Phase 1: No Knowledge of QI Phase 2: Not Involved with QI Activities Phase 3: Informal or Ad Hoc QI activities Phase 4: Formal QI Activities Implemented in Specific Areas Phase 5: Formal Agency-Wide QI Phase 6: QI Culture

Phase 1: No Knowledge of QI

In this phase, LHD staff and leadership are unaware of QI and its importance. QI is not considered as a way of doing business, evidence base is not used in decision-making, and a reactive rather than proactive approach is used to address problems.

Phase 2: Not Involved with QI Activities

In this phase, leadership understands and discusses QI with staff but does not enforce the implementation of or dedicate sufficient staff time and resources for QI.

Phase 3: Informal or Ad Hoc QI activities

Discrete QI efforts are practiced in isolated instances throughout the LHD, often without consistent use of data or alignment with the steps in a formal QI process.

Phase 4: Formal QI Activities Implemented in Specific Areas

Following adoption of one or more formal QI models, QI is being implemented in specific program areas, but QI is not yet incorporated into an organization-wide culture.

Phase 5: Formal Agency-Wide QI

QI is integrated into the agency strategic and operational plans. PM/QI Council oversees the implementation of a detailed plan to ensure QI throughout the LHD. Policies and procedures are in place and data are commonly used for problem-solving and decision-making.

Phase 6: QI Culture

QI is fully embedded into the way the agency does business, across all levels, departments, and programs. Leadership and staff are fully committed to quality, and results of QI efforts are communicated internally and externally. Even if leadership changes, the basics of QI are so ingrained in staff that they seek out the root cause of problems. They do not assume that an intervention will be effective, but rather they establish and quantify progress toward measurable objectives.

When building a culture of quality in LHDs, a natural evolution of change tends to occur, impacting both the people and processes within the organization. The QI Roadmap provides LHDs with guidance on progressing through six phases or levels of QI maturity until a culture of quality has been reached and can be sustained. For each phase, the Roadmap presents common organizational characteristics and strategies and resources for transitioning to the next phase. The QI Roadmap also describes six foundational elements of a QI culture that LHDs should cultivate over time. Whether a novice or advanced in QI, any LHD can adapt the QI Roadmap as a guide to understanding the current state and identifying next steps for advancing to the next stage of QI integration.


Funding was provided by the Robert Wood Johnson Foundation (ID# 69283). The contents of this website are solely the responsibility of NACCHO and do not necessarily represent the official views of the sponsors. NACCHO is grateful for this support.


Click here to view references used in the development of the QI Roadmap.


Organizational Culture of Quality Self-Assessment Tool (SAT)

The SAT is aligned with the Roadmap but offers a deeper assessment of each of the foundational elements. If your organization is ready for a more in-depth assessment, download the tool.


Contact NACCHO Staff

Contact Pooja Verma at 202.507.4206 or with questions or for more information.