Develop a QI Plan

Developing a Quality Improvement Plan

The greatest value of conducting a QI self-assessment comes from what is done with the results. The QI assessment should be used to identify targeted strategies to advance QI culture and these strategies should be incorporated into a QI plan for implementation.

An agency QI plan provides and establishes accountability around formalizing the QI program. It outlines the agency QI vision, establishes the QI program governance structure, specifies QI processes and methods for selecting and implementing projects, and provides an action plan for how to grow the QI culture. To view the national standards for developing a health department QI plan, click here to access the Public Health Accreditation Board Standards and Measures, Measure 9.2.1 A: Develop and implement QI processes integrated into organizational practice, programs, processes, and interventions. A QI planning cycle may range from 1-5 years, depending on the agency process and resources. An adopted QI plan should be monitored for progress and evaluated at least annually. The QI plan should also link to other plans governing the agency to maintain that improvement efforts are focused on the agency’s strategy.  The following table summarizes how the QI plan should link to other plans:

Agency Plan

Link to QI Plan

Community Health Improvement Plan (CHIP)
  • CHIP goals /objectives not on track should be considered and prioritized for potential QI projects.
  • QI projects on CHIP goals may need to be implemented with community partners. This is more common for agencies partnerships that are experienced with QI.
Agency Strategic Plan
  • Strategic plan goals and objectives not on track should be prioritized for potential QI projects. This will align improvement efforts with agency strategy.
Workforce Development Plan (WFD Plan)
  • QI training needs should be incorporated into the WFD plan to ensure that staff have the necessary knowledge, skills, and abilities to perform QI functions.
Operational Plans
  • Operational plans at the work unit level (e.g. specific programs, services) should identify opportunities for QI based on performance data.
Employee Performance Plans
  • QI goals may be incorporated into individual performance plans to hold all staff accountable to implementing QI.

NACCHO has collected example QI plans from local health departments across the country. Each plan is informed by assessment results based on the NACCHO Roadmap, and each has been reviewed for quality.

LHD Agency QI Plan

Population Size

FTEs

Accreditation Status

Los Angeles County, CA

9,818,605

3755

Accredited

Franklin County, KY

460,000

75

Accredited

Scott County, IA

170,385

45.5

Not yet accredited

Maricopa County, AZ

4 Million+

500

Accredited

Tacoma-Pierce County, WA

814,600

261

Accredited

Santa Clara County, CA

1,781,642

450

Accredited