Systems change: What is systems change?

This toolkit promotes a “systems change” approach to chronic disease prevention and screening within a clinical setting. “Systems” are the practices within an organization that guide daily operations.

Health care systems can enact organizational changes as part of quality improvement efforts. This often involves the creation or modification of policies, which are written procedures that employees are expected to follow. Once a policy is created and implemented, it can be evaluated and modified to ensure that it’s sustainable for years to come. This systems change approach aligns with quality improvement processes used in Patient-Centered Medical Home settings, such as the RE-AIM model.

PDSA model

For the purposes of this toolkit, we’ll use the PDSA (Plan, Do, Study, Act) model as an example of how you and your local public health agency can help facilitate systems change within the clinical setting.


Define the problem, plan the changes and establish baseline measures:

To recruit clinics and facilitate various systems change activities, your agency will require resources to carry out the project. The resources will depend on the scope of the project’s activities and how involved your agency is with the project, but personnel time and material resources will be needed to work with clinics and the community.

Making the case for working with clinics

The resources available at each local public health agency and at the community level vary widely. To cover expenses such as operating costs and LPHA staff time, potential strategies could include:

  • Adjusting a full-time employee (FTE) job description to devote some time to working with community clinics. Many LPHA employees are already comfortable working in the community, so this is a natural extension of that role. As mentioned in the case examples earlier, working with clinics can complement public awareness and other outreach work. Providing technical assistance and momentum for quality for improvement project may be just the push clinics need to take on a project. It’s important that the person in this position be visible within the clinical setting.

  • Contacting our student opportunity coordinator to discuss possible opportunities for having an intern from the Colorado School of Public Health.

  • Specifying working with community clinics as part of a grant application for a larger community initiative. For example, if your LPHA has identified obesity prevention as a priority area, including working with clinics as part of your proposal.

  • Partnering with a community organization, nonprofit or educational institution. Forming partnerships could help share the workload and recruit partners with different areas of expertise. Forming an advisory group with members of the LPHA, community group, and local clinic could be a starting point to conduct a needs assessment and scope of a potential project.

Before you begin to work with clinics to increase the use of preventive services, it’s a good idea to familiarize yourself with the subject. Becoming an “expert” (or partnering with one) on chronic disease prevention, guidelines and recommended tests will allow you to speak knowledgeably to the partnering clinics and guide them in their decision-making process.

About chronic disease

Chronic disease is the leading cause of mortality and morbidity in adult Americans.

  • In 2010, more than 50 percent of all deaths were from heart disease, cancer or stroke.

  • Almost half U.S. adults, or 107 million people, reported having at least one of six chronic illnesses in 2008: cardiovascular disease, cancer, chronic obstructive pulmonary disease, asthma, diabetes or arthritis.

  • The management of these conditions is costly to the health care system. For instance, obesity, which can lead to heart disease, stroke, type 2 diabetes and cancer, costs the U.S. $147 billion annually.

Public health, both nationally and locally, has realized the potential in preventing chronic diseases and has launched campaigns to encourage physical activity and healthy eating, as obesity is a major risk factor for many chronic conditions. In addition to public awareness, engaging people at the health care level is key. Under health care reform, preventive services, such as yearly checkups, cancer screenings and cholesterol screening, are now covered by most insurance plans.

Below are examples of screenings that could be incorporated in a primary care visit, depending on the age and health history of the individual. These are general recommendations for average-risk individuals, guidelines may vary depending on an individual’s personal or family history.

Condition-specific resources

Breast cancer screening

  • The American Cancer Society recommends yearly mammograms starting at age 40.

  • Breast cancer screening guidelines are less standardized than those for cervical or colorectal cancer. Check with your local clinic to learn about the practices in your community.


Cervical cancer screening

  • The American Cancer Society recommends Pap tests for women every three years beginning at age 21.

  • Beginning at age 30, the preferred way to screen is with a Pap test combined with one for human papilloma virus.


Colorectal cancer screening

  • The American Cancer Society recommends screening beginning at age 50 for average-risk men and women, intervals vary depending on type of test.

  • See “Why local public health?” for more information.


Diabetes screening

The American Diabetes Association recommends that all adults 45 and older be considered for diabetes screening by their provider.


Blood pressure screening

  • The U.S. Preventive Services Task Force recommends blood pressure screening for adults 18 and older.

  • The American Heart Association recommends blood pressure screening at regular health care visits or at least once every two years beginning at age 20.


Body mass index (BMI) screening

The American Heart Association recommends BMI screening at each regular health care visit.


Cholesterol screening

The American Heart Association recommends cholesterol screenings every five years beginning at age 20.


Tobacco screening and referral

The U.S. Preventive Services Task Force recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.

​​​​​​Now that you’re familiar with chronic diseases and the systems change approach, the next step is identifying clinics in your community that are interested in implementing systems change strategies. Use your network to identify clinics that are poised to make systems changes. Often, this sort of project works well if the clinic has implemented or shown interest in other quality improvement efforts. Once you have a list of possible partners, organize meetings with the clinics’ decision-makers, such as the medical director, office manager and other key staff.


Things to consider when selecting a clinic to engage
  • Established relationships between your organization’s management and that of the clinic.

  • Needed improvements to the clinic’s screening policies and practices.

  • Characteristics of the clinic (size, type, number of patients served).

  • Characteristics of the clinic’s patient population (insured versus uninsured).

  • Obstacles that may prevent or deter the clinic from implementing systems change (limited resources, time constraints, other ongoing projects).

  • Existing or potential “clinic champions” (someone to head up the intervention on the clinic side).

  • Commitment of the clinic’s leadership to increasing chronic disease prevention.

  • Local capacity of endoscopic screening providers.

  • Partnerships between clinic and local cancer treatment providers.                                                                                                                                    

Adapted from Working With Healthcare Delivery Systems to Improve the Delivery of Tobacco-use Treatment to Patient: An Action Guide.


Clinic talking points

Why should a clinic be interested in systems change/quality improvement for chronic disease? Here are a few talking points to use when recruiting clinics:

  • Baseline assessments are opportunities to capture current screening rates and to set goals for improvement. Reassessing screening rates can demonstrate whether quality improvement efforts are successful.

  • Gathering screening data can help in reporting required measures, such as National Quality Forum (NQF) and Uniform Data System (UDS).

  • Implementing a system change approach can help them reach more patients in a sustainable way.

Often a clinic’s most precious, and most limited, resource will be time. However, with a local public health agency playing an essential organizational/technical assistance role, it’s possible to mobilize clinic staff for change. To carry out a successful project with a clinic, here are a few people with whom it will be important to develop relationships:


Clinic champion
  • Advocates for devoting clinic resources to this project and works closely with key decision-makers in the clinic.

  • Main point of contact for the project coordinator.

Medical director/practice manager
  • Key decision-maker regarding policies, processes and practices, who gives the approval to update these as necessary.

  • Allocates resources to maintain the office policy and leads implementation.

Clinical and office staff
  • Must have buy-in to support the project’s efforts, participate in trainings, offer feedback and adopt the new policy/practices by integrating them into daily routines.

Once a clinic has agreed to take on the project, a scope of work can be drafted.

Creating a scope of work

Once a clinic has agreed to take on the project, a scope of work can be drafted. This document doesn’t need to be complex, but should be written out and signed by both the local public health agency and the clinic. Having a written document demonstrates a shared commitment to the project and ensures that both parties are aware of their roles and deliverables. The scope of work should include:


  • Goals of the project.

  • Roles and responsibilities.

  • Expectations.

  • Timeline with deadlines for “deliverables” (e.g., office policy and work flow document).

  • Lines of communication.

    • Designate one person at the clinic to be the point of contact — ideally someone who will “champion” the project.

    • Establish a best way to communicate (email, phone, frequency, etc.).

Sample scope of work document


Implement the plan, collect the data:

After a scope of work has been established, the first step is to conduct a baseline assessment. A baseline assessment will measure the clinic’s current screening rate (or another determined measure). This is important to document, as it will serve as a reference point for assessing whether the intervention was effective in accomplishing the intended objective. Plan a reassessment of measurements six months to one year after implementing the intervention.

There are a number of considerations when determining which type of baseline assessment is right for each clinic. If the clinic uses paper charts, a chart audit will be necessary. Keep in mind that chart audits are time-intensive and may require outside technical assistance. It is ideal to coordinate this assistance for the clinic if possible, to reduce any burden on their staff time.

If the clinic has an electronic health record (EHR), a review of the required data may be possible. Many clinics have upgraded to an EHR recently, so older health records are still in paper form. Therefore, a combination of a chart audit and EHR review may be necessary to arrive at the most accurate numbers.

Someone at your LPHA may have the expertise to conduct a chart audit, or you may have to seek an outside consultant. Qualifications for a chart auditor include:

  • A background in biostatistics, epidemiology or related field.

  • Knowledge on how to find and interpret chart information.

The person must have the time to devote to performing the audit. A chart audit typically draws data from a representative sample of the patient population.

Work with the clinic to conduct a preliminary assessment of the current screening environment. This needs assessment will help identify areas that the clinic would like to improve. Here are a few topics to consider:


Define a need or problem that the intervention will address

At the most basic level, the health problem that will be addressed is the high rates of mortality and morbidity from a certain health condition. Other needs are more clinic-specific, such as the need to gather baseline screening data, improve low screening rates or decrease health inequities in the clinic population, or the lack of an explicit policy or reminder system.


Define the desired outcomes

The overarching goal is to improve clinical practice that will increase screening rates. These outcomes should be time-specific and measurable. Other outcomes could include:

  • Increasing the knowledge of providers and staff to carry out screening.

  • Adoption of a standard policy that uses best practices.

  • Increased awareness of a patient’s screening status due to improved tracking and reminder systems.

Discuss the scope of the intervention

What activities are realistic for staff to undertake? What resources are required? Baseline assessments can be time-consuming and often an outside consultant may be needed. Creating an office policy is not as time-intensive but clinic leaders must be willing to spend the time creating and refining it. If the clinic is interested in staff training, staff members must have the flexibility to be away from their clinic duties to attend the training.


Identify current screening policies and practices

To engage and support the clinic’s effort to implement strategies to increase screening rates, you must understand the environment in which they operate. Discuss what’s currently working for screening and areas that the clinic would like to see improved. The questions in the link below can be helpful in determining the current landscape.


View a sample clinic assessment checklist.
  • Provider recommendations.

  • Office policy and workflow.

  • Reminder systems.

  • Effective clinic communication.


The National Colorectal Cancer Roundtable developed a useful guide to increasing colorectal cancer screening rates in a primary care practice. Although the Primary Care Clinician’s Evidence-Based Toolbox and Guide focuses on CRC, the systems change concepts presented can be applied broadly to cancer screening and chronic disease prevention. The toolbox’s checklist for increased screening includes:

Provider recommendation

Evidence has shown that a recommendation from a doctor is the most powerful single factor in a patient’s decision about whether to obtain cancer screening. This positive impact has been demonstrated for breast, cervical and colorectal cancers. A comprehensive approach to screening will ensure all appropriate patients receive a recommendation, even if they don’t come in for regular exams. For instance, if a patient comes in for a blood draw or flu shot, it’s an opportunity to check whether he or she is up to date on preventive screenings.

It’s important to remember that other providers and support staff (nurses, medical assistants, front desk) can be a crucial link in referring a patient for screening and follow-up. Standing orders can empower clinic staff to refer a patient for a cancer screening or schedule a follow-up test. For instance, team-based approaches have been shown to increase the number of patients with controlled blood pressure.To ensure a consistent recommendation occurs, the other elements — an office policy, reminder systems and effective communication — must also be part of the practice.

Office policy and work flow

An office policy lays out the clinic’s commitment to screening and prevention. It’s often useful to accompany an office policy with a workflow plan and step-by-step procedure for staff to follow. This workflow can be used as a living document that can be revisited and improved as the clinic works through process improvements.

While adhering to national standards, a clinic should develop a policy to fit its practice, there’s no “one size fits all” policy. It should consider the realities of local standards of care, insurance coverage, and patient preference. A comprehensive policy should also include risk assessment for patients of different risk levels.

The chart in the link below is a visual representation of a policy for CRC and is a good way to communicate the policy to office staff who\'ll implement it.

Reminder systems

Reminder systems can be targeted toward either patients or providers. Reminders for patients include “cues to action,” such as postcards, phone calls and letters. Reminders for providers include chart prompts, which can be physical stickers or paperwork highlighting that a patient is due for a screen or built into the clinic’s electronic health record to automatically flag the provider if a screening is due.

Another highly effective way of having patients complete screenings for chronic disease is to schedule while the patient is in-office. Providers, nurses and medical assistants can use a standardized notecard to communicate with the front desk about scheduling follow-ups, screenings and lab tests.


Effective communication

Shared decision-making can make a patient more likely to get a screening test. By exploring different options with a patient, the provider can find the test that the patient is most likely to complete.

Another strategy is stage-based communication, which can be used to give patients a “sales pitch” appropriate to their stage. Patients who have never heard of a specific screening need basic information to increase their awareness, while those who are hesitant will need to be convinced of the benefits and acceptability. For more information, refer to the Primary Care Clinician’s Toolbox.

What Works, from The Community Guide


Measure outcomes and summarize results:

  • Recheck the data.

  • Compare newly generated data with baseline.

  • What changes need to be made?

Recruiting community clinics

In the “do” portion of this quality improvement initiative, a baseline and needs assessment was completed. To determine the effectiveness of the quality improvement activity in the “do” phase, the clinic and local public health agency should monitor progress made by comparing baseline data and the original needs assessment to mid- or post-intervention data.

  • Example:

During the "do" phase, the LPHA assisted the clinic in its decision-making process to pick a quality improvement initiative. The clinic decided to work on improving its reminder systems, with the goal of improving screening rates. As a result of the nominal group process, the clinic is stamping the FOT-B test with a due date. For the "do" phase, the initiative is being tested only with the patients of one provider.

Compare newly generated data to baseline


Refine the changes as needed, plan for next cycle:

  • Clinicwide use plan.

  • Plan to study again.


The community clinic has completed the first three phases of the PDSA cycle and is ready for the “act” phase. The intervention has been chosen, tested and adjusted according to the “study” phase. After completion of the first three phases, the intervention is ready for clinic-wide use.

To ensure smooth implementation, the entire PDSA cycle needs to be reviewed with all those involved in clinic-wide implementation.


Plan to “study” again

Work with the key players of the “do” phase to determine when and how to review data again.