Organization of Health Care to Improve Care for People with Chronic Conditions

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.


Changes for Improvement


Make Sure the Senior Leaders and Staff Visibly Support and Promote the Effort to Improve Chronic Care

  1. Encourage the senior leader to:
    • Visit the clinical team.
    • Speak about the improvement effort in all-staff meetings.
    • Participate in writing the aims and goals of the initiative and provide guidance for the clinical team.
    • Make monthly updates to the community.
  2. Present local morbidity/mortality data to the Board of Directors to make a compelling case for the need to change current practice.
  3. Have the physician champion share tested tools and interventions at provider meetings to engage interest and involvement.
  4. Have team members present improvement activities at staff meetings.
  5. Have the senior leader help identify the most enthusiastic and respected clinician to be on the improvement team and test changes in his/her practice.



  • Invite the senior leader to make a 10-minute presentation to the "community" at a group class (make sure it is after the class has been well established so that there will be enough people there to make it worthwhile).  Ask the patients at the class to give the senior leader feedback.
  • Ask for the Board of Directors' support early and often.
  • Give feedback to the Board regarding how support has made a difference.
  • As tools are tested and proven, ask interested providers to try them.
  • Discuss data that is available and uses for the data.
  • At every provider meeting, share something positive: a patient case study or tool.
  • Involve providers by asking for their input and ideas.
  • Don't be afraid to share "learning opportunities" - the ideas that did NOT work.  Present patient cases from which providers can learn about pitfalls, and reduce the fear of presenting mistakes, dead ends, trials that show us what doesn't work and why.  "Get messy! Make mistakes!"
  • Ask the senior leader or Medical Director to formally introduce the improvement project and team to promote the effort and ask the staff to help when needed.
  • Provide patient comments when appropriate.
  • Be enthusiastic, so that others will want to participate.

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