Public health departments, voluntary public health accreditation, and public health quality improvement (QI) initiatives share the goal of creating and maintaining healthier communities. Quality improvement is an ongoing, dynamic process designed to analyze and improve strategies; it is also a vital part of accreditation.1,2 It is specifically addressed in Domain 9 (Evaluate and Continuously Improve Health Department Processes, Programs, and Interventions) of the Public Health Accreditation Board (PHAB) standards and measures for those pursuing accreditation.3 However, QI tools, methods, and principles are being applied in meaningful ways throughout the “accreditation lifecycle” to achieve and maintain strong performance on all PHAB standards and measures. If a health department integrates QI into all of its problem-solving activities and delivery of essential public health services, then employees will come to view QI as an ally that helps them continually improve processes and enables them to serve customers more efficiently and effectively. This transformation does not occur overnight; it takes planning and an intentional culture shift within the agency, which over time helps employees think differently about challenges and solutions.
The “accreditation lifecycle” can be seen as 5 stages on the road to attaining and then sustaining accreditation. The Table describes performance and problem-solving challenges at each stage and outlines opportunities for incorporating QI tools and methods, as well as full-blown QI projects.
On the basis of the Public Health Foundation's experience working closely with health departments at various stages of accreditation preparation, we see intrinsic value in deploying QI across the spectrum of activities related to attaining and sustaining accreditation. This may range from integrating QI into daily work (eg, using a specific tool to support a strategy or activity) to more intensive QI projects that address performance gaps. Quality improvement makes any endeavor more efficient and effective, particularly when it is part of a robust performance management system.4 Integrating QI into every phase of accreditation preparation supports a culture of continuous improvement while optimizing preparation activities. Finally, well-designed QI projects that improve performance on specific PHAB measures can also fulfill the Domain 9 requirement to complete QI projects.
Top QI Tools and Methods
Health departments are meaningfully deploying QI on their journeys to become accredited. Here, we have provided a glimpse of selected tools and methods that health departments are using; tool descriptions were adapted from the Public Health Quality Improvement Encyclopedia.5
Plan-Do-Check-Act and AIM statement
Sometimes referred to as Plan-Do-Study-Act, PDCA is a QI framework used to assess and improve strategies. Some health departments apply PDCA as they assess whether their current practice fulfills the requirements of PHAB standards and measures and to change practices and documentation if improvements are needed. Consider the following sequence:
Plan: Review documentation of current practice related to a particular PHAB standard. Develop an AIM statement to guide collection of baseline data (eg, “in order to be a higher performing health department, we want to do x (where ‘x' is what the PHAB standard requires) by y date.” If, after reviewing the data, the PHAB standard does not appear to be met, then identify reasons that it is not met and solutions to improve alignment with the PHAB requirement. Develop an improvement theory (eg, identify what each potential improvement will contribute to the AIM) and action plan, including roles, responsibilities, and timelines.
Do: Put the improvement theory into action and collect data, making observations and documenting lessons learned as practice improves.
Check: Use the data collected to assess progress toward meeting the AIM and fulfilling the PHAB requirement, documenting strengths and weaknesses based on objective criteria.
Act: Take one of the following actions: (a) adopt the improvement theory practices and upload the documentation already gathered to e-PHAB, PHAB's electronic accreditation system; (b) adapt the improvement theory to strengthen the health department's practices related to the PHAB standard (return to Do step); or (c) abandon the improvement theory and explore other practices that may help achieve the PHAB standard (return to Plan step).
The Rhode Island Department of Health used this approach, completing a QI project with a focus on meeting requirements for Domain 8: Maintain a Competent Public Health Workforce. The QI team used a PDCA cycle, AIM statement, and flowchart to increase enrollment in TRAIN (the online learning management system) from 25% to 96% of employees; the results helped the agency document performance fulfilling the PHAB requirements.6
This tool lists the activities of a project in rows with start and end dates. Considered together, the rows represent the project timeline. The Sedgwick County (Kansas) Health Department views accreditation preparation as a project onto itself and has been using the Gantt chart as a project management tool throughout its accreditation preparations. The accreditation team continuously updates the Gantt chart as activities unfold. This approach reflects Sedgwick County's success in building a culture of QI over several years by implementing its QI plan.7
This tool depicts all steps and decision points (visible and invisible) in a process. It maps the current state, uncovers sources of variation and waste, and helps identify areas for improvement. Health departments are using flowcharts to improve processes that are required by numerous PHAB standards. For example, the Arizona Department of Health Services used a flowchart to identify points of integration among home visits for multiple purposes and then developed a more efficient home-visiting process to increase efficiency and access to resources as required for Domain 7 (Improving Access to Health Care Services). Similarly, in Comanche County (Oklahoma), efforts to engage with the community to identify and address health problems (Domain 4) led to a QI project that improved community engagement. The result was increased diversity among those participating in community outreach meetings and increased meeting effectiveness scores.
Cause and effect diagram
Also known as an Ishikawa diagram or a fishbone diagram, it displays multiple potential causes for a problem. It is often combined with other tools, such as Brainstorming (to generate many potential causes) and Five Whys (to drill down to a root cause). In Houston, the health department used cause and effect diagrams in several QI projects to improve administrative processes (ie, general funds, human resources, and accounts payable and receivable) with the goal of meeting requirements for Domain 11 (Maintain Administrative and Management Capacity).
These diagrams show relationships between 2 or more categories of considerations so that teams can prioritize tasks and make informed decisions. As a PHAB beta-test site, the Franklin County (Kentucky) Health Department used a Prioritization Matrix to rank identified areas for improvement in Domains 8, 9, and 11 and select which to address first. The Prioritization Matrix enabled some quick wins early on as the team built momentum to tackle larger issues. The Kane County (Illinois) Health Department used a sequence of QI tools (Radar Chart, Prioritization Matrix, and L-shaped Matrix) to assess workforce Core Competencies for Public Health Professionals8 and prioritize workforce development needs to fill competency gaps. These 2 examples demonstrate how QI can help organize plans and actions within entire domains or across domains.
While QI will not solve every problem, health departments are using it throughout the accreditation lifecycle to help organize, assess, and improve accreditation preparations and to improve performance on PHAB standards and measures. We encourage health departments to experiment with different QI methods and tools as they prepare for accreditation to find the ones that work well for their organizations.
1. Riley WJ, Moran JW, Corso LC, Beitsch LM, Bialek R, Cofsky A. Defining quality improvement in public health. J Public Health Manag Pract. 2010;16(1):5–7.
2. Bender K, Halverson PK. Quality improvement and accreditation: what might it look like? J Public Health Manag Pract. 2010;16(1):79–82.
3. Public Health Accreditation Board. Public Health Accreditation Board Standards & Measures, Version 1.0. Alexandria, VA: Public Health Accreditation Board; 2011.
5. Moran JW, Duffy GL. The Public Health Quality Improvement Encyclopedia. Washington, DC: Public Health Foundation; 2012.