The Nine Pillars of Quality Improvement

This assessment provides data for developing action plans to systematically improve the culture of quality within public health agencies. It is recommended that this assessment be conducted with a team of senior leaders. Come to consensus on each measure within the nine pillars. Upon completion, develop action plans for the lowest scoring pillars to continuously strive towards a culture of quality. This assessment could be conducted quarterly or annually to track progress toward the aim.

The Nine Pillars:

#1: Operations Management — Our leadership of Quality Improvement permeates the organization where employees individually and in teams take charge of their contribution to public health.

#2: Human Resources — We have involved and motivated employees that understand the need for their participation in quality improvement efforts as part of their routine duties.

#3: Safety ‐ We have a safe working environment for both employees and our clients. The physical environment and the procedures we follow contain consideration for a safe delivery of service. This applies to medical as well as physical performance of service.

#4: Regulatory ‐ We follow strict regulatory guidelines at the Federal, State and Local level. Decisions are in alignment with these requirements. Quality improvement initiatives help create processes that align the activities of the department with these requirements. Quality Improvement is also used to challenge and eliminate unproductive, overly complex or outdated policies and procedures that have been created to monitor and report achievement of regulatory requirements.

#5: Accreditation ‐ Accreditation is now a reality and emphasis is now focused on meeting standards that support the efficient and effective delivery of services. The use of Quality Improvement tools and processes are in complete alignment with required compliance, creation, and documentation of accreditation standards.

#6: Customer Relations ‐ The focus of our Public Health initiatives has always been to deliver the health related services that the community requires. Emphasis today is increasingly focused on “Customer Driven” activities and “Customer Satisfaction”. All our Public Health activities and services are focused on the customer

#7: Cost Control ‐ Our Public Health Department has the data to show it delivers the most cost effective services possible to our customers. Quality and Process improvement techniques help define, improve, and deliver these cost effective services.

#8: Work Force Competencies ‐ Our Public Health Department’s work force competencies recognize the need for all staff to have quality improvement skills. We have designed and deliver the needed QI skill courses to our workforce to increase their competencies and close identified skill gaps

#9: Training ‐ The aim of our Public Health department is to have a highly trained workforce that delivers customer focused services that are consistent. Quality Improvement initiatives are used to assure that the processes and procedures we require of employees are consistent, efficient, and effective. We conduct regular and consistent training helps align public health initiatives with performance of delivery of service.

Rate each component using the scale that follows. Specific PHAB Measures (version 1.5) have been noted in parenthesis. Rating Scale:

0 — nothing in place

1 — just getting started

2 — moving in the right direction

3 — adequate — have made good progress over the last year

4 — performing — processes and plans are in place

5 — It’s culture — performing and sharing results with staff and/or public health system partners

#1: Operations Management

The agency QI Plan defines roles and responsibilities for all staff related to leading and/or supporting QI efforts. (9.2.1.1)

Documented QI activities demonstrate how staff executed their roles in problem selection, cause identification, solution development, implementation of process changes, etc. (9.2.2) The health department regularly conducts a Public Health Performance Management Self‐ Assessment to determine the extent to which QI processes, staff engagement and visible leadership are apparent to all in the organization. (9.1.3.6)

#2: Human Resources

Employee retention programs include reward and recognition programs and employee satisfaction surveys. (8.2.2.3)

The agency has policies to assure supervisors’ encouragement of systems thinking, change management, data use for decisions, and a culture of quality improvement. (8.2.4.1) Completion of QI projects or progress on QI efforts are integrated into the employee expectation and evaluation (job description) process. (8.2.4.2)

#3: Safety

The health department implements processes, programs and interventions to assure that facilities are safe, accessible, and secure through regularly scheduled inspection reports. (11.1.7.2)

The health department conducts regular safety trainings related to topics such as fire, blood borned pathogens, safe (defensive) driving, and/or safe handling of materials.

#4: Regulatory

The health department documents efforts to ensure the consistent application of public health laws. (6.2.1)

The health department provides annual reports that summarize complaints, enforcement activities, or compliance. (6.3.4)

The health department provides (and documents) information to regulated individuals or entities about their responsibilities related to public health laws. (6.2.3)

#5: Accreditation

The health department has a quality improvement plan that includes all required elements. (9.2.1)

The health department documents implementation of quality improvement activities. (9.2.2) Staff participation in quality improvement activities is based on the QI plan. (9.2.2)

#6: Customer Relations

Each program within the department has clearly defined who the customer is.

The health department has a process to capture and analyze customer feedback in order to address the expectations of various public health customers. (9.1.4)

The health department takes action based on the feedback. (9.1.4)

#7: Cost Control

Goals and objectives are set for financial management systems.(9.1.3.2)

Financial reports are developed and distributed at least quarterly and reviewed by senior management with a QI lens and framework for cost control. (11.2.3.2)

QI projects routinely monitor costs or cost savings as a standard measure of achievement.

#8: Work Force Competencies

The agency has a written plan to assess workforce competencies using nationally adopted core competencies. (8.2.1.1)

Assessment data are used to develop plans to close gaps in capacity and capabilities. (8.2.1.1)

Position descriptions include the public health core competencies required for the position as well as QI participation expectations.(8.2.2.4)

#9: Training

Types of quality improvement trainings and their audiences (participants) are clearly outlined in the written QI plan. (9.2.1.1)

The health department documents its staff development in the area of performance management. (9.1.5.1)

Continuous training in QI is provided to meet needs at various levels and experience. (9.2.1)