Creating quality improvement culture in public health agencies

Objectives: We conducted case studies of 10 agencies that participated in early quality improvement efforts. Methods: The agencies participated in a project conducted by the National Association of County and City Health Officials (2007-2008). Case study participants included health directors and quality improvement team leaders and members. We implemented multiple qualitative analysis processes, including cross-case analysis and logic modeling. We categorized agencies according to the extent to which they had developed a quality improvement culture. Results: Agencies were conducting informal quality improvement projects (n = 4), conducting formal quality improvement projects (n = 3), or creating a quality improvement culture (n= 4). Agencies conducting formal quality improvement and creating a quality improvement culture had leadership support for quality improvement, participated in national quality improvement initiatives, had a greater number of staff trained in quality improvement and quality improvement teams that met regularly with decision-making authority. Agencies conducting informal quality improvement were likely to report that accreditation is the major driver for quality improvement work. Agencies creating a quality improvement culture were more likely to have a history of evidence-based decision-making and use quality improvement to address emerging issues. Conclusions: Our findings support previous research and add the roles of national public health accreditation and emerging issues as factors in agencies' ability to create and sustain a quality improvement culture.