About the Roadmap to a Culture of Quality


The public health field is a dynamic environment with new health issues emerging every day. In recent years, quality improvement (QI) has been introduced to, and embraced by, the field of public health as a means to achieve efficiencies and improve quality of services during a time of tough economic and political pressures. Although QI has a notable presence in public health practice, isolated QI processes are not sufficient to balance budget cuts with competing public health priorities. Local health departments (LHDs) need a more comprehensive approach to transform organizational culture, wherein the concepts of QI are ingrained in the shared attitudes, values, goals, and practices of all individuals in the LHD. Beyond discrete process improvements, achieving and sustaining an integrated agency-wide culture of QI is necessary to achieve efficiencies, demonstrate return on investment, and ultimately impact health outcomes.

How was the Roadmap to a Culture of Quality Developed?

When initiating QI activity in LHDs, a natural evolution of change tends to occur, reflecting impact on both the people and processes within the organization. To gain a solid understanding of the barriers, drivers, and nuances along the journey to a QI culture, the National Association of County and City Health Officials (NACCHO) convened LHD staff responsible for leading QI efforts in their agencies across the country, as well as QI consultants who have worked with LHDs. These experts discussed the various points along a spectrum regarding the uptake of QI in LHDs and strategies to move toward a culture of QI. As a result of this meeting in April 2011, the foundation for this Roadmap to a Culture of Quality (the Roadmap) was built, based on real experiences of practitioners in the field.

The Roadmap provides LHDs with guidance on progressing through six phases or levels of QI integration until a culture of QI has been reached and can be sustained. For each phase, the Roadmap presents common organizational characteristics, strategies, and resources for transitioning to the next phase. The Roadmap also describessix foundational elements of a QI culture that LHDs should cultivate over time. Whether a novice or advanced in QI, any LHD can adapt the Roadmap as a guide to understanding the current state and identifying next steps for advancing to the next stage of QI integration.

Accreditation and QI

The Public Health Accreditation Board’s (PHAB’s) voluntary, national accreditation program for state, local, and Tribal health departments, a cornerstone of which is QI, reinforces the increasing importance for system-wide QI in public health. The program’s creators, whose development process included significant input from LHD practitioners, have carefully designed the accreditation process to ensure evidence of continuous QI, whereby accredited health departments must not only apply for reaccreditation every five years but must also submit annual reports demonstrating improvements in areas identified as weaknesses during the accreditation process.(2) Further,Domain 9 of the PHAB Standards and Measures Version 1.5 outlines specific requirements related to performance management and QI.(3) PHAB is partly responsible for stimulating QI activity in the field as several LHDs use accreditation as a platform for continuous QI.(4)

Sustaining the Culture of QI

One of the greatest challenges associated with building a culture of QI is sustaining progress. Too often, QI projects are implemented, but improvements are not monitored; staff are trained without the opportunity for application; QI is initiated but sidetracked by competing priorities; and expertise is built but lost through staff turnover. Every step along this Roadmap requires a deliberate effort to hold the gains previously made and diffuse them throughout the LHD. The further an LHD is from a QI culture, the easier it is to regress to the initial state. By carefully building each of the six foundational elements using the strategies and resources outlined in this Roadmap, LHDs can strengthen ability to sustain improvements. Even when a QI culture has been fully achieved, the LHD must continuously assess the culture and address issues that may threaten the presence of QI in the LHD.