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Journey to a Quality Improvement Culture

Gorenflo, Grace MPH, RN

Journal of Public Health Management and Practice: September/October 2011 - Volume 17 - Issue 5 - p 472–474
doi: 10.1097/PHH.0b013e318229102a

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 several distinct characteristics of local health departments with a culture of quality improvement.

National Association of County and City Health Officials, Washington, District of Columbia.

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

Disclosure: The author reports no conflict of interest.

  • The customer is front and center.
  • Management expects staff to solve problems.
  • Problems themselves are not only freely aired but also embraced as opportunities for improvement.
  • QI is integrated with the strategic plan.
  • Improvement is continuous.

Local health departments (LHDs) with a culture of quality improvement (QI) embody the above distinct characteristics. While not an overnight phenomenon, the shift to an organization that exemplifies QI lies well within the reach of any LHD with leadership that embraces this operational philosophy.

In September 2011, Public Health Accreditation Board's (PHAB's) launches a national accreditation program. PHAB's program serves as a platform of QI, including a domain devoted to this aspect of organizational practice. To achieve accreditation status, health departments must provide documentation that demonstrates the prominent role of QI in health department operations.

NACCHO's support of PHAB's accreditation program is based in large part on the central role that QI plays in the program. Exemplary QI practices are embedded in various health departments, and NACCHO seeks to describe the culture of LHDs, which results from, and is sustained by, embracing QI as part of their daily work.

NACCHO convened two learning communities, comprising QI consultants and LHD QI leaders, to explore what a QI culture means and what it takes to get there. This article will summarize what NACCHO learned from these experts about the attributes of a QI culture and the phases of cultivating a QI culture and outline plans to assist LHDs in moving toward institutionalizing QI as a part of doing business and achieving accreditation.

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What Is a QI Culture?

An organization with a QI culture is buttressed by strong leadership—a director who supports QI efforts at all levels and, in the most desirable scenario, has participated in them. Ideally, the LHD's governing entity also has knowledge of and experience with QI and is an advocate of a QI culture.

In an organization with a QI culture, staff at all levels operate according to QI principles. Job descriptions and performance management systems delineate expectations for employees to engage in QI efforts. Most importantly, staff think and act differently as a result of their QI experience. They routinely collect and use data to understand the source of problems and develop effective solutions—and to measure progress toward improvement. They apply QI tools in their daily work to establish priorities, consider relative advantages and disadvantages of various activities and approaches, obtain buy-in and achieve group consensus, and develop action plans for new projects.

At the behest of management, all staff in an organization with a QI culture readily reveal problems they encounter. They know that exposing weaknesses and flaws can be done without fear of repercussion, as the organization focuses on improvement, not blame or discipline. Staff are expected to proactively enhance external customer experience and internal operations as opposed to only reacting when problems arise. This requires flexibility in decision making, wherein front-line staff are empowered to engage in QI processes and make decisions to facilitate improvement.

Collaboration and learning are hallmarks of a QI culture. Throughout the organization, staff engage each other in various improvement activities, embracing the need to engage all those who “touch” a process to contribute to its betterment. Staff continually learn from one another, whether it be the new application of a QI tool, an improvement that can be replicated elsewhere in the organization, or a newly acquired skill. A spirit of teamwork prevails.

In an agency with a culture of QI, the “customer” is at the forefront of the organization's operations. Customers are both external and internal to the LHD—the population in the LHD's jurisdiction, and staff, who are the customers of internal processes. All LHD staff are oriented to customer satisfaction and strive to maintain a high level of satisfaction.

QI is integrated in the strategic plans of LHDs that have achieved QI culture. Thus, QI is part of the way the LHD does business. It is not an add-on or a separate activity. Rather, QI is part of what is expected by leadership and even by staff.

In an organization with a QI culture, improvement is continuous. QI activity is implemented in a cyclical fashion using data to check and measure progress and either adjust the course as needed or maintain the gains. Embracing an attitude of always striving to do better, staff see benefits in the journey, not just in achieving a goal.

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Phasing in a QI Culture

As noted earlier, NACCHO engaged two learning communities to help define the phases to achieving a QI culture, and this section provides an overview of what was discussed. A logical progression to a QI culture consists of deliberately considering the underpinnings of the desired culture, taking stock of what the organization needs to cultivate, and planning and implementing incremental steps. NACCHO is committed to supporting LHDs looking to achieve a culture of QI and is in the process of designing resources and technical assistance for such LHDs. Support will be framed around several categories that are designed to assist LHDs in thinking about their point on the spectrum.

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No Knowledge of QI

LHDs with leadership and staff that do not have a working knowledge of QI or do not see its relevance to public health practice are at the very beginning of the spectrum. NACCHO's assessments of LHDs have found that very few LHDs fall squarely within this category.

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Not involved with QI activities

Staff from LHDs in this category have a basic knowledge of QI. Some may have even received training, and the LHD might have a plan in place to engage in QI. Yet, no systematic QI efforts have been undertaken.

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Informal or Ad Hoc QI Activities

One or more QI effort is under way in the LHD; however, the effort(s) may not include a systematic process, and/or it is more or less a random occurrence.

Those involved may have anxiety about doing things incorrectly or discovering problems they are reluctant to admit.

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Formal QI Activities Implemented in Specific Areas

QI efforts have progressed to the point where they are following established QI models, and areas for improvement have been specifically targeted. In-house technical assistance is available and likely is a separate function.

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Formal Agency-wide QI

At this point, the organization has a QI plan that is integrated into the strategic plan. An internal QI committee oversees the implementation of a detailed plan to ensure QI throughout the organization. Policies and procedures for QI are in place, and data are commonly used for problem solving and decision making. Charts and graphs showing progress toward measurable objectives are visible throughout the organization.

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Culture of QI

The major distinction of this category is all that LHD staff think and act according to basic principles of QI as a result of individual experience and organizational expectations. Even if leadership changes, the basics of QI are ingrained in staff. They are not content to consider problems at face value and instead seek out the root cause of a problem. They do not presume that an intervention will be effective; rather, they establish and quantify progress toward measurable objectives to gauge the results of an intervention. They are not satisfied with the status quo and instead maintain a quest for improvement.

Now more than ever, with shrinking budgets and nary a shortage of work, LHDs are well-served by attaining an organizational culture of QI as a means to continually realize efficiencies and improvements. The journey to a QI culture takes leadership, commitment, and persistence. NACCHO will provide resources and technical assistance to move LHDs through this journey. As LHDs become accredited by PHAB, additional peer learning and best practices will emerge to further facilitate this quest. For more information about NACCHO's QI efforts, visit

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