Results and quality are undeniably important to every public health organization and initiative. To place these concepts into perspective at the macro level of public health, more than 2 million lives hang in the balance between the gap in our current performance and 9 major mortality targets to be achieved in Healthy People 2010.1 Evidence from business, government, healthcare, and other industries suggests that quality management practices can positively influence almost every type of measure, ranging from bottom line results and outputs to employee relations and customer satisfaction.2
Although most state and local agencies report that they carry out quality improvement (QI) or performance management* activities,6–9 the difficulty in identifying widespread QI practices or measurable outcomes related to these activities8,10,11 suggests that we may be overestimating our efforts. Different approaches are needed to ensure that effective QI practices are better understood and routinely practiced on the front lines of public health. Can voluntary accreditation help propel our field toward QI? Or have we overestimated its potency as an elixir for quality systems? Time will tell, but the answer is up to us.
On the basis of our collective experience with QI and public health practice, we offer the following four thoughts to frame important ongoing discussions about the relationship between QI and accreditation.
QI is an essential role for all health departments—before, during, after, and independent of voluntary accreditation.
At the national level, only recently have QI responsibilities of public health organizations become explicit in the expectations and standards for public health practice. The field's growing recognition of these responsibilities is evident in the domains and goals of the proposed framework for a voluntary accreditation program (for which the first purpose is to “promote high performance and continuous quality improvement.”12) They are also pivotal in the National Association of County and City Health Officials' Operational Definition of a Functional Local Health Department and the proposed 2007 revisions to the National Public Health Performance Standards Program (NPHPSP) instruments.
No matter where an organization stands in relation to accreditation, QI matters to its success. For those that opt to pursue national accreditation or other voluntary standards, systematic QI methods are the means to assess one's current performance, as well as coordinate efforts to prepare for, maintain, remediate, and advance beyond minimum standards. For a variety of reasons, accredited and nonaccredited organizations alike will have performance goals that fall outside of accreditation standards. QI methods enable organizations to nimbly respond to emerging challenges and deliver locally important results in areas such as health outcomes and program outputs, organizational excellence (eg, Baldrige criteria), and essential services.
Because QI is paramount to the goals of accreditation, its design must not be left to chance alone.
The experience of many accreditation and performance standards programs shows that QI is often short-changed at the outset and takes a backseat to conformity assessment. Despite the stated QI purposes of many accreditation and performance assessment initiatives, limited dispersion of QI practices and evidence of persistent quality gaps have led QI and evidence-based practice to emerge as priorities for future iterations of accreditation programs in healthcare,13 public health, and other fields. The take-home message for architects of future accreditation programs is this: Without an explicit QI focus in the design of an accreditation or standards initiative, the QI practices will not automatically occur.
This lesson has been borne out among the participants in the Multi-State Learning Collaborative showcased in this issue of the Journal of Public Health Management and Practice. They fell victim to what we call the Peggy Lee phenomenon. At the state level, they observed that accreditation or assessment alone is necessary but insufficient to dramatically improve the performance of state and local public health agencies. This proved true across both new and mature state accreditation programs, begging the famous question of the iconic singer, “Is that all there is?” As a result, Multi-State Learning Collaborative grantees began to put in place innovative QI activities.
In response to the need for a greater attention to QI in state accreditation and performance assessment programs, the Robert Wood Johnson Foundation has funded a second phase of the Multi-State Learning Collaborative project devoted to exploring QI. This project, coordinated by the National Network of Public Health Institutes and Public Health Leadership Society, will provide a rich laboratory from which states and the national accreditation program can learn promising ways to design QI into accreditation initiatives.
Future accreditation designs should aim to support QI on many levels. Above all, the accreditation standards should define expectations for a quality management system and use quantifiable measures that can be tracked over time. From the outset, programs should offer meaningful QI guidance, assistance, and reports. Assistance offerings may include self-assessment and readiness tools, as well as methods to link both successful and unsuccessful participants to improvement resources and peer networks. Similar guidance is now offered by the NPHPSP14 following a marked growth in its QI offerings in recent years. Accreditation reports must also provide valuable feedback to managers and staff so that progress can be assessed. Additional examples of ways that accreditation programs might support QI may be found at www.phf.org/Accreditation-QI-Strategies.pdf.
Testing and refining strategies that contribute to the spread of QI practices and improved outputs and outcomes are consistent with the QI concept of Plan-Do-Check-Act and the evaluation recommendations from Exploring Accreditation.
Establishing QI as a separate, but related, initiative is essential to the success of the public health field, as well as the continued success of accredited organizations.
Voluntary accreditation has the potential to drive QI in the public health field, but it should not be the sole driver. Leaders, funders, and practitioners must not wait until initiating an accreditation process to devote attention to QI.
To date, there are many promising approaches to QI, but no single tried and proven formula for public health. Therefore, as the field develops, there is room for many contributors under a QI umbrella. Just as many groups advance QI, patient safety, and evidence-based medicine in healthcare beyond the National Committee for Quality Assurance and the Joint Commission on Accreditation of Healthcare Organizations, public health similarly will benefit from partnerships with many skilled consulting and training entities that can help practice organizations apply QI techniques and improve. However, healthcare ultimately may not be the best model for public health.
Our field must cultivate a diverse network of QI-competent organizations and people to provide the assistance practitioners need to adopt new QI approaches and achieve improvements. Outside of public health, coaches experienced with Baldrige, Six Sigma, and related QI initiatives in private, government, and nonprofit organizations have effectively assisted public health departments.15,16 Health groups experienced with population-based models such as Quality Improvement Organizations (QIOs) and QI collaboratives may also have much to offer. Within public health, we must fund and develop QI consultation expertise among interested public health institutes, training centers, and other nonprofit, academic, and governmental groups.
To spread QI activities through voluntary accreditation and other initiatives, national, state, and local leaders have a responsibility to create QI-friendly policies and systems.
Finally, we must recognize that our current public health system is not built to support QI. Public health organizations cite systemic barriers to QI including categorical funding streams, program requirements, lack of incentives for improvement or systems thinking, lack of leadership, unavailability of QI-skilled personnel, and technical assistance resources.6,9
Consistent with the QI concept that results are properties of systems, voluntary accreditation's success in QI is tied to our ability to change such system barriers for the better. As Mays concluded, for accreditation to yield meaningful and sustained improvements, it should be considered “only in the context of an integrated system of tools and approaches for generating improvements in public health practice.”17 (p24)
Now is the time to experiment not only with ways to optimally design accreditation programs for QI but also with ways to better engineer our public health system to allow QI to flourish. Public health organizations have the ability to control or influence many system changes that could better support QI.
We must not wait for a national accreditation body to advocate for technical support and greater incentives, such as those recommended by the Exploring Accreditation Steering Committee. We need a QI-friendly system today to achieve greater health for all Americans. Let us not follow the refrain of Peggy Lee by asking later, “Is that all there is?”
3. Turning Point Performance Management National Excellence Collaborative. From Silos to Systems: Using Performance Management to Improve the Public's Health
. Seattle, WA: Turning Point Performance Management National Excellence Collaborative; 2002.
4. Landrum LB, Baker SL. Managing complex systems: performance management in public health. J Public Health Manag Pract
6. Turning Point Performance Management Collaborative. Survey on Performance Management Practice in States
. Seattle, WA: Turning Point National Program Office; 2002.
7. National Association of County and City Health Officials. 2005 National Profile of Local Health Departments
. Washington, DC: National Association of County and City Health Officials; 2006.
9. Robert Wood Johnson Foundation (RWJF). Quality Improvement in Public Health: Summary of an April–May 2006 Survey
. Unpublished survey conducted for RWJF by the Public Health Leadership Society and National Network of Public Health Institutes.
10. National Association of County and City Health Officials. An Evaluation of MAPP and NPHPS in Local Public Health Jurisdictions
[unpublished document]. Washington, DC: National Association of County and City Health Officials; 2006.
11. Public Health Foundation. Implementing Performance Improvement after the National Public Health Performance Standards Assessment: Results of Qualitative Interviews and Evaluation
[unpublished document]. Washington, DC: Public Health Foundation; 2005.
13. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century
. Washington, DC: National Academies Press; 2001.
16. Brewster J, Holden W, Mason M, Schmidt R, Smith T. Washington State Multi-state Learning Collaborative showcase. Paper presented at: Multi-State Learning Collaborative Reverse Site Visit and Looking Toward the Future Meeting; September 21, 2006; Itasca, IL.
*Because quality improvement and performance management are related activities and concepts, for the purposes of this article, we refer to all such activities as “QI.” For definitions and additional discussion of these concepts in relation to public health practice, see Turning Point Performance Management National Excellence Collaborative,3 Landrum and Baker,4 and the Public Health Foundation.5