The public health field is a dynamic environment with health departments having to navigate emerging public health threats while dealing with budget cuts and increasing political pressures. Quality improvement (QI) has been introduced to, and embraced by, the field of public health as a means to achieve efficiencies and improve quality of services to improve overall community health.
Quality Improvement (QI) in public health is the use of a deliberate and defined improvement process, such as Plan-Do-Study-Act,1 which is focused on activities that are responsive to community needs and improving population health. It refers to a continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes that achieve equity and improve the health of the community.2 NACCHO offers the following resources for integrating QI into local public health practice.
Organizational culture is the embodiment of the values, principles, norms, and attitudes that collectively contribute to its daily operations. It is the essence of how work is accomplished and matures over several years. Transforming culture to embrace QI when minimal knowledge or experience exists requires strong commitment and deliberate management of change over time. The following resources will assist in assessing and growing a QI culture.
Roadmap to a Culture of Quality (QI Roadmap)
NACCHO’s QI Roadmap provides guidance on six foundational elements of a QI culture and how to progress through six phases of QI maturity. Each phase presents common organizational characteristics to diagnose the current culture and transition strategies and resources for advancing to the next phase. Click here to access the QI Roadmap.
NACCHO's Organizational Culture of Quality Self-Assessment Tool (QI SAT)
The NACCHO QI SAT aligns with the QI Roadmap and allows for an in-depth and objective assessment of QI culture across all six foundational elements and 20 sub-elements of a QI culture. It offers a scoring summary sheet which results in a numerical score for each foundational element and one overall score for the agency. Based on your score, the SAT provides a menu of transition strategies to advance to the next phase. NACCHO also offers a facilitator guide and canned PowerPoint to assist with administering the tool. Click here to access the QI SAT and supplemental resources.
NACCHO conducted a webinar about the new QI SAT 2.0 on 12/13/2018. You can find the slides here.
An agency QI plan provides and establishes accountability around formalizing the QI program. It outlines the agency QI vision, establishes the QI program governance structure, specifies QI processes and methods for selecting and implementing projects, and provides an action plan for how to grow the QI culture. QI assessment results should be used to select the priorities in the QI plan. An adopted QI plan should be monitored for progress, evaluated at least annually, and should align with other agency plans including to maintain focus on overall strategy and performance.
QI Plan Guides
- The Ohio State University Center for Public Health QI Plan User’s Guide and template
- ASTHO guide to QI plans
Example QI Plans
Below are example QI plans from accredited local health department (LHD), each of which were informed by QI assessment results and have been reviewed for quality by NACCHO staff.*
- Los Angeles County, CA- Adopted 2017
- Tacoma-Pierce County, WA-Adopted 2017
- Scott County, IA - Adopted 2017
- Franklin County, KY - Adopted 2016
- Santa Clara County, CA-Adopted 2016
- Maricopa County, AZ - Adopted 2014
*These QI plans were evaluated against the PHAB Standards and Measures Version 1.0 by NACCHO Staff. These individuals, based on their understanding of the standards and measures, have classified them as meeting the PHAB requirements and being high-quality documents. These have not been approved by PHAB or any PHAB site visitors for the purposes of meeting relevant standards and measures.
All staff, from executive leaders to frontline staff, should continuously improve their work. Empowering employees to engage in QI requires access to QI training and resources. NACCHO has developed some presentations and compiled other resources for LHDs to use when the need for training arises. Listed below are a collection of QI trainings available for different levels of health department staff.
- NACCHO Compendium of QI Training Resources – Gathered from national, state, and local level agencies, this resource includes a listing of free, online, QI trainings including webinars, self-paced courses, and training tool.
- QI Culture Staff Orientation Slides– This PowerPoint presentation can be tailored to orient staff to concepts related to building a culture of quality. It includes slides, talking points, and facilitator instructions.
- Introducing QI and Plan-Do-Study-Act Slide Deck – This PowerPoint can be used to introduce basic QI concepts to staff and provide an overview of each phase of the Plan-Do-Study-Act (PDSA) cycle, a QI method for continuous improvement.
For more resources around QI trainings, visit the QI Roadmap Resources section and sort by the foundational element, “Employee Empowerment.”
As an agency gains more expertise and experience with QI projects, QI should spread to all departments, programs, and services. The following resources provide guidance on selecting and implementing QI projects.
QI Project Prioritization and Selection
The agency QI Committee or QI leaders should create criteria and processes for selecting a QI project to ensure selection of projects with the greatest potential for impact. Potential projects should also be screened to determine whether they are appropriate for a formal QI process. The following resources provide guidance implementing these processes:
- QI Project Prioritization and Selection Process – This resource offers recommended sources for identifying QI projects and screening and prioritization criteria for project selection.
- Guide to Prioritization Techniques – This guide offers five commonly used prioritization techniques including instructions, templates, and examples from the field.
- Worksheet 6 QI Project Nomination Form - A worksheet from NACCHO's Guide to Performance Management, agencies can use this worksheet to allow staff to nominate a QI project.
There are a variety of QI processes and tools that can be used to implement QI projects. It is important to define for staff the QI processes that will be used and to cultivate expertise around selecting and implementing the most appropriate methods. Some common QI methods include Plan-Do-Study-Act (PDSA), Kaizen, Lean, and Six Sigma. There are also several QI tools and templates that can be used to implement different phases of these QI methods (e.g. flowcharts, cause-and-effect diagram, control charts). The following resources may assist with implementing QI projects:
- ABCs of PDSA Article – Provides a simple overview of each phase of a PDSA cycle.
- Implementing a QI Project Webinar – This 33 minute NACCHO webinar offers more detailed guidance around how to select a QI project and implement a PDSA cycle.
- Public Health Quality Improvement Exchange – Provides a database of health department QI projects, searchable by topic area and QI method.
- American Society for Quality: Quality Tools A to Z – This webpage offers a listing of a variety of QI tools and methods including instructions for use and downloadable templates.
- Public Health Memory Jogger - This QI pocket-guide provides step-by-step instructions on using 22 of the most common QI tools and techniques
- QI Storyboard Template – One page template for summarizing and documenting QI projects and displaying results.
- QI Project Step-by-step guide - The QI Step-by-Step Guide walks you through each phase of a QI project and provides you with examples, tools and templates to successfully carry out a QI project.
- For more resources around QI trainings, visit the QI Roadmap Resources section and sort by the foundational element, “Continuous Process Improvement.”
1. Plan-Do-Study-Act (PDSA) is an iterative, four-stage problem solving model used for gaining learning and knowledge for the continual improvement of a product, service, or process.
2. Riley, W., Moran, J., Corso, L., Beitsch, L., Bialek, R., and Cofsky, A. Defining Quality Improvement in Public Health. J Public Health Management Practice 2010; 16(1)5-7.