Public Health Quality Improvement (QI): Journey to a Culture of Quality

This entry is part 9 of 42 in the series Focus on Accreditation and Innovation

by Ronald W. Chapman, MD, MPH, and William Riley, PhD

Focus on Accreditation and Innovation addresses current issues related to the Public Health Accreditation Board’s national public health department accreditation program, and the Public Health National Center for Innovations. This series highlights the experiences and perspectives of accredited health departments and explores topics related to the Standards and Measures, research and evaluation findings, and the latest innovations in public health practice.

Quality Improvement work in public health has come a long way in a short time. A decade ago, QI efforts in public health were infrequent. Today there are public health QI staff and QI conferences leading to improved public health services delivered to communities across the United States.

Public health accreditation has been the major driving force for the increased interest in public health QI. Quality improvement is a central foundation of the Public Health Accreditation Board (PHAB). Since 2013, a total of 189 state, local, and tribal health departments and one centralized state integrated local public health department system have been accredited, which serve almost 200 million persons. Each of these accredited health departments has demonstrated proficiency in successfully introducing quality improvement methods into their operating system and many departments have advanced further toward a transformational change in their quality improvement capability. The accreditation Standards and Measures Version 1.5, Domain 9, quotes a Jan/Feb 2010 article from the Journal of Public Health Management and Practice:

“Quality Improvement in public health is the use of a deliberate and defined improvement process that 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 processes which achieve equity and improve the health of the community.”

Unlike many accreditation systems, a central feature of the PHAB accreditation methodology focuses on continuous improvement as standards have increased interest and expanded the application of QI in public health systems and services. Hundreds of QI projects have been implemented in public health departments across the country. In response to the rising demand for QI information, training, and leadership, many health departments and national organizations have developed QI tools and resources such as the Association of State and Territorial Health Officials (ASTHO), National Association of County and City Health Officials (NACCHO), Public Health Quality Improvement Exchange (PHQIX), Public Health Foundation, and Community of Practice for Public Health Improvement (COPPHI).

Many health departments are in the initial QI developmental stages. An assessment of the department’s culture of quality (for example, using a tool like NACCHO’s Roadmap to a Culture of Quality Improvement) can be a helpful first step.  Departments eventually need to choose a QI model. The PDSA (Plan, Do, Study, Act) model is one of the most common QI models used by health departments. Kaizen, LEAN, and Six Sigma are also being used.

Once a model is chosen, staff need to be trained and a common QI language needs to be disseminated across the department. Some staff are naturally attracted to QI work and they become QI Champions. Successful QI efforts depend heavily on visible and consistent department leadership support. The health department will need to develop and maintain a workable QI plan.

Three challenges remain: 1) continue to advance the level of sophistication of QI in health departments, 2) fully integrate QI into a health department performance management system, and 3) increase the evidence base for how QI and accreditation improve public health outcome measures. Ultimately, QI should integrate with performance management measures and the department’s dashboard to improve services and processes.

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Public health has just begun the QI journey and is already leading the way in governmental QI efforts. Many health departments report that their QI efforts have been noticed and adopted by other local and state government agencies.  The recognition of public health as a QI leader provides credibility and complements public health’s reputation as a leader in improving the health of communities.

For further reading:

For more on this topic, read the May/June 2018 JPHMP Supplement on the Impact of Accreditation.

Ronald W. Chapman, MD, MPH, serves as Health Officer for California’s Yolo County. He is also a Health Strategist consultant focused on helping health departments build quality improvement and performance management systems. [Full bio]





William Riley, PhD, is a professor in the School for the Science of Health Care Delivery at Arizona State University, where he teaches process engineering, health finance, and health care quality and safety design. He previously served as the Associate Dean for the School of Public Health at the University of Minnesota. [Full bio]

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