Organizational culture is defined as the shared beliefs, perceptions, norms, values, and expectations of individuals in organizations.1 It develops over time as these shared attitudes are taught to the new staff until it becomes the way an organization does business. The term “QI culture” has frequently been referenced in public health,2–4 but the public health field may benefit from a more concise definition of what this means for local health departments (LHDs) to most effectively leverage quality improvement (QI) to achieve sustained improvements.5
The National Association of County & City Health Official's (NACCHO's) Roadmap to an Organizational Culture of Quality Improvement (QI Roadmap) defines 6 foundational elements of a culture of QI that may be developed over time to help achieve a sustainable QI culture.6 On the basis of the literature and input from LHD practitioners, these 6 elements include (1) leadership commitment; (2) QI infrastructure; (3) employee empowerment; (4) teamwork and collaboration; (5) customer focus; and (6) continuous process improvement.6 The QI Roadmap also presents 6 phases of QI culture maturity, allowing LHDs to identify strategies for cultivating a sustainable QI culture. The QI Roadmap has been referenced and aligned with other QI resources in the field, including the QI Maturity Tool,7 which has been used to assess QI maturity in public health departments.8 In addition, NACCHO's 2010 National Profile of Local Health Departments (Profile Study) included a QI module that asked respondents to identify which QI Roadmap phase most accurately reflects LHDs' QI activities.9 Findings indicate that 69% of LHDs reported implementation of QI activity either on an informal or ad hoc basis or a formal basis in specific areas of the agency. However, only 15% of LHDs reported having a formal, agency-wide QI program.9 Achieving and sustaining an organizational culture of QI are necessary to move beyond discrete process improvements and achieve agency-wide efficiencies. Once LHDs have taken the initial steps of conceptually understanding QI and implementing discrete QI projects, it is important to anchor and sustain this progress to ultimately achieve a QI culture.
QI Initiatives in Public Health
Where QI was once primarily a practice of the manufacturing industry, its application has now spread to virtually every sector in the United States, including private, health care, government, social service, and public health. Due in large part to national initiatives and programs such as the Multi-State Learning Collaborative,10 the National Public Health Improvement Initiative,11 and the Public Health Accreditation Board (PHAB),12 coupled with an increasing need to create efficiencies in an uncertain economic climate,13 LHDs have been initiating QI efforts and building a foundation for a QI culture.
Since early discussions around the need for an accreditation program for public health departments, continuous QI has been a guiding principle in the development of the PHAB national, voluntary accreditation program.14 The PHAB program has been designed in such a way that by virtue of LHDs' engagement in accreditation they are also working toward a QI culture. Domain 9 of the PHAB Standards and Measures requires not only documentation of implemented QI projects but also a QI plan documenting the LHDs' efforts to integrate QI into all programmatic and operational aspects of LHDs, demonstrating an agency-wide commitment to QI.15 In addition, the accreditation process requires that accredited LHDs submit annual reports demonstrating improvements and apply for reaccreditation every 5 years, supporting a framework for continuous process improvement.15
When QI was first introduced to LHDs, focus was directed toward gaining buy-in around its value, building basic knowledge and skills, and creating opportunities for learning and application. An early foundation for a QI culture was built through knowledge and application as found in the Profile Study, indicating that 74% of LHDs have provided formal QI training to the staff and 73% of LHDs have conducted at least 1 QI project.9 Now that LHDs have collectively established a foundation for a QI culture, it is important to explore how well this progress is being sustained and how LHDs can successfully make QI an integral part of the agency culture.
The purpose of this study was both to examine the degree to which LHDs with significant experience around QI and accreditation have established a culture of quality, based on key indicators, and to understand the barriers and facilitators associated with sustaining the progress made around QI maturity among LHDs with more advanced experience with QI.
Survey design and respondents
Thirty LHDs, of varying population size and geographic location, were invited to respond to an online Qualtrics survey designed to understand the degree to which various aspects of a QI culture are in place within the agencies. Aligned with the foundational elements in the QI Roadmap (as described in the previous section), survey items assessed the following domains, or aspects, of a culture of quality: (1) leadership commitment; (2) QI infrastructure; (3) customer focus; (4) employee empowerment; (5) teamwork and collaboration; and (6) continuous process improvement. The 35-item questionnaire included indicators within each of the 6 domains to assess the degree to which the LHDs have embedded quality into organizational culture. The indicators were based on a review of the literature around quality management principles and frameworks.16 , 17 The survey included a mix of multiple-choice and 5-point Likert scale (“not at all,” “to a small degree,” “to a large degree,” “always,” and “I don't know”) items. Three LHDs pilot tested the survey via Qualtrics, and the survey was revised on the basis of feedback received. To understand LHD barriers and successes around building and sustaining progress toward a QI culture, survey respondents were selected on the basis of LHDs' demonstrated involvement in national- or state-level performance improvement initiatives including, but not limited to, the Multi-State Learning Collaborative, the PHAB beta test, NACCHO Demonstration Sites Projects, NACCHO QI Leaders Learning Community, and the National Public Health Improvement Initiative. Those LHDs that either participated in or are participating in 2 or more of these initiatives were invited to complete the survey. Electronic mail invitations were sent to the staff responsible for leading QI initiatives in LHDs. Of the 30 invited LHDs, 22 responded (73% response rate).
Survey results were used to screen for LHDs with the most evidence of agency-wide QI activities to participate in telephone interviews for qualitative data collection. To identify those that have made at least some progress on each of the 6 domains of a QI culture, only respondents that indicated a rating of “always” or “to a large degree” for at least 1 of the indicators within each of the 6 domains were included in the selection pool. Telephone interview questions were designed to understand the barriers and facilitators around sustaining a culture of quality in LHDs that have already made significant progress. Fourteen LHDs met all the criteria for telephone interviews, with a mix of the following population categories: 4 small LHDs (<50 000); 6 medium LHDs (>50 000 500 000); and 4 large LHDs (500 000+). To minimize the bias from LHD demographics, 10 LHDs representing a mix of population size were selected (3 small LHDs, 4 medium LHDs, and 3 large LHDs) for telephone interviews. The facilitated discussions were recorded, transcribed, and open-coded for emerging themes using QSR's NVivo 9 Qualitative Data Analysis Program (QSR International, Burlington, Massachusetts).
Quantitative results from the survey and qualitative results from the interviews are summarized and presented in the following text.
Current QI culture in participating LHDs: Survey results
Of the 6 domains of a QI culture measured in this survey, the percentages of respondents that reported “to a large degree” or “always” to at least 1 indicator in each domain are as follows: leadership commitment (100%); employee empowerment (100%); teamwork and collaboration (100%); continuous process improvement (86%); customer focus (72%); and QI infrastructure (64%). Respondents indicated greatest success around leadership commitment, with 100% reporting that leadership dedicates resources to QI either “to a large degree” or “always,” and 86% reporting that leadership communicates to the staff about QI either “to a large degree” or “always.” With regard to QI infrastructure, 83% of respondents indicated that a QI council oversees QI initiatives in the agency either “to a large degree” or “always,” and 75% indicated that a QI plan guides QI initiatives either “to a large degree” or “always.” Although 86% of respondents indicate that a formal improvement model is used to improve processes either “to a large degree” or “always,” only 23% indicate that the staff at every level are using QI tools to improve processes in their work. Respondents reported minimal success around the customer focus domain, with 72% indicating that customer satisfaction data are used to drive improvement efforts either not at all or “to a small degree.”
Drivers for sustaining a QI culture
When asked about the primary drivers for sustaining a culture of quality, the phone interviews revealed 3 major themes as drivers toward a culture of quality: (1) leadership commitment; (2) accreditation; and (3) dedication of staff time to QI.
Most commonly identified as primary importance for sustaining progress toward a culture of quality was leadership commitment. Eight interview participants discussed the critical role the health official or other top leader plays in communicating the vision for quality and performance, setting clear expectations and holding all staff members accountable for results. Additional strategies leaders were commonly identified as using include attending QI meetings (identified 5 times), including QI as a recurring agenda item on leadership and staff meetings (identified 5 times), and participating in QI initiatives themselves (identified 3 times). Quality improvement does not have to begin with leadership when QI champions already exist within the agency. In cases where QI champions already exist within the agency, without strong leadership commitment, QI often became prevalent in specific areas of the agency where these champions exist. However, despite the often persistent efforts of the QI champions, QI did not spread agency-wide and become a part of the culture unless leadership buy-in was achieved. This was primarily due to the QI champions' limited authority needed to achieve broad buy-in and accountability from the staff. Seven interviewees also identified that support from the local governing entity is important because sustainability relied heavily on funding for staff time and resources for QI. Three of the interviewees also explained that the local governing entity was so bought into performance improvement that when a previous health officer left the LHD, they deliberately searched for a replacement who understood and believed in accreditation and QI.
Seven interviewees identified accreditation as a driver for building a culture of quality. Accreditation as a driver of QI was repeatedly described as something beyond specific QI requirements in Domain 9 of the PHAB Standards and Measures. Although in 2 cases, accreditation was identified as the initial impetus for discrete QI efforts in the agency, accreditation was also a primary contributor to QI becoming increasingly part of the organizational culture. As the LHD goes further into the accreditation preparation process, reviewing the standards and measures and collecting documentation, opportunities for improvement emerge to the surface. Accreditation provided a structured and objective framework for understanding gaps in performance and benchmarking against nationally recognized standards. Interview participants emphasized that as the staff engaged in the accreditation preparation process and understood how the PHAB standards related to their work, using QI as a tool to continuously improve upon their ability to meet the PHAB standards became increasingly desirable over time.
Six interviewees identified dedication of staff time to QI as another significant contributor to sustaining progress toward a culture of quality. Designating a QI coordinator whose responsibilities included overseeing and facilitating QI initiatives, developing knowledge and skills around QI, and serving as a QI resource for the rest of the staff was stressed as a key factor in the achieved success of the LHDs. Four interviewees indicated that without a QI coordinator, progress would not have been sustained to the same degree. Absent the designated QI staff, QI tends to be put on hold as other job responsibilities are prioritized. Hiring a QI coordinator ensures ownership of keeping QI at the forefront for all staff members. However, 2 interviewees cautioned that the QI coordinator must not be seen as, or become, the sole staff member responsible for QI. As such, a commonality among 5 of the LHDs was that once QI matured, a QI council with cross-sectional representation was developed to drive and oversee QI initiatives agency-wide. Each member of this group was responsible for engaging his or her respective department or division in QI. The establishment of a QI council was described as a useful strategy for diffusing QI throughout the agency, as it placed ownership of the agency's QI initiatives on several staff members outside of the QI coordinator.
Barriers to sustaining a QI culture
All 10 interviewees identified lack of staff knowledge and staff resistance to QI as barriers to initiating QI within LHDs. These barriers are consistent with existing research around building QI into an organizational culture.18 Once these initial barriers were addressed through proper trainings, resources, and communication strategies, LHDs faced additional barriers around sustaining the progress. Interviewees were asked to elaborate on the emerging barriers associated with sustaining the progress toward a QI culture. This section summarizes the barriers described during the interviews.
After initiating QI initiatives in LHDs, 6 interviewees identified staff turnover as a barrier to sustaining progress toward a QI culture. Local health departments often invested in growing the QI knowledge and skills of a select few staff members and when they leave, LHDs' in-house expertise is lost. Losing a QI coordinator or strong QI champion was particularly problematic, as these staff members are generally the most invested in the success of QI in the agency and are specifically responsible for maintaining progress around QI. When these staff members leave, knowledge is lost, QI meetings and projects are put on hold, and enthusiasm for QI diminishes.
Five interviewees identified continued budget cuts as a significant barrier to sustaining QI in LHDs. Although the interviewees completely embrace QI and expressed understanding that QI is a mechanism to become more efficient as resources decline, QI itself requires resources. As the staff are laid off, some staff resistance to QI reemerges because the staff get busier and feel they don't have time for QI due to additional responsibilities. It is important to note that the type of staff resistance when QI was first introduced differed from this emerging resistance, as it previously centered around the perception that QI is busy work, or the “flavor of the month,” with little value added. From that point, as change was properly managed and the staff were educated and empowered around QI, the staff accepted QI as an important aspect of doing business. Two interviewees explained that because QI started to permeate the culture of the agency, it would continue to remain at the forefront despite shrinking resources. However, they feared that continued budget cuts and declining resources could pose a threat to the sustainability and momentum of QI in the future. All 3 of the small LHDs (<50 000 population) interviewed cited budget cuts as a barrier to sustainability.
Five interviewees identified crises such as a large-scale food outbreak investigation or a major event for the agency, such as an office move as another significant barrier to sustaining progress. These types of events disrupted the typical work processes at play in the agency, causing QI projects to be put on hold and QI meetings to be cancelled. In these situations, focus is sidetracked from QI and revisited once the competing priorities have been dealt with. Interviewees discussed how staff understood that QI should be used as a tool to address these issues, but a reactive rather than proactive approach is still used during a crisis or major event.
Several limitations of this study should be taken into consideration. Because the sample size of this study was very small and the survey respondents and interview participants were intentionally selected to be more experienced with QI, results from this study cannot be generalized to all LHDs. The LHDs in this study have demonstrated participation in national- and state-level performance improvement initiatives, and as such may have a different set of challenges or drivers from those that have not yet engaged in performance improvement efforts. Further research should be done around the sustainability of QI in a larger sample of LHDs of varying size and QI experience. Another limitation of this study is that all the data collected from the survey and interviews were self-reported and cannot be independently verified. Finally, there is potential for recall bias in the data, as survey respondents and interviewees were asked to report on QI initiatives that may have occurred in the past.
Discussion and Conclusions
This is among the first few studies to specifically examine the barriers and facilitators associated with sustainability of progress toward a QI culture in LHDs, and this topic merits further examination to better understand how to assist LHDs. Building and sustaining a culture of QI requires time and resources, which are often a challenge among LHDs that already face shrinking resources and budget cuts. Understanding the most effective strategies for sustaining QI efforts will help LHDs ensure that the valuable resources put into QI are yielding results that last over time. Further research around QI sustainability among LHDs of varying sizes would also be valuable, as small LHDs with very limited staff and funding would likely face unique challenges from very large LHDs that operate in a more complex environment.
Because budget cuts continue to be a significant barrier to sustaining progress and pose a foreseeable threat to future sustainability of QI initiatives, LHDs must begin collecting data and demonstrating the value and efficiencies achieved from QI projects. These data must be collected and used to attract funding for implementing QI so that LHDs can provide evidence to funders that QI needs dedicated resources. Because of the importance of leadership commitment to the sustainability of a QI culture, resources and effort should be directed toward achieving this before investing a great deal of time and resources to QI. In addition to being QI champions who promote and engage in QI, leaders possess the authority to dedicate staff time, resources, and funding. A lack of this leadership commitment makes it difficult to sustain QI efforts.
An important finding in this study is that accreditation is perceived to be a significant driver for sustaining a culture of QI in LHDs. This finding provides early evidence that the PHAB national, voluntary accreditation program is promoting and facilitating continuous performance improvement in some LHDs, and further research should be done to understand the links between accreditation and QI. PHAB and other national partner organizations have been very persistent about promoting accreditation as a platform for continuous QI, rather than simple compliance with a set of standards. Most encouraging about these findings is that LHDs are relying on QI tools and techniques to meet standards in all of the PHAB domains, not just Domain 9, which specifically relates to QI.
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