Elements of a QI Culture

Foundational Elements of a QI Culture

An organization’s evolution from implementation of small, discrete quality improvement (QI) efforts to complete infusion of QI into its culture will occur through a process of cultivating these foundational elements over time. These elements lay the foundation for a comprehensive approach to transformational change that considers both the processes and people involved.


Leadership Commitment

Leadership commitment is vital for the success and sustainability of a culture of quality. Senior management initiate and lead the process for transformational change, set the QI vision, dedicate resources to QI, communicate progress, establish clear expectation, address staff concerns, 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. Without leadership commitment, progress toward the desired state will diminish and likely result in relapse to the previous state.

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. 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., maintaining transparency, meeting training needs, attaining staff support).

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.
  • 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. The 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. QI efforts outlined here should align with strategic priorities. The QI plan is frequently combined with an agency PM plan. 

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 staff orientations, including QI in job descriptions and performance appraisals, providing ongoing training opportunities, granting authority to make decisions, and eliminating fear of consequence or placing blame. 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. For public health departments, this means understanding and meeting its community's needs. Programs and services should be community driven, and continuous assessment of internal and external community needs should drive improvement efforts to meet and exceed expectations. This involves working with the community to co-design solutions to existing problems.

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.  Collaboration among divisions and programs aids in standardizing processes, breaking down silos, and developing innovative solutions. 

Continuous Quality Improvement

Abandoning the notion of perfection, continuous quality improvement is a never-ending quest to improve processes and outcomes by identifying root causes of problems. This involves making gradual improvements to reduce variation and redundancies, improve quality of programs and services, and increase customer and community satisfaction. The most widely used improvement process in public health is Rapid Cycle Improvement through the use of successive Plan-Do-Check-Act (PDCA) cycles.