Quality improvement (QI) is a priority for Medicaid and Children’s Health Insurance Program (MAC) programs. Yet too often state MAC QI staff are disappointed that their efforts haven’t delivered better results. Why is that, and more important, what can state MAC QI staff do to generate and sustain improved health care and health outcomes for beneficiaries?
Tom Nolan, a QI expert, outlines a simple three-part framework for successful QI: will, ideas, and execution. Will is both a desire for change and active engagement in creating change. Ideas are alternatives to the status quo. Execution is the work of putting those ideas into motion, fostering improvement, and sustaining that change.
Quality improvement isn’t easy
Will. State MAC QI staff have will in abundance. Over the past four years, these staff demonstrated their will by participating in numerous QI technical assistance (TA) events. On behalf of the Centers for Medicare & Medicaid Services (CMS), Mathematica provided QI-related TA to more than 9,000 state MAC QI staff and their QI partners. More than 53 state Medicaid-led teams, representing 34 states, participated for two years in monthly TA meetings supporting their QI projects.
Ideas. MAC programs present many opportunities for improvement yet face inherent resource constraints, making it difficult to deploy complex solutions. This can lead to the trap of overly simplistic and relatively low-cost solutions. For instance, concluding that lack of knowledge is driving poor outcomes, a MAC QI team might focus on educational interventions such as letters, trainings, resource guides, or social media campaigns. But research shows that knowledge deficits are rarely the cause of poor quality.
Execution. State MAC QI staff often feel pressured to quickly resolve issues on their expanding to-do lists. But not having enough time to learn about contextual issues and determine the right changes to make result in solutions that fail to make an impact.
A better way forward
How can state MAC QI staff succeed in improving health services and outcomes for beneficiaries? Let’s return to Nolan’s framework and some of the tools Mathematica has created in collaboration with CMS to help states succeed in QI.
Will. Nolan writes that will is required at all levels of an organization for a QI initiative’s success, “but especially the will of top management to make a new way of working attractive and the status quo uncomfortable.”
State MAC QI staff must engage their senior leaders, the people responsible for incorporating QI into the state’s quality strategy, managed care and other contracts, budgets, and policy decisions. Executives must free up resources, such as staff time for QI projects and data analysts to support quality measurement. Executives are also key to connecting siloed groups in the agency, such as the quality and managed care oversight teams. State MAC QI staff can sustain the will of leadership by keeping them informed and engaged in the QI project through regular, brief updates, supported by data, and by making strategic requests for leadership support.
Ideas. To improve their ideas, state MAC QI staff need to embrace the complexity of QI. Nolan writes, “No single initiative or set of unaligned projects will likely be enough to produce system-level results.”
One useful tool for understanding the complexity of a system and opportunities for change is a driver diagram. Driver diagrams identify primary drivers, or the processes, structures, or norms that affect the desired outcome, and secondary drivers, or moments, places, and process steps where change occurs. With the primary and secondary drivers in place, states can review research studies, look at the experiences of other state Medicaid programs, and consult experts to identify evidence- and experience-based change ideas that lead to improvement.
States should develop their driver diagram from the perspective of the state Medicaid agency to clearly identify actions the agency can take. Mathematica helped CMS create driver diagrams for several QI topics, including improving postpartum care, oral health, tobacco cessation, and behavioral health.
Execution. State QI teams should test their way into successful programs and policies. One way is through the Model for Improvement, “a simple yet powerful framework for accelerating improvement.” Like the scientific method applied in research, the Model for Improvement starts with questions: What do you want to improve? What changes will you make? How will you know that the change is an improvement (for instance, what data will you collect and study to know you’ve met your improvement goal)? Change ideas are tested in quick, iterative cycles; studied; and either adapted for more testing or abandoned.
Once the state MAC QI team has a high degree of confidence and data indicating the change will reliably produce the desired outcome, the team can work to adopt the improvement across the system. This process of testing and learning enables the team to consider context and make any modifications needed to successfully spread a change throughout its organization or system.
Medicaid QI is hard. But successful and sustainable improvement is important for beneficiaries and state MAC QI staff. Mathematica has worked with CMS to offer states multiple opportunities to learn about proven QI methods, including successful state Medicaid QI stories and guidance for starting a QI project. To learn even more, state MAC QI staff and their QI partners participate in MAC QI Open School, consult with QI advisors during MAC QI Office Hours, or work on QI projects with their peers in affinity groups.
For more information on Medicaid QI, reach out to MACQualityImprovement@mathematica-mpr.com.
