Building the Evidence for Quality Improvement Initiatives in Public Health Practice

    • August 7, 2009

The Robert Wood Johnson Foundation (RWJF) is committed to increasing the successful application of quality improvement (QI) in public health departments. Quality improvement refers to a continuous effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes and other indicators of quality in an organization. In the case of public health, QI generally employs a deliberate and defined set of activities to improve the quality of services or processes that have a significant bearing on a department’s ability to achieve equity, respond to community needs and improve the health of a community. 

Drawing on lessons learned from other sectors, the public health field is rapidly adopting QI methods to become more effective and efficient in delivering services and impacting health outcomes. RWJF believes that QI, by creating stronger programs and services, will ultimately enable local, state, tribal and territorial health departments to better protect, promote and preserve health in the communities they serve—keeping people safer from health threats ranging from foodborne illness to hurricanes to disease outbreaks. 

Additionally, in preparation for national public health accreditation, many health departments are looking at QI as a means of improving performance to meet accreditation standards. Currently, however, there is little published evidence on the value and impact of QI in public health, and only preliminary evidence exists about the factors that promote the successful implementation and spread of QI efforts in governmental health departments. 

In addition to working to ensure that departments receive training and technical assistance to prepare for accreditation and to improve the overall quality of governmental public health, the Foundation recognizes the need to build the evidence of the value and impact of QI in this field. Beginning in 2009, the Foundation is funding 13 local, state and tribal health departments who will evaluate the impact of a range of QI approaches on key public health performance indicators, such as immunizations and management of foodborne illness outbreaks. 

  • The Baltimore City Health Department will evaluate the use of the Model for Improvement QI approach to improve processes and outcomes in the department’s Adolescent and Reproductive Health, Surveillance, and Sexually Transmitted Disease Clinical Services programs.
  • The Berrien County Health Department in Benton Harbor, Mich., will evaluate the use of the Plan-Do-Study-Act and Rapid Cycle Improvement approaches to improve program performance, and outcomes related to the department’s Children’s Special Health Care Services and Restaurant Inspections programs.
  • The Duval County Health Department in Jacksonville, Fla., will evaluate the use of the Model for Improvement approach to improve clinic immunization rates for children ages 19 to 35 months old. The evaluation will also address the costs and benefits of using the approach, lessons that can be applied to other projects, and impact on staff knowledge and stakeholder satisfaction.
  • The Franklin County Board of Health in Columbus, Ohio, will study the use of the Model for Improvement method to increase immunization rates among children up to age 2 in three rural and suburban local health departments. The evaluation of the project will address the effectiveness of the approach, barriers to implementing QI methods, and lessons learned.
  • The Guilford County Department of Public Health in Greensboro, N.C., will examine whether health outcomes can be improved by using the Six Sigma method to manage client flow in a public health clinic system. The department will use the approach to reduce patient wait times and maximize staff efficiency in prenatal care, family planning, sexually transmitted disease, immunization and adult health care service clinics.
  • The Ingham County Health Department in Lansing, Mich., will study whether using the Model for Improvement approach within a Communities of Practice framework can improve the performance of public health nurses and public health advocates as well as client satisfaction. 
  • The Los Angeles County Department of Public Health will examine if the use of PREPARE and a learning collaborative approach enhances QI capacity within diverse units across a large, urban health department. If successful, this approach could inform public health accreditation efforts and be useful to similarly-sized local health departments.
  • The City of Milwaukee Health Department will evaluate a project to improve adolescent immunization rates through school-based clinics in Milwaukee using Plan-Do-Study-Act. The evaluation will identify barriers in school-based clinic processes, examine the effectiveness of a revised implementation plan on immunization rates, and examine the QI process and its impact on the health department. 
  • The Port Gamble S’Klallam Tribal Community Health Department in Kingston, Wash., will implement Plan-Do-Study-Act to improve clinic processes and outcomes using the department’s electronic medical records system, with a focus on screenings and immunization schedules. The department will evaluate the project’s impact on both staff performance and patient outcomes. 
  • RiverStone Health in Billings, Mont., will implement and evaluate a QI project aimed at improving the Yellowstone City-County Health Department’s ability to prevent, detect and manage foodborne illness outbreaks. RiverStone will assess the impact of the Model for Improvement approach on departmental processes and personnel attitudes.
  • The South Carolina Department of Health & Environmental Control in Columbia, S.C., will evaluate the impact of the Model for Improvement QI approach on the efficiency of family planning clinics at two local health departments. They will determine impact by comparing outcomes from these health departments with select local health departments not implementing QI.
  • The Tacoma-Pierce County Health Department in Tacoma, Wash., will evaluate the impact of QI approaches on both agencywide and program-specific projects. At the program-level, they will use the Model for Improvement to improve Chlamydia testing and treatment and solid waste code enforcement. At the agency level, they will focus on performance measures and recommendations from the 2008 Washington State Standards for Public Health site review.
  • The Tulsa Health Department in Tulsa, Okla., will evaluate the impact of the Plan-Do-Study-Act QI approach of agencywide and program-specific quality improvement projects. They will examine the project’s impact on agency efficiencies, use of data systems, and QI culture within the department. 

The School of Public Health at the University of Minnesota will provide technical assistance to grantees. The University of Minnesota will hold two national meetings to bring together grantees, and will establish a learning collaborative that will enable grantees to share best practices. At the end of the grant, a compendium of best practices that have emerged through this work will be posted to a public Web site.