Integrating Chronic Care and Business Strategies in the Safety Net (Toolkit)

Phase 2. Assess Data & Set Priorities for Improvement

Key Change 2.1. Use Data to Set Priorities 

Most medical practices would like to improve aspects of their clinical and business processes and outcomes. Whether you want to decrease your patients' cardiovascular risk or increase staff satisfaction, you'll need data. Baseline data help you assess the current state of care and provide a picture of where you are succeeding and where improvement is needed. In other words, the baseline data help to inform the priorities for improvement. Ongoing data collection helps you see if the improvements you are implementing make a difference.

In reality, data may not be readily available for the issues that you care most about. If you believe a particular clinical goal is important to tackle—such as improving diabetes processes and outcomes—it might be worth asking your information support team to conduct a special data run or a chart audit to gather baseline data. A sample of about 25 charts should be enough to get you started. For more information on what clinical data might be interesting to collect and measure, the National Quality Forum Starter Kit can help (go to the tool in key change 2.2 below).

To support improvement in clinical measures, practices often need to understand their business infrastructure and capabilities. Below are tools that can help your team collect data about the five areas teams are most often interested in:

  • Patient satisfaction & activation.
  • Staff satisfaction.
  • Office processes & efficiency.
  • Financial system function.
  • Available resources in the community.

One advantage to incorporating both clinical and non-clinical goals in your improvement efforts is that it enables creative thinking when implementing strategies for change. Sites can often brainstorm ways to improve multiple measures at once. Keep in mind that collecting this information is not an end in and of itself; it is only useful in guiding decisions for improvement.

Actions Tools
Patient Satisfaction & Activation
Assess your patients' experiences with chronic care.

Patient Assessment of Chronic Illness Care (survey)12

Patient Assessment of Chronic Illness Care Scoring Guide13

Assess overall patient satisfaction. CAHPS® Adult Primary Care Survey14
Staff Satisfaction
Assess staff satisfaction.
Primary Care Staff Satisfaction Survey15
Office Process & Efficiency
Assess your system's chronic care capability.

Assessment of Chronic Illness Care (survey)16

Assessment of Chronic Illness Care Scoring Guide17

Assess your office processes. Primary Care Practice Know Your Processes (survey)18
Financial System Function
Assess your financial systems.
Finance Collaborative Pre-Work (survey)19
Available Resources in the Community
Assess what community resources are available for patients.
Building Your Community (guide)20

Additional Resources

  • The Patient Cycle Tool, available at, will be helpful for those who have gone through a collaborative, or want to focus on access and efficiency as a way to improve chronic care. This is one of a variety of tools that help to quantify cycle time from the patient's perspective.
  • First, Break All the Rules by Marcus Buckingham. This book includes a staff satisfaction survey recommended by many safety net providers. 

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Key Change 2.2. Select performance measures based on your needs assessment

Now that you know something about your team and your business infrastructure, it is time for your team to select specific clinical system changes that will be the focus of your improvement effort. The key changes should be evidence-based and supported by a useful clinical guideline.

You'll want to identify a reasonable number of performance measures tied to the evidence based system changes you intend to make. Think broadly, and identify a few performance measures that represent the major clinical, business, satisfaction, and operations goals you identified in key change 2.1 above. Many practices find using a "dashboard" of measures a helpful and concise way to monitor multiple measures. Be careful to balance the comprehensive number and variety of your data measures with the time and resource burden of collecting and tracking those data. Improvement efforts will be greatly facilitated if each measure is simple and has a clear operational definition.

It is important to track your measures throughout the process of implementing improvements so that the team can monitor its progress. Seeing improvements in the numbers can be incredibly motivating for the team. Using the measurement process as a mechanism to inform the clinic or organization about the improvement effort is one of the best ways to generate interest in and commitment to the aim and improvement priorities.

The tools below provide a wide variety of guidelines, models, and measures. You're likely to find something that fits your needs.

Actions Tools
Procure and adapt specific guidelines. National Disease Guidelines (online)21
Choose clinical performance measures. National Voluntary Consensus Standards for Ambulatory Care (measures)22
Establish system-level performance aims.
Be sure to include a measure of self-management support.

Redesign and Finance Measures23

% of patients with self-management goals noted in the registry

Additional Resources

  • Promote the transparency of data. This is one of the best ways to generate interest in and support for improvement. One great book that talks about creative and interesting ways to display data is The Elements of Graphing Data by W.S. Cleveland.
  • Utilizing a dashboard of measures is one way that organizations can get a handle on multiple metrics including patient satisfaction, finances, clinical measures, and market share. One example of a dashboard is located on the JENY Web site, an online community for quality improvement professionals. 

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Key Change 2.3. Build performance measurement capacity

A data collection system is the backbone of performance improvement efforts. Without data about your patients, you can't proactively plan care or demonstrate improvements in process or outcomes. That said, data collection for performance measurement can be expensive, time consuming, and misleading if not done well. To maximize data measurement efforts:

  • Leverage information technology (IT) to harvest data that are already in the system.
  • Avoid developing new IT capacity to start on data collection; you may be waiting a long time.
  • For those data not readily available, create the easiest process to secure them with an eye toward building future IT capacity. Double data entry or manual chart extraction requirements invariably stymie efforts to sustain and spread the improvement.
  • Begin using your measurement system to create efficient clinical and business processes, and document the successes.
  • Engage the rest of your system in the need for improved performance measurement capability, demonstrating the return on investment associated with your efforts.

One way to maximize both clinical quality and efficiency is to use a patient-centered data registry rather than one focused on a specific disease. In fact, there is nothing inherently disease specific about a registry at all. It is just a spreadsheet used to collect patient data. You can always add columns. For example, Chronic Disease Electronic Management System (CDEMS) is a publicly available database tool that can be used even without electronic medical records and enables a practice to get a holistic sense of its patients needs.

It is likely that your ability to identify and track data will influence the performance measures you chose to focus on, so you can think of key changes 2.1, 2.2, and 2.3 as iterative.


  • Use the guidelines and dashboard to inform the process for data collection and measurement.
  • Start thinking at the beginning of ways to eliminate waste by considering the use of technology to monitor both clinical and business components.
  • To the extent to which strategy, resources, and priorities for improvement are aligned, transformation is more sustainable.
Actions Tools
Build database and implement reminder system.

Chronic Disease Registries: A Product Review (online)24

CDEMS Registry (online)25

Focus leadership attention on improvement by building business and clinical improvement capability. Executive Review of Improvement Projects (white paper)26
Use monthly reports to track progress toward goals.

Quantitative Diabetes Monthly Report Template (worksheet)27

Narrative Monthly Report Template (worksheet)28

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Page last reviewed October 2014
Page originally created August 2008
Internet Citation: Phase 2. Assess Data & Set Priorities for Improvement. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.