Lesson Learned	Illustrative Quote
Start small, focus on participants’ priorities, and build from there.	“We are moving in that direction of finally rallying our resources, understanding what we want to do …Everybody I think started with smaller simpler projects but are sort of building up to this.” (Medical Director)
Coach. We grossly underestimated the need for quality improvement coaching and had to quickly increase support in this area.	“The program team plays an invaluable role in keeping clinics organized, setting goals, supporting forward movement on QI initiatives in small bites (here is how to process map, can’t do it? Then we will meet with you and teach you), and in bringing the disparate clinics together.” (Medical Director)
Work with champions and build meaningful relationships.	“Interest dwindles when the champion provider leaves. We’ve lost four since 2004. We really need a consistent champion provider to assist with buy-in from other providers, to explain what we’re doing and why. They won’t listen to me.” (QI Team Leader)
Understand organizational and political dynamics and culture.	“Change is kind of threatening to a lot of people around here….We’re famous for lack of sustainability, because everybody’s super busy…And everybody’s got their own agenda, right? ….Everybody’s got their own agenda!” (CEO / Executive Director)
Follow the principles of community-based research.	“If they’re brought in and your opinions are asked and they’re part of the change, then they would be much more likely to wanting to have it; or you know they would continue rather than fizzle out if they are part of the change” (Nurse)
Keep the grand vision and roadmap in view to aspire to.	“So I felt for a long time that it was ‘a little of this’ and ‘try this and try that’ and it was very frustrating personally. I will say for the first time, now I can see how all these little projects and little discussions are leading up to these big things that we want to do and now I can see how there is more coming.” (CEO / Executive Director)
Provide communication training simultaneously to patients and providers.	“[Doctors] want to just turn in and turn you out and when you try to talk to them, they’ve got their and I’ve got my way, so why don’t you hear me out and I hear you out. I think that’s one thing doctors need to start working on with the patient…I think some of those physicians should come in here and look at the tape…Learn from Dr. Peek and then come back to me.” (Patient)
Identify personnel at clinics who view Community Engagement as a core component of quality improvement efforts	“It’s important to have this greater mission to promote diabetes education in the greater community whether they come through our doors or not.” (CEO / Executive Director)
Align with other major strategic initiatives that support integrative approaches	“Five or six of our docs have been involved with the Urban Health Initiative. One of our docs is double appointed with the University of Chicago and X. We’re excited about our participation.… And, diabetes is the darling of the Bureau of Primary Health Care, so we want to do the best we can with those patients.” (CEO / Executive Director)
Do not give up - integrating community and health care system is time-consuming and challenging, but support and payoffs are substantial	“Think of a 1000 piece puzzle. You can’t really see the final product until you have the edges done and some of the major figures in the puzzle complete. Then it starts to come together. Unlike a puzzle- you will never finish your QI efforts.” (Medical Director)