The effort to improve care should be woven into the fabric of the organization and aligned with a quality improvement system. Senior leadership must identify the effort to improve chronic and preventive care as important work, and translate that into clear goals reflected in the health center’s policies, procedures, business plan, and financial planning. The entire organization must be engaged in the improvement effort. Senior leaders and clinician champions are visible and committed members of the team, and give personnel the resources and support they need to pursue it.

Health care systems can create an environment in which organized efforts to improve the care of people with chronic illness take hold and flourish. Critical elements include a coherent approach to system improvement, leadership committed to and responsible for improving clinical outcomes, and incentives to providers and patients (including nonfinancial incentives such as recognition and status) to improve care and adhere to guidelines.