CASE STUDY: INSTITUTIONALIZATION OF CONTINUOUS QUALITY IMPROVEMENT This case study presents an example of a local public health agency that adopted and institutionalized continuous quality improvement. As you read through the case, refer to the NACCHO Roadmap to a Culture of Quality Improvement (NACCHO, 2013) and consider these questions:

• ■   According to the NACCHO Roadmap, which elements of a CQI culture are present and which appear to be lacking?

• ■   What could the organization do to address elements that appear to be lacking?

• ■   What are three additional steps the organization could take to ensure sustainability of their CQI efforts?

CQI in a Local Public Health Agency: Macon County, North Carolina After becoming accredited through North Carolina’s accreditation program in 2008, the Macon County, North Carolina, Public Health Department began to focus on changing its quality culture. They established a QI council and part-time position for a quality program manager and began to implement a quality improvement program. Over the course of 2 years, they trained staff and leadership in quality improvement tools and methods, including Lean (see Chapters 4 and 5).

During this time, staff members completed small quality improvement projects, which helped them apply the concepts they were learning and secure buy-in throughout the organization. After staff were trained and had completed a few successful small-scale projects, the health department began focusing on “projects that would have a greater impact on the organization’s overall performance, improve patient/customer service outcomes, and achieve demonstrable cost savings.” One such project aimed to improve the appointment scheduling process by seeing all patients within 72 hours of requesting an appointment, while also improving patient and staff satisfaction. The team participated in a rapid cycle

improvement event (or, kaizen event) that involved using Lean and Plan-Do-Study-Act cycles, performing a gemba walk (direct observation of the work), creating work flow diagrams and detailed process maps, and generating and testing change ideas. Soon after, the clinics were scheduling patients for visits in less than 72 hours. Their no-show rates decreased, visit numbers increased, staff downtime decreased, and both patient and staff satisfaction increased.

Leveraging this success, the health department began to spread quality improvement initiatives to other areas of the organization and focused on projects related to the client feedback process, child health visit flow, and vaccine storage and management among others. To keep staff informed of the organization’s quality improvement work, as well as foster ongoing staff engagement, the health department keeps an electronic directory of their work (including project aim statements, meeting notes, process maps and flow diagrams, as well as other team-related communication) and highlights activities and results in the hallways of their organization. They also reinvest cost savings from the projects into other vital activities of the health department. Overall, the health department’s continuous improvement efforts have led to organizational efficiency as well as improved care and patient experience (Bruckner, See, & Randolph, 2013).

▶ Conclusions The need to improve the public’s health in the United States is evident. Although public health organizations are still early in the process of institutionalizing CQI compared to organizations in many other industries, they have made remarkable progress and adoption in the second decade of the 21st century, particularly with the support of accreditation locally and nationally. The increased attention placed on the adoption of CQI in public health is both timely and encouraging. Numerous factors are presented to explain the growth of CQI in public health and, most important, the substantial progress that has been made toward true institutionalization of CQI in public health. Among those factors is accreditation, with similarities to the impact accreditation has had on health care globally (see Chapter 12). Continuing to use

accreditation efforts to promote CQI and learning from health care and other industries will help accelerate widespread adoption and institutionalization of CQI. Public health organizations that adopt CQI to help employees work as a team, address gaps in performance by analyzing and redesigning processes, and encourage innovation to meet the needs of communities hold the promise for a healthier future, both in the United States and throughout the world.