Quality Improvement Resources

Continuous quality improvement is a term frequently used in healthcare and public health. Regularly reviewing data and engaging in deliberate quality improvement activities are important steps to increasing the control rates for cardiovascular disease and diabetes in Idaho.

Process improvement

Process improvement requires testing changes using Plan-Do-Study-Act (PDSA) cycles. The model for improvement asks questions such as, what are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement?

The Agency for Healthcare Research and Quality provides a decisionmaker’s guide to help you answer questions such as, does this innovation fit? Should we do it here? Can we do it here? How can we do it here?

Health Information Technology (HIT)

HIT can be used securely to increase screening and identify patients with undiagnosed hypertension and prediabetes. By incorporating systems and standardization to identify patients at risk, health systems may be able to prevent and manage diabetes and hypertension in earlier stages of disease progression.

Telehealth can also remove barriers to participation in lifestyle change programs.

HIT resources


Learn strategies, recommendations, and best practices in HIT. This HIT guide is intended for:

  • Administrators.
  • Physician practice owners.
  • Clinicians.
  • Practitioners.
  • Other health professionals who want to utilize health IT.

The Centers for Disease Control and Prevention (CDC) recommends telehealth interventions for the following conditions:

  • Recently diagnosed cardiovascular disease.
  • High blood pressure.
  • Cardiovascular disease, diabetes, HIV infection, end-stage renal disease, asthma, or obesity.

Telehealth intervention can improve:

  • Medication adherence.
  • Clinical outcomes.
  • Dietary outcomes.

Effective telehealth communication includes:

  • Text messaging.
  • Web-based applications.
  • Interactive content.
Offer Diabetes Self-Management Education and Support (DSMES) and National Diabetes Prevention Program (National DPP) using telehealth technologies

Eliminate barriers to providing DSMES and National DPP services by offering telehealth options. This CDC guide provides organizations:

  1. Steps to getting started with telehealth
  2. Additional details about each of the technologies
Patient engagement guide

HIT allows for better communication with patients, which influences care and outcomes. This patient engagement HIT guide is intended for:

  • Providers.
  • Practice staff.
  • Hospital staff.
  • Other health professionals who want to engage patients in HIT.

The patient engagement health IT guide provides a compilation of tips and best practices from providers and health systems.

Team-based care

Team-based care is an organizational intervention that incorporates multiple healthcare members to improve patient care and outcome. Health professionals may include primary care providers, pharmacists, nurses, community health workers (CHW), dietitians, and other health workers. All providers work together to share the responsibility to support patients in medication adherence, health behavior changes, appointment keeping, and following prescribed recommendations. The Community Guide summarizes the evidence to support team-based care in improving blood pressure control. Implementing team-based care improves value-based care, where the focus is on quality of service and patient outcome.

Team-based care resources

Collaborative practice and medication therapy management

Collaborative practice agreements exist between pharmacists and healthcare providers and medication therapy management. This summary of resources identifies scientific evidence to support strategies to manage high blood pressure and cholesterol levels. Methods and resources are available for:

  • Public health professionals.
  • Pharmacists.

The collaborative practice agreement set include user-friendly resources for:

  • Doctors, nurses, physician assistants, and other providers.
  • Pharmacists.
  • Government and private payers.
  • Decision-makers.


Community Health Workers (CHW)

CHWs are individuals with shared ethnicity, language, and life experiences as the local community they work with. Their connection between the community and local healthcare system bridges the gap and increases access to care.

The CDC's technical assistance guide describes how to successfully implement CHWs. CHWs are not clinicians or healthcare providers. The services they provide do not replace the level of care that physicians, nurses, and physician assistants provide to patients. As an integrated member of your care team, they can assist with the daily challenges you face like time, follow-up, and patient education. With the right tools and resources, CHWs can assist with:

  • Case management and care coordination.
  • Outreach and community education.
  • Health promotion and health coaching.
  • Community and cultural competence.
  • Home-based support.
  • Basic initial health screenings.
Patient-Centered Medical Home (PCMH)

Improve access to care by transforming how primary care is organized and delivered. The PCMH model ensures that patients receive well-coordinated services to address all aspects of their health. The five core functions of the PCMH are:

  1. Comprehensive care
  2. Patient-centered
  3. Coordinated care
  4. Accessible services
  5. Quality and safety
Community Health Emergency Medical Services (CHEMS)

Idaho CHEMS are healthcare providers who receive additional education and can expand their role to provide cardiovascular screenings. CHEMS plays a vital role in bridging the gap between the healthcare delivery system and medical health neighborhoods to assist in patient care plans.