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Defining Quality Improvement in Public Health

DOI:10.1097/PHH.0b013e3181bedb49
Authors:
William Riley at Arizona State University
William Riley
John W Moran
John W Moran
John W Moran
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Liza Corso at Centers for Disease Control and Prevention
Liza Corso
Leslie M Beitsch at Florida State University
Leslie M Beitsch
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Abstract

Many industries commonly use quality improvement (QI) techniques to improve service delivery and process performance. Yet, there has been scarce application of these proven methods to public health settings and the public health field has not developed a set of shared principles or a common definition for quality improvement. This article discusses a definition of quality improvement in public health and describes a continuum of quality improvement applications for public health departments. Quality improvement is a distinct management process and set of tools and techniques that are coordinated to ensure that departments consistently meet the health needs of their communities.
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Defining Quality Improvement in Public Health
William J. Riley, John W. Moran, Liza C. Corso, Leslie M. Beitsch, Ronald Bialek, and Abbey Cofsky
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Many industries commonly use quality improvement
(QI) techniques to improve service delivery and process
performance. Yet, there has been scarce application
of these proven methods to public health settings and the public
health field has not developed a set of shared principles or a
common definition for quality improvement. This article
discusses a definition of quality improvement in public health
and describes a continuum of quality improvement applications
for public health departments. Quality improvement is a distinct
management process and set of tools and techniques that are
coordinated to ensure that departments consistently meet the
health needs of their communities.
KEY WORDS: performance improvement, public health
departments, quality improvement techniques, QI applications
for public health departments
The underlying premise—and promise—behind im-
proving the performance of a public health department
is that doing so results in healthier people and commu-
nities. For these aspirations to be realized, public health
departments need a clear definition of quality improve-
ment and widely accepted guidelines for implementa-
tion. Industries such as manufacturing and healthcare
commonly use quality improvement (QI) techniques
to improve service delivery and process performance.
Yet, to date, there has been scarce application of these
proven methods to achieve similar objectives in pub-
lic health settings. In this article, we discuss a defini-
tion of quality improvement in public health and de-
scribe a continuum of QI applications for public health
departments.
The public health community has expressed an in-
creasing interest in quality improvement. Programs
J Public Health Management Practice, 2010, 16(1), 5–7
Copyright C
2010 Wolters Kluwer Health |Lippincott Williams & Wilkins
such as the National Public Health Performance Stan-
dards Program,1the Turning Point Performance Man-
agement National Excellence Collaborative,2and the
Multi-State Learning Collaborative: Lead States in Pub-
lic Health Quality Improvement3have been out in front
of this movement, engaging many public health depart-
ments in quality-improvement activities. Nonetheless,
unlike many industries that have embraced QI to im-
prove quality and lower costs, the public health field
has not developed a set of shared principles and a com-
mon definition for QI.
●Defining and Describing Quality and Quality
Improvement in Public Health
The Accreditation Coalition, a group of organizations
supported by the Robert Wood Johnson Foundation
and the Centers for Disease Control and Prevention,
has recognized the need for a common definition of
QI in public health to promote public health accredita-
tion and quality improvement. In response, a subcom-
mittee was charged with crafting a definition of qual-
ity improvement for public health departments and
Corresponding Author: William J. Riley, PhD, School of Public Health, Univer-
sity of Minnesota, 420 Delaware St SE, MMC 729, Minneapolis, MN 55455
(riley001@umn.edu).
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William J. Riley, PhD, is Associate Dean, School of Public Health, University of
Minnesota, Minneapolis.
John W. Moran, PhD, MBA, CQIA, CQM, CMC, is Senior Quality Advisor, Public
Health Foundation, Washington, District of Columbia.
Liza C. Corso, MPA, is Team Leader, Office of Public Health Systems Performance,
Office of the Chief of Public Health Practice, Centers for Disease Control and
Prevention, Atlanta, Georgia.
Leslie M. Beitsch, MD, JD, is Professor of Health Policy, Florida State University
College of Medicine, Tallahassee, and Director, Center for Medicine and Public
Health, Tallahassee, Florida. He currently serves as Associate Dean for Health Affairs.
Ronald Bialek, MPP, is President, Public Health Foundation, Washington, District of
Columbia.
Abbey Cofsky , is a Program Associate, Public Health Team, Robert Wood Johnson
Foundation, Princeton, New Jersey.
5
6❘Journal of Public Health Management and Practice
TABLE 1 ●Characteristics of “Small qi” and “Big QI”
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Topic “Small qi” “Big QI”
Improvement Program or unit level—specific project focus Organization-wide with a system focus
Quality-improvement planning Program or unit level—specific project focus Organization-wide and often tied to the strategic plan
Evaluation of quality Performance of a process capability over time Responsiveness to community needs
Processes Delivery of program or unit-level services Organization-wide processes that cut across all programs
and activities
Quality improvement goals Individual program or unit-level plans Organization’s strategic plan
Utilization of QI Program or unit level—specific project focus Entire organization
Benefit of high quality Improving the efficiency and effectiveness of core programs
and support processes in the public health department
that lead to improved community health status
Improving the efficiency and effectiveness of the public
health department management system
organization-wide to develop a culture of quality that
results in improved community health status
practitioners. In early 2009, after reviewing the appro-
priate literature and existing definitions, the subcom-
mittee proposed the following definition of QI:
Quality improvement in public health is the use of a
deliberate and defined improvement process, such as
Plan-Do-Check-Act, which is focused on activities that
are responsive to community needs and improving
population health. It refers to a continuous and ongoing
effort to achieve measurable improvements in the
efficiency, effectiveness, performance, accountability,
outcomes, and other indicators of quality in services or
processes which achieve equity and improve the health
of the community. (R. Bialek, L. M. Beitsch, A. Cofsky,
et al, unpublished data, 2009)
Defined this way, QI is a distinct management pro-
cess and set of tools and techniques that are coordinated
to ensure that departments consistently meet their com-
munities’ health needs and strive to improve the health
status of their populations. This definition builds on
the Department of Health and Human Services’ recent
effort to define quality in public health. A decade ago,
the Institute of Medicine proposed a definition of qual-
ity that has since been broadly applied in the acute-care
sector of the health system4and provided significant di-
rection for hospitals, physicians, researchers, and policy
makers. Recognizing the importance of similarly rally-
ing the public health field around a common definition
of quality, the Department of Health and Human Ser-
vices led an effort to develop what is now known as the
Consensus Statement of Quality in the Public Health
System. This statement defines quality in public health
as “the degree to which policies, programs, services,
and research for the population increase desired health
outcomes and conditions in which the population can
be healthy.”5It also identifies a set of goals that will
foster quality-improvement activities and help achieve
quality in public health.
●The Continuum of Quality Improvement
Quality improvement, as defined above, encompasses
activities that focus on specific processes or projects—
such as improving customer satisfaction or increasing
immunization rates—as well as a public health de-
partment’s adoption of an organization-wide commit-
ment to quality improvement. This distinction between
project-level QI and organization-wide QI is referred to
as “Small qi” and “Big QI,” respectively.
When public health departments first introduce QI
activities, they typically do so at a small project level
(“Small qi”). As they become more experienced with
QI, departments frequently take on more “Small qi”
projects, involve more staff, and spread QI competence
to more areas of the department. Through this process
of repetition, saturation, and diffusion, QI becomes a
part of the culture of the public health department and
is incorporated agency-wide (“Big QI”).
The successful integration of QI into an organiza-
tion’s culture requires both a top-down and bottom-
up approach. The staff can push QI activities along the
continuum from “small qi” to the culture of “Big QI.”
However, for quality improvement to truly penetrate
the culture of a health department, leaders and man-
agement must commit to ensuring that staff come to
consider QI to be “business as usual.” Table 1 be-
low describes the two ends of the QI continuum from
competence with individual projects, Small qi, to an
organization-wide QI culture, Big QI. The table identi-
fies seven characteristics of fully implemented QI in a
public health department.
The goals of moving along this continuum are to
continuously improve the timeliness, effectiveness, and
responsiveness of programs, and to optimize inter-
nal resources to improve the health of the community.
Transformational change is possible in a health depart-
ment when small, incremental improvements (“Small
Defining Quality Improvement in Public Health ❘7
qi”) are linked with large, meaningful changes (“Big
QI”) at the organizational level.
●Discussion
For public health departments to reach their full po-
tential, improving the health of the people and com-
munities they serve, high performance, efficiency, and
evidence-based practices are critical. Lessons from
other industries suggest that it is possible to become
a high-performing organization through broad imple-
mentation of QI as a management approach. For this to
happen, public health leaders must be willing to make
a long-term commitment to developing processes that
demonstrate improved results and drive inefficiency
from the system. Large-scale change is seldom quick or
easy and cannot be done without the commitment and
personal stewardship of the public health leader. Lead-
ers must publicly declare their intention to make QI a
reality and must also develop a vision for the organiza-
tion, build a QI infrastructure, and implement basic QI
methods, concepts, and principles. When implement-
ing either “Big QI” or “Small qi,” leaders must make
certain that quality improvement helps bring forth so-
lutions to problems experienced by both public health
providers and people needing their services. One so-
lution should not come at the expense of the other.
When all elements work together, the result is a system-
atic approach to delivering efficient, quality programs
and services that result in improved community health
outcomes.
Leaders wishing to move public health department
toward “Big QI” should adopt a specific QI model to
begin this transformation. QI models applicable to pub-
lic health include Lean,6the Model for Improvement,7
Six Sigma,8Juran’s Trilogy,9the Baldrige Method,10 and
the Turning Point Model.2In our view, “Big QI” is a
prerequisite for public health departments, to achieve
optimal performance and a necessary first step to im-
proving population health on a consistent, sustainable
basis.
●Summary
Public health departments are part of the first line of de-
fense in keeping the public healthy and safe. This duty
to safeguard population health is best met by combin-
ing public health science with the highly reliable tech-
niques of quality improvement. There is growing ev-
idence that QI techniques can be applied successfully
in public health departments.11 By eliminating ineffi-
ciency, error, and redundancy, public health depart-
ments can continually improve critical processes and
reduce costs associated with poor quality. Public health
departments must continually challenge and improve
core processes and functions. This requires purpose-
ful leadership throughout all levels of the department,
beginning with a strong and unwavering commitment
from the executive director.
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