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Improving Culture, One Quality Improvement Project at a Time

Vander Schaaf, Emily, B., MD, MPH; Cornett, Amanda, C., MPH; Randolph, Greg, D., MD, MPH

Journal of Public Health Management and Practice: January/February 2018 - Volume 24 - Issue 1 - p 57–62
doi: 10.1097/PHH.0000000000000554
Research Reports: Research Full Report

Context: A culture of quality improvement (QI) values collaboration, transparency, and staff empowerment. Organizations exhibiting a culture of QI are more likely to engage in QI.

Objective: We examined whether local health departments' (LHDs') participation in a longitudinal, experiential QI training program changes QI culture.

Design: Prior to and following participation in a QI training program, all employees of participating LHDs were asked to complete an 8-item survey assessing components of QI culture on a 5-point scale.

Intervention: From 2010 to 2015, multidisciplinary teams from North Carolina LHDs participated in sequential cohorts of a 6-month QI training program, during which the teams completed a QI project.

Main Outcome Measure: We dichotomized culture survey responses, with 4 or 5 being “Supportive.” We compared adjusted proportions, using linear regression, clustering at LHD, and controlling for cohort.

Results: Data from 42 LHDs were included. At baseline, 7.8% responded that their LHD had a supportive culture for all 8 components, compared with 12% at follow-up (P < .001), adjusted for cohort and clustering by LHD. At follow-up, the percentage of employees responding that their LHDs had supportive cultures increased for all components of culture including communication by 4.1% (95% CI: 2.0%-6.2%), problem solving by 2.9% (95% CI: 1.6%-5.5%), team work by 5.2% (95% CI: 2.5%-7.8%), vision by 4.3% (95% CI: 1.1%-7.5%), performance measures by 5.6% (95% CI: 1.6%-9.6%), recognition by 4.7% (95% CI: 1.4%-8.0%), for conflict by 5.5% (95% CI: 1.7%-9.4%), and alignment by 5.8% (95% CI: 2.3%-9.2%).

Conclusions: Engagement with structured QI training programs—and perhaps simply completing QI projects—can cause small, but important changes in organizations' cultures, thus increasing engagement in future QI and improving overall care and services. The article demonstrates that when LHDs participate in a longitudinal, experiential QI training program, their cultures of QI improve. Local health departments participating in similar training programs might experience similar improvements in culture, increasing subsequent participation in QI projects and improving related health outcomes.

Population Health Improvement Partners, Morrisville, North Carolina (Drs Vander Schaaf and Randolph and Ms Cornett); and Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, University of North Carolina, Chapel Hill, North Carolina (Drs Vander Schaaf and Randolph).

Correspondence: Emily B. Vander Schaaf, MD, MPH, Division of General Pediatrics and Adolescent Medicine, UNC Department of Pediatrics, 231 MacNider Building, CB #7225, Chapel Hill, NC 27599 (

The authors thank North Carolina's local health departments for their participation in this quality improvement training program. Also thank you to the staff from Population Health Improvement Partners that worked tirelessly to collect survey data from participating health departments, including Claire See, Andrea Davis, Meredith Carroll, and Melissa Barrentine Martin. Thank you to the funders: the Blue Cross Blue Shield of North Carolina Foundation and the Duke Endowment as well as the National Research Service Award (NRSA) grant T32 HP14001. Additional thanks to Asheley Skinner, PhD, for statistical support. EBV's fellowship was funded through a Health Resources and Services Administration National Research Service Award (NRSA) grant T32 HP14001. QI 101 was funded by the Blue Cross Blue Shield of North Carolina Foundation and the Duke Endowment.

We have no conflicts of interest to disclose.

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