Foundational Elements of a QI Culture

The culture of an organization is the embodiment of the core values, guiding principles, behaviors, and attitudes that collectively contribute to its daily operations. (5) Culture drives the policies, practices, and processes used to accomplish an organization’s work. It matures over many years as norms are passed from one generation of staff to the next. Shifting an organization’s culture requires commitment and deliberate management of the change process.

When a quality culture is achieved, all employees, from senior leadership to frontline staff, have infused QI into the way they do business daily. Employees continuously consider how processes can be improved, and QI is no longer seen as an additional task but a frame of mind in which the application of QI is second nature.


The elements described below make up foundation of a culture of quality. Each of these elements is likely already present to a certain degree in many health departments, but must be fully developed to ensure progress toward a strong culture of quality. An organization’s evolution from implementation of small, discrete quality improvement (QI) efforts or an informal application of quality concepts to complete infusion of QI into its culture will occur through a process of cultivating these foundational elements over time. Combined, these elements lay the foundation for a comprehensive approach to transformational change that considers the processes and people involved and will lead an agency toward a sustainable QI culture.

Leadership Commitment

Leadership commitment is vital for the success and sustainability of a culture of quality. The health director and senior management initiate and lead the process for transformational change, dedicate financial and human resources to QI, communicate progress, hold staff accountable, address resistance to change, and exhibit visible support for QI. Middle managers and supervisors ensure that all employees have the direct support needed and are being held accountable to QI values and behaviors. Without leadership commitment, progress toward the desired state will diminish and likely result in relapse to the previous state. (6)

Change management is an important skills for leaders who wish to shift an organization’s culture. It is defined as a structured approach to transitioning an organization from a current state to a future desired state. (7) Change management frameworks consider both the process side of change (e.g., building the infrastructure, processes, and systems needed for effective QI) and the human side of change (e.g., alleviating staff resistance, maintaining transparency, meeting training needs, attaining staff support). (8)

Learn more about change management here.

QI Infrastructure

To achieve a culture of quality, and organization must have the systems and structure in place to support QI. QI must be aligned with the organization’s mission, vision, and strategic plan and linked to organizational and individual performance. The following are components of a strong QI infrastructure:

  • PM/QI Council— The performance management and/or QI Council (PM/QI Council) governs the agency’s quality program. It is responsible for overseeing the implementation of the PM system and QI plan, specifically implementing,
    evaluating and revising the QI plan; supporting individual QI projects; reviewing performance data and reporting progress; and recommending next steps.  All divisions/departments should be represented on the PM/QI Council. (10)
  • Performance Management System—This cyclical process of measuring, monitoring, and reporting of progress toward strategic organization, division, and program goals and objectives provides a structured, data-driven approach to identifying and prioritizing necessary QI projects.(9) The performance management system (PM system) should be guided by an agency’s strategic plan.
  • QI Plan—Outlining the organization’s QI goals and objectives, this living document provides direction and structure for QI efforts. Leadership should continuously evaluate and revise the QI plan to progress further and maintain momentum. The agency’s strategic plan should inform the QI plan, and QI efforts should align with strategic priorities.

Employee Empowerment

Leadership should empower staff to infuse QI into their daily work by ensuring they have the necessary awareness, knowledge, skills, resources, and support. This can be accomplished by incorporating QI into orientation, including QI in job descriptions and performance appraisal, providing ongoing training opportunities, granting authority to make decisions, and eliminating fear of consequence or placing blame.(10, 11, 12) Additionally, QI champions serve to spread expertise and advocate for QI, which reduces the impact of any staff turnover.

Customer Focus

Because a customer focus is a core tenet of quality, it should be incorporated into the vision and values of the agency. Services offered should be customer driven, and continuous assessment of internal and external customer needs should drive improvement efforts to meet and exceed customer expectations and prevent dissatisfaction.(13)

Teamwork and Collaboration

In an organization with a culture of quality, teams have clearly defined performance expectations and gather routinely to brainstorm, solve problems, implement QI projects, and share lessons learned. (14) Collaboration among divisions and programs aids in standardizing
processes and breaking down silos. Peer sharing is a norm.

Continuous Process Improvement

Abandoning the notion of perfection, continuous process improvement is a never-ending quest to improve processes by identifying root causes of problems. Process improvement involves making gradual improvements in everyday processes to reduce variation and redundancies, improve quality of services, and increase customer satisfaction. Widely used models for continuous process improvement include Lean, Six Sigma, and Business Process Re-engineering.(15) The most widely used improvement process in public health today is Rapid Cycle Improvement through the use of successive Plan-Do-Check-Act (PDCA) cycles.(16)