A Culture of Quality: Is it Elusive?

We have been working on QI efforts for about the last two years, and feel like we have made great strides toward implementing a QI culture. What recommendations would you have not only for sustaining the gains that have been made, but also to continue to develop the skills of staff at all levels?

Response by Jim Butler

As Public Health Quality Improvement (QI) Consultants we are frequently asked by clients; “We are using QI tools and PDSA, but how do we know when we have created a culture of quality in our health department?”

Does this sound like you? There is a growing body of literature on what a public health culture of quality is and how it is created.  But for many of us, it remains elusive.   There isn’t a short snappy answer, but much of what constitutes a culture of quality is actually embedded in the practice of doing QI. If you want to peek at some literature, NACCHO has a Roadmap to a Culture of Quality Improvement that describes six key phases on a path to a QI culture available at (http://www.naccho.org/topics/infrastructure/accreditation/upload/QI-Roadmap-11-16-11.pdf).   Another great source is Michigan’s second edition of Embracing Quality in Public Health-A Practitioner’s Quality Improvement Guidebook, which has a new chapter devoted to Building a Culture of Quality in Public Health (www.mphiaccredandqi.org).

Whether you are new to QI or a seasoned practitioner, it’s important to remember that QI is not just a destination or one time project.  Rather, it’s a purposeful, but sometimes meandering journey that involves making improvements and learning more about your work—a lot more!   QI is iterative and works on processes related to the work we do each day. 

It is the everyday practice of QI that sets the stage for creating a culture of quality.  Doing QI changes the way you approach your work.  I can usually spot a person or team practicing QI.  They ask about data before making a change and look for root causes of the problem under consideration. They rely on aim statements and testing their theories of improvement. And they learn from their experiences without fear of failure by understanding that QI is as much about learning as making an improvement.  They simply learn and move on.   

So is that all there is?  Do we just need to practice QI to have a culture of quality?

Not exactly; a little more is required.

Leadership and management play a key role in creating a culture of quality.   A clear vision for QI, including a QI Plan is included in the department’s infrastructure and integrated into the Health Improvement Plan, Strategic Plan, Vision, Goals, and Objectives.  Leadership practices QI by example, provides time and funding for QI training, sponsors QI efforts, discusses QI with managers and staff, supports team QI efforts,  and most importantly celebrates and recognizes accomplishments.

Champions and mentors play a key role too.  Their enthusiasm and ability to provide encouragement and support for QI lend credence to the value of QI in our everyday work.

But the real catalyst for creating a culture of quality is YOU!  Not your supervisor, or some new policy and procedure, but you.  A culture of quality cannot be mandated; it must come from within the organization itself.  It may be reflected in the mission and documented in the QI Plan and practiced by using PDSA, but a culture of quality is an attitude and a set of values employed by all to improve the quality of the services provided and outcomes achieved.  It is accepting that we (management, staff, and clients) are all in this together working in harmony to operate to our fullest potential.  It is working in a trusting environment where everyone is treated fairly and has the same goals, to do the best we possibly can.  In the final analysis, it isn’t tools or a methodology, or policy and procedures that create a culture of quality; it is people—everyone counts!

One QI, one passionate person, one idea, and one small success are all you need to begin your QI journey. You can be the catalyst for your department!

I have noticed departments seeking to create a culture of quality apply the 4 basic QI Principles, and during their PDSA cycles ask the 3 Key Questions:

Principles Key Questions
  1.  Develop a strong customer focus
  2. Continually improve all processes
  3. Involve employees
  4. Mobilize both data and team knowledge to improve decision making
  1. What are we trying to accomplish?
  2. How will we know that a change is an improvement?
  3. What changes can we make that will result in improvement?

You’ll know you have a culture of quality when the 4 basic principles and 3 key questions are present and practiced each day by all staff as a regular part of work.

As you learn from doing QI, you progress toward that goal of a culture of quality.  Michigan’s QI Guidebook concludes by saying the best way to learn QI is to do QI, so I encourage you to…

Start Now.

Start Today.

Just Start.

That culture of quality you seek will not remain elusive for long!


Submitted by Gina Febbraro on

Along the lines of creating a culture of quality improvement, is there a measurement tool that we can use to gather baseline data on staff's knowledge, willingness and/or readiness to participate in performance management and quality improvement initiatives?  

Other than implementing QI principles to assess culture, is there a tool that we can use to do so?

I appreciate your thoughts!