1. Creating a Culture of Quality Improvement
Los Angeles County Department of Public Health
Division of Quality Improvement
Hello and welcome to An Introduction to Quality Improvement in Public Health, a course designed to provide you with a basic understanding of how quality is managed in a Public Health Department setting. Before we get started, please complete the pretest.
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2. Goal #1: Develop an understanding of what Quality looks like in Public Health

3. Quality in Public Health is…
The degree to which policies, programs, services, and research for the population increase the desired health outcomes and conditions in which the population can be healthy -PHQF, 2008
Before we can define quality improvement, we must first understand what is meant by the term “quality” when it comes to public health. Quality in Public Health is the degree to which policies, programs, services, and research for the population increase the desired health outcomes and conditions in which the population can be healthy.
In other words, is the work that we are doing to improve the health of Los Angels county residents actually making a difference? Have we seen improvements in the health of the population that can be attributed to the work that we are doing here at DPH?
For example…

4. Quality at LACDPH Quality is the result of Worthy Work Well Done
Worthy= We must have a clear direction (Strategic Plan)
Work= Our work should have an intelligent direction based on evidence and best practices.
Well Done= Our work should be carried out by a skilled and competent workforce and measured to track our performance.

5. Goal 2: Develop a clear understanding of Quality Improvement and why it is necessary

6. Quality Improvement
Quality Improvement (QI) is an integrative process that links knowledge, structures, processes and outcomes to enhance quality throughout an organization.
-National Committee for Quality Assurance
Quality Improvement is an integrative process that links knowledge, structures, processes and outcomes to enhance quality throughout an organization.
In other words….Quality Improvement is WORKING TO DO THE RIGHT THINGS RIGHT!

7. Why QI?
In a time of decreased funding and increased demand, QI can help answer key questions in public health:
Are we using our resources (staff, money, time) in the best way?
We often hear “work smarter, not harder”
Are we getting the intended outcomes?

8. Are we actually improving the health of the public in the most effective and efficient way possible? And if not, how can we do it better?

9. QA & QI -They are not the same!!!
Quality Assurance:
Quality Improvement:
Reactive; works on problems after they occur
Regulatory
Led by management
One point at a time
Proactive – works on processes before problems occur
Self-determined
Led by staff
Continuous
Exceeds expectations
Source: Public Health Foundation

10. 3 Levels of Quality Improvement
Topic
Organization-Level
Program-Level
Individual-Level
Improvement
System Focus
Specific project focus
Daily work level focus
Quality Improvement Planning
Tied to the Strategic Plan
Performance Measures tied to program-level Strategic Plan
Tied to yearly individual performance
Evaluation of Quality
Responsiveness to a community need
Performance of a process over time
Performance of daily work
Processes
Cut across all programs and activities
Delivery of a service
Daily work
Quality Improvement Goals
Strategic Plan
Individual Program level Strategic Plans
Individual Performance Evaluations

11. Importance of Quality Improvement
Quality Improvement positions an agency to achieve:
Customer satisfaction
Efficient use of resources
Measurable outcomes
Community impact

12. Connect staff with the benefits of Quality
Goal #3
Connect staff with the benefits of Quality

13. Quality in Public Health Benefits Everyone
Customers/Clients
Employees
The Organization

14. Benefits of quality to clients
Improved services
Improved choices
Expectations met or exceeded
Client oriented employees
Friendlier atmosphere
Give examples

15. Benefits of quality to employees
Pride in services delivered
Job satisfaction
Improved communications
Streamlined work processes
Happier clients
Strong client relationships
Give Examples

16. Benefits of quality to the organization
Improved/expanded services
Client oriented employees
Improved client relations
Improved community relations = better political relations
Lower costs/cost contained
Improved funding
Give Examples

17. Goal #4 Develop a clear structure and framework for quality management

18. Continuous Quality Improvement Efforts

19. Determine Priorities and Goals
What are the healthy behaviors and outcomes we want for people who live in LA County?
What would these conditions look like if we could see them?
Adapted from Mark Friedman’s “Results Accountability.” The questions on the left are the “big picture” questions that describe the general health goals we hope to achieve (Question 1) and specific conditions we plan to work on (Question 2). However, there will likely be more conditions to work on then we have time or resources to actually do. Here is where the need for strategic planning comes in...
Currently, we have guidance from the LA County Strategic Plan and a newly released DPH Strategic Plan that helps us prioritize goals. In addition, Division Directors may require each program to create its own strategic plan.

20. Performance Measures

21. Results Based Accountability
POPULATION INDICATORS
(measures of population-level
health outcomes)
PERFORMANCE MEASURES
(measures of program
effort and output)
AND
DPH and the Chief Executive Office use Mark Friedman’s “Results Accountability” approach for selecting goals and measures to assess the services we provide to the residents and visitors of Los Angeles County. This approach includes a quick and easy way to gain consensus on long-term goals and the actions/business processes needed to achieve them over time.
One of the benefits of this approach is that measures are separated into 2 categories:
Population-level indicators (with shared accountability); answers the question “How is the population better off?”
Program- and SPA-specific performance measures (program accountability); answers the question “How effective is the program?”
DPH will continue to use these 2 sets of measures and apply other selected “Results Accountability” principles in its PI efforts.
Four quadrant approach to program performance measures
Data development agenda
Headline measures
Public Health
Measures

22. Population Indicators
Longer life span
Increased quality of life
Increased health equity
Less disease
Less premature death
Healthier choices
Safer environment
Healthier homes
POPULATION-LEVEL
HEALTH OUTCOMES
& BEHAVIORS
How do we measure “success” in improving health at the population level? The list on the left includes currently accepted categories of health behaviors and outcomes. From these categories, Indicators can be created/written. The Indicator is the underlined portion, and we have specified the direction we want the Indicator to move in. Yellow indicates actual health outcomes, whereas white indicates upstream determinants of health (i.e. behaviors, built environment)

23. Population Indicators
Percent of students who had at least one drink of alcohol in the past 30 days
Rate of foodborne illness hospitalizations each year (per 100,000)
Percentage of children covered by health insurance
Death rate from colorectal cancer
All of these examples of indicators were taken from the current set of DPH Public Health Measures (except #4). The respective categories are:
Healthy choice/behavior
Less disease
Less premature death

24. Performance Measures Policies Created People Informed
Improved Behaviors
Surveillance Performed
Investigations Completed
Increased Access to Services
Client satisfaction
MEASURES OF
PROGRAM
EFFORT & OUTPUT
How do we measure our work?

25. Performance Measures
Percent of outbreaks (excluding scabies) investigated within standard timeframe
Percentage of children under 6 years who participate in fully operational population-based [immunization] registries
Number of cities that adopted a policy that prohibits smoking in outdoor areas
All of these examples of indicators were taken from the current set of DPH Public Health Measures. The respective categories are:
Investigations completed
Surveillance completed
Policies created

26. Reporting of Progress

27. Performance Improvement Process

29. Who Manages Quality at DPH?

30. Who Manages Quality at DPH
Everyone Plays a Role in Quality Management:
Director of Public Health
Division of Quality Improvement
Strategic Directions Council
Executive Team
Performance Improvement Team
Program Directors
Managers/Supervisors
All Staff

31. In order to establish a lasting culture of Quality, you must:
Have a clear direction of what quality should look like in your organization
Understand Quality

32. Goal #5:
Clearly communicate your Quality Improvement plan and efforts throughout the organization

33. Step 1: Create a Quality Improvement Program Description Document
Give an overview of Quality at the organization
Describe the structure for managing quality throughout the organization
Establish roles and responsibilities for all levels of staff in relationship to Quality Improvement efforts.
List and describe the organization’s QI efforts
Establish QI goals for the organization

34. Step 2: Train staff
Introduction to Quality Improvement for all employees
Incorporate QI into existing trainings
Conduct orientation sessions to orient staff to the QI Plan
Provide advanced QI training to prepare staff to conduct quality improvement projects

35. Step 3: Provide Support Technical Assistance 1:1 Consultation
Presentations at program-level meetings

36. Summary
In order to establish a culture of quality, you must first decide what quality in your organization will look like and communicate that vision to others
The structure and process for quality improvement should be visible and easily understood by everyone in the organization
Buy-in and support at all levels is essential to successfully establishing a culture of Quality

37. Thank you!
Emily Peach, MPH, CHES Performance Improvement Manager Quality Improvement Division (213)