ASF Standards · Primary Health Clinic · Standard 3
Standard 3 — Chronic Disease Management
Criteria in this standard
3.1 — Chronic Conditions Are Tracked in a Registry, Not Managed Only at the Point of Visit
3.2 — Control Targets Are Specific and Actively Measured, Not Assumed From General Improvement
3.3 — Patients Overdue for Chronic Disease Follow-Up Are Proactively Identified and Contacted
3.4 — Team-Based Care Coordinates Chronic Disease Management
3.5 — Medication Adjustment Follows a Defined Process When Targets Aren't Met
3.2 — Control Targets Are Specific and Actively Measured, Not Assumed From General Improvement
3.3 — Patients Overdue for Chronic Disease Follow-Up Are Proactively Identified and Contacted
3.4 — Team-Based Care Coordinates Chronic Disease Management
3.5 — Medication Adjustment Follows a Defined Process When Targets Aren't Met
3.1
Chronic Conditions Are Tracked in a Registry, Not Managed Only at the Point of Visit
Non-Negotiable
Every patient with a chronic condition — diabetes, hypertension, and other ongoing conditions — is entered into an active disease registry that tracks their status between visits, not managed only reactively during whatever visit happens to occur.
In plain terms: Every patient with diabetes, hypertension, or another chronic condition is on an active list that the practice uses to manage them between visits — not just when they happen to come in.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Adapted | Full |
Why this matters
A chronic disease registry is the tool that turns a practice from reactive to proactive. Without it, the practice knows about a diabetic patient only when she attends; it cannot say how many diabetics it has, how many are controlled, how many are overdue. With it, the practice can run the list: who has not had an HbA1c in a year, who has not had a foot check, whose blood pressure is uncontrolled. The registry is the foundation for everything in this standard — targets (3.2), outreach (3.3), team care (3.4), medication adjustment (3.5). A practice that manages chronic disease only at the point of visit manages it only for patients who visit.
What good looks like
- Every chronic disease patient is genuinely entered into an active registry.
- The registry tracks status between visits, not only at the point of care.
- The registry is genuinely used to inform real care decisions.
Common failure modes
- Chronic conditions are managed only reactively during whatever visit occurs.
- The registry reflects only the most recent visit, with no between-visit tracking.
- A registry exists but isn't genuinely consulted in actual practice.
Worked example
In practice
A 4-room health centre with an estimated 400 diabetic patients — but no one had counted.
BeforeDiabetes was managed at visits. No list existed. When the Coordinator searched the records for diabetes diagnoses, 520 patients were found — 30% more than estimated. Of those, 180 had no HbA1c in the previous 12 months and 90 had not been seen at all. Nobody had known.
ActionA diabetes and hypertension registry was built from the EHR with a defined data set: last HbA1c, last BP, last foot check, last eye screening, last visit, current medications. The registry is reviewed monthly by the practice nurse, who generates outreach lists. New diagnoses are added at the point of diagnosis. Other chronic conditions (asthma, COPD, CKD) were added in phase two.
AfterThe Monitor reviewed the registry: 520 diabetics with complete data fields; monthly review records; outreach lists with outcomes. Verified.
If you are starting from zero — do this first
- Search your records for every diabetes diagnosis. Count them. Compare to your guess.
- Build a registry with the key measures for each patient.
- Review it monthly.
- Add hypertension, then other conditions.
The most common mistake: Managing chronic disease at visits and assuming that is the same as managing chronic disease.
Self-assessment questions
1. Is every patient with a chronic condition entered into an active registry tracking their status? — A real, maintained registry, not management limited to whatever happens to come up during a visit.
Evidence: Chronic disease registry documentation
Evidence: Chronic disease registry documentation
2. Does the registry track status between visits, not only reflect data from the most recent encounter? — Genuine, ongoing tracking, not a static snapshot from the last visit alone.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
3. Is the registry actively used to inform care, not maintained as a record separate from actual practice? — Real, integrated use, not documentation disconnected from real clinical decisions.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
Common reasons for a PARTIAL answer
- The registry covers diabetes and hypertension well but less consistently other chronic conditions. — Every genuine chronic condition benefits from the same systematic tracking discipline.
- Registry entry happens at diagnosis but isn't consistently maintained as a patient's status changes. — A registry needs to reflect a patient's current, real status to provide genuine ongoing value.
- The registry exists and is accurate but is reviewed only during scheduled chronic-care visits, not more broadly.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current chronic disease management for reliance on point-of-visit care versus registry tracking. |
| Week 2 | Build or strengthen a registry covering all patients with chronic conditions. |
| Week 3 | Establish a process for keeping registry status genuinely current between visits. |
| Ongoing | Integrate registry consultation into standard clinical workflow. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Registry completeness review | Reviews the registry for genuine, complete coverage of all patients with chronic conditions. |
| DOCUMENT | Between-visit tracking review | Reviews whether the registry genuinely tracks status between visits, not only at the point of care. |
| OBSERVE | Registry use observation | Observes whether the registry is genuinely consulted and used to inform actual care decisions. |
Supervisor tips
- Ask to see the actual registry and confirm it reflects genuinely current patient status. — A specific, current registry reveals genuine practice, not documentation for its own sake.
- Ask a clinician how they'd identify all their patients with a specific chronic condition. — A specific, confident answer reveals genuine registry use, not reliance on memory.
Evidence base
[11] Patients with diabetes require access to systematic and ongoing care delivered by a team of healthcare providers, with registry-based tracking established as foundational to achieving national quality benchmarks for chronic disease control in primary care.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
3.2
Control Targets Are Specific and Actively Measured, Not Assumed From General Improvement
Non-Negotiable
Chronic disease control is measured against specific, evidence-based targets — HbA1c below 7.0 percent for diabetes, blood pressure below 130/80 mmHg for hypertension — with the actual result documented, not a general sense that a patient seems to be doing better without a specific, measured number.
In plain terms: Chronic disease control is measured against specific evidence-based targets — HbA1c under 7%, blood pressure under 140/90 — for each patient and across the practice, not just 'getting better.'
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
'Improving' is not a target. A diabetic patient whose HbA1c has fallen from 11% to 9.5% has improved and remains poorly controlled, at high risk of complications. A target — HbA1c <7% for most adults, <8% for the frail elderly; BP <140/90; LDL <100 mg/dL for high cardiovascular risk — tells the clinician and the patient when the job is done and when it is not. Measured for each patient, targets drive treatment. Measured across the registry, they tell the practice what proportion of its diabetics are controlled — the number that matters for outcomes.
What good looks like
- Control is measured against specific, evidence-based numeric targets.
- Actual results are documented for each patient, not assumed from trend.
- The practice calculates its own genuine, aggregate control rate.
Common failure modes
- Improvement is assumed generally, without specific, measured targets.
- Results aren't documented, relying on general impression alone.
- No aggregate rate is calculated; only scattered individual data exists.
Worked example
In practice
A 5-room health centre with a diabetes registry (3.1) but no targets.
BeforeClinicians reviewed HbA1c results and adjusted treatment by judgment. There was no defined target. When the Coordinator applied the national target of <7% to the registry, 34% of diabetics were at target; clinicians had estimated 'most.' Hypertension: 41% at <140/90.
ActionTargets were adopted from national guidance and individualised where appropriate (frail elderly, hypoglycaemia risk). Each patient's registry entry shows the target and the current value with a red/green flag. The practice-level proportion at target is reported monthly. Clinicians receive their own panel's proportion at target.
AfterThe Monitor reviewed the registry with target flags, six monthly reports (diabetes at target 34% → 51%; hypertension 41% → 58%), and clinician-level feedback. Verified.
If you are starting from zero — do this first
- Adopt national control targets for diabetes and hypertension.
- Apply them to your registry: what proportion is at target?
- Show the target and current value on every registry entry.
- Report the proportion at target monthly.
The most common mistake: Treating 'lower than last time' as success — the target is the target.
Self-assessment questions
1. Is chronic disease control measured against specific, evidence-based numeric targets, not general impression? — A specific, documented number against a defined target, not a general sense of improvement.
Evidence: Control target measurement documentation
Evidence: Control target measurement documentation
2. Is the actual result documented for each patient, not assumed from overall trend? — A real, specific documented result, not an inference from general direction of change.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
3. Is the practice's own aggregate control rate calculated, not just individual results recorded without a genuine summary view? — A real, calculated practice-level rate, not only scattered individual data points.
Evidence: Aggregate control rate documentation
Evidence: Aggregate control rate documentation
Common reasons for a PARTIAL answer
- Targets are used for diabetes but not consistently for hypertension or other chronic conditions. — Every chronic condition with an established target deserves the same measurement discipline.
- Individual results are documented but aren't consistently checked against the specific target at each visit. — A documented result that isn't compared against the target doesn't provide genuine, actionable information.
- Aggregate rates are calculated periodically but not reviewed often enough to drive real, timely improvement.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current chronic disease measurement for reliance on general impression versus specific targets. |
| Week 2 | Establish consistent documentation of actual results against defined targets for every chronic condition. |
| Week 3 | Build a process for calculating and reviewing the practice's own aggregate control rate. |
| Ongoing | Review aggregate control rates on a regular schedule to drive genuine improvement. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Target measurement review | Reviews whether chronic disease control is measured against specific, evidence-based targets. |
| DOCUMENT | Individual result documentation review | Reviews whether actual results are documented for individual patients, not assumed from trend. |
| DOCUMENT | Aggregate rate review | Reviews whether the practice calculates its own genuine, aggregate control rate. |
Supervisor tips
- Ask for the practice's actual, current aggregate control rate for a specific chronic condition. — A specific, real number reveals genuine measurement, not general impression.
- Ask to see a specific patient's documented result compared against the defined target. — A real, specific comparison reveals whether measurement genuinely happens, not just data recording.
Evidence base
[12] Documented national health data has found a persistent gap between the proportion of patients diagnosed with a chronic condition such as hypertension and the proportion with confirmed, documented control, establishing specific, measured control — not assumed improvement — as the genuine standard for chronic disease management quality.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
3.3
Patients Overdue for Chronic Disease Follow-Up Are Proactively Identified and Contacted
Non-Negotiable
The practice proactively identifies patients with a chronic condition who are overdue for testing or follow-up — particularly those with poor control — and actively reaches out to them, not waiting passively for the patient to schedule their own next visit.
In plain terms: The practice runs its chronic disease list to find patients overdue for tests or visits — especially those who have not been seen at all — and contacts them.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | N/A | Full | Adapted | Full |
Why this matters
The registry (3.1) and targets (3.2) identify who is overdue. This criterion asks that the practice does something about it: a phone call, a letter, an outreach visit. The patients who are overdue are disproportionately the ones at highest risk — they have stopped coming because they feel fine, because they cannot afford it, because they are depressed, because they have moved. Proactive outreach finds the diabetic with an HbA1c of 12% who has not been seen in 18 months. Waiting for them to come back means waiting for the complication.
What good looks like
- Overdue patients are genuinely, actively identified through a real process.
- Active outreach genuinely follows identification, not just passive awareness.
- Patients with poor control are specifically prioritized in outreach.
Common failure modes
- The practice waits passively for overdue patients to schedule their own visit.
- Identification happens but doesn't lead to genuine outreach.
- Outreach, if it happens, doesn't prioritize the highest-risk patients.
Worked example
In practice
A 6-room health centre with a registry showing 180 diabetics overdue for HbA1c.
BeforeThe overdue list existed. Nobody acted on it. Outreach was 'not something we do.' Of the 180, 60 had not attended in over a year. Two of those were later found to have developed diabetic foot ulcers requiring hospital admission.
ActionA monthly outreach process was established: the nurse phones every patient overdue for a key measure, books a visit, and records the outcome. Patients who cannot be reached by phone get a letter, then a home visit by a community health worker for the highest-risk. Outreach outcomes are tracked: contacted, booked, attended.
AfterThe Monitor reviewed four months of outreach logs: 320 contacts, 210 attended; the number overdue for HbA1c fell from 180 to 55. Verified.
If you are starting from zero — do this first
- Run your registry for patients overdue for a key measure by more than six months.
- Sort by last visit date — who has not been seen at all?
- Phone them, starting with the longest absent.
- Track contacted, booked, attended.
The most common mistake: Generating the overdue list and filing it — the list is the beginning of the work, not the end.
Self-assessment questions
1. Does the practice proactively identify patients with a chronic condition who are overdue for testing or follow-up? — Real, active identification, not passive awareness that some patients may be overdue.
Evidence: Overdue patient identification process
Evidence: Overdue patient identification process
2. Is there a specific, active outreach process for these patients, not just identification without follow-through? — Genuine outreach, not identification that doesn't lead to real contact.
Evidence: Outreach record
Evidence: Outreach record
3. Are patients with poor control specifically prioritized in this outreach, not treated the same as those with good control? — Genuine prioritization of the highest-risk patients, not undifferentiated outreach.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
Common reasons for a PARTIAL answer
- Outreach happens for diabetes but not consistently for other chronic conditions with similar follow-up needs. — Every chronic condition with a real follow-up requirement benefits from the same proactive discipline.
- Identification happens but outreach attempts aren't tracked to confirm the patient was actually reached. — An outreach attempt that doesn't confirm actual contact provides limited real protective value.
- Outreach happens once but isn't repeated if the initial attempt doesn't succeed.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current follow-up practice for reliance on patient-initiated scheduling versus proactive outreach. |
| Week 2 | Establish a systematic process for identifying overdue chronic disease patients. |
| Week 3 | Build an active outreach process prioritizing patients with poor control. |
| Ongoing | Track outreach attempts and successful contact rates. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Overdue identification process review | Reviews the specific process for identifying patients overdue for chronic disease follow-up. |
| DOCUMENT | Outreach record review | Reviews evidence of genuine, active outreach to identified overdue patients. |
| DOCUMENT | Prioritization review | Reviews whether patients with poor control are specifically prioritized in outreach efforts. |
Supervisor tips
- Ask for a real, recent example of a patient identified as overdue and how outreach actually happened. — A real example reveals whether this is genuine practice, not just policy language.
- Ask how outreach differs for a patient with poor control versus one with good control. — A specific, thoughtful answer reveals genuine prioritization, not undifferentiated practice.
Evidence base
[13] Established diabetes quality improvement practice specifically includes a process to identify and proactively reach out to patients with poor glycemic control who have not had a test in more than four months, rather than waiting for the patient to independently schedule follow-up.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
3.4
Team-Based Care Coordinates Chronic Disease Management
Core
Chronic disease management genuinely involves the full care team — nurses, pharmacists, or other appropriate team members, not the physician alone — with real, coordinated roles, not the physician bearing the entire ongoing management burden without support.
In plain terms: Nurses, pharmacists, and other team members share chronic disease management with the doctor — running reviews, adjusting within protocols, educating — not everything through the doctor alone.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | N/A | Full | Adapted | Full |
Why this matters
A doctor with 500 diabetic patients cannot see each one quarterly and do everything. A nurse can run the foot check, the education, the recall. A pharmacist can review medications and adjust doses within a protocol. A community health worker can do outreach. Team-based care is how primary care scales: the doctor does what only a doctor can do; the rest is shared. It requires defined roles, written protocols for what each team member may do, and communication — a shared record, a team huddle, a case review. A practice where the doctor does everything is a practice where a lot does not get done.
What good looks like
- Chronic disease management genuinely involves the full care team.
- Team members have clear, specific, defined roles.
- Real evidence shows team-based care is genuinely improving control rates.
Common failure modes
- Chronic disease management falls entirely on the physician alone.
- Team roles are ambiguous or overlapping, with no clear ownership.
- No evidence connects team involvement to genuine outcome improvement.
Worked example
In practice
A 5-room health centre with two doctors, three nurses, and no team-based chronic care.
BeforeAll diabetic reviews were doctor appointments. Nurses did vital signs and vaccinations. The doctors were overwhelmed; 15-minute diabetes reviews covered medication only; foot and eye checks, education, and dietary review were rarely done. Waiting time for a diabetes review was eight weeks.
ActionA nurse-led diabetes clinic was created: nurses run a 30-minute structured review (HbA1c, BP, foot check, eye referral, education, medication adherence) under a written protocol, with doctor review for patients above target or with complications. A pharmacist reviews medications quarterly and adjusts within protocol. A weekly team huddle discusses complex patients. The doctor sees patients who need medical decisions.
AfterThe Monitor observed a nurse-led review, reviewed the protocol and huddle records, and saw the diabetes review waiting time fall from eight weeks to two. Foot checks: 20% → 85%. Verified.
If you are starting from zero — do this first
- List what a diabetes review should include. How much of it does the doctor actually do in 15 minutes?
- Write a nurse-led review protocol.
- Define what the pharmacist may adjust.
- Start a weekly team huddle.
The most common mistake: Keeping every chronic disease decision with the doctor because 'the doctor is responsible' — responsibility can be structured, not hoarded.
Self-assessment questions
1. Does chronic disease management genuinely involve the full care team, not the physician alone? — Real, coordinated team involvement, not physician-only management.
Evidence: Team-based care role documentation
Evidence: Team-based care role documentation
2. Do team members have specific, defined roles in chronic disease management, not undefined or overlapping responsibility? — Clear, specific role definition, not ambiguous shared responsibility that no one actually owns.
Evidence: N/A — tested directly
Evidence: N/A — tested directly
3. Is there real evidence that team-based involvement is genuinely improving control rates, not just present without measurable effect? — Genuine, measurable impact, not team involvement without demonstrated benefit.
Evidence: Team-based care outcome evidence
Evidence: Team-based care outcome evidence
Common reasons for a PARTIAL answer
- Nursing staff are genuinely involved but pharmacist expertise, where available, isn't systematically used. — Different team members bring genuinely distinct, complementary expertise to chronic disease management.
- Team involvement is strong for diabetes but less developed for other chronic conditions. — The same team-based approach benefits management of any chronic condition, not diabetes alone.
- Roles are defined but not consistently followed in actual daily practice.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current chronic disease management for genuine team involvement versus physician-only care. |
| Week 2 | Define specific, clear roles for team members in chronic disease management. |
| Week 3 | Extend team-based involvement to chronic conditions beyond diabetes where appropriate. |
| Ongoing | Track outcomes to confirm team-based involvement is genuinely improving control. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| OBSERVE | Team involvement observation | Observes actual chronic disease management for genuine team member involvement, not physician-only care. |
| DOCUMENT | Role definition review | Reviews whether team members have specific, clearly defined roles in chronic disease management. |
| DOCUMENT | Outcome evidence review | Reviews evidence connecting team-based involvement to genuine control rate improvement. |
Supervisor tips
- Ask a nurse or other team member to describe their specific role in chronic disease management. — A specific, confident answer reveals genuine, defined involvement, not nominal team structure.
- Ask how control rates have changed since team-based roles were established, if they have been. — A real, specific answer reveals genuine, measured impact.
Evidence base
[14] Meta-analysis of team-based chronic disease care found that compared with usual care, team-based approaches involving patients, primary care providers, and additional healthcare professionals such as nurses or pharmacists were associated with greater reductions in blood glucose levels and greater improvements in blood pressure and lipid control.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.
3.5
Medication Adjustment Follows a Defined Process When Targets Aren't Met
Non-Negotiable
When a patient's chronic disease control falls short of the defined target, medication or treatment adjustment follows a specific, defined process within a reasonable timeframe — not left unchanged indefinitely simply because the patient hasn't raised a concern.
In plain terms: When a patient's diabetes or blood pressure is not at target, treatment is adjusted according to a written stepped process at defined intervals — not left unchanged visit after visit.
| Facility category | Crisis | Transition | Small | Standard |
|---|---|---|---|---|
| Applicability | Adapted | Full | Full | Full |
Why this matters
Clinical inertia — seeing a patient above target and not changing treatment — is the most common failure in chronic disease management. The HbA1c is 8.5%, the visit is busy, the patient seems fine, the medication is left as it is. Six months later, the same. A defined process breaks inertia: if above target at review, adjust per the stepped protocol (increase dose, add agent, refer); recheck at a defined interval (three months for diabetes); document the decision or the reason for not adjusting. The protocol makes adjustment the default and inaction the exception that needs justifying.
What good looks like
- Treatment adjustment follows a specific, defined process when targets aren't met.
- Adjustment happens within a genuine, reasonable timeframe.
- Defined follow-up confirms whether an adjustment actually worked.
Common failure modes
- Treatment remains unchanged indefinitely despite a patient not meeting target.
- Adjustment, when it happens, is significantly delayed with no defined timeframe.
- No follow-up confirms whether an adjustment succeeded.
Worked example
In practice
A 4-room health centre with a diabetes registry showing many patients above target for years.
BeforePatients above target were reviewed and their medication continued unchanged. The Coordinator found 40 patients with HbA1c above 8% for over two years with no treatment change. Clinicians said 'we discussed lifestyle' or 'they didn't want more medication' — undocumented.
ActionA stepped medication adjustment protocol was adopted from national guidance for diabetes and hypertension: at each review, if above target → adjust per protocol step; if not adjusted → document the reason (patient preference, hypoglycaemia risk, etc.); recheck at three months. The registry flags patients above target with no adjustment in six months for review at the team huddle.
AfterThe Monitor reviewed 30 records of patients above target: all showed adjustment or a documented reason; the registry flag list had fallen from 40 to 8. Verified.
If you are starting from zero — do this first
- Run your registry: patients above target for over a year with no medication change.
- Adopt a stepped protocol for diabetes and hypertension.
- Require adjustment or a documented reason at every review.
- Flag non-adjusted patients for team review.
The most common mistake: Continuing the same treatment because the patient 'seems fine' — the complications come later, quietly.
Self-assessment questions
1. Does treatment adjustment follow a specific, defined process when a patient's control falls short of target? — A real, defined process, not indefinite continuation of unchanged treatment.
Evidence: Treatment adjustment protocol documentation
Evidence: Treatment adjustment protocol documentation
2. Does adjustment happen within a reasonable, defined timeframe, not delayed indefinitely? — A specific, genuine timeframe, not an open-ended delay.
Evidence: Adjustment timing record
Evidence: Adjustment timing record
3. Is there defined follow-up after a treatment adjustment to confirm it's actually working? — Real, scheduled follow-up, not an adjustment made without checking whether it succeeded.
Evidence: Post-adjustment follow-up record
Evidence: Post-adjustment follow-up record
Common reasons for a PARTIAL answer
- Adjustment happens reliably for patients seen regularly but less consistently for those with sporadic visit patterns. — A patient with sporadic visits still deserves genuine, timely treatment adjustment when control is poor.
- A defined process exists but isn't consistently followed when the clinician feels a patient's situation is 'close enough' to target. — A defined target deserves consistent application, not informal discretion about what counts as close enough.
- Adjustments are made but follow-up to confirm effectiveness happens inconsistently.
Implementation plan
| When | What |
|---|---|
| Week 1 | Review current treatment adjustment practice for evidence of clinical inertia. |
| Week 2 | Establish a specific, defined adjustment protocol with a genuine timeframe. |
| Week 3 | Build defined follow-up after every treatment adjustment. |
| Ongoing | Audit adjustment timing and follow-up completion for patients with poor control. |
How the Monitor verifies this
| Method | What | Detail |
|---|---|---|
| DOCUMENT | Adjustment protocol review | Reviews the specific, defined process for treatment adjustment when targets aren't met. |
| DOCUMENT | Adjustment timing review | Reviews records for a sample of patients with poor control to confirm adjustment happens within a reasonable timeframe. |
| DOCUMENT | Follow-up after adjustment review | Reviews whether defined follow-up occurs after a treatment adjustment to confirm effectiveness. |
Supervisor tips
- Ask for a real, specific example of a patient whose treatment was adjusted after not meeting target. — A real, traceable example reveals whether adjustment genuinely happens promptly, not just in policy.
- Ask what happens if a scheduled follow-up after adjustment doesn't occur. — A specific, confident answer reveals genuine tracking, not an assumption follow-up will happen.
Evidence base
[15] A hypertension management program that included evidence-based practice guidelines for pharmacological treatment adjustment and defined follow-up after medication changes was associated with measurably improved hypertension control rates, establishing a defined adjustment process, distinct from unchanged treatment, as genuinely effective practice.
ASF training courses on GMJ Academy →
Foundation courses A-00 to A-03 are live. Criterion-specific modules are being developed and will link here when published.