Reflections on the Chronic Care Model-23 Years Later.

O n March 19, 2019, the firmament of expertise on the improvement of quality in complex systems lost one of its brightest stars with the death of Tom Nolan, PhD. A protégé of Dr. W. Edwards Deming, Nolan worked in many industries, but in the last two decades of his life, his primary focus was on improving health care, to the benefit of countless patients, families, and communities worldwide. Nolan contributed many important concepts and frameworks to the health care quality movement, but one of his most important was also one of the simplest. “What are the necessary and sufficient conditions for improvement in large systems?” he asked. His answer was threefold: “Will, ideas, and execution.” He regarded the assurance of these conditions as a fair description of the duties of boards, executives, and senior leaders who wished to foster change at scale.1 Providing will refers to the tasks of fostering discomfort with the status quo and attractiveness for the as-yet-unrealized future. Providing ideas means assuring access to alternative designs and ideas worth testing, as opposed to continuing legacy systems. And execution was his term for embedding learning activities and change in the day-to-day work of everyone, beginning with leaders. Nolan’s simple framework launched never-ending debates among aficionados of improvement as to which of the three conditions is toughest to supply. Of course, all three are. But, in my experience, the sleeper, apparently easy, but really not easy at all, is ideas. Without change, there is no improvement. Therefore, here is the task: to find or create new models of a system that can outperform the existing system, and then to offer those models to the people without whom they cannot be put to use—the workforce. In health care, ideas can come from a fire hose of suppliers. One is the vast published medical