"I’m doing the best I can!": Nine pillars to support public health quality improvement adoption
To deliver the highest quality and most effective Public Health services an organization must start with developing a quality improvement mindset throughout the organization. But it can be difficult to carve out time when you’re constantly fighting fires. Nine pillars you need to focus on.
The primary focus of a Public Health Department is to protect and improve its community’s wellbeing. It must to do so by operating in an environment where all of its functions and programs are effective, efficient, and focused on its customers’ needs.
Public Health Departments are using Quality Improvement tools and techniques as a way to insure the improvement of services to their customers.
We are often asked "How can I add Quality Improvement to my already busy activity schedule? I am already doing the best I can without having to add another task!"
While it may seem like it is just another task at first, the public health departments that structure their daily activities, using quality improvement, find that in the long run they make their work less complicated and more effective. Quality Improvement is not an additional task; it is a structure to maximize our use of time and resources while focusing on delivering what our customers want and need.
Figure 1 (below) shows a graphic entitled "Public Health Operations" which contains nine pillars of emphasis that must be in addressed in order to have an effective and efficient public health Quality Improvement program. Quality Improvement is the central ingredient that sustains and improves these pillars.
A public health department that addresses each of these nine pillars, with a focus on quality improvement, will maximize the effectiveness of their programs. Using Quality Improvement tools and techniques plus having the people and organizational goals aligned will yield superior results.
Figure 1: Public Health Operations
To deliver the highest quality and most effective Public Health services an organization must start with developing a quality improvement mindset throughout the organization. Once this mindset is ingrained in the organization all actions are done with the objective of the creation and improvement of processes that maximize quality services and efficient delivery systems that are focused on their customers.
The nine pillars to focus on are:
#1: Operations Management:
Leadership support for improvement initiatives is a key component of developing a customer centric organization focused on Quality Improvement. Today’s Public Leader  "walks the walk and talks the talk" of Quality Improvement. They support and encourage quality improvement teams to solve the issues that lead to higher productivity and quality. Leadership is not just from the top. As Donald H. McGannon stated "Leadership is action, not position." 
Leadership of Quality Improvement permeates the organization where employees individually and in teams take charge of their contribution to public health. The entire Public Health team must be engaged in improving operations management. Everyone is a change leader. 
#2: Human Resources:
Motivated employees are our best asset to make change. With increasing demands on Public Health Departments to provide improved and cost effective services, we must help our employees understand the need for their participation in quality improvement efforts as part of their routine duties.
The best way to help our employees embrace their activities with quality improvement is to involve them in improvement efforts. Participation in change initiatives takes away the fear of change that many employees feel and increases job satisfaction. Departments that tap the involvement of their employees in quality improvement efforts will yield the best results.
A safe working environment is necessary for both employees and our clients. The physical environment and the procedures we follow must contain consideration for a safe delivery of service. This applies to medical as well as physical performance of service. Safety applies from how we handle medical waste to how we lift and move boxes. A look at how we handle safety issues will help us improve our work processes and yield a safer place to work and provide service.
Lean quality improvement efforts can be applied to the work environment to make it safer and organized to promote better delivery of services. A "Lean" workplace is conducive to safety . "Quality, delivery, cost, safety and morale (QDCSM) are all important goals at Toyota. Taiichi Ohno said that safety comes before everything else, but we must never forget that safety is the foundation of all our activities." 
Public Health Departments are required to follow strict regulatory guidelines at the Federal, State and Local level. Decisions must be in alignment with these requirements. Funding for and satisfaction with services provided must meet these standards. 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.
Accreditation of Public Health Departments is now a reality and emphasis is now focused on meeting standards that support the efficient and effective delivery of services. The accreditation process provides structure and guidelines for development of efficient and effective Public Health Departments.
The use of Quality Improvement tools and processes are in complete alignment with required compliance, creation, and documentation of accreditation standards. The work applied toward accreditation is really not more work on top of what we already produce. Quality improvement, in time, streamlines our work processes and increases effectiveness. In "business" terms, accreditation and Quality Improvement produce an ROI (Return on Investment).
#6: Customer Relations:
The focus of 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 Public Health activities and services should be focused on the customer. Do the actions of our health department demonstrate delivery of the highest quality processes that we can provide our community?
Increasingly, there are competing sources for services that Public Health Departments traditionally provide. Decisions must be made using customer satisfaction as a guide and then provide the services and deliver them efficiently and effectively to the customer.
How do we handle emerging competition that did not exist just a few years ago? We do it by soliciting customer feedback regularly and working toward satisfying customer needs. We study other successful models of delivery and adapt/adopt as necessary. The Quality Improvement Process guides our efforts at continuously improving customer satisfaction
#7: Cost Control:
More than ever, Public Health Departments are required to deliver the most cost effective services. More with less is the word of the day. Process improvement techniques help define, improve, and deliver these cost effective services. Additionally, these quality initiatives support the need for services with data that supports continuation, improvement, or addition of new services.
Clearly, departments that cannot document and support their activities will be under increasingly more pressure to justify developing cost effective services. Budgeting, forecasting and financial management are the primary areas where quality improvement processes can apply.
#8: Work Force Competencies:
We know that quality improvement work force competencies are increasingly being adopted in Public Health. Detailed studies are conducted to align the competencies of the workforce to the needs of Public Health organizations. The tools and techniques of quality improvement are used to diagnose and understand the gaps that may exist in the current workforce’s ability in the quality improvement arena. Once identified, these quality improvement tools can be used to design and deliver these need competencies of the public health department’s staff.
The best way to have customer focused services that are consistent and superior is to have a highly trained workforce. Clear job requirements for employees are a must in today’s environment. We know that our many dedicated employees are making their best efforts to deliver the services they provide.
Quality Improvement initiatives are used to assure that the processes and procedures we require of employees are consistent, efficient, and effective. Regular and consistent training helps align public health initiatives with performance of delivery of service.
Gone are the days of decisions without data and gone are the days of ineffective processes. Today’s Public Health Departments employ tools and techniques of quality improvement used in quality improvement teams to improve the delivery of all of their programs to their customer. Before any public health processes and services are provided, they must be created and maintained within a framework of Quality Improvement.
Using quality improvement processes as a core of our thinking and actions enhance all areas of Public Health Departments. The attitude of all employees that quality improvement is a necessary part of their daily activities is extremely important for long term adoption and success .
Quality Improvement is not an additional task or set of activities to be performed; it is a way of organizing our thoughts and actions to be most effective in delivering public health’s services to our communities. Over time, quality improvement efforts will yield the highest quality health outcomes at the best cost of delivery with the highest satisfaction.
We have analyzed each of the Nine Pillars to Support Public Health Quality Improvement Adoptionindividually but it is the sum total alignment with each of the nine pillars that we have identified to make your Public Health Department be the best it can be.
 Starting Process Improvement? Ten Tips for Senior Management H. Lenderman and J. Moran,PEX Process Excellent Network, UK, September 25, 2012, http://www.processexcellencenetwork.com/people-performance-and-change-in-process-improveme/articles/ten-tips-for-senior-management-when-starting-proce/&mac=SSIQ_OI_Featured_2011&utm_source=processexcellencenetwork.com&utm_medium=email&utm_campaign=SSIQOptIn&utm_content=9/25/12?elq=599a32ce88ed42d5ba8300ae5dd160c7&elqCampaignId=498
 The PDCA Cycle for Change Leaders, J. Moran and L. Beitsch, The Quality Management Forum, Summer Edition, 2012, Volume 38, Number2
 http://www.leanreflect.com/2007/12/safety-is-foundation-taiichi-ohno.html, accessed 10/28/2012
 Using QI Skills In Daily Work, John W. Moran, Grace Duffy, and Beth Pierson, The Quality Management Forum, Winter 2011, Volume 36, Number 4