The Phases of a Culture of Quality

Starting with the Phase 1 tab, assess the organization against the characteristics in each phase to determine which phase the organization currently falls. Conduct this assessment for each of the foundational elements. Many organizations tend to be further along among some foundational elements over others. Implement the transition strategies based on the phase your organization is in for each foundational element. Organizations may select one element to focus improvement efforts, or to work toward improvement in more than one element at a time. For example if an organization is in Phase 1 for Leadership Commitment where resources are not appropriately allocated to working on QI, it may choose to focus most efforts on transition strategies focused on gaining leadership commitment prior to addressing the other elements.

No Knowledge of QI

Characteristics

  • Employees are unaware of QI and/or mistake it for quality assurance or quality control. No Knowledge, skills, and abilities (KSAs) necessary to undertake QI exist.
  • No QI trainings, resources, or mentors are available to employees.
  • No desired set of core QI KSAs have been identified for employees.
  • Employees do not have performance measures to track performance and identify opportunities for improvement in their work.
  • No financial resources or staff time devoted to QI.

Transition Strategies

Characteristics

  • Teams are rarely or never formed for the purposes of problem solving or innovation.
  • Existing teams often lack clearly defined roles, objectives, and targets for success.
  • Peer sharing and learning across divisions, departments, programs, etc. rarely occurs.
  • Performance of existing work teams is not tracked for progress and accomplishments.

Transition Strategies

  • Explore already existing external QI learning communities at the local, state, or national level.
  • Identify methods for information sharing (e.g. social media, storyboards, “lunch and learns”).
  • Assess functionality and performance of existing teams.

Characteristics

  • Leaders do not understand QI or principles of quality, or see the value to public health practice.
  • Executive leaders do not dedicate or seek out resources for QI.
  • Leaders do not use data driven decision making to guide the agency’s strategy and activities.
  • Leaders are generally satisfied with the status quo.

Transition Strategies

  • All leaders learn about, understand, and embrace the key principles of QI from a managerial and philosophical perspective.
  • Leaders learn about strategies for championing a QI culture (e.g. change management, QI planning).
  • Leaders begin to assess the current organization culture and readiness for QI (e.g., level of QI knowledge, group dynamics, leadership, communication and decision-making styles, norms, and behaviors).
  • Leaders communicate to all staff and the governing entity the urgency for and benefits of QI, highlighting QI success stories in public health and other industries.
  • Leaders begin to identify members of a PM/QI Council to assist with leading the development of a QI program.

Characteristics

  • Internal and external customers of the agency have not been formally identified.
  • Staff are generally unaware of their own customers’ needs.
  • Customer needs and satisfaction data are not collected or used for decision making and improvements.
  • Internal agency assumptions are prioritized over customer needs/values.

Transition Strategies

  • Incorporate customer focus into agency vision and values.
  • Assess and build knowledge in concepts of customer focus (e.g. customer satisfaction, value streams).
  • Begin to identify all of the agency’s internal and external customers.

Characteristics

  • No staff are responsible for overseeing or governing quality initiatives in the agency.
  • No agency plans or policies address quality.
  • A current agency strategic plan likely does not exist.
  • Existing performance measures are used for purposes of grant reporting (often “widget counting”) and are not linked to strategic goals or performance improvement.

Transition Strategies

  • Leaders identify members of a PM/QI Council with all divisions/departments represented. This group will oversee the implementation of the QI program and/or performance management system (PM system).
  • Leaders work with the PM/QI Council to develop a team charter, outlining the mission and roles and responsibilities of each member.
  • Explore strategic plans, QI plans, and performance management systems of similar agencies, and common processes for developing each.
  • Conduct a performance management self-assessment (e.g. inventory current use of performance measures and data).

Characteristics

  • Agency processes are not clearly defined, unnecessarily complex, and consist of redundancies and variations throughout the agency.
  • Problems are often ignored and remain unaddressed for long periods of time.
  • Processes may result in lower quality products and services than what is possible.

Transition Strategies

  • Explore the different models for continuous process improvement (e.g. Lean, Six Sigma, Rapid Cycle Improvement) and determine the best fit for the agency.
  • Build knowledge on basic QI methods and tools.
  • Explore QI projects implemented in similar agencies.
NameDesciptionTypeFoundational ElementSource
Baldrige Self-Assessment ToolWhether adopting the Baldrige framework for performance management, use this self-assessment tool to evaluate your agency's processes, their impact on results, and progress toward agency goals and objectives. TemplateQI Infrastructure National Institutes of Standards and Technology
Building A Healthy Community GameA game developed by Boston Public Health Commission to allow staff to apply QI principles in a hands on way and within a public health context. See accompanying "Building A Healthy Community Game" Facilitation Guide.TrainingEmployee EmpowermentBoston Public Health Commission
Building A Healthy Community Game Facilitation GuideA game developed by Boston Public Health Commission to allow staff to apply QI principles in a hands on way and within a public health context. See accompanying "Building A Healthy Community Game" PowerPoint.TrainingEmployee EmpowermentBoston Public Health Commission
Change Management for Effective QI: A PrimerThis article describes methods to manage the introduction of change through QI. LiteratureLeadershipAmerican Journal of Medical Quality
Comparison of Change TheoriesThis article summarizes several change management theories and assumptions about the nature of change and shows leaders how successful change can be encouraged and facilitated for long term organizational success.
ArticleLeadership International Journal of Scholarly Academic Intellectual Diversity
Designing, deploying, and using a performance management system in public health: cultural transformation using the PDCA approachThis discussion of three different performance management system models offers important points for consideration when implementing a performance management system.LiteratureQI infrastructurePublic Health Foundation
Escambia County Health Department QI Team Charter (July 2009)This example team charter displays Escambia County's approach to form a QI team/council. ExampleQI InfrastructureEscambia County Health Department
Finding Public Health GameA game for employees to practice improvement cycles, developed by Boston Public Health Commission. See accompanying "Finding Public Health Game" facilitation guide. TrainingEmployee EmpowermentBoston Public Health Commission
Finding Public Health Game Facilitation GuideA game for employees to practice improvement cycles, developed by Boston Public Health Commission. See accompanying "Finding Public Health Game" PowerPoint.TrainingEmployee EmpowermentBoston Public Health Commission
Implementing a Quality Improvement Plan"Implementing a Quality Improvement Plan" presentation from NACCHO (33:20)PresentationContinuous Process ImprovementNACCHO
Intro to Performance Management guideThis guide from the Minnesota Department of Health is a good introduction to selecting performance measures, communcating about progress.GuideQI infrastructure MN DOH
Introduction to QI PowerPointThis PowerPoint introduces the basics of QI to LHD staff. The content serves as a primer before delving into more in-depth information on how to use and apply QI in the agency.TrainingEmployee EmpowermentNACCHO
Investigating changeBefore embarking on a major change, such as introducing QI into an agency, this discussion tool can help the planning process using 8 change parameters. ToolLeadershipPublic Health Foundation
NICHQ - Engaging Senior Leadership in Your Quality Improvement WorkLeadership commitment is critical to a culture of quality and should be attained as early as possible. This webinar presents strategies for engaging leadership in QI and compelling reasons for why QI is important.
Webinar Leadership PHQIX/NICHQ
Performance Management ModuleNACCHO webinar on developing a performance management system PresentationQuality Improvement infrastructureNACCHO
Performance management webinarThe webinar includes presentations from two local health departments on their experience building, maintaining, and improving their performance management systems.  
Webinar QI infrastructure; Leadership Train
PHF Performance Management toolkitThe PM toolkit is divided into approaches to performance management and performance management system framework components and resourcesWebsiteQI infrastructurePublic Health Foundation
Sedgwick Co. Health Department QI Consultant RFPThis example Request for Proposals to engage a QI consultant to provide QI training to staff. LHDs can use this to understand criteria for selecting a QI consultant and view an example QI training plan and other activities to be implemented by a QI consultant. ExampleEmployee EmpowermentSedgwick County Health Department
Sustaining a Continuous QI Culture: Organizational SurveyA tool for leaders to assess the current culture of quality in an agency and the readiness and willingness of staff to embrace QI. Results can be used to inform strategies for both the people and process sides of change.
TemplateQI InfrastructureAssociation of Public Health Laboratories
Switch: How to Change When Change is HardFor leaders initiating transformational change, this book provides insight into concepts of change management useful for moving toward a culture of quality.
LiteratureLeadershipChip Heath, Dan Heath
Team Chartering TemplateThis template will help outline the mission, targeted goals and objectives, and team member roles and responsibilities for any team including a Quality Council and QI project teams. A team charter helps to clarify the mission of a team and helps the members stay on task.
TemplateQI InfrastructureJohn Moran
The ABCs of PDCAThis article provides an overview of the PDCA cycle for QI including what to consider when starting a QI project and the basic elements in each phase of the cycle.
Article Continuous Process ImprovementGrace Gorenflo and Jack Moran
The Quality Management Forum, Winter 2010 IssueThis article provides an introduction to QI in public health, describing various levels of QI (macro, micro, and individual) and detailing applicable QI techniques for public health practice. Literature Employee Empowerment, LeadershipThe Quality Management Forum
Turning Point Performance Management Self-Assessment ToolA tool for assessing what components of a performance management system an agency has in place and what it needs to develop.
TemplateQI InfrastructureTurning Point Performance Management National Excellence Collaborative
Turning Point: Performance Management Project and Publications Provides a wealth of performance management related literature, health department examples, and tools.
Website QI Infrastructure Public Health Foundation

Not Involved with QI Activities

Characteristics

  • Some employees have a high level understanding of QI but do not possess the knowledge, skills, and abilities (KSAs) necessary to undertake QI.
  • Select employees (e.g. QI champions, Accreditation/QI Coordinator) have received some QI training. QI trainings, resources, or mentors are not readily available to employees.
  • Employees are resistant to QI out of fear of punishment and lack of QI skills, and do not understand its value in public health.
  • Performance measures may exist in some or all parts of the agency, but are not used by employees to monitor/improve their individual work.
  • No financial resources and minimal staff time are devoted to QI.

Transition Strategies

  • Develop a training plan for building appropriate levels of performance management and QI KSAs for every level of staff.
  • QI champions engage in training opportunities to enhance ability to lead QI efforts and offer coaching to staff.
  • Leaders assess the source of staff resistance and develop strategies to counter resistance through effective messaging, training, and incentives.
  • Communicate information around agency strategy and performance improvement information (e.g. agency mission, vision, strategy).
  • Enable staff participation in improvement activities through feedback systems and inclusive problem solving.

Characteristics

  • Teams are rarely or never formed for the purposes of problem solving, improvements, or innovation.
  • Existing work teams may have defined roles, objectives and metrics for success, but team performance is likely not tracked for progress and accomplishments.
  • Peer sharing and learning across divisions, departments, programs, etc. is infrequent.

Transition Strategies

  • Ensure that teams throughout agency have clearly defined roles and expectations.
  • Create templates for setting the direction and processes for teams (e.g. team charter, agendas, work plans).
  • Begin to introduce use of tools/techniques to facilitate collaboration and sharing across the agency.
  • Actively participate in existing external QI learning communities and conferences, and share lessons learned with all staff.

Characteristics

  • Some leaders have received training in quality management principles and/or QI but do not demonstrate buy-in for QI.
  • Executive leaders do not dedicate or seek out resources for QI.
  • Data and quality are not incorporated into agency decision making.
  • Executive leaders have not set expectations for staff to engage in QI.

Transition Strategies

  • Leaders begin to seek out and dedicate additional human and financial resources for QI.
  • Leaders incorporate QI into the organization’s value statement and guiding principles.
  • Leaders work with PM/QI Council to develop a plan for change management including timelines, costs, short- and long-term goals, communication and training plans, and implications for staff and stakeholders.
  • Leaders actively communicate about the importance of QI and staff expectations, and continue to alleviate staff resistance.
  • Introduce QI to the local governing entity (LGE) and actively garner buy-in.

Characteristics

  • No formal process to identify internal and external customers of the agency exists.
  • Customer satisfaction data may be collected in some parts of the agency, but is not consistently used.
  • Customer needs are not considered in decision making processes.
  • Performance measures related to customer satisfaction are not used.
  • Staff are not empowered to resolve customer concerns.

Transition Strategies

  • Identify the agency’s customers and stakeholders to determine where customer satisfaction should be assessed. (These individuals may have been previously identified as a part of a strategic planning or health improvement planning process).
  • Begin to identify existing customer satisfaction data and data needs for all programs and services. Prioritize programs and services to assess for, and improve, customer satisfaction.
  • Develop plans and actions for how the agency will use customer data in performance management, strategic, and improvement planning.

Characteristics

  • A PM/QI Council exists but is still not fully functional.
  • No agency plans or policies address quality.
  • A current agency strategic plan likely does not exist or is not being implemented.
  • Existing performance measures are used for purposes of grant reporting (often “widget counting”) and are not linked to strategic goals.
  • Improvement efforts are implemented in the absence of performance data.

Transition Strategies

  • PM/QI Council assumes ownership of all QI efforts, and reports to agency leaders as appropriate.
  • Identify aspects of core operations and program areas for which performance is already being measured and data are being collected or are available.
  • PM/QI Council develops a plan for establishing clear performance measures and objectives
  • PM/QI Council drafts a QI plan with time-framed and measurable goals and objectives.

Characteristics

  • Agency processes are not clearly defined, unnecessarily complex, and consist of redundancies and variations through the agency.
  • Problems are inconsistently addressed and often rely on opinions or a “hunch,” over facts and data.
  • Problems are addressed in a reactive rather than proactive manner, and usually result in a temporary fix.
  • Staff are generally satisfied with the status quo and resistant to changing processes through QI.

Transition Strategies

  • Explore the different models for QI projects (e.g., Lean, Six Sigma, Rapid Cycle Improvement) and determine the best fit for the agency. For PHAB documentation requirements on use of a formal improvement process, see PHAB Measure 9.2.2.)
  • Develop criteria and a process for nominating and selecting QI projects.
  • Explore options for a “winnable” QI project(s) and lead the planning and implementation of these projects.
NameDesciptionTypeFoundational ElementSource
2017-2018 QI Plan TacomaThe Quality Improvement plan for Tacoma-Pierce County Health DepartmentExample DocumentationQI InfrastructureTacoma-Pierce County Health Department
Embracing Quality in Public Health: A Practioner's Performance Management Primer Online TrainingThis is a free, self-paced online training on performance management. It takes approximately 1 hour to complete and offers a certificate of completion that may serve as PHAB documentation for Domain 9. TrainingEmployee Empowerment, QI Infrastructure The Michigan Public Health Institute
Embracing Quality in Public Health: A Practioner's Quality Improvement GuidebookUse this guide to identify and understand science based QI models, strategies, and tools and educate staff on how to implement QI processes.
GuideEmployee EmpowermentMichigan Public Health Institute
Franklin County Health Department Performance Management Plan (2016-2020)An example Performance Management Plan from a PHAB accredited local health departmentExample DocumentationQI Infrastructure
Franklin County Health Department QI Plan (2016)This example provides insight into how Franklin County approached the QI plan and may help serve as a general guide to developing a QI plan in another agency. ExampleQI InfrastructureFranklin County Health Department
Intro to the PDSA cycleIntroductory video training to the PDSA cycle, good for employees who are brand new to QI.
Tool Continuous Process Improvement IHI
Juran on Leadership for Quality: An Executive HandbookIn this book, Juran provides leaders with specific, field-tested methods for building a QI program. It provides guidance on developing a QI Council, nominating and selecting QI projects, applying the Juran Trilogy to operations, and much more. Literature Leadership, QI InfrastructureJ.M. Juran
Kane County Health Department QI PlanThis example provides insight into how Kane County approached the QI plan and may serve as a general guide to developing a QI plan in another agency.
ExampleQI InfrastructureKane County Health Department (IL)
Lean six sigma powerpointA PowerPoint presentation from Tacoma/Pierce County comparing QI methods
Training Leadership phQIX
Los Angeles County Department of Public Health Quality Improvement Plan 2017An example QI plan from a PHAB accredited local health departmentExample DocumentationQI InfrastructureLos Angeles County Department of Public Health
Maricopa CDPH QI Plan 2014-2017An example QI plan from a PHAB accredited local health departmentExample DocumentationQI InfrastructureMaricopa County Department of Public Health
Measuring Customer Satisfaction: Nine Steps to SuccessOutlines a 9-step process for public health agencies to collect and apply meaningful customer satisfaction data.
Guide Customer Service Association of State & Territorial Health Officials
Northern Kentucky Health Department Quality Improvement Policy (2012)An example QI policy from a PHAB accredited local health departmentExample DocumentationQI InfrastructureNorthern Kentucky Health Department
QI Action Plan TemplateAn action plan template for use in the QI PlanTemplateQI InfrastructureNACCHO
QI Plan TemplateIncluding the main components of a QI plan, complete this template as a general guide to developing an agency QI plan.
TemplateQI InfrastructureMCPP Healthcare Consulting, Inc.
Quality Improvement Plan Toolkit: Guidance & Resources to Assist State and Territorial Health Agencies in Developing a QI PlanProvides guidance around how to develop a QI plan that will meet Public Health Accreditation Board Standards.

Guide QI Infrastructure Association of State & Territorial Health Officials
Quality Improvement Plans: A how-to guideThis 42-minute training from Minnesota Department of Health will delve into what is meant by a culture of quality and how to create a QI planWebinarQI infrastructureMN DOH
Quality Management TemplateThis document defines roles and responsibilities related to quality for leaders in an agency, including executive staff, management, and the QI Council.
TemplateQI InfrastructureMCPP Healthcare Consulting, Inc.
Santa Clara County Public Health Department Quality Improvement Plan (2016)An example QI plan from a PHAB accredited local health departmentExample DocumentationQI InfrastructureSanta Clara County Public Health Department
Scott County Health Department Quality Improvement Plan An example QI plan from a local health department submitted for the Accreditation Support Initiative (ASI) Example DocumentationQI InfrastructureScott County Health Department (IA)
Sedgwick County Health Department QI PlanThis example provides insight into how Sedgwick County approached the QI plan and may help serve as a general guide to developing a QI plan in another agency.
ExampleQI InfrastructureSedgwick County Health Department (KS)
Step-by-step QI guideA step-by-step interactive guide to QI projects
Guide/Website Continuous Process Improvement PHIP
Tacoma-Pierce County Health Department QI Plan (2017)This example provides insight into how Tacoma-Pierce County approached the QI plan and may serve as a general guide to developing a QI plan in another agency.
ExampleQI InfrastructureTacoma-Pierce County Health Department (WA)
Team Charter TemplateThis template will help outline the mission, targeted goals and objectives, and team member roles and responsibilities for any team including a Quality Council and QI project teams. A team charter helps to clarify the mission of a team and helps the members stay on task.
TemplateTeamworkJohn Moran
Team Process Review ChecklistQI project team leaders should use this checklist to identify essential considerations during the initation and life cycle of a QI project team.
TemplateTeamworkJohn Moran
The Performance Based Management Handbook: Establishing and Maintaining a Performance-Based Management ProgramDetailed guidance on every step in the process of initiating a performance mangagement system.
GuideQI InfrastructureU.S. Dept. of Energy
The Public Health Memory Jogger IIThis QI pocket-guide provides step-by-step instructions on using 22 of the most common QI tools and techniques, along with real-life public health examples of application. GuideContinuous Process Improvement, Employee EmpowermentPublic Health Foundation, GOAL/QPC

Informal or Ad Hoc QI activities

Characteristics

  • QI champions exist and have basic knowledge, skills, and abilities (KSAs) to lead QI projects and mentor staff.
  • Basic QI training/resources are available, but opportunities for application are limited.
  • Employee QI KSAs are assessed and gaps are incorporated into workforce development and QI plans.
  • Employees remain resistant to QI and may view it as a passing phase and added responsibility. QI is avoided due to competing priorities.
  • Employees are engaged with developing and understanding performance measures related to their work and how they connect with the agency mission.

Transition Strategies

  • Celebrate and incentivize QI successes.
  • Encourage staff to engage in QI projects and create opportunities to apply QI knowledge, skills, and abilities (KSAs).
  • All staff attend training on an organization-wide performance-management process including how to develop performance measures, input and access data, identify performance gaps, and report methods and frequency.
  • Encourage employees to use performance data to evaluate and improve individual performance.
  • Mentor employees and provide advanced QI training to those that need it, including advanced tools of quality, statistical and data analysis, and more complex models for QI, as appropriate.

Characteristics

  • Groups of employees may meet on an informal or ad-hoc basis for the purposes of problem solving or innovation.
  • One or two teams may have convened to implement formal or informal QI projects.
  • Team performance may be monitored for progress against objectives but targets and commitments are not consistently met.
  • Some employees may participate in formal external learning communities to improve work.
  • Peer sharing and learning is occurring on an informal basis but no formal methods for sharing and collaboration exist within the agency.

Transition Strategies

  • All staff increase use of collaborative QI techniques for problem-solving including group brainstorming sessions and discussions.
  • Encourage employees to participate in internal and external QI learning communities.
  • QI champions lead functional QI teams in implementing discrete projects sponsored by the PM/QI Council.
  • Leaders provide staff the opportunity to share results achieved through various mechanisms (e.g., staff meetings, storyboards on display).
  • Hold teams accountable to performance goals.
  • Create and disband teams, as appropriate.

Characteristics

  • Executive leaders understand QI and its value to the agency’s work. Middle managers/supervisors may still demonstrate resistance.
  • Executive leaders communicate to employees about the agency’s QI goals on an inconsistent basis.
  • Executive leaders have dedicated some resources (training, FTE, etc.) but do not actively seek out additional resources or funding for quality initiatives.
  • The local governing entity (LGE) is informed about agency QI initiatives and goals.

Transition Strategies

  • Leaders continuously communicate updates on QI progress and future plans, maintaining an inclusive and transparent process.
  • Leaders continue to communicate to employees key messages including: (1) QI is not about placing blame or punishment; (2) QI is a way to make daily work easier and more efficient; (3) QI is within reach of all staff and will get easier with practice.
  • Leaders continuously assess the culture of the agency including staff commitment and engagement and sustainability of progress toward building a QI culture.
  • Leaders regularly update and engage the governing entity around QI.
  • Leaders role model QI behavior and values with employees, customers, and partners.

Characteristics

  • The agency’s internal and external customers and stakeholders have been formally identified.
  • Some parts of the agency use customer satisfaction data to implement improvements (typically clinical).
  • The development of performance standards and measures related to customer satisfaction is informally occurring in some parts of the agency.

Transition Strategies

  • Identify existing customer satisfaction data and data needs.
  • Develop customer satisfaction performance measures throughout the agency. Include measures related to accessibility, courtesy, value, quality, timeliness, and helpfulness.
  • Identify customer satisfaction data sources and develop data collection instruments.
  • Develop a process for monitoring and reporting on customer satisfaction data, and incorporate into the performance management process.

Characteristics

  • A draft QI plan may exist but has not yet been adopted and implemented.
  • One or two staff (e.g. QI Coordinator) are responsible for leading QI and PM related activities.
  • The PM/QI Council is fully functional and actively overseeing agency-wide QI and PM initiatives.
  • A strategic plan may exist but likely did not result from a process that included stakeholder engagement, environmental scanning, data gathering, etc.
  • Divisions, departments, programs have process and output performance measures but meaningful outcome measures are not used. Performance is not linked to agency strategy.
  • Some performance data exists but is not consistently used for decision making, performance monitoring, and QI project identification.

Transition Strategies

  • Implement a formal process for choosing performance standards and targets and for developing respective performance measures to manage performance around core functions (e.g., human resources, finance) and public health programs and services (e.g., MCH, customer service).
  • Develop performance standards and measures at the organization, division, and program level, measuring both processes and outcomes. Align performance standards and measures with the agency strategic plan.
  • All staff identify performance data needs and sources.
  • Leaders, PM/QI Council, and IT staff conduct a formal requirements gathering process to understand needs for  a data-collection system for storing and tracking performance data (e.g., Excel, Access, software).
  • Establish a formal process for routinely reporting progress against performance standards/targets to all stakeholders (e.g., external customers, governing entity, leaders) including methods and frequency of analysis and reporting.
  • Begin to identify areas for improvement based on a gap analysis using performance data.
  • PM/QI Council develops a formal process to evaluate and revise the QI plan annually.

Characteristics

  • A small number of processes are being improved through discrete QI projects using a formal QI model (e.g. PDCA), however, projects do not always fully align with steps in the selected model (e.g. lack of baseline data, insufficient Root Cause Analysis).
  • Basic QI tools are being used to implement informal or ad-hoc improvements or problem solving (e.g. Cause-and-Effect Diagram, Flowcharts, Brainstorming).
  • Performance data is inconsistently used as a part of improvement projects.
  • QI projects may not be resulting in significant improvements or take an excessive amount of time to complete.
  • Process improvements are not documented or monitored for sustained success.

Transition Strategies

  • All staff practice using the seven basic tools of quality in daily work to identify root causes of problems, assess efficiency of processes, interpret findings, and correct problems.
  • The PM/QI Council identifies and sponsors “winnable” QI projects using agency performance data. QI efforts are linked to strategic priorities and identified from performance data to the extent possible. (Lack of performance measures and data in this phase should not hinder initiation of discrete QI efforts as opportunities for staff to practice will facilitate learning.)
NameDesciptionTypeFoundational ElementSource
Aim Statement Development TemplateThis template guides through a series of questions to develop Aim statements for QI projects, defining what the project is intended to accomplish with short, intermediate, and long-term measures.
Template Continuous Process ImprovementMCPP Healthcare Consulting, Inc.
All Systems GoPrior to selecting an information system or software for performance management, it is important to complete a requirements gathering process. This resource offers initial guidance on important considerations for selecting a system and an initial planning checklist.
GuideQI Infrastructure Public Health Informatics Institute, NACCHO
American Society for Quality Certification As an agency gains more experience with QI, staff may need advanced training. ASQ offers 17 different certification exams that require varying levels of knowledge and experience. The "QI Associate" and "Quality Process Analyst" certifications are ideal for staff responsible for leading QI efforts.
TrainingEmployee EmpowermentAmerican Society for Quality
ASQ Quality Tools WebsiteContains a list of useful quality tools, including tool descriptions, instructions for use, examples, and other materials for each tool. WebsiteContinuous Process ImprovementAmerican Society for Quality
Big City Health Department Population Indicator and Performance Measures LibraryThis resource is intended to provide a library of indicators and performance measures, categorized by common public health topic areas. Local health departments (LHDs) can use this library as one resource to find and identify common performance measures that may be adapted to an LHD's own performance management system.ExampleQI InfrastructureNACCHO
Change ConceptsAn excerpt from the Improvement Guide, a list of change concepts that can jog thinking about how to select and plan QI projectsGuide Continuous Process ImprovementIHI
Competencies for Performance Improvement Professionals in Public HealthThe core competencies may help in creating developing job descriptions and performance objectives, conducting performance reviews and evaluations, creating workforce development and training plans, and in preparation for accreditation.GuideQI InfrastructurePublic Health Foundation
Example LHD Performance Management Documentation The following listing includes example performance management documentation from LHDS funded through the Accreditation Support Initiative. Sites were funded to work on topics ranging from community health improvement planning, accreditation preparation, workforce development, QI, performance management, and workforce development. For a complete listing of results from three rounds of ASI funding, please visit www.naccho.org/asi.Example DocumentationQI Infrastructure NACCHO
Games for QI trainingDesigned for QI trainers and facilitators, this guide offers 21 games to teach QI concepts to staff using adult learning techniquest.Guide Teamwork, employee empowerment NQC
Guide to Prioritization Techniques This document outlines five prioritization methods to select the top priority QI projects, including descriptions of each method as well as examples of how LHDs have used the methods.
Guide Continuous Process ImprovementNACCHO
IHI "Science of Improvement on a Whiteboard" free video series"Just in time" training options covering the IHI model for improvement, and basic and advanced tools of quality. Trainings Continuous Process Improvement IHI
Logic modelsA comprehensive guide to creating logic models with several examples of common public health related topics. Logic models are useful when creating meaningful performance metrics for a performance management system.
Website LeadershipMetrics for Health Communities
MDH QI toolkitThe Minnesota Department of Health offers concise explanations of the most common QI tools used in public health. Each tools includes instructions for implementation and examples
WebsiteContinuous Process Improvement MN DOH
Measuring Customer Satisfaction: Improving the experience of King County's customersGuidance on an implementation framework for managing customer satisfaction, a common design for measuring customer satisfaction across programs, strategies for making service delivery improvements, and tools and resources for measuring customer satisfaction.
GuideCustomer Service Office of the King County Executive, WA
PDSA by spinning coinsA straightforward activity to teach importance of testing theories and collecting data in PDSA cycles.
Tool Continuous Process Improvement, Employee Empowerment IHI
Performance and Outcomes Measures Data Description FormThis form outlines the key components and considerations in the performance measure development process.
TemplateQI InfrastructureMCPP Healthcare Consulting, Inc.
Public Health Quality Improvement ExchangeThis centralized database of peer reviewed QI projects can assist LHDs in identifying effective interventions. Use this tool to search for QI projects by program or topic area, specific QI tool or technique, LHD size, PHAB domain, and more. WebsiteContinuous Process ImprovementRTI International, RWJF
QI Project Tracking SheetThis checklist lists out every key step in the Plan-Do-Study-Act (PDSA) process, allowing the user to track progress on a QI project. ToolContinuous Process ImprovementSedgwick County Health Department (KS)
QI Storyboard Development GuideA storyboard is a one-page, graphic representation of a completed QI project and is a mechanism to share QI project results throughout the organization. This guide describes how to develop a storyboard. GuideTeamwork and CollaborationMulti-State Learning Collaborative
QI Storyboard TemplateThis storyboard template is a one-page, graphic representation of a completed QI project. Storyboards are an effective way of communicating results of a QI project throughout the agency. They can be displayed on the walls, e-mailed to staff, included in an organization-wide newsletter, posted on the agency website, etc.
TemplateTeamwork and CollaborationRobert Wood Johnson Foundation
Root Cause AnalysisContains guidance on determining the root cause of a problemGuideContinuous Process ImprovementPublic Health Foundation
Selecting QI team membersThis brief guide offers some qualities to look for when selecting members of a QI teamGuide TeamworkPublic Health Foundation
SMART objectives presentation and handoutsThis 30-minute video is an introduction to writing good goals and smart objectives. This is a valuable skills for writing Aim statements in a QI project and objectives in agency plans (e.g. strategic plan)WebinarQI infrastructureMN DOH
Standardized Performance Measures for the National Public Health Improvement InitiativeThis guide to performance measurement includes standardized performance measures for assessing efficiency and effectiveness resulting from performance and quality improvement initiatives.
GuideQI InfrastructureCenters for Disease Control and Prevention
Team Charter TemplateThis template will help outline the mission, targeted goals and objectives, and team member roles and responsibilities for any team including a Quality Council and QI project teams. A team charter helps to clarify the mission of a team and helps the members stay on task.
Template Continuous Process Improvement, TeamworkJohn Moran
The Performance Based Management Handbook: Collecting Data to Assess PerformanceOffers a systematic approach to the process involved in data collection, from identification of data needs, to the selection of data collection methodologies, to measuring performance.
GuideQI InfrastructureU.S. Dept. of Energy
The Performance Based Management Handbook: Establishing an Integrated Performance Measurement SystemDetailed guidance on performance measurement, including the importance of performance measurement, how to link performance measurement to the strategic plan, various performance measurement frameworks, and developing performance measures.
GuideQI InfrastructureU.S. Dept. of Energy

Formal QI Activities Implemented in Specific Areas

Characteristics

  • Employees in certain areas of the agency have knowledge, skills, and abilities (KSAs) to complete formal QI projects
  • Basic and advanced level QI training/resources are available based on employee needs, i.e., QI training goals in workforce development and QI plans are being met. Opportunities for application exist in many parts of the agency.
  • Employee engagement in QI initiatives is incentivized and successes are celebrated.
  • Performance data are used by supervisors and employees to evaluate individual performance and implement improvements.
  • Employees understand the value of QI but may still view it as an added responsibility.

Transition Strategies

  • Staff are encouraged to identify quality concerns aligned with strategic plan and performance and implement staff suggestions.
  • Leaders grant QI champions and staff authority to make decisions regarding quality issues in their own work processes, as appropriate.
  • Make readily available beginner- and advanced-level trainings and resources to accommodate both new and experienced staff. Establish formal process to orient and train new staff in PM and QI.
  • QI champions continue to advocate for QI, mentor staff, and recruit additional champions throughout the agency.
  • Acknowledge and celebrate all successes around QI.

Characteristics

  • Informal groups are commonly formed throughout the agency for problem solving and innovation through the use of QI techniques (e.g. brainstorming, process mapping).
  • Formal QI project teams are more frequently formed in specific divisions, departments, programs, etc.
  • Teams have clearly defined objectives, performance measures, and consistently meet targets and commitments.
  • One or more formal methods for peer sharing and learning exist within the agency (e.g. learning community, storyboards, lunch & lunch).
  • Best practices and QI successes are shared but may be applied or translated to other parts of the agency.

Transition Strategies

  • QI champions and staff continue to participate in internal and external QI learning communities.
  • PM/QI Council sponsors multiple QI teams across divisions and programs to implement QI projects.
  • QI teams begin to break down silos by sharing results achieved and lessons-learned with staff from other programs or divisions.
  • Create physical space conducive to group innovation (e.g. common areas, conference rooms).

Characteristics

  • Executive leaders expect employees to be trained in QI and engage in QI initiatives as appropriate.
  • Leaders in certain parts of the agency hold staff accountable to QI initiatives.
  • Leaders consistently communicate about QI to staff to create buy-in and alleviate resistance.
  • The local governing entity receives ongoing updates around QI initiatives and progress in the agency.
  • Leaders proactively seek out resources for QI and appropriately budget for staff time, training, etc.

Transition Strategies

  • Leaders continuously provide regular updates on progress and future plans, maintaining an inclusive and transparent process.
  • Leaders continuously assess the quality culture of the agency, including employee commitment and sustainability of progress made through improvement efforts.
  • Executive leaders expect managers and supervisors to hold their employees accountable to QI.
  • Executive leaders develop formal QI policies or procedures.
  • Leaders hold QI and performance discussions at leadership meetings in a standardized way.

Characteristics

  • Internal customers are engaged in decision making and improvement processes.
  • Some leaders consider customer needs in decision making processes.
  • Some areas of the agency have a formal process for assessing customer needs and satisfaction, reporting progress, and making improvements.

Transition Strategies

  • Standardize use of data-collection methods/instruments to multiple programs and services when possible.
  • Standardize department-wide process for assessing customer satisfaction, developing and implementing action plans to continuously improve programs/services offered, and report results. Align this process with the performance management process.
  • Empower employees to take appropriate corrective action on customer issues across the organization.

Characteristics

  • An agency QI plan has been adopted and is being implemented.
  • A formally established, cross-sectional PM/QI Council meets regularly to monitor, oversee, and lead implementation plan for formal agency-wide QI and PM efforts.
  • A strategic plan informed by key stakeholders and data from an environmental scanning process is being monitored and implemented.
  • Some parts of the agency have clearly defined process and outcome performance measures that are linked to program, department, and/or agency level strategic goals.
  • Some parts of the agency have formal processes for data collection, analysis, and reporting against pre-defined objectives and standards. No centralized system for storing and accessing data exits.
  • Data driven decision making is more common and QI projects or improvement initiatives are often identified from existing performance data.

Transition Strategies

  • Leaders and PM/QI Council implement a standardized performance management process to collect, store, monitor, analyze, and report on performance data.
  • Leaders and PM/QI Council work with staff to link the agency strategic plan, QI plan, and all operational plans.
  • Continuously assesses progress against QI plan.
  • Leaders begin to request return on investment data including costs and cost savings resulting from QI efforts.
  • Leaders request data prior to approving changes or making decisions.
  • Adopt and develop an information system for storing, analyzing, and reporting performance data (e.g. spreadsheet(s), database, commercial software) based on a requirements gathering process. Train employees on how to use the system.

Characteristics

  • A formal QI model is commonly used to improve processes in some parts of the agency, and projects are aligned with the steps in the model (e.g. PDCA).
  • Staff are increasingly comfortable with using various basic QI tools and techniques (e.g. flowcharting, Cause-and-Effect Diagram, Brainstorming) for problem solving.
  • Performance data is being used in some areas of the agency but consistency and reliability issues exist.
  • Formal QI projects are more consistently resulting in process improvements, however, successes are not always documented and monitored, or spread to other parts of the agency.

Transition Strategies

  • Hold improvement gains resulting from previous QI projects through quality-control strategies such as documenting and training staff on revised processes, continuing to measure improvements, creating checklists and reminders, and performing audits.
  • PM/QI Council uses performance data to identify and initiate multiple QI projects throughout the organization.
  • PM/QI Council monitors improvements and works with leaders to document and standardize improved processes throughout organization.
  • Identify and use evidence-based practices, when possible, and contribute to the evidence base of public health through national conferences and publications.
NameDesciptionTypeFoundational ElementSource
25 Frequently Asked Questions about Return on InvestmentIdeal for those learning about ROI, this article answers the most frequently asked questions.
ArticleQI InfrastructureROI Institute, Inc.
Comparing Lean and QI methodologies WhitepaperThis whitepaper comparing the Lean approach to the IHI Model for Improvement compares the two, highlighting their similarities and differences and discussing ways that they can be combined to apply the strengths of each approach to QI.
Literature Leadership IHI
Measuring Return on Investment in the Public SectorThis book shows how all types of public sector organizations are using ROI evaluation as a way to meet challenges and build accountability into specific programs, including training, education, human resources, and community development initiatives.
LiteratureQI InfrastructurePatricia P. Phillips, Jack J. Phillips
Project Screening Criteria for Selecting QI Projects This template guides QI leads through a series of questions to screen for and distinguish more effective agency programs and activities from those that may need to be revisited.
Guide Continuous Process Improvement MCPP Healthcare Consulting, Inc.
Sedgwick Co. Health Department QI Policy Adopting a QI policy can help to formalize QI in the organization and establish accountability for QI in the agency. ExampleLeadershipSedgwick County Health Department
The Performance Based Management Handbook: Analyzing, Reviewing, and Reporting Performance DataOffers guidance on analyzing data and prepares management to review, make informed decisions, and report to stakeholders performance information collected during the performance management cycle.
GuideQI InfrastructureU.S. Dept. of Energy
The Return on Investment on Measuring Return on Investment in Prevention Improvement EffortsThis publication presents key talking points around ROI and communicating the benefits.
Fact SheetQI InfrastructureNC Center for Public Health Quality
The ROI Institute, Inc. ROI Institute is a service-driven organization which assists organizations in improving their programs and processes through the use of the ROI Methodology. Visit this website to find ROI tools, resources, publications, and other consultation services. WebsiteQI InfrastructureROI Institute, Inc.
Utilizing the Advanced Tools of QI to Leverage the Power and Reach of Public HealthThe article discusses the advanced tools of QI and how they interact with and support the PDCA process. It specifically highlights the Affinitiy Diagram and Interrelationship Diagraph, providing step-by-step instructions along with examples of how they were applied.
ArticleContinuous Process Improvement Ron Bialek, Louise Kent, John Moran

Formal Agency-Wide QI

Characteristics

  • Employees with necessary KSAs to complete formal QI projects exist in all areas of the agency.
  • An inventory of internal and external QI trainings and resources (basic and advanced) are available to all staff.
  • Employees are incentivized to engage in QI initiatives through both non-financial and financial rewards (e.g. bonus, promotions), as feasible
  • Most employees fully embrace QI and view it as a valuable tool to improve their work.
  • Employees use performance measures and data to identify and implement improvements to their own work.
  • Employees understand how they contribute to the agency’s overall mission, vision, and strategy.

Transition Strategies

  • Leaders and managers incorporate QI competencies in position descriptions.
  • Leaders and managers incorporate QI into performance-appraisal process.
  • Hold every level of staff accountable to identifying QI opportunities aligned with agency strategic plan and improving quality in own work processes.

Characteristics

  • Informal groups of employees from various parts of the agency are commonly formed for problem solving and innovation.
  • Formal QI project teams are formed throughout the agency.
  • Several formal methods for peer sharing and learning exist within the agency (e.g. learning community, storyboards, lunch & lunch).
  • Best practices and QI successes are applied and translated from one part of the agency to another.

Transition Strategies

  • PM/QI Council continues to sponsor multiple QI teams across divisions and programs to implement QI efforts.
  • Staff routinely form sharing sessions or use other mechanisms to exchange successes and lessons-learned.

Characteristics

  • Executive leaders and middle managers throughout the agency hold staff accountable to engaging in QI.
  • All leaders are knowledgeable about QI and quality principles, and are able to support staff around QI initiatives.
  • Executive leaders dedicate sufficient staff time and resources to reaching agency QI goals.
  • Leaders engage in QI initiatives and role model the level of engagement expected of staff.
  • Leaders address staff resistance or other barriers to QI on an ongoing basis.

Transition Strategies

  • Leaders continue to update employees and stakeholders on progress and future plans, dedicate resources to QI, and assess agency culture and sustainability of progress.
  • Leaders continue to role model QI behavior and values with employees, customers, and partners.
  • Select new organization leaders that exhibit QI values and dedication to continually improve.

Characteristics

  • Employees are empowered to take corrective action against customer dissatisfaction.
  • Evidence exists that the agency consistently meets internal and external customer needs.
  • Customer satisfaction performance standards and measures are standard throughout the agency, as appropriate.
  • Customer satisfaction data is actively used to improve performance.

Transition Strategies

  • Continue to monitor, assess, improve, and report on customer satisfaction for all programs and services.
  • Refine and improve the customer-satisfaction measurement process.
  • Involve both internal and external customers in improvement activities.
  • Use customer data to define new offerings and services.
  • Incorporate customer feedback into performance appraisal process.

Characteristics

  • An agency QI policy may exist.
  • A formal process for implementing, monitoring, and evaluating a QI plan is in place.
  • The PM/QI Council oversees all QI/PM initiatives, ensures sustainability of successes achieved, and takes necessary action to address barriers among quality initiatives.
  • A formal process for developing and revising performance measures that are linked to program, department, and agency strategic goals is implemented agency-wide.
  • All programs, departments, or divisions have clearly defined plans for performance data collection, analysis, and reporting against pre-defined objectives and standards.
  • A centralized information system for storing and accessing performance data allows for user-friendly performance monitoring and reporting.
  • Agency and department level decisions are always data driven. Performance data is used to identify agency QI projects.

Transition Strategies

  • All staff in all divisions and program areas continue to collect, monitor, analyze, and report performance data.
  • PM/QI Council uses performance data to identify and recommend QI efforts throughout the organization.
  • PM/QI Council continuously assesses progress against QI plan and revises annually.
  • Leaders routinely measure return on investment using cost and benefit values.

Characteristics

  • Formal QI projects are being implemented to improve processes in all departments and divisions of the agency.
  • Formal QI projects result in documented process improvements and monitored for sustainability. Improved processes are standardized and adopted agency-wide.
  • Basic and advanced QI tools and techniques are commonly used for informal problem solving and formal QI projects.
  • Reliable performance data is consistently used to assess for performance gaps, and identify and implement QI projects.
  • Many agency-wide processes are clearly defined, efficient, and standardized throughout agency.

Transition Strategies

  • Continue to hold improvement gains resulting from previous QI efforts.
  • PM/Council continues to sponsor QI projects, as appropriate.
  • Staff continue to use, and contribute to, evidence base and model practices.
NameDesciptionTypeFoundational ElementSource
Economic Impact & Return on Investment: As Applied in Public HealthPresents ROI basics including terminology, formulas for calculating ROI, and an ROI Process Model.
PresentationQI InfrastructureNC Center for Public Health Quality
QI Project Return on Investment WorksheetThis blank worksheet outlines key variables when calculating ROI on QI projects, including projects costs, financial benefits, and intangible benefits.
TemplateQI InfrastructureNC Center for Public Health Quality
Tacoma-Pierce County Employee Development and Performance Review Tool Leaders can increase accountability around QI by incorporating QI into position descriptions and the performance-appraisal process. This example performance appraisal tool shows how Tacoma-Pierce incorporates QI competencies. ExampleEmployee EmpowermentTacoma-Pierce County Health Department

QI Culture

Characteristics

  • All employees have the appropriate knowledge, skills, and abilities (KSAs) to fulfill their quality related role in the agency.
  • Employees are granted an appropriate level of autonomy to fulfill their quality related roles in the agency.
  • New employee orientation includes agency values and goals around quality. All new employees are trained in QI within a predefined period.
  • QI is incorporated into job descriptions and the performance appraisal process.
  • Attitudes and propensity for quality are considered in hiring decisions.
  • Employees are viewed and treated as the agency’s greatest asset.

Characteristics

  • The agency uses and contributes to the evidence base in the field. The agency is widely regarded as innovative and quality driven.
  • Informal groups are commonly formed for idea generation, innovation, and improvement. Formal teams are readily formed to implement improvements.
  • All functioning teams in the agency are structured with clear goals and targets, and consistently meet commitments.
  • An environment of peer learning and sharing is highly encouraged and prevalent with multiple venues for sharing.

Characteristics

  • Executive leaders and middle managers fully embrace quality and hold staff accountable to engaging in QI.
  • Executive leaders ensure sustainability of the quality culture by proactively maintaining resources.
  • Leaders quickly identify and address resistance or barriers to sustaining the quality culture.
  • Leadership turnover has minimal negative impact on the quality culture. Knowledge of quality principles and attitudes toward QI are considered when hiring new leadership.

Characteristics

  • Customer needs and values are central in decision making and daily operations.
  • Externally, the agency is viewed as being customer focused, and continuously meets and exceeds customer expectations.
  • Internal and external customers are proactively engaged in decision making and improvement processes.

Characteristics

  • QI plan goals and objectives are consistently met and challenge the agency to continuously strive for improvement.
  • A strong governance structure for quality initiatives exists ensuring the agency is accountable to quality related goals.
  • Performance data drives all decision making and improvement activities in the agency.
  • An efficient and cost effective automated system for centralized data analysis and reporting is in place.

Characteristics

  • The use of formal and informal QI tools and methods to solve problems and create improvements is second nature to employees.
  • Large, agency-wide QI initiatives consistently yield significant improvements.
  • QI initiatives are occurring at all levels of the agency, on a formal and informal basis.
  • Agencies processes are standardized, efficient, and ultimately yield high quality products and services to the community.