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Identify Needs and Set Priorities

Clinical practices can be viewed as microsystems that provide health care to specific patient populations. The care they provide should be:

  • knowledge-based
  • patient-centered
  • proactive
  • effectively delivered [1] [2] [3]

The Patient Centered Medical Home (PCMH) concepts recommend that practices provide first contact, continuous, comprehensive, whole person care for patients across the practice. These principles include:

The Patient-Centered Primary Care Collaborative describes the PCMH home as a model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. It has become a widely accepted model for how primary care should be organized and delivered throughout the health care system. It calls for a team care model that promotes accessibility, compassion, transparency, and is built on trust and communication. Its success is enhanced by health information technology and by smarter ways to pay for care.

  • whole-person care
  • personal clinician provides first contact, continuous, comprehensive care
  • care is coordinated or integrated across the health care system
  • team-based care

To achieve these components of care, redesign might be needed in the following areas: [3]

  • Better methods for finding best practices and assuring that such clinical models become organizational standards
  • Better use of information technology to access information and to support clinical decision-making
  • Improved workforce knowledge and skills
  • More consistent development of effective clinical teams and teamwork

Self-assessment helps us think through what we are doing, why we are doing it, and what we must do next. The process of self-assessment itself stimulates communication and leads to change.

  • Better coordination of care among services and settings
  • More informative measurement of performance and outcomes

How Self-Assessment Can Help

Self-assessment for systems change can help clinical practices:

  • Get organized
    Identify immediate tasks and long-term goals
    Develop insight into unfamiliar aspects of the system
    Prepare for agency accreditation
  • Set priorities
    Identify areas of weakness and strength
    Find out what others think are important components of health systems change
  • Coordinate efforts
    Promote team work and staff development
    Encourage interdepartmental coordination
  • Monitor change
    Consider evaluation from the beginning: What are we trying to improve, how will we know that change is an improvement?
    Monitor progress toward desired goals
  • Identify resources
    Determine resources, collaborations, or partnerships that exist or need to be developed
    Clarify budget needs and provide data for discussion with administration
    Identify duplication and wasted effort

Key Changes to Transform into a PCMH

An extensive literature review and study of transformation efforts underway identified eight change concepts that practices need to embrace to effectively transform into a PCMH. Within each of these concept areas the authors suggest several key changes or actions practices could make. The concepts and key changes are aligned with elements of the Chronic Care Model.

Inclusion of Chronic Care Model Elements into PCMH Change Concepts

Change Concept

Key Changes

Chronic Care Model Elements

Engaged leadership

Visible leadership for culture change and QI

Health care organization

Quality improvement strategy

Use formal QI model

Establish metrics to evaluate improvement

Optimize use of health information technology

Health care organization

Information systems


Use panel data to manage population

Information systems

Proactive care

Continuous, team-based relationships

Establish and support care delivery teams

Distribute roles and tasks among team

Practice redesign (team care)

Organized evidence-based care

Use planned care according to patient need

Use patient data to enable planned interactions

Use point-of-care reminders

Practice redesign (planned care)

Decision support

Information systems

Patient-centered interaction

Encourage patient involvement in health and care

Provide self-management support at every encounter

Activate patients

Self-management support

Enhanced access

Care coordination

Link patients with community resources

Provide care management services

Community resources

Practice redesign (care management)

Table source: Wagner EH, Coleman K, Reid RJ, Phillips K, Abrams MK, Sugarman JR: The changes involved in patient-centered medical home transformation. Prim Care 2012; 39(2): 241-59.

Find additional resources from the Safety Net Medical Home Initiative.

The Institute of Medicine proposed ten simple rules to enhance change in health care microsystems. Listed beside each new rule is the current rule. [3]

New Rule Current Rule
1 Care is based on continuous healing relationships. Care is based primarily on visits.
2 Care is customized according to patients’ needs and values. Professional autonomy drives variability.
3 The patient is the source of control. Professionals control care.
4 Knowledge is shared freely. Information is a record.
5 Decision-making is based on evidence. Decision-making is based on training and experience.
6 Safety is a system property. "Do no harm" is an individual responsibility.
7 Transparency is necessary. Secrecy is necessary.
8 Needs are anticipated. The system reacts to needs.
9 Waste is continuously decreased. Cost reduction is sought.
10 Cooperation among clinicians is a priority. Preference is given to professional roles over the system.

Program Assessment Tools

Health care teams can use the tools below to identify areas for improvement in their care for chronic illness and evaluate the level and type of improvements made in their system.

1. Institute for Healthcare Improvement

2. MacColl Institute for Healthcare Innovation and website Improving Chronic Illness Care provides an Assessment of Chronic Illness Care (ACIC) survey and a Patient Assessment of Chronic Illness Care (PACIC) survey. The content is derived from the Chronic Care Model.

3. Medical Home Builder is an online tool designed to help practices improve patient care, organization, and workflow and become a PCMH.

4. AAFP’s TransforMed helps primary care practices become high-performing PCMHs.

5. Indian Health Services Division of Diabetes Treatment and Prevention Program Planning and Evaluation Workbook January, 2010

Other Assessment Tools

1. Baldrige Criteria for Performance Excellence provide a systems perspective for understanding performance management. The criteria are a set of questions focusing on critical aspects of management that contribute to performance excellence: leadership, strategic planning, customer focus, measurement, analysis, and knowledge management, workforce focus, operations focus, and results.

Develop a Team

Implementing changes in a clinical setting requires buy-in, commitment, and effort from the health care team. The team should be diverse and represent people from every area of the clinic or office possible. This diverse team approach helps when brainstorming potential solutions. The team approach also encourages a division of labor among team members during the improvement effort.

It is essential that a key person coordinate the team effort in a supportive, coaching-oriented way. The team leader/coordinator does not have to be a physician. Review the common characteristics shared by high-performance teams by clicking here.


1. Organizations that accredit (or recognize) diabetes education programs require some program/patient assessment and include:

 2. The National Committee for Quality Assurance (NCQA)
NCQA assesses and reports on the quality of managed care plans. This information enables purchasers and consumers to distinguish among plans based on quality, and to make more informed health care purchasing decisions. NCQA efforts are organized around accreditation and performance measurement in areas such as member satisfaction, quality of care, access, and service.

NCQA developed the Diabetes Recognition Program (DRP) to provide clinicians with tools to support the delivery and recognition of consistent high quality care. This voluntary program is designed to recognize physicians and other clinicians, who use evidence-based measures and provide excellent care to their patients with diabetes.

The NCQA Patient-Centered Medical Home program for improving primary care gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time.


  1. Wasson JH, Anders SG, Moore LG, et al. Clinical microsystems, part 2. Learning from micro practices about providing patients the care they want and need. Jt Comm J Qual Patient Saf 2008; 34(8): 445-52.
  2. Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Institute of Medicine, Washington, DC, 2001.
  3. Berwick DM. A User’s Manual for the IOM’s ‘Quality Chasm’ Report. Institute of Medicine. Health Aff (Millwood) 2002; 21:80-90.