Changing clinical practice by improving systems: the pursuit of clinical excellence through practice-based measurement for learning and improvement.

Physicians often wait for a health plan, a health maintenance organization (HMO), or an integrated health care system to bring about change or improvement in health care. But small changes in systems--the patient self care system, an individual practice, or a group practice (microsystem)--can have a profound impact on outcomes in an organization (macrosystem). With simple graphical tools, physicians and patients can be taught to measure and be empowered to improve both health and health care. Using these tools and a well-known and widely accepted method for clinical improvement called rapid cycle testing, a population of patients with diabetes improved average fasting blood sugar (FBS) from 187 to 110 and the average hemoglobin A1c (HbA1c) from 10.5 to 7.2.