Achieving a QI Culture Across a Public Health Agency

Summary

Impact Statement:

This initiative describes how quality leaders at the Salt Lake County Health Department challenged the status quo to transform organizational quality culture. Members of the SLCHD Quality Council identified a need to increase the health department's emphasis on quality after a review and discussion about the Building Blocks of a Quality Culture (Moran and Riley) and reviewing examples of QI culture development at other local health departments. The SLCHD QI project team implemented an agency-wide applied learning initiative that combined didactic QI training, a variety of facilitated conversations and implementation of "big QI and little qi" projects. Survey data captured before and after the initiative showed major improvement in self-reported perceptions of QI culture; greater in upper management than in middle management.

Summary:

After preliminary training on QI concepts, key SLCHD leaders assessed the overall quality culture in the agency by administering a QI building blocks survey and comparing upper management's responses to those from middle management. With a measure of the level in each area, SLCHD formulated the aim statement to improve the culture of quality, as measured by perceptions of upper and middle managers, before August 2013. Facilitated groups analyzed the identified areas needing the most improvement for each division: “process focus” for upper management and “empowerment” for middle management. In March, 80 managers met in groups to identify the most problematic issues, and they met again in May to identify solutions. After distilling the list and prioritizing solutions, they presented a proposal to the administration, who formally endorsed their recommendations. Solutions included such initiatives as rotating department committee membership, providing supervisory checklists to improve feedback, and planning for a new intranet for better interactions among programs. In August, a second survey was completed, and results showed that middle managers believed that the quality culture had improved in five areas, whereas upper managers believed that it had improved in all six areas.

Organization that conducted the QI initiative:

SLCHD

Citation:

Neville, B. Public Health Quality Improvement Exchange. Achieving a QI Culture Across a Public Health Agency. Fri, 09/15/2017 - 11:29. Available at https://www.phqix.org/content/achieving-qi-culture-across-public-health-agency. Accessed September 14, 2024.

Background and Aim

Planning and Execution Details

QI Implementation:

A survey was sent to 25 upper managers and 45 middle managers, asking them to assess their perception of six areas from the Building Blocks of a Quality Culture (Moran & Riley, n.d.): commitment, capability, understanding of customer expectations, empowerment, process focus, and institutionalization. Each building block was explained, and participants were asked to assign a rating: 0 = nothing in place; 1 = just getting started; 2 = moving in the right direction; 3 = adequate, good progress; 4 = very good performance; and 5 = found through organization. In addition to rating the current quality culture, the managers were also asked to identify what rating they hoped the agency would have 1 year in the future. Analysis of resulting responses showed that the lowest levels, as well as the greatest disparities between current and future levels, were in “process focus” for upper management and “empowerment” for middle management, so those two areas were singled out for emphasis, while acknowledging that all areas would be influenced by the initiative. The concept of empowerment is important according to Srinivasan and Kurey (2014), who said, "One of the defining traits of an organization with a true culture of quality is that employees are free to apply judgment to situations that fall outside the rules." In January 2013, facilitated groups analyzed process focus for upper management and empowerment for middle management. They used brainstorming and cause-and-effect diagrams to identify concerns and underlying causes. In March, 80 managers met in tables of 10 from a mixture of work assignments to identify more specific problematic issues they wanted addressed. In May, they met again to identify solutions to the concerns, and they generated an overall list of 80 possibilities. Then a smaller group, composed of one manager from each table, was invited to a focus group and, with a facilitator, distilled the list to 16 initiatives. A prioritization matrix was formed, and all 80 managers were allowed to rank weighted priorities via an online survey. The highest-ranking solutions were presented to SLCHD administration, who agreed to endorse the proposals. Srinivasan, A., & Kurey, B. (2014, April). Creating a culture of quality. Harvard Business Review. Retrieved from https://hbr.org/2014/04/creating-a-culture-of-quality

Focus activities

Administration:

Accreditation

Customer Service/satisfaction

Department management

Organizational effectiveness

Performance Management

Quality Improvement and Accreditation Readiness

Workforce development

QI Methods:

PDCA/PDSA Cycle (Plan, Do, Check/Study, Act)

Total Quality Management

QI Tools:

Brainstorming

Cause and Effect Diagrams

Prioritization Matrix

Radar Chart

Root cause analysis

QI Tool Documentation:

Storyboard of quality culture project

Results of post-survey compared with pre-survey

Initiative Dates:

6/19/12 to 8/31/13

Initiative Duration:

Between 12-18 months

Methods of evaluation:

The QI team used a pre-test/post-test evaluation design and repeated the initial survey after solutions were implemented. Participants again scored perceptions of quality culture based on the six Building Blocks of a Quality Culture (Moran & Riley, n.d.). As the interventions tested were aimed at enhancing just two of the building blocks, the QI team tested all of them to see whether other improvements were attained. The QI team analyzed the results to find improvements in each of the individual areas over 2012 levels, and they compared the forecast results for 2013 to the actual 2013 results.

Supplemental Materials:

Storyboard

Supplemental Files:

Attachment	Size
QI storyboard Poster Quality Culture.pdf	1.69 MB

Results

Measurable QI Outcomes:

Commitment: Middle management increased 3.4%; upper management increased 23.3%. Capability: Middle management decreased 14.1%; upper management increased 37.2%. Understanding of customer expectations: Middle management increased 4.0%; upper management increased 18.9%. Empowerment: Middle management increased 16.0%; upper management increased 42.5%. Process focus: Middle management increased 2.5%; upper management increased 49.1%. Institutionalization: Middle management increased 14.9%; upper management increased 58.8%. According to upper management's perception, quality culture improved in all six areas by an average of 38% over the 2012 levels. Actual 2013 levels fell within 17% of the forecast levels. According to middle management's perception, quality culture improved in five areas, with capability declining 14%. The five areas improved by an average of 8% over 2012 levels and fell within 27% of the forecast levels.

Other QI Outcomes:

The "capability" area decreased for middle managers after the initiative. This might relate to managers' impression of QI and training needs. The initial survey was made before any QI trainings occurred, and managers might have felt relatively confident in their own understanding of QI concepts. The post-survey occurred after four formal focus group sessions in which QI tools were introduced, and it is possible that managers by then realized that they needed training on several new concepts.

Lessons Learned, Observations and Insights:

The difference between the perception of quality culture by upper management compared with that of middle management was predictable, according to one management consultant. She noted that it was logical that middle management, being in positions of less power in the agency, would feel less empowered. The QI team members were not surprised that the middle managers generally rated improvements as less favorable than upper managers did. Given the discrepancy, even the modest increases in quality culture by middle managers were evidence of considerable success.

Future Plans:

The post-survey occurred after four formal focus group sessions in which QI tools were introduced. Ongoing efforts include a total of 16 items that the focus groups proposed and that the administration endorsed. The 16 items are in various stages of implementation; some are complete, such as the supervisory communications checklist, whereas others, such as a new intranet system, are waiting for technology development before they will be finished. The QI Council will re-evaluate after 1 year of implementation to assess progress with the 16 items.

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Submission Status:

Completed

Comments

Thanks for sharing your

Thanks for sharing your great work. As you are experiencing, changing an organization's culture takes time and effort, and clearly you all are doing a lot to train staff and engage them in QI activities. Given the importance of staff feeling empowered to make positive change, I'm curious about any plans you all have to focus on this particular aspect of a QI culture. I read the actions listed on the storyboard that you shared, and I wasn't sure if some of them were targeted for this purpose. Thanks in advance for any additional information that you can provide!

Link to the resource where this submission is also published:

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Achieving a QI Culture Across a Public Health Agency

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

Thanks for sharing your

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Achieving a QI Culture Across a Public Health Agency

Summary

Background and Aim

Planning and Execution Details

Results

Training and Preparation

Information about the Community

Information about the Health Department

QI Staff Information

Accreditation Details

Contact Information of the Submitter

Comments

QI Spotlight