Technical Assistance

Featured Project: Strong Systems, Stronger Communities TA cohorts


SSSC TA cohorts workshop, February 2019

The National Association of County and City Health Officials (NACCHO), with support from the Center for State, Tribal, Local and Territorial Support within the Centers for Disease Control and Prevention (CDC), is pleased to offer a new technical assistance (TA) opportunity titled Strong Systems, Stronger Communities (SSSC) TA Cohorts. The SSSC TA cohorts project supports local health departments (LHDs) in completing public health performance improvement projects through a tailored in-person and virtual training and TA program. The LHDs selected to participate in the SSSC TA Cohorts utilized performance improvement methods to address the social determinants of health and improve population health through work in one of two categories:

  • Quality improvement (QI) activities to improve population health
  • Addressing the Social Determinants of Health (SDoH) through the community health improvement plan (CHIP)

The first cohort of SSSC TA Cohorts featured eight competitively selected LHDs completing projects in two categories:

Category 1: LHDs complete the QI SAT 2.0 to assess the organization’s culture of quality and implement a population health QI project.

  • Amarillo Public Health, TX
  • Durham County Department of Public Health, NC
  • Milford Health Department, CT
  • Siouxland District Health Department, IA
  • Tri-County Health Department, CO

Category 2: LHDs in this category conduct a gap analysis on one of the strategic priorities from their CHIP using the community health improvement matrix (CHIM) and work to implement upstream strategies into an action plan for addressing the priority.

  • Public Health Solutions, NE
  • Orange County Department of Health, NY
  • City of St. Louis Department of Health, MO


Applications for the SSSC TA Cohorts are closed. Please email pi@naccho.org for questions about the SSSC TA Cohorts. A summary of the projects completed by each of the participating LHDs during year 1 of the SSSC TA Cohorts (2018-2019) is below.

Amarillo County Health Department (TX)

To determine the current NACCHO QI Roadmap Phase, Amarillo Public Health established a process to implement the NACCHO QI SAT which involved meeting with staff to educate them on the process, encouraging honest feedback, administering the SAT, and completing the NACCHO QI SAT scoring summary. The agency scored in Phase 3: Informal or Ad Hoc QI on NACCHO’s Roadmap to a Culture of Quality. Strengths of the current QI culture included customer service and opportunities for strengthening the QI culture related to teamwork and collaboration. The Health Informatics Program Manager took the lead to establish a Quality Improvement team which was made up of a volunteer from each program area. This team began meeting bi-weekly and developed a Quality Improvement Plan for Amarillo Public Health. In addition the efforts made to formalize an agency-wide QI culture, Amarillo Public Health make great strides in applying formal QI methods to a population health QI project aimed at increasing the percent of residents in Amarillo that are covered by closed PODs in the event mass prophylaxis is needed from 15% to 30%. Through the project, the agency improved its recruitment strategy focusing on the 10 largest employers in the jurisdiction in order to target a larger percentage of the community. By the end of the project, the agency increased the number of residents covered by closed PODs from 39,582 to 79,848 – a 100% increase. See their QI Project storyboard.

Durham County Public Health (NC)

NACCHO administered and scored both DCoDPH’s leadership and staff assessment(s) QI SAT 2.0 via Qualtrics. Leadership team and staff selected transition strategies to advance the culture of quality at DCoDPH. Transition strategies were selected from hard copies of the Leadership Version of QI SAT (2.0) survey. Next steps were prioritized by leadership and staff during a consensus building and prioritization activity. Our plan is to include identified priorities in our updated QI plan based on assessment results. DCoDPH Project aim statement: By December 31st, 2019, increase from 9.8% to 80% the percentage of times the vendor complies with Durham County government’s order for 100% healthy food item refills in 21 of its 21 vending machines by improving the ordering process with the vendor. This TA continues to have a positively forward moving effect of DCoDPH’s QI orientation. For example, we are on our way to becoming an LHD with an improved QI culture. The County-Wide Healthy Vending Policy, Vending RFP & Scope of Services are near completion. All that was learnt during this educative process will be reflected in our updated QI Plan. See their QI storyboard.

Milford Health Department (CT)

Through the SSSC, the Milford Health Department was able to accomplish many of the deliverables that are required to conduct public health Quality Improvement projects. After attending the training in Washington DC in February 2019, the Milford Health Department has invested several resources in order to adopt a culture of quality improvement practices. We began by identifying a leadership team and then provided training on what we learned at the in-person training and obtained buy-in from leadership. Shortly after, we administered the NACCHO Organizational Culture of Quality Assessment Tool Version 2.0. This tool helped us identify training needs and prioritize action items that should be included in our QI plan. Our original QI project was to focus on monthly immunization clinics; however, after the DC training, we adjusted the project in order to ensure it truly represented a population health project. As such, based on historical vaccination data, the focus of the QI project was specific to Milford seniors and their declining flu vaccination rates, including at the Milford Senior Center. Utilizing root cause analysis with a fishbone diagram, we were able to determine some reasons for declining vaccination rates among this population. Based on these results, we brainstormed ideas to increase vaccination among seniors and created an affinity diagram. Ultimately, we developed an aim statement that by December 2019 MHD hopes to increase the number of older adults who get vaccinated for the flu from 7% to 10% by improving our education efforts through an education campaign.

Siouxland District Health Department (IA)

With the recent completion of the Siouxland Area Community Health Needs Assessment and Health Improvement Plan, the population health issue of vaping among adolescents had been identified, as the percentage of students vaping continues to increase. In 2018, only 12% (120) students within Sioux City had been presented to on the harmful effects of smoking. SDHD completed a root-cause analysis to determine why our tobacco prevention specialist was not being utilized by schools. SDHD developed an improvement theory that if SDHD reached out to school administrators for approval annually and are granted permission to schedule vaping presentations with each middle school PE/Health teacher more students would be reached. Utilizing the “Targeted Public Health Messaging Worksheet” SDHD was able to strategize the best way to engage the school district and what type of language to include in their one-page presentation proposal document. The Sioux City Community School District Assistant Superintendent approved the presentation and granted SDHD permission to reach out to each of the three middle school principals, who in turn reached out to their PE/Health teachers. Two of the three middle schools responded, and thus eight presentations were given at two middle schools during PE/Health classes - reaching a combined 713 students. Since reporting out progress on the SSSC QI project to the Siouxland District Health Department’s Board of Health, the Board has granted permission and has encouraged the Tobacco Prevention Specialist at SDHD to market the Vaping presentation to school districts outside of the county jurisdiction, if gap filling services are needed. The QI project storyboard is located here.

Tri-County Health Department (CO)

Through the SSSC project, TCHD completed a leadership and all staff QI assessment using the NACCHO QI Self-Assessment 2.0 Tool. The initial results of the survey revealed an overall QI culture score of 3.9, which is close to Phase 4: Formal QI in Specific Areas of the Agency on the NACCHO Roadmap to a Culture of Quality. Through this process, TCHD identified its QI strengths as enabling staff to improve performance through QI, understanding customer needs and satisfaction through data, strategic planning, and performance measurement. Identified areas for strengthening TCHD’s QI culture included formalizing use of QI methods in improvement projects, establishing resources and structure for a more formal QI program, and adopting a QI plan based on self-assessment results. In addition to assessing the QI culture, TCHD selected a QI project to focus on increasing online WIC referrals from clinics in the TCHD jurisdiction in order to increase the number of WIC eligible community members that access WIC services. This project relates to the longer-term community health improvement plan goal to increase total WIC caseload by 8% by December 31, 2024. The improvement theory for this QI project was that if the amount of consultation with medical providers were increased then online referrals to WIC would increase, which would lead to increased families signing up for WIC. Through the QI project, TCHD increased online WIC referrals from an average of 92 in 2018 to 123 in 2019. Over the next 12-24 months, TCHD plans to refine and establish QI and performance management rhythms that will ingrain foundational QI ideas and principles into agency culture. See their QI project storyboard.

City of St. Louis Department of Health (MO)

City of St. Louis Department of Health (DOH) staff trained an additional 20 staff on using the Community Health Improvement Matrix (CHIM) which included 13 staff from our health department and 7 from a neighboring jurisdiction’s health department during a team retreat. The approach to train two health departments’ staff is tied to our shared Community Health Assessment and Community Health Improvement Plan (CHA-CHIP). We also took the opportunity to build logic models and identify strategies to use in the CHIM, define outputs, and align outcomes from our CHIP action plans. Over the two-day retreat, staff learned what are considered as downstream, mid-stream, and upstream strategies; learned the different levels of intervention in the socioecological model and contextual or primary, secondary, and tertiary levels of prevention. In addition to learning how to use the CHIM tool, staff completed the CHIM for all eight CHIP action plans, analyzed results (strategy gaps and overlaps), and disseminated to our action team leads and the leadership of the St. Louis Partnership for a Healthy Community, our overarching CHA-CHIP coalition. Sharing the CHIM with partners validated that the action plans were aligned with our CHIP priorities, namely, Addressing Social Determinants of Health as Root Causes of Community Health. This helped improve partner confidence with action planning and implementation and cross-action team sharing and co-learning. See their Action Plan to address healthy homes.

Public Health Solutions (NE)

Through the SSSC project, Public Health Solutions created a Community Health Improvement Matrix (CHIM) for our organization’s programs, in order to identify potential areas for moving priority work upstream. This information was also used to provide staff training on the importance of upstream strategies, incorporating social determinants of health and health equity into grant-writing and program planning and evaluation, and the importance of creating measurable organizational objectives that we can monitor on an ongoing basis. PHS learned two very valuable lessons through the SSSC project period. The first is the need to set realistic goals and objectives, and that the process for increasing stakeholder engagement cannot be rushed. The second lesson learned is that while our organization has undergone extensive training on moving public health work upstream, there is an additional need for training our community partners on health equity and the impact of community determinants of health on programmatic success and overall health outcomes. In the next 1-2 months, we will reconvene the regional steering committee to identify any missing partners we should engage, create a partnership agreement, discuss training options for SDOH, CHIM, and upstream strategies, and allow new members to self-select to a CHIP priority subcommittee. See their completed community health improvement matrix.

Orange County Department of Health (NY)

OCDOH created a community collaborative comprised of three local hospital systems, two federally qualified health care facilities, private healthcare practices and community-based organizations to increase access to and screening rates for breast, cervical, and colorectal cancer in Orange County. Through this joint collaborative, we conducted a residential survey and had a large brainstorming session to determine the reasons why residents may not access cancer screenings. Through this process, we collectively developed strategies to address the underlying barriers and gaps and created a formal action plan to address issues. Before the SSSC cohort, OCDOH focused on only a small audience and didn’t have the collaborative effort we have now. Prior to the SSSC, we did not have the right partners at the table to accomplish the goals we set out a few years ago. We would not have been able to accomplish the progress we have made to date without the cohort. OCDOH has created a three-year action plan that includes regularly scheduled meetings. We are confident in our ability to continue the efforts of the SSSC because of the strong commitment from our community partners. See their action plan to increase cancer screening.