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Journal of Public Health Management & Practice:
doi: 10.1097/PHH.0b013e31822ca3d3

Why Don Berwick Is Almost Right: How Public Health Quality Improvement Operates Within Complex Systems

Beitsch, Leslie M. MD, JD; Moran, John PhD, MBA, CMQ/OE, CQIA, CMC; Duffy, Grace CMQ/OE, CQIA, CLSSMBB

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Author Information

Center for Medicine and Public Health, Florida State University College of Medicine, Tallahassee (Dr Beitsch); Public Health Foundation, Washington, District of Colombia (Dr Moran and Ms Duffy); and University of Minnesota School of Public Health, Minneapolis (Dr Moran).

Correspondence: Leslie M. Beitsch, MD, JD, 1115 W Call St, Tallahassee, FL 32306 (

Disclosure: The authors declare no conflicts of interest.

Don Berwick, through his work at the Institute for Healthcare Improvement (IHI), and others have demonstrated the value of quality improvement (QI) approaches for achieving better clinical outcomes in the health care sector.1,2 Similar efforts have been under way in public health for the past decade. Several national and state initiatives have advanced the practice of quality improvement and performance management in public health and laid a strong foundation for the field. Examples include the Turning Point Performance Management Excellence Collaborative,3 the National Public Health Performance Standards Program,4 the Multi-State Learning Collaborative,5 and quality improvement programs in the Departments of Health in Florida and Washington.6,7 In addition, there are numerous successful examples in local health departments across the country.8 Each of these endeavors has contributed to the advancement of the science undergirding quality improvement. Through this learning, it has become apparent that although health care models have proven to be a source of great inspiration for public health, there is not always a perfect translation from one discipline to another.

The field of QI in public health is steadily advancing. A definition specific to public health has been formulated and published.9 Studies of QI uptake demonstrate increasing capacity across the broader public health enterprise.10,11 Guidance to the field has been provided through a series of recent publications.1219

In this brief commentary we offer our explanation for some of these differences between health care and public health QI. In addition, we provide a model that may help guide health departments as they navigate implementation of QI in the complex public health systems in which they practice.

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Quality Improvement Is a Targeted Intervention

A common feature of most successful QI efforts is a focused starting point or aim statement. This shared origin is the same whether the anticipated result is a clinical or public health outcome. Simply framed, an aim statement is the definition of what your QI approach is attempting to achieve—what characteristics determine success for the intervention being planned. In other words, you will know if your efforts have been fruitful by establishing the metrics of success up front.

To galvanize the entire QI team around a common purpose, aims must meet specific parameters. A 3-part test describes these requirements: (1) discrete, (2) measurable, and (3) time bound. The following example is illustrative: First trimester entry into prenatal care for pregnant women residing in Grapefruit County, Florida, will be increased from its current 74% to 85% by December 31, 2011. This is discrete even though we are addressing a broad construct like prenatal care, because it is specifically focused on first trimester entry into care. Furthermore, it is measurable and has structured timelines thereby meeting all 3 required features of a sufficient aim statement.

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Concentric Circles (Focus on Internal Quality First)

The aim statement occupies the center of the concentric circles in our proposed QI model for public health systems (see Figure 1). In the health care context, as in manufacturing, most QI initiatives take place within the 4 corners of the hospital campus, or within a given clinical care setting. There are similar examples in public health. Many of them emphasize clinical and operational processes within a health department. These activities take place within the innermost of the concentric circles. To illustrate, consider activities that improve patient flow, efficiencies, and customer satisfaction in immunization or Women, Infant, and Children's Supplemental Nutrition Program (WIC) clinics. The same is true for necessary administrative procedures common to all organizations such as processes that examine and streamline human resources hiring or contracting and procurement. All QI activities should begin with an aim statement setting forth the desired result of the initiative.

Figure 1
Figure 1
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Internal Versus External

Referring now to Figure 2, as one moves from the center of the concentric circles outward, there is a gradual shift from an internal focus to external orientation. The innermost circle emphasizes the activities occurring within the health department itself (local or state). This is the sphere in which QI learning can take place in the safest environment, and, as noted earlier, most closely correlates with QI within the health care setting or the manufacturing assembly line. It is also where QI knowledge and experience can be honed for more complex challenges that are more likely to occur in the external setting, where public health problems typically involve more partners and collaborators, and the choreography is more demanding (see Figure 3 PDSA uphill diagram).

Figure 2
Figure 2
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Figure 3
Figure 3
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Why focus internally when most challenges and potential payoffs are external to the health department? We have already cited the need to develop QI expertise. In terms of partnership development and strategy, it simply makes sense to acquire these skills internally before marketing them with partners and others. One additional issue requires mention: organizations are more ready and willing to partner with competent/successful collaborators. Demonstrating that the health department is a quality organization with finely tuned processes, both clinically and administratively, is a sound marketing approach.

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Operational Versus Strategic

In the concentric circles model, QI activities remain more operationally focused the closer you are to the diagram center (see Figure 2), and more community directed as you move outward. Operational centricity is about streamlining and efficiencies of internal activities—getting the health department house in order. Alternatively, strategic direction connotes a more goal-oriented, outcomes-based approach. Each circle traveling from the center to the periphery indicates greater strategic intention. Regular partners and collaborators are reflected in circles nearer the center, with less routine (possibly nonparticipating) organizations more distant from the center.

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Why Strategy Matters

The visionary efforts by Don Berwick and others have led to dramatic changes in how hospitals and other health care settings view operational processes to improve patient safety. This approach was initially operational when it involved QI around processes in a single setting or a few hospitals. It became strategic when the Institute for Healthcare Improvement created a national movement, with the aim of saving 100 000 lives. The same is true for public health at both the micro (community) and macro (state/national) levels. If the health of a community, state, or country is to be improved, the transformation does not occur by an exclusively internal and operational approach. Rather it requires a thoughtful, deliberate effort to develop a winning strategy that mandates collaboration and QI across broader public health systems. Success for Berwick and the Institute for Healthcare Improvement was achieved when one sector (hospitals) engaged. For public health the stakes and challenges are much greater, requiring multisectoral strategies and partnerships reflecting the full complexity of the public health system.

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Control Versus Influence

A distinguishing feature of public health is that most of the functions for which public health is responsible (the 10 essential public health services)20 are not confined to the health department building itself, or controlled exclusively by the health department. Rather a process of engagement and partnership with the community is required to achieve the desired outcome. In contrast with the clinical setting, or even the WIC and immunization examples, public health typically lacks full ownership or control of the many “moving parts” within a complex system (see Figure 2).

The prenatal care aim statement for Grapefruit County is just one of many possible examples. Simply improving first trimester entry into prenatal care for health department patients may only marginally improve the overall community rate. Besides the health department, all providers of prenatal care, hospitals with obstetrical services, community health centers, local medical society, advocates, consumers, and many others must be at the table. Each participant (and nonparticipant) brings their unique resources and challenges to the task at hand. In short, control of the process within the health department alone does not equate to achieving the stated aim. However, engaging and influencing the other chief participants in the prenatal care public health system may yield a better result and achieve the desired change in health outcome.

Even well-defined, but important, undertakings frequently involve numerous participants, many outside the health department. Completing a multisectoral community health assessment as described by Mobilizing for Action through Planning and Partnerships (MAPP)21 within a predetermined timeline is no less complex an endeavor than improving the first trimester entry into prenatal care. Currently, a community health assessment is required as a prerequisite for accreditation under the new voluntary national program.22 Although much of the process remains within the control of health department staff, actual control may prove illusory. This is largely true because much of the direction is premised upon community partner direction and engagement. The ability to influence and engage becomes even more critical when moving from the community health assessment into the community health improvement-planning phase.

In fact, a strong argument can be made that the dimensions of activities in which health departments have full control are relatively few. Moreover, and most significantly, these activities are less important to the overall health of the community relative to those where public health has only marginal control. Contrast this scenario with that of clinical care, which not only controls all aspects of its health care setting, but whose most important functions occur within this controlled context.

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Systems and QI complexity increase when progressing from the center of the circle to the periphery. Just as the focus shifts from internal to external, operational to strategic, and control to influence, the ability to achieve results through QI morphs as you transition from near the center to outermost concentric circles (see Figure 2). Activities that are largely internal, operational, and controlled reflect a QI opportunity to develop sufficient capacity or improve processes within the organization or organizations, whereas multisectoral engagement across the public health system holds the potential to also impact health status/outcomes. Improvements in all 3 (capacity, process, and outcomes) are needed currently in public health. Precisely where health department QI energy is directed should depend upon the effect that is most desired.

The long-sought public health Holy Grail is achieving changes in health status for the populations it serves. Quality improvement approaches in combination with tools such as the National Public Health Performance Standards that bring the public health system together can harness the synergy offered by multisectoral collaboration in complex systems.

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In the current dynamic environment, QI momentum in public health is rapidly increasing. Health care, although an inspiration to public health in terms of recent adoption of QI, is not always a perfect analogy. For the most part, public health operates in far more complex systems with dramatically fewer resources. A concentric circle model can provide a better understanding of this complexity and offer a framework for navigating QI implementation.

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© 2012 Lippincott Williams & Wilkins, Inc.