Experiences and Advice from Small Local Health Departments Using Quality Improvement and Performance Management for Accreditation

Posted on February 11, 2025 by Matthew Fifolt

This entry is part 2 of 7 in the series Mar 2025

Disproportionately fewer small local health departments (LHDs) have sought accreditation from the Public Health Accreditation Board (PHAB) as compared to state and large city and county governmental health departments. In “Using National Public Health Accreditation to Explore Quality Improvement and Performance Management in Small Local Health Departments,” our research team explored the experiences of participants from four small LHDs in the United States (population jurisdiction ≤ 50,000).

The National Association of County and City Health Officials¹ defines QI as 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. PM is closely linked to QI as it provides a structured, data-driven approach to identifying and prioritizing opportunities for improvement.²

Based on the integral role of QI/PM in the accreditation process, one set of questions focused specifically on QI/PM, including participant advice for other small LHDs regarding QI/PM. We used rigorous qualitative methods to interview 22 participants from four small LHDs. The following are key findings from this study:

Tools for Implementing QI. All participating LHDs used Plan-Do-Study-Act/Plan-Do-Check-Act as their QI model for process improvement.³ Additionally, representatives identified multiple tools and resources for tracking performance including Microsoft Excel, Microsoft Access, Microsoft Teams, Asana, and Clear Impact.
Building staff buy-in. Participants noted that staff buy-in for QI/PM was commensurate with their leader’s knowledge of QI/PM processes as well as their commitment to using the results of improvement activities to enhance overall operations. Individuals further observed that staff members were more willing to participate in QI/PM activities if they had ownership of improvement projects and understood how the results would improve community health outcomes.

“Quality is not pointing out something someone is doing wrong, quality is doing your job and constantly looking for ways to make it even better.”

Integrating QI/PM into daily work. Interviewees suggested that when QI/PM was done correctly, activities were not separate from but rather integrated into their daily work. Participants identified specific improvement project examples to demonstrate how QI/PM was integral to their daily operations and noted that it was critical for all staff members to participate in QI/PM for these activities to be effective.

“We have seen over and over again areas where…by going through the process and being able to identify areas where we could make small adjustments, that made a huge impact in positive returns.”

Advice for other health departments. Recommendations ranged from practical advice, such as Find a QI/PM model that is easy to understand to more philosophical perspectives, such as Always be open to quality improvement, see every opportunity as an opportunity for improvement. Additionally, participants agreed that QI/PM should be framed as a strategy for improving the health outcomes of community members, which makes it more meaningful for all involved.

Key Findings

Read Our Article

Small LHDs can successfully incorporate QI/PM into ongoing public health practice to better meet community needs, not just meet requirements for public health accreditation.
Small LHDs can improve staff QI/PM abilities and buy-in through education, staff selection and ownership of QI projects, and leadership modeling and communicating expectations.
Meeting PHAB Standards & Measures gives health departments a foundation to incorporate QI/PM systems and efforts on an ongoing basis.

For more information, read “Using National Public Health Accreditation to Explore Quality Improvement and Performance Management in Small Local Health Departments” in the March 2025 issue of the Journal of Public Health Management and Practice.

Acknowledgments

Coauthors of the full research article include Paul C. Erwin from the University of Alabama at Birmingham School of Public Health, Peg Allen, Andrew N. Crenshaw, and Ross C. Brownson from the Prevention Research Center at Washington University in St. Louis (WashU), and Britt Lang and Amy Belflower Thomas from the Public Health Accreditation Board. We thank Mary Adams and Renee Parks at WashU. Support for this work was provided by PHAB and through funding from the Centers for Disease Control and Prevention (CDC) under Grant Number NU90TO0000002 and award number U48DP006395.

National Association of County and City Health Officials. Quality improvement. https://www.naccho.org/programs/public-health-infrastructure/performance-improvement/quality-improvement. Published 2025. Accessed February 1, 2025.

National Association of Conty and City Health Officials. Measuring what matters in public health. https://www.naccho.org/uploads/downloadable-resources/NACCHO-PM-System-Guide.pdf. Published 2018. Accessed February 1, 2025.

Agency for Healthcare Research and Quality. Plan-Do-Study-Act worksheet, directions, and examples. https://www.ahrq.gov/health-literacy/improve/precautions/tool2b.html. Published March 24. Accessed February 1, 2025.

Related resources

Britt L, Rich N, Kronstadt J, et al. Public health department accreditation and innovation: a brief report of the approaches used to promote innovation. J. Public Health Manag. Pract. 2022;28(Suppl. 4):S138-S142.
Gregg A, Bekmuratova S, Palm D, et al. Rurality, quality improvement maturity, and accreditation readiness: A comparison study of Colorado, Kansas, and Nebraska local health departments. J. Public Health Manag. Pract. 2018;24(6):E15-E22.
National Association of County and City Health Officials. Measuring what matters in public health. NACCHO; 2018.

About the Author

Matthew Fifolt: Matthew Fifolt, PhD, is an Associate Professor in the Department of Health Policy and Organization in the School of Public Health at the University of Alabama at Birmingham. His research focuses on program and quality improvement in evidence-based public health practice through high-quality program evaluation and assessment.