Quality improvement initiatives: issues in moving from diabetes guidelines to policy.

OBJECTIVE To outline the principles that direct the Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) dedicated to diabetes quality improvement (QUERI-DM). RESEARCH DESIGN AND METHODS We discuss the VA initiatives aimed at improving diabetes care for veterans as well as general issues that should be considered in quality improvement initiatives. We specifically describe some of the epidemiological, statistical, and organizational issues that have guided our quality improvement (QI) programs. RESULTS The five principles that have guided the QUERI-DM process are: 1) treating clinical guidelines and goals distinct from quality standards and quality improvement priorities; 2) targeting high-risk patients and high-impact quality issues; 3) profiling processes over outcomes; 4) targeting processes that will improve patient outcomes; and 5) paying attention to the loci of practice variation. CONCLUSIONS The authors recommend that all five principles be considered when moving from practice guidelines to performance measures and QI initiatives. Targeting high-priority problems and high-risk groups can greatly improve the effectiveness and efficiency of QI interventions.