular morbidity among the
diabetic patient. Along with hyperglycemia, dyslipidemia is a contributing factor for
the occurrence of diabetic retinopathy. It is postulated that dyslipidemia results in
formation of hard exudate by increasing blood viscosity and altering the fibrinolytic
system. Diabetes poses a serious threat to low-income countries such as Bangladesh.

It is one of the leading causes of premature morbidity and mortality, and requires lifelong healthcare services. Women with diabetes are affected in all stages of their lives.
Uniquely, diabetes affects the health of mothers and their unborn children. Poverty,
ignorance, and gender discrimination adversely affect women with diabetes. Diabetic
retinopathy (DR), a common complication of diabetes mellitus, affecting the blood
vessels in the retina; results from chronically high blood glucose levels in people with
poorly controlled DM. If untreated, it may lead to blindness(Akhter A., 2009)
In Bangladesh, many people suffer from diabetes retinopathy. According to
(Rahman Md.R, Arslan M. I, Hoque Md.M, Mollah F.H. & Shermin S.,2011), a study
was carried out in the department of Biochemistry, Bangabandhu Sheikh Mujib
Medical University, Dhaka during the period of January 2006 to December 2007 to
evaluate the serum lipid profile in newly diagnosed type 2 diabetic subjects with
diabetic retinopathy. Another study of Bangladesh ( Faruque GM , Ahsan K,& Aim
A,2008), suggest that diabetic retinopathy patients need assessment of serum lipids
and they may need lipid-lowering agent to halt the progression of diabetic retinopathy
and also to protect the patients from systemic morbidity of hyperlipidemia. Another
study of Bangladesh ( Medical newsletter, Square pharmaceutical limited,
Bangladesh, 2010), 250 women between the ages of 18 and 25 years showed that the
socioeconomic consequences included diminished capacity to work due to cataract,
diabetic retinopathy and blindness, leg amputation, and chronic pancreatitis. Endstage renal disease and hypoglycemia were causes of premature death (30%). Drop
out from school or college owing to poverty and diabetic complications was not
uncommon. A few women were divorced, separated, or abandoned by their husbands,
who often took a second wife. Another study (Ahmed K. R., 2009) diabetic
retinopathy (DR) is the most significant cause of visual impairment and blindness,
thereby reducing the quality of life and serious economic and social consequences.
Further an intervention study on this issue would have long term implication of DR on
the promotion of health and reduction of disease burden. Subsequently the effects of
these interventions on risk factors and the target outcome should be monitored, and
their impact and cost-effectiveness should be evaluated. So I choose this area to
highlight and improve to continuous quality improvement project.

Aim of the project:

1.

Providing leadership and shared vision to inspire others to become involved in

improving health care quality.

2. Fostering partnerships and collaborations between key parties, such as health care
professionals, providers, patients, purchasers.
3. Fostering planning and setting goals that includes specific steps and deliverables so
that partners move together.
4. Enhancing measurement and reporting to identify the most troublesome areas and
5.

prioritize resources and attention to those areas that most need improvement.
Improving the infrastructure of health care quality through attention to professional
education, data systems, financing and delivery systems, research, and patient

education resources, among others.

6. Including evaluation and accountability to track how well or poorly a quality
improvement intervention is working and the health care system is performing.
7. Creating incentives to reward the delivery of high quality care.
8. Overviews of programs on national diabetes measures, chronic care improvement, and
disease and self-management.
9. Overviews of the Federal programs that partner and provide funding for diabetes
quality improvement efforts in the country.
10. More extensive profiles of diabetes quality improvement approaches in the country.
11. A worksheet for analyzing current diabetes quality improvement activity in the
country.
12. Various factors that affect health care outcomes and the delivery of quality care
including socioeconomic factors, biological and behavioral differences, and health
system characteristics and the role these factors play in assessments of health care
quality in the country.

Element/ component of Continuous quality improvement project on

diabetes care:
The Six core components of the diabetes care program. These are as follows:
a.Community Mobilizing all the available community resources to meet the needs
of people with chronic illnesses.

b. Health System Creating organizational cultures, systems and mechanisms that

promote safe, high quality care throughout the health care system.
C. Self-Management Support Empowering and preparing patients to manage their
health and navigate the health care system.
d. Delivery System Design Assuring the delivery of effective, efficient clinical care
and self-management support through appropriate design of the delivery system
e. Decision Support Promoting appropriate clinical care consistent with scientific
evidence and patient preferences.
f. Clinical Information Systems Organizing patient and population data to
facilitate efficient and effective care for people with chronic illnesses.
Source: MacColl Institute for Healthcare Innovation, Group Health Cooperative,
2004.

Process of continuous quality improvement project on diabetes care:

The process of continuous quality improvement project on diabetes care are
as follows:
1. Data:
Data looks at the importance of data collection in assessing quality and the
role ofquality measurement and examines a variety of data sources on diabetes care
quality that theleaders can use to assess the quality of care. Also provides guidance on
selecting reliable measures and collecting good data and discusses the inherent
limitations of particular data sources.
2. Information:
Information takes the next step in the quality improvement chain by showing the
leaders how to turn data into information to answer key questions that should be
understood before action is taken.
3. Action:

Action provides the leaders with a variety of tools and examples from
diabetes carequality initiatives that can inform the efforts.
4. Improvement:
Improvement provides models, tools and checklists for the leaders to use
incrafting a quality improvement strategy for a given . The projects examines the
Plan-Do- Study-Act model, which is used frequently in quality improvement in
clinical settings, and adapts that model to the policymaking.
5. The way forward:
The Way Forward concludes the Resource Guide and examines the
opportunities contribute to improving diabetes care quality. In general, as the leaders
begin the process of quality improvement, they must make several key decisions. This
Resource Guide provides guidance related to each of the following decision points:
1. Make quality improvement a priority.
2. Decide on a general topic areas for analysis.
3. Identify measures that address the topic.
4. Develop an inventory of data sources for the country or locality.
5. Determine benchmarks for the measures selected.
6. Conduct or commission analyses to create information that addresses the questions
raised.
7. Utilize an existing or develop a new advisory group, committee, or workgroup
focused on quality improvement.
8. Find resources to develop and support the initiative.
9. Design and take action aimed to improve quality.
10. Evaluate the result.

Members of continuous quality improvement committee :

According to Network for Regional Healthcare Improvement (NRHI) ,2004
members of continuous quality improvement committee:
1. Cooperative Healthcare Reporting Initiative (CHRI)

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2.
3.
4.
5.
6.

Integrated Healthcare Association(IHA)

Breakthroughs in Chronic Care Program (BCCP)
Health Quality Partners (HQP)
Institute forClinical SystemsImprovement(ICSI)
Community Measurement (CM)
Data collection:

Understanding the Foundation of Quality Improvement project the

importance of data collection in assessing quality and the role of quality
measurement. This module is providing:
1.

A listing and explanation of a variety of quality measures from the National

Healthcare Quality Report (NHQR) and the National Healthcare Disparities
Report (NHDR) on diabetes care. The diabetes data in the NHQR come from

five data sources:

a. Behavioral Risk Factor Surveillance System(BRFSS), a telephone
surveydesigned by the CDC and conducted by individual country. BRFSS data
are only diabetes related data reported by the NHQR. BRFSSprovides
country-level estimates for four of the five process measures.
b. Medical Expenditure Panel Survey(MEPS)Household Survey, a national in
person survey, conducted by AHRQ. MEPS data are used for all five process
measures and report data by national population subgroup.
c. National Health and Nutrition Survey(NHNS), a physical examination survey
conducted byclinicians who staff a tractor-trailer clinic that travels to sampled
communities under the auspices of the National Center for Health
d.

Statistics(NCHS/CDC).
Healthcare Cost and Utilization Project(HCUP), a census of hospital
discharge records by AHRQ. HCUP data are used to report on the three

outcome measures of avoidable hospitalization.

e. National Hospital Discharge Survey (NHDS), a national sample of hospitals
and a sample of their discharge, conducted by NCHS . NHDS is used for one
outcome related avoidable hospitalization.
2. Data tables and maps that leaders can use to assess the quality of care in their
country.

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3.

Guidance on selecting reliable measures, collecting good data, and the

inherent limitations of data sources.

4. Estimates for all country on the direct and indirect costs of diabetes and on
the medical carecosts related to diabetes .
.

Key strategy of continuous quality improvement project diabetes

care :
Diabetes Programmes are a tried and tested strategy for mounting an
effective and coherent approach to improving the outcomes of diabetes treatment and
care.Essentially, these programmes are comprehensive plans to improve the NIO&H,
quality of diabetes treatment and care. They can be relatively simple or highly
detailed depending on local needs and available resources. They may be developed
and implemented as stand-alone strategies or action plans. In either case, the purpose
is to integrate and link evidencebasedactivities that are planned and coordinated
nationally and implemented across the NIO&H. These plans must be documented,
transparent and freely available tostakeholder groups. They must have stated goals
and objectives, supported by a strategic plan, specified timeframes and milestones,
dedicated funding and a means of evaluation.
Diabetes Programme is a systematic and coordinated approach to improving the
organization, accessibility and quality of diabetes treatment and care and is usually
manifest as a comprehensive policy, advocacy and action plan covering.The core
elements of a comprehensive diabetes program are:
1. Primary prevention - Preventing the development of risk factors
2. Secondary prevention - Preventing the development of diabetes
3. Tertiary prevention - Preventing the development of complications through early
diagnosis and treatment and care of people with diabetes:
a. Medication, equipment and supplies
b. Information and communication systems
c. Monitoring, surveillance and evaluation systems

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Guiding principles:
The core principle underpinning diabetes programmes is social justice. This
should be manifest in strategies to promote equal access to opportunities to achieve
the best outcomes for all peoplewho need them, regardless of race, religion,
socioeconomic status or geographical location. In practice, this means:
1. Access to basic requirements for effective and affordable treatments, diagnostics and
technologies for all who need them.
2. Consideration and affirmative action to ensure that access is afforded to vulnerable
groups.
3. Policy and practice is based on the available evidence and guided by expert opinion,
stakeholder consensus, and a person-centred approach

Strategic plan:
Vision:
To treatment and control diabetes diseases and ensure toimprove the
quality nursing care of patients in NIO&H.
Mission:
To treatment and control diabetes diseases and conditions by building the
knowledge about self-care and ensure quality nursing care in NIO&H.
Goal:
1. Improve and expand diabetes surveillance and monitoring throughout the NIO&H to
assess the burden of diabetes and guide policy development and evaluation activities.
2. Promote early detection of diabetes and treatment of type 2 diabetes across the life
span through collaboration with health systems and communities.
3. Foster and facilitate collaboration with NIO&H among health-related organizations
in the development and dissemination about the knowledge of diabetes.

Program priorities:

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There are five priorities areas are:

1.
2.
3.
4.
5.

Surveillance/ Data collection system

Access
Education
Health promotion
Partnership/ Collaboration

Continuous Quality ImprovementStrategies:

These are the Continuous Quality Improvement strategies as follows:

a. Provider reminders:
Information tied to a specific clinical encounter, provided verbally, in writing,
or by computer, that is intended to prompt the clinician to recall information (e.g., to
make medication adjustments or order appropriate screening tests), or to consider
performing a specific process of care. The phrase tied to a specific clinical
encounter distinguishes reminder systems from the audit and feedback strategy,
where clinicians are typically presented with summaries of their performance relative
to a process or outcome of care over multiple encounters.
b. Facilitated relay of clinical data to providers:
Clinical information collected directly from patients is relayed to the provider
in situations where the data are not generally collected during a patient visit, or when
collected using a means other than the existing local medical record system (e.g.,
transmission of a patients home glucose level). The investigators expected there to be
some overlap with the provider reminder systems strategy, but kept them separate at
the abstraction stage. This was done to allow for the possibility that the data could be
subsequently analyzed with and without collapsing the strategies.

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c. Audit and feedback:

Any summary of a health care providers clinical performance or an
institutions clinical performance that is reported, either publicly or confidentially, to
or about the clinician or institution (e.g., the percentage of a provider's patients who
have achieved or have not achieved some clinical target). The practice of
benchmarking refers to the distribution of performance data from institutions or
providers regarded as leaders in the field. It is considered a type of audit and
feedback, so long as local data is provided in addition to the benchmark figures.
d. Provider education:
Any intervention that includes one of the following three sub strategies:
educational workshops, meetings e.g., traditional Continuing Medical Education
(CME), and lectures (live or computer-based); educational outreach visits (the use of a
trained person who meets with providers in their practice settings to disseminate
information intended to change the provider's practice); or the distribution of
educational materials (published or printed recommendations for clinical care,
including clinical practice guidelines, audio-visual materials and electronic
publications).
e. Patient education:
Live appearance patient education, for individuals or members of a patient
group or community, or via the distribution of printed or audio-visual educational
materials. Only those approaches that include patient education as part of a
multifaceted strategy were evaluated. Those in which patient education was the sole
approach were excluded. One of the upcoming volumes in the Closing the Quality
Gap series may be used to review the topic of patient education with regard to its
effect on a variety of chronic diseases, including diabetes.
f. Promotion of self-management:

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The distribution of materials (e.g., devices for glucose self-monitoring) or

access to a resource that enhances the patients' ability to manage their condition, the
communication of clinical test data back to the patient, or follow-up phone calls from
the provider to the patient with recommended adjustments to care. There was some
overlap with the patient education and patient reminders strategies, but elected to
separate the strategies at the abstraction stage. This was done to allow for the
possibility that the data could be analyzed subsequently, with and without collapsing
the strategies.
g. Patient reminders:
Any effort directed toward patients that encourages them to keep appointments
or adhere to other aspects of self-care.
h. Organizational change:
Changes in the structure or delivery of care designed to improve the efficiency
or breadth and depth of clinical care. These include the use of disease management or
case management tactics (coordination of assessment, treatment, and arrangement for
referrals by a person or multidisciplinary team in collaboration with or supplementary
to the primary care provider); other personnel or team changes; the use of
telemedicine (communication and case discussion between distant health care
professionals); Total Quality Management (TQM) or Continuous Quality
Improvement (CQI) approaches (quality problem cycles of measurement, intervention
design, implementation, and re-measurement); and changes to medical records
systems or hospital information systems.
i. Financial, regulatory, or legislative incentives:
Interventions with positive or negative financial incentives directed at
providers (e.g., linked to adherence to some process of care or achievement of some

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target patient outcome). This strategy also included positive or negative financial
incentives directed at patients, system-wide changes in reimbursement (e.g.,
capitation, prospective payment, or a shift from fee-for-service to salary pay
structure), changes to provider licensure requirements, or changes to institutional
accreditation requirements.

Developing a Strategy for Diabetes Quality Improvement program:

Quality health care is a goal that all health care professionals and
policymakers can achieve, yet many do not know where to begin.The challenge of the
health care system is to define what is quality health care and lead participants in
the health care system to increase quality, reduce mistakes, and attain quality results
for every patient every time. The project should be only 5 years. Others can point to
the great strides that have been made in manufacturing and other services by applying
the principles of quality improvement.

Model for Quality Improvement:

While local contexts differ, models of quality improvement give the common
elements needed to stimulate change and improvement in any situation. As State
leaders embark on new initiatives or revitalize existing ones, quality improvement
models can inform those efforts. The key is to find asuitable model for an individual,
and then pick and choose the components that aremost useful for a specific local
context. Explained below is a model that may be useful for the leaders developing
quality improvement strategies.

Plan-Do-Study-Act (PDSA) Model:

A time-tested quality improvement tool still useful today is the Plan-DoCheck-Act or the Plan-Do-Study-Act model for guiding quality enhancement
projects of all types. The PDSA model conceptualizes the continuing cycle

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ofimprovement. W. Edwards Deming popularized the Plan- Do-Check-Act model (an

idea of Walter Shewhart, a statistician at the Bell Telephone Laboratories) and focused
manufacturers on the need to apply the model constantly to the production process.
Deming is credited with General Douglas McArthur for rebuilding Japan after World
War II and setting the foundation for Japanese production quality (Tortorella, 1995).
Its steps for effective quality improvement include:
1. Plan:
Nurse set the goals of the quality improvement cycle questions, predictions,
data to be collected, and the who, what, when, where of the project.
Nurse decides on a set of questions or topic areas related to quality
improvement.
Nurse develop an appraisal of how the performs, why, and how could
improve.
Take an inventory of current diabetes quality improvement
programs.Programmingand other local and nongovernmental initiatives.
Nurse develops an inventory of potential data sources that can address the
topic and help analyze variation in practice across the country.
Nurse determines whether special data collection must be undertaken and
how that can beaccomplished.
Nurse develops a preliminary evaluation plan to inform data collection needs.
2. Do:
Nurse carry out the plan and document problems and unexpected
observations.
Assemble data.
Make initial estimates of measures agreed to by the Partners and compare
them to benchmarks.
Initial assessments may lead the Committee to revise its original plan.
Nurse conducts (or commission) analyses to answer the questions raised in
the planning stage and to develop information for deciding on actions to be
taken.
3. Study:
Nurse Completes the analysis of the data, compare to predictions, and
summarize lessons.

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Nurse studies the data and its implications for the quality improvement
strategy
Prioritize areas for improvement.
Nurse puts together the case for taking action.
4. Act :
Nurse determine the changes to be made and decide what will happen in the

next cycle (Langley, Nolan, Nolan, et al., 1996).

Refine the action and evaluation plans with the Partners.
Nurse finds resources to develop and support the initiative.
Nurse implement the action plan.
Nurse implement the evaluation plan.
Nurse assess whether improvement has occurred based on the evaluation data.

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Plan:
Set goals, predict,

Do:
Act:

Test the plan,

Implement,

document
problems,

evaluate,

Study:
Complete data
analysis, review

Source: Adapted from Langley G, Nolan K, Nolan T, et al. The Improvement Guide:
A Practical

Importance of Evaluation:
Evaluation is essential to understand whether a quality improvement activity
is accomplishing planned goals, whether goals and actions are ultimately improving
the health outcomes of the population, and what adjustments are necessary.
Evaluation in quality improvement can be done quickly, as oftensuggested by
facilitators, to maintain momentum of the quality improvement activity. Evaluation
can also look at longer term, underlying components of the program.

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Steps

Engage
stakeholder

Ensure the use

and share
lessoned
learned

Describe the
program

Standards
Utility, Feasibility
Propriety, Accuracy

Focus
evaluation
design

Justify
conclusio
n

Gather credible
evidence

Source: Centers for Disease Control and Prevention. Framework for

ProgramEvaluation in Public Health. MMWR 1999;48(No. RR-11). Available at:
(http://www.cdc.gov/eval/framework.htm (accessed March 3, 2004).
The CDC provides 30 standards under the four subgroups of utility, feasibility,
propriety, and accuracy. These standards are guidelines for conducting sound and fair
evaluations and may be briefly described as follows:
Utility ensures that the evaluation serves the needs of intended users.
Feasibility results in evaluations that are realistic and sensible.
Propriety ensures ethical integrity in the conduct of the evaluation.
Accuracy leads to information that is technically sound.

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Steps in the Evaluation Process:

The six steps in the evaluation process may vary as to when they are carried out,
though one step usually lays a foundation for the next. Steps will be repeated as
results become clear and new issues arise. Each step serves to ensure the effectiveness
of the evaluation.
a. Engaging stakeholdersis essential to ensure that the evaluation address
the important elements ofthe program and that the evaluation is used.
Stakeholders include those served by the program, thoseplanning and directing
the program, and those involved in program operations.
b. Describing the program serves two functions. First, it lays out in detail the
programs goals andstrategies so that everyone involved understands them.
Second, it provides an opportunity forconsensus building around the goals and
strategies.
c. Focusing the evaluation design addresses the greatest issues of concern. This
step includesidentifying the purpose of the evaluation; defining the users and
usefulness of the evaluation; listingstakeholders questions that need to be
addressed; establishing methods to ascertain information uponwhich the
evaluation will be based; and developing consensus around particular roles
andresponsibilities pertaining to the evaluation.
d. Gathering credible evidence contributes to the robustness of the evaluation.
Developing credibleevidence involves defining appropriate indicators,
identifying legitimate sources of information;ensuring the quality of data
gathered; and aligning the infrastructure for collecting evidence with
theenvironment (and individuals) from which the information is gathered.
e. Justifying conclusions is important to ensure that the evaluation will be used.
When consensus isreached regarding the goals and strategies of the program,
when the values of the evaluation arealigned, and when the evidence gathered
is credible, then conclusions will naturally be justified.
f. Ensuring use and sharing lessons learned includes designing mechanisms
for feedback anddissemination of the information gained in the

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evaluation.Employing an evaluation specialists or, at the least, assembling an

evaluation team with a designatedleader will help facilitate the process. Issues
regarding internal bias and external influences must beaddressed to ensure
integrity of the analytic work and a trusted evaluation of a program or project.
To be effective, however, evaluation strategies must be timely and useful. They should
be considered at the beginning of the project and they should have a reasonable
deadline for completion. Including an experienced evaluator on the quality
improvement team can help ensure that the evaluation will be sound, useful, and
timely. The evaluation should feed back to the quality improvement cycle and direct
future actions.

Outcome of retinopathy (According to literature):

Retinopathy, the potential sight threatening condition, is a significant public
health problem all over the world; however this morbidity is largely preventable and
treatable. It is significantly associated with impairment ofvision and blindness. The
socioeconomic burden resulting from visual impairment or blindness caused by
retinopathy, particularly in working age group, is a serious concern (Akhter A.,
2009). According to (Faruque GM, Ahsan K, & Aim A., 2008), the study suggest that
diabetic patients with diabetic retinopathy was fundus picture hard exudates,
hemorrhages and other features of diabetic retinopathy.. Analytical result of this study
reveals that the patients of diabetic retinopathy have been found to have close
association with elevated serum lipid levels. This study suggests that diabetic
retinopathy patients need assessment of serum lipids and they may need lipidlowering agent to halt the progression of diabetic retinopathy and also to protect the
patients from systemic morbidity of hyperlipidemia. This study provided information
about patients outcome, doctors outcome; nurses outcome is very low. Because
huge amount of money spend, tendency of infection rate is more than non-diabetes
patient. Good diabetes management has been shown to reduce the risk of
complications. But when diabetes is not well managed, it is associated with serious
complications including heart disease, stroke, blindness, kidney disease and

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amputations leading to disability and premature mortality. There is also a substantial

financial cost to diabetes care as well as costs to the lives of people with diabetes.
Another study.( Ahmed K.R., 2009) result suggest that gap of knowledge, attitude,
and practice of diabetes patients seeking care in diabetes hospital in Bangladesh.
Patients with diabetes mellitus without diabetic retinopathy should be encouraged to
have annual dilated eye examinations to detect the onset of diabetic retinopathy. Our
data also support that controlling blood glucose and blood pressure levels can delay
the development of retinopathy or slow its progression. People with diabetes should
work closely with their health care team for improvement outcomes. Based on the
findings from this study and future population dynamics, it is imperative that eye care
service delivery be organized in coordination with diabetes care.A closer cooperation
between the diabetologists and ophthalmologists is required to reduce the risk of
complications and improve the quality of care. If untreated, it may lead to blindness.
If diagnosed and treated promptly, blindness is usually preventable the target outcome
should be monitored, and their impact and cost-effectiveness should be evaluated.
( Ahmed K.R., 2009)

Conclusion:
Diabetes is one chronic condition that has a compelling case for quality
improvement for the country. The disease burden from diabetes is great in terms of the
number of people affected, the cost of complications, its effect on quality of life, and
the disparities in care between racial and ethnic groups. Despite its prevalence and
cost, research has demonstrated that type 2 diabetes can be prevented, and
complications from both type 1 and type 2 diabetes can be prevented or significantly
delayed with appropriate treatment. Health care analysts and researchers have long
documented extensive gaps in the quality of care delivered to country. Diabetes also
has widely accepted, evidence-based guidelines for care and a strong case for a return
on investment for purchasers and society from diabetes quality improvement efforts.
Quality measures of processes of care that are linked to increases or decreases in
deaths or other medical outcomes help medical staff know how to change care in
order to improve patient outcomes. Process measures often reflect evidenced-based

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guidelines of care for specific conditions. Outcome measures often relate to patient
health status. Ideally, improvement in a particular process measure yields
improvement in the associated outcome measure. Increasing national attention has
been focused on improving diabetes care in the outpatient setting through the
implementation of evidenced-based guidelines and promotion of chronic care
approaches that emphasize prevention and improving outcomes.

References:
1. Agency for Healthcare Research and Quality ( Stanford UniversityUCSF Evidencebased Practionersin) (2004), Closing the Quality Gap: A Critical Analysis of
Quality Improvement Strategies
2. Bob Wise B., Nusbaum P.L., Curtis C., & Holmes A.P., Diabetes Strategic Plan 20022007
3. Coffey R.M., Matthews T.L & McDermott K.(2004), Diabetes Care Quality
4.
5.
6.
7.

Improvement:A Resource Guide for State Action

Endocrine Health Network Working Party (2008), Diabetes Model of Care
Kass B,(2004),Diabetes Care Quality Improvement: A Workbook for State Action
International Diabetics Federation, Global Diabetes plan 2011- 2021
Mosses G., Karp M., &Rabson B. G (On behalf of the network for the regional health
care improvement), Regional Coalitions for Health Care Improvement: Definition,

Lessons, and Prospects.

8. The Wisconsin collaboration Diabetes quality improvement project 2012
9. The Critical Access Hospital Diabetes Project Workgroup ( 2006), Assessment of
Inpatient Diabetes Care Management and Educationin Wisconsin Critical Access
Hospitals
s of