Achieving breakthrough levels of improvement for people with chronic conditions requires that an organization make changes to improve six fundamental areas in parallel:

• Self-Management: Effective self-management is very different from telling patients what to do. Patients have a central role in determining their care, one that fosters a sense of responsibility for their own health.
• Decision Support: Treatment decisions need to be based on explicit, proven guidelines supported by at least one defining study.
• Clinical Information System: A registry — an information system that can track individual patients as well as populations of patients — is a necessity when managing chronic illness or preventive care.
• Delivery System Design: The delivery of patient care requires not only determining what care is needed, but clarifying roles and tasks to ensure the patient gets the care; making sure that all the clinicians who take care of a patient have centralized, up-to-date information about the patient’s status; and making follow-up a part of standard procedure.
• Organization of Health Care: The effort to improve care should be woven into the fabric of the organization and aligned with a quality improvement system.
• Community: Community programs and organizations that can support or expand a health system’s care for chronically ill patients and prevention strategies are often overlooked.

Many health care organizations in several countries have used the Model for Improvement* very successfully to improve chronic illness care. Using the key elements of the model, especially testing changes on a small scale with Plan-Do-Study-Act (PDSA) cycles,** has helped organizations improve care for their patients with chronic conditions.

Improvement efforts should be led by a multidisciplinary core team. Forming the Team

	Setting Aims Improvement requires setting aims. The aim should be time-specific and measurable; it should also define the specific population of patients that will be affected.
	Establishing Measures Teams use quantitative measures to determine if a specific change actually leads to an improvement.
	Selecting Changes All improvement requires making changes, but not all changes result in improvement. Organizations therefore must identify the changes that are most likely to result in improvement.
	Testing Changes The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change in the real work setting — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method used for action-oriented learning.

Sources:

*Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.

**The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as the Plan-Do-Check-Act (PDCA) cycle. W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "Check" with "Study."