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Achieving a Culture of Quality Improvement

Gorenflo, Grace MPH, RN

Journal of Public Health Management and Practice: January-February 2010 - Volume 16 - Issue 1 - p 83–84
doi: 10.1097/PHH.0b013e3181c7e079

The National Association of County and City Health Officials (NACCHO) is the national organization representing local health departments. It supports efforts that protect and improve the health of all people and all communities by promoting national policy, developing resources and programs, seeking health equity, and supporting effective local public health practice and systems.

This column describes NACCHO's efforts in promoting a culture of quality improvement within local health departments in addition to its work to enhance its own working environment as a means to systematically meet and exceed its members' needs.

Grace Gorenflo, MPH, RN, is Director, Accreditation Preparation and Quality Improvement, National Association of County and City Health Officials, Washington, DC.

Corresponding Author: Grace Gorenflo, MPH, RN, National Association of County and City Health Officials, 1100 17th St, NW Second Floor, Washington, DC 20036 (

“I've got to admit it's getting better, it's getting better all the time.” This Beatles tune says it all. Within a quality improvement (QI) culture, each individual acts with an eye toward improvement.

A working environment rooted in a culture of QI routinely uses data to examine process and product to enhance all aspects of operations. Curiosity and experimentation are accepted as well as expected characteristics of organizational and staff attitudes, values, goals, and practices. In addition to promoting a culture of QI within local health departments (LHDs), the National Association of County and City Health Officials (NACCHO) is now working to enhance its own working environment as a means to systematically meet and exceed its members' needs.

An intentionally small number of voluntary, self-identified cohorts are successively convened to undertake QI efforts in both programmatic and operational areas. Staff who are involved in QI activities provide updates at internal staff and management meetings regarding their progress, lessons learned, and challenges encountered. These updates are delivered with the goal of familiarizing all NACCHO employees with the QI staff's experiences and kindling curiosity that leads to the formation of new cohorts. Storyboards posted throughout the office graphically illustrate progress and accomplishments, sparking further interest, conversation, and questions.

Like the members it serves, NACCHO operates within a context of limited resources and competing demands. NACCHO's QI process is designed to gradually and deliberately generate internal demand for QI that will be met through a cadre of staff serving as NACCHO's own internal consultants. Pennsylvania State University organizational psychology professor Sam Hunter, PhD and his graduate students are imparting their expertise and advising on and studying NACCHO's progress toward establishing a QI culture.

While lessons emerge constantly, NACCHO shares the following with LHDs that wish to embark on a similar journey.

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Pick the Low-Hanging Fruit

Start small with problems that are relatively easy and quick to tackle. NACCHO's cohorts begin their QI efforts by determining and prioritizing criteria to guide the identification of what problem to address through QI. Initially, attributes such as “simple,” “able to complete in a short period of time,” and “manageable scope” emerge as priority criteria, with other criteria including elements such as likelihood of success, urgency, importance, value of a solution, and passion and motivation. Over time and with more experience, staff are revising their prioritized list of criteria for problem identification and are prepared for, and aspire to, addressing more complex, longer-term issues.

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Know What You Are Doing

According to QI guru W. Edward Deming, “If you can't describe what you are doing as a process, you don't know what you're doing.” Setting aside time to document and examine processes yields incredibly rich information about decision making, work values, working relationships, and other aspects of organizational culture that may not normally be considered or tended to. Many of the processes used at NACCHO have evolved organically and have been adapted over time to accommodate variables such as new staff, different funding streams, and organizational growth. Quality improvement work is equipping staff to scrutinize and improve on long-standing processes, to develop more effective processes for new initiatives, and to adapt or adopt improvements generated by others.

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Get the Facts

Presuming to know the reason for a problem rather than systematically discovering potential root causes and obtaining baseline measures misses a critical opportunity to focus resources in the most meaningful manner. Root-cause analysis methods are very straightforward. They yield illuminating, and sometimes surprising, results while promoting critical thinking. In other aspects of their work, staff are now asking “Why?” instead of leaping to their own conclusions.

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Leave No Staff Behind

Consider how best to appeal to personal interests and talents. For those who tend to think “outside the box,” QI offers an opportunity to flex creative muscles and explore all options. For the scientific minds, QI offers a workplace laboratory—an opportunity to create hypotheses and run experiments. For the cynics, QI offers a platform to be constructive with criticism and test ideas about how to do things better.

Furthermore, cultivate and sustain an environment of “psychological safety”—one in which staff freely offer their thoughts and opinions because they genuinely believe their contributions are heard, and where experimental solutions are tried and sometimes “fail,” but it is understood that the only real failure in QI stems from not being willing to experiment at all. Tending to group dynamics and ensuring that leaders model behaviors that support the desired environment are hallmarks of NACCHO's initiative.

In summary, cohort by cohort, NACCHO staff are creating a new culture. Within each cohort, leaders materialize with a deeper understanding and enhanced ability to teach others. With time, all NACCHO staff members will be engaged in QI efforts on a regular basis, assisted by a cadre of their peers who teach and coach these efforts. NACCHO is proud to join LHDs in the quest “to get better all the time.”

© 2010 Lippincott Williams & Wilkins, Inc.