Posted: July 20th, 2022





Read Three of your colleagues’ postings from the Discussion question.

Respond to  three  of your colleagues’ postings with a critique of their data mechanisms. Explain whether the data mechanism is practical, how long it might take, any alternatives you might suggest, and/or any electronic data collection possibilities that might apply.








RE: Discussion – Week 2


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The purpose of this discussion is to take on the role of the staff nurse in the scenario mentioned and post an explanation of how I would go about finding out how many diabetics are in your practice and how many meet all components of HEDIS comprehensive diabetes care.

Healthcare systems prioritizing quality understand that better patient outcomes are the foundation for their survival and competitiveness (Yoder-Wise, 2019). Healthcare Effectiveness Data and Information Set (HEDIS) evaluates health care performance where advancements could significantly enhance people’s lives (O’Neill, 2022). Comprehensive diabetes care through National Committee for Quality Assurance (NCQA) consists of an assessment of adults 18–75 years of age with diabetes (type 1 and type 2) who had each of the following: Hemoglobin A1c (HbA1c) testing, HbA1c poor control (>9.0%), HbA1c control (<8.0%), eye exam (retinal) performed, medical attention for nephropathy, and BP control (<140/90 mm Hg) (O’Neill, 2022).

Since this practice is small and limited, staff working together to get quality incentives is essential. The administrative files used before EMR and during the use of EMR should have patient demographics and codes to help identify diagnoses and or procedures used to help identify certain patients (Spath, 2018). Every member of this team can participate in the quality incentive report. The billing team can help find the codes that patients with diabetes have to locate the correct patients. Once the billing has the correct data available, I would get the medical assistants and nurses to work together to investigate the diabetic charts to see if HEDIS checks were made with these patients, such as HbA1c testing and eye exams performed. Once the report is finished, the nurses can report to the physicians.

Quality management’s objective is to improve the system, not to place blame (Yoder-Wise, 2019). Successful patient outcomes are dependent on improvement. Leaders such as nurses and physicians need to work together with commitment to quality improvement processes to develop better patient outcomes.


O’Neill, A. (2022, June 3). Comprehensive Diabetes Care. NCQA.Org. Retrieved July 18, 2022, from

Spath, P. (2018). Introduction to healthcare quality management, third edition (3rd ed.). Health Administration Press.

Yoder-Wise, P. S. (2019). Leading and managing in nursing (7th ed.). Mosby.

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RE: Discussion – Week 2


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In our scenario, we are tasked with finding out how many patients with diabetes our office serves, and then making sure all HEDIS components of diabetic care are being met for these patients.

Per Spath (2018) HEDIS stands for Healthcare Effectiveness Data and Information Set. It contains 91 measures of quality of care, and it is a required standard to measure performance for many health plans.

For Diabetes,  HEDIS sets standards for  A1C testing,  Measures for A1C control, Blood Pressure control standards, stipulates an eye exam, and for Medicare patients states the necessity to care for kidney disease (Comprehensive Diabetes Care – NCQA. Retrieved July 17, 2022).

Our scenario stated that there was no EHR until last year. In the best-case scenario, each of our patients is already in the system and we would simply be able to run a report to see who has a diagnosis of diabetes and run reports as well to score the quality of care given, based on HEDIS indicators of quality care.

In a worst-case scenario, the 2 nurses, the medical assistant, and the billing staff would have to look through each paper chart to find which patients had diabetes and then look at their medical history for indicators of quality care.

Once the patients are identified, a method would be needed to compare the actual standard of care to the HEDIS indicator of quality.

Kutz et al (2018) is a paper that describes a medical practice that fell below HEDIS standards for Comprehensive Diabetic Care. Per Kutz et al (2018) this described practice utilized a Lean Six Sigma model to identify gaps in care. Per Spath (2018) lean Six Sigma combines the benefits of both Lean (which improves systems by getting rid of waste and making processes uniform) and Six Sigma (which provides a total approach to reducing “process variations”).

Per Kutz (208) their team used Lean Six Sigma to compare their data against standards set by HEDIS. They identified what was missing in the care of their patients and then developed “EHR templates” to ensure a uniformization of care across the board for their patients.

It is noted, however, that our instructions for our paper state not to use Six Sigma unless we have an expert available to us. The assumption is then, that it is very complicated to learn. In Perla et al (2011) we are given the more simple “run chart” where we can plot scores along both a horizontal and vertical axis. For this example, we could plot along the vertical line the total number of our patients who had an eye exam this year. The horizontal line could show the yearly progression of eye exams completed to see our progress in quality improvement. Or we could plot mean A1C scores for our patients every 90 days and look for overall improvement in these scores.




Comprehensive Diabetes Care – NCQA. Retrieved July 17, 2022, from

Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46. doi:


Kutz, T. L., Roszhart, J. M., Hale, M., Dolan, V., Suchomski, G., & Jaeger, C. (2018). Improving comprehensive care for patients with diabetes. BMJ Open Quality, 7(4) doi:


Spath, P. (2018). Introduction to healthcare quality management (3rd ed.). Health Administration Press.






RE: Discussion – Week 2



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Healthcare agencies strive to provide the highest quality, safest, efficient, and cost-effective care possible (Yoder-Wise, 2019). Healthcare agencies that use a quality management program experiences many benefits (Yoder-Wise, 2019). Quality management programs must be measured. One way to measure is by using the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS measure addresses a broad range of health and customer service issues and includes 91 measures across seven domains of care (Spath, 2020).

Comprehensive diabetes care assesses adults 18-75 years of age with diabetes (type 1 and type 2) who had each of the following: HbA1C testing, HbA1C poort control (>9.0%), HbA1C control (<8.0%), retinal eye exam performed, medical attention for nephropathy, and BP control (<140/90 mm HG) (Neill, 2022). HEDIS measures help to ensure that providers are monitoring the status of diabetes, screening for potential complications, and helping patients achieve diabetes control (Neill, 2022).

In the scenario presented, I would work with the billing staff to see if they could cun a report of all the patients that had the code for diabetes billed whether it be from a provider visit or from having lab work done. This would be a start, then I would pull the charts and start looking at them for the diabetes diagnosis. For charts within the EHR system, using the report ran by billing would help narrow down patients diagnosed with diabetes. Once the list is generated, the next step would be to see how many diabetic patients met the components of the HEDIS measure. A report would then be drafted of all the patients who have diabetes and would include those who met the HEDIS comprehensive diabetes care measure. This process would take some time and would require the collaboration from all the staff since this practice is small.


Neill, A. O. (2022, June 3). Comprehensive diabetes care – ncqa. NCQA.

Spath, P. (2018). Introduction to healthcare quality management (3rd ed.). Health Administration Press.

Yoder-Wise, P. S. (2019). Leading and managing in nursing (7th ed.). Mosby.

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