QI Spotlight

Authored by: Grace Gorenflo, PHQIX Expert Panel Member

Public health departments make improvements all the time. Improvements come in many forms; for example, staff find new venues for outreach activities, sharpen risk communication messages, form new partnerships, reconfigure their workplace to use space more efficiently, and revise staff schedules to meet client and program needs. Improvements may be driven by findings from after-action reports, program evaluations, customer or employee satisfaction surveys, or performance management activities. Improvements may also occur simply because staff decide to address a problem that hinders their ability to work efficiently and effectively.

Quality improvement (QI) is a formal, structured way to address problems. It involves using a defined improvement process (e.g., Plan, Do, Check, Act cycles; Kaizen; Lean Six Sigma) to identify the underlying cause of a problem, test solutions, and achieve measurable improvements. Anyone who has engaged in QI knows that it requires expertise, a team’s time and energy, and ongoing efforts to monitor and hold the gains. Given the demands of a QI effort, it is important to understand when QI is needed to achieve an improvement—and when it is not. 

When QI Is Not the Answer

Before committing a team to undertake a QI process, it helps to determine whether an improvement can be made another way. The following are examples of when QI is not a suitable pathway to improvement:

Personnel problems exist.

A central tenet of QI is that it is about the process, not the people. What this means is that the focus of QI is on making process improvements, not “weeding out the bad apples.” If an employee is underperforming or not following established policies and procedures, it is important to directly approach the problem as a human resource issue. Individual performance plans and reviews are a valuable tool to address employee performance. When a QI process is used without addressing known performance issues, a few things can happen. For example, if someone is clearly not performing well, it could potentially undermine leadership’s assertions that QI is not about weeding out bad apples. In addition, any new process designed could accommodate underperformance and therefore fail to achieve optimal efficiencies.

Employees do not follow the same process.

One of the first steps in a QI effort is to map the process. At that point, teams sometimes find that an established process does not exist, or it does exist, but employees are unaware of it. When teams find themselves in this situation, the focus should shift to developing and documenting a process and providing standardized training for all staff. Likewise, if the team knows that an institutionalized process does not exist, then they do not need to undertake a QI effort; rather, they should work to develop and establish the process.

A plan does not exist.

In working toward accreditation, many health departments are developing strategic plans; community health improvement plans; and plans for workforce development, performance management, and QI. Generating plans when none existed is definitely an improvement; however, a QI process is not needed to do this work.

Problems have pre-determined solutions.

We have all experienced a time when a problem arose, and “the boss” unilaterally identified the solution (which is certainly the boss’s prerogative). Situations like these call for transparency from the person in charge, and the solution should simply be implemented without any pretense regarding the use or value of employee input. Putting a QI team through the motions not only wastes a significant amount of time, but it also could cause trust issues and damage employee morale.

Solutions are self-evident.

What should you do if phones are not answered in a timely fashion, a piece of equipment that needs to be centrally located always ends up in someone’s office, or customers complain because a service counter is always too backed up during peak hours? Knowing that a team needs to be involved in identifying an improvement, one may think that QI is in order. However, the aforementioned scenarios are examples of problems that most likely have a somewhat obvious cause and an easily identifiable solution. For example, staff can develop a schedule that ensures that the task of answering phones promptly is divided among them, they can agree on a better location to store equipment or institute a sign-up sheet, they can cross-train and assign staff to assist when additional “hands on deck” are required to provide sufficient customer service, or they can draft and implement a new policy or procedure. If a solution to a problem appears to be self-evident, give it a try. Staff can be engaged to brainstorm, divvy up responsibilities in a mutually agreeable way, and decide how to hold each other accountable without going through a formal QI effort. 

When QI Is the Answer

QI offers a systematic, powerful way to address a number of problems, especially when data indicate that the department is not achieving desired results. QI is especially useful when the cause of a problem is not apparent, because it is designed to carefully explore a problem and identify its underlying cause, thereby avoiding the potential to treat only a “symptom” and miss the root of the problem. QI is also designed to ensure that the most efficient, effective process is designed, tested, and used by all staff members who touch the process. With a QI approach, the team members know whether the desired improvement has been achieved because they measure the results of their work and monitor the process over time. Some examples include the following:

  • Specific tasks or a set of tasks are not completed in a timely fashion (e.g., processing vital records, conducting inspections).
  • Many errors are made (e.g., inaccurate coding or laboratory results).
  • Specific targets are not achieved (e.g., too many children are not age-appropriately immunized).
  • Expenses have unexpectedly increased (e.g., those associated with inventory or transportation).
  • Outcomes are inconsistent (e.g., the number of completed inspections varies significantly from quarter to quarter).
  • The process is cumbersome (e.g., staff complain that too much paperwork is involved or that too many approvals are needed).

These represent only a handful of examples of issues that a QI project could best solve, and this is by no means an exhaustive list. Rather, this list is intended to help illustrate the types of situations when it is appropriate and desirable to assemble a team to conduct a QI effort.

QI can be a powerful tool to make many types of measurable improvements; however, a QI approach can sometimes be unnecessary, inefficient, and even counterproductive. Carefully considering the best approach to making an improvement will help ensure that the “juice is worth the squeeze” when you and your team decide to engage in a QI effort.

Acknowledgment: Thanks to Marni Mason, MarMason Consulting, and Becky Sechrist, Minnesota Department of Health, for sharing training materials that contributed to this document.


Gorenflo, G. & Madamala, K. Is the Juice Worth the Squeeze? Deciding When to Use QI. Wed, 03/14/2018. Available at https://www.phqix.org/content/juice-worth-squeeze-deciding-when-use-qi.




Authored by: Gurleen Roberts, Cobb & Douglas Public Health, and Ty Kane, Incite Health LLC

To truly have a culture of quality, ongoing quality improvement (QI) efforts must be occurring at all levels of the agency, from executive leadership to front-line staff. This article attempts to provide public health practitioners with a step-by-step approach for choosing a QI project. 

Practical Strategies for Choosing a QI Project

This three-step approach can assist in choosing a QI project by generating and prioritizing a list of ideas.

Phase 1: Consider Potential Starting Points

To begin, it is important to pay attention to existing agency activities that could reveal the need for improvement. Observing an agency’s operational patterns and addressing the root causes is likely to have a ripple effect—improving multiple processes and growing the culture of quality. Here are some common information sources that can be used to generate topics for a QI project:

  • Are there performance measures in your agency’s performance management system that need improvement?
  • Do recent customer or employee satisfaction results highlight an area needing improvement?
  • Are there opportunities to practice QI while also helping your agency prepare for accreditation or reaccreditation?
  • Does your agency’s QI plan contain QI goals or a calendar of QI projects?
  • Did any program data, such as an audit or report, reveal an opportunity for improvement?
  • Have staff or customers been asked directly for their improvement suggestions?

Whether you’re referring to customer satisfaction data or a review of performance measures, this step helps to ensure that the team has considered these common existing agency activities for potential improvement areas before brainstorming.

Phase 2: Brainstorm Ideas for a QI Project

If you could generate several ideas for a QI project from Step 1, this step may be skipped. However, if you’re looking to generate more ideas, brainstorming is an easy way to cultivate creativity and innovation by allowing participants to build on each other’s ideas, think openly, and challenge the status quo, and it gives all participants an equal voice in the process. This type of creative thinking is important in public health because it gives agencies opportunities to maximize their internal resources and increase their impact on their communities’ health.

Here’s how you can try it yourself:

Supplies: sticky notes, markers, flipchart, or wall

Participants: all members of one program, department, or team

Team Supervisor or Authority Figure (not attending): It helps to ask the team supervisor to not attend the brainstorming session to allow staff the opportunity to share their opinions without perceiving judgement.

Facilitator: It helps to include a neutral party that is not participating in the activity, such as a Quality Council member or someone from a different part of the organization. 

Steps for Phase 2

Example: What are some ways the clinic can reduce the amount of time it takes patients to check in and register upon arrival?

Figure 1: Brainstorming and categorizing responses into similar groups

1. Write the main brainstorming question at the top of the flipchart, and ensure that everyone understands the purpose of the brainstorming session

2. Ask each participant to write down one idea per sticky note, ensuring that everyone submits at least one response.

3. Stick ideas on the flipchart under the question, grouping similar ideas together (as shown in Figure 1).

4. Read responses aloud, and ask for clarity if needed.

Responses (grouped in the following categories):

  • Ensure that pre-visit preparation steps support efficiency upon patient arrival.
  • Standardize the check-in sheet and improve visualization of the check-in window, so patients can easily understand how to check in.
  • Standardize registration paperwork to include only necessary information for all visit types.
  • Improve communication between check-in staff and registration staff to reduce the time it takes between these steps.

Phase 3: Prioritize Ideas

Now that a list of potential QI projects has been created, it can be prioritized systematically to ensure that the most important issues are fairly addressed. A systematic prioritization, done by a staff team, is transparent and defensible, and it promotes buy-in from participating staff. A prioritization tool, such as a matrix or a Pareto chart, can be used to rank a list of projects in order of importance based on criteria that the agency determines to be significant. If using a matrix, weighted scores can communicate the preference of certain criteria over others. For best results, modify the criteria to your agency’s needs.   

Potential criteria to consider include the following:

  • Urgency of process improvement (other services depend on it, it affects essential public health service delivery, the state mandates it, etc.)
  • Strategic alignment (community health assessment/improvement plan, strategic plan, QI plan, performance management system, workforce development plan, reaccreditation or accreditation, agency policies, etc.)
  • Impact on stakeholders (think of impact as the number of additional departments, processes, and/or stakeholders benefiting from this improvement, etc.)
  • Resources needed to complete (staff, funding, time, etc.)

Now, it’s your turn! Consider the following:

Supplies: sticky notes of project ideas from the brainstorming activity, marker, flipchart, handout of selected criteria (optional)  

Participants: all members of one program, department, or team who participated in brainstorming ideas

Team Supervisor or Authority Figure: It will help to include the team supervisor in the prioritization step because he or she can provide insight into the effort required for the project.

Facilitator: It is helpful to include a Quality Council member or someone with performance management or strategic planning expertise to align efforts with existing QI projects and agency priorities.  

Steps for Phase 3

1. Before the prioritization session, determine which prioritization tool and criteria to be used. Print the tool with the criteria for participants’ reference. Also, draw the tool on a flipchart.

2. During the prioritization session, review the tool and criteria to ensure that everyone understands the purpose of the prioritization. Place the sticky notes from the brainstorming session onto the flipchart tool.

3. In small groups, ask participants to evaluate the first project based on how well it fits the criteria on the tool handout. Repeat for all projects and total project rankings.

4. Once everyone has finished, discuss responses for each project as a group and write the final consensus on the flipchart.

5. Focus the first Plan, Do, Study, Act cycle on the highest-scoring project, and once that project is complete, move to the project scoring the second highest, and so on.

Example: What are some ways the clinic can reduce the amount of time it takes patients to check in and register upon arrival?

Prioritized list of projects based on these criteria (urgency of process improvement, strategic alignment, impact on stakeholders, resources needed to complete):

  1. Standardize the check-in sheet and improve visualization of the check-in window, so patients can easily understand how to check in.
  2. Improve communication between check-in staff and registration staff to reduce the time it takes between these steps.
  3. Standardize registration paperwork to include only necessary information for all visit types.
  4. Ensure that pre-visit preparation steps support efficiency upon patient arrival.

Next Steps

PLAN: Now that you have chosen a QI project, you can begin planning it with the QI framework of your choice.

REVIEW: Keep this documented list of prioritized projects so that after the first project is completed, the team can refer to the list and start on the next QI effort without hesitation.

REVISE: Prioritize projects annually to plan for improvements for the upcoming year. This will encourage sustainability and support the creation of a manageable project plan with a timeline, goals, and objectives for one QI effort at a time.

By systematically prioritizing these improvements, participating staff have a voice in the process and are engaged before the project begins, increasing the likelihood of successful completion. 



Roberts, G. & Kane, T. Choosing a QI Project. Wed, 03/14/2018. Available at https://www.phqix.org/content/choosing-qi-project.




QI Spotlight Icon Although the value of immunizations is unquestionable among public health and medical practitioners, communities across the country continue to experience challenges achieving the Healthy People 2020 goals for age-appropriate vaccination levels. At the time of this writing, there are 12 Quality Improvement projects on PHQIX on the topic of childhood immunizations. Six of these projects have a specific aim statement related to increasing immunization and/or reducing missed opportunities to vaccinate children and adolescents 1. Health departments can benefit from learning strategies that have been tested as part of these QI efforts and that potentially can be adapted and adopted in other community settings. The following brief synthesis highlights themes across these six projects, provides documentation that may be helpful to health departments seeking to improve vaccination levels among children and adolescents, and includes links to the PHQIX submissions for those who would like additional information.

Root causes of the problem

Root causes of low immunization rates were specific for each particular QI project; however, there were several themes that emerged. Minimal knowledge of current immunization recommendations & reporting requirements was noted by schools and parents. Another theme was that both staff and clients had a limited understanding of immunization services that were available. Several projects noted an inconsistent assessment of immunization status or lack of a standardized immunization tracking system by either health department staff or schools. Finally, skepticism by parents about vaccine side effects and effectiveness, and inconsistent information provided to clients was also noted.

Implementation Strategies

A variety of strategies were implemented by health departments, schools and health care providers to address these root causes and assist in increasing immunization rates among children and adolescents. Training for health department staff was provided. Educational materials and presentations specifically for parents and clients were developed and disseminated. Several health departments implemented surveys to either parents, health care providers or department staff. Health departments also revised immunization related policies and procedures such as standardized tracking sheets and a WIC immunization referral check list. Adding more immunization clinics and advertising them to schools was another strategy implemented by health departments.

The following chart below summarizes the primary root causes and accompanying strategies. Resources generated by these QI efforts are provided below.

Primary Root Causes Revised Policy & Procedures Educational materials for clients Training & educational materials for staff Additional Immunization Clinics
Minimal knowledge of current immunization recommendations & reporting requirements X X X
Limited understanding of services offered by both staff and clients X X X
Inconsistent assessment of immunization status or lack of a standardized immunization tracking system X X
Skepticism by parents about vaccine side effects and effectiveness X X X

Resources developed from PHQIX QI projects to improve immunization rates in children & adolescents

Immunization Policy and Procedures for Health Departments

Immunization related Surveys for Parents, Providers and Staff

Immunization related materials for working with Schools

PHQIX QI Projects to Increase Immunization Rates among Children and Adolescents

Thank you to the following Health Departments who shared their QI projects & resources.

Green Lake County Department of Health and Human Services
Avoiding Missed Opportunities: Immunizing Adolescents in Green Lake County

Kittitas County Public Health Department
Immunization Status of Adolescents in Kittitas County: Immunize at Every Opportunity

Southeast Health District
Improving the Immunization Rate for Children Seen in Public Health Clinics

Spokane Regional Health District
School Immunization Record Review Project

St. Clair County Health Department
WIC Immunization Referral Process

Sullivan County Public Health Services
Improving School Entry Immunization Rates in a Rural New York County

1 The aim statements for the six other Childhood Immunization QI Projects were focused on increasing the efficiency and accuracy of immunization records as well as improving the management of vaccine inventory.



Madamala, K. & Gorenflo, G. QI at Work: Strategies to Increase Immunization Rates among Children and Adolescents. Thu, 04/20/2017. Available at https://www.phqix.org/content/qi-work-strategies-increase-immunization-rates-among-children-and-adolescents.




QI Spotlight Icon High-performing health departments continually improve by assessing the quality of programs and services and by acting on identified opportunities for improvement. Customer surveys are a common method to capture real-time information and data about the quality of programs and services from the viewpoint of those being served. If planned and executed carefully, customer surveys can capture customer feedback that can then be used to plan for improvements.

1. Conducting a Customer Satisfaction Survey

Measuring Customer Satisfaction: Nine Steps to Success is a resource developed by the Association of State and Territorial Health Officials (ASTHO) to help users prepare and implement surveys, then act on the results (ASTHO, 2014). The toolkit includes useful examples and an easy-to-use nine-step guide to conducting a survey from start to finish. The following summary lists ASTHO’s nine steps to success and provides examples of each step from Prentiss County (Mississippi) Health Department’s PHQIX submission titled "Prentiss County Customer Service Satisfaction Project."

9 Steps to Success

Background: Historically, Prentiss County has had low participation in the Women, Infants, and Children (WIC) program among eligible residents. This led a quality improvement (QI) team to consider root causes of the low participation numbers.

Step 1: Identify the Purpose of the Survey
The survey’s purpose was to examine factors related to client satisfaction in the Prentiss County WIC clinic and identify potential barriers to participation in the WIC program.

Step 2: Select a Program (or Set of Programs) and Identify Customers To Be Surveyed
The customers surveyed were WIC participants and clients.

Step 3: Determine How Results Will Be Used
The QI team planned to use results to gather data and help identify areas for improvement to promote overall client satisfaction and access to WIC program services.

Step 4: Determine Your Budget and Plan within It
This QI project was conducted as part of the National Network of Public Health Institutes Quality Improvement Award Program, an initiative that promoted shared learning by providing small grants ($5,000) to selected health departments to conduct a QI project designed to result in measurable change. In addition to the grant, individualized, distance-based coaching was part of the award.

Step 5: Identify People To Include in Survey Planning and Implementation
The WIC QI project team planned and implemented the survey. The QI team included a QI coordinator, chief nurse, district nutritionist, district administrator, warehouse clerk, and senior epidemiologist.

Step 6: Design the Survey
Survey questions were designed to examine clinic wait times and environment, staff attitudes toward clients, quality of care, client satisfaction, and client service practices in the WIC clinic from the perspective of WIC participants.

Step 7: Select Survey Administration Methods
A broad needs assessment survey was conducted during spring 2013. The two-page paper survey was administered in the clinic setting to as many WIC participants and clients as possible. A post-intervention client satisfaction survey was conducted 3 months after the start of the project.

Step 8: Pilot and Modify the Survey before Full-Scale Rollout
The QI project team indicated that this survey was based on surveys used elsewhere; presumably, the Prentiss County team did not pilot the survey before implementation.

Step 9: Analyze the Data, Report, and Follow Up
The pre-intervention survey revealed long lobby wait times, staff with poor attitudes, and disrespectful employees. Using quality tools and Plan, Do, Study, Act, the QI team provided training to WIC clerical staff to reduce wait times, to develop “courtesy phrases” for WIC clerical staff to use when clients visit the WIC clinic, and to reassign staff as needed. A follow-up satisfaction survey was conducted and revealed improvement in the percentage of clients who were satisfied during their visit to the clinic.

More information about Prentiss County’s QI project can be found at https://www.phqix.org/content/prentiss-county-customer-service-satisfaction-project.

2. Tips To Plan and Implement a Survey

Tip 1: Stay true to the overall purpose of the survey as you design the survey questions. If you are interested in conducting a survey to measure customer satisfaction, consider using these key topics listed in Measuring Customer Satisfaction: Nine Steps to Success:

  • Speed of service
  • Staff professionalism
  • Availability of staff, services, or products
  • Customer care
  • Product or service quality

Tip 2: Carefully consider the advantages and disadvantages of various survey distribution methods. Common distribution methods include direct mail, suggestion drop boxes, convenience sampling, or group administration. In Measuring Customer Satisfaction: Nine Steps to Success, ASTHO presents this summary of survey administrative methods.

MetricMail SurveysE-mail or Web-Based SurveysTelephone SurveysIn-Office Paper Surveys
Response rate Low Moderate High Moderate
Speed Slow Very fast Fast Very fast
Cost per completed survey Low Lowest High Low
Anonymity High Questionable None Questionable
Ability to clarify survey questions and responses None None High High
Administrative bias Limited Sample bias Interview bias Sample bias

Tip 3: Consider using free or inexpensive survey tools to collect and analyze survey data. Data collection and analysis can be time consuming. Tools like Survey Monkey, Qualtrics, or Google Forms can be invaluable as you gather and review completed surveys.

3. Customer Focus as an Agency Priority

High-performing public health departments have a strong customer focus. A customer-focused agency should possess an overall strategy for customer engagement, linked to its strategic plan, that answers the following questions:

  • How do we identify our customers?
  • How do we capture and analyze customer feedback?
  • How will we take action based on customer feedback?

Embracing Quality in Public Health: A Practitioner’s Quality Improvement Guidebook (Tews, Heany, Jones, VanDerMoere, & Madamala, 2012) encourages public health agencies to develop a strong customer focus, using customer input to improve public health programs and services.

4. Other Examples from PHQIX Submissions

These PHQIX submissions highlight the crossroads between customer satisfaction and QI in public health practice.

Examples from PHQIX

Allegan County (Michigan) Health Department (ACHD)
ACHD wanted to hear from its customers before making programmatic changes, but its staff knew that only 33% of health department programs used a standardized client satisfaction survey process. Using QI, ACHD increased the percentage of programs that offered a systematic client survey process, resulting in the availability of valuable feedback from clients, which has enabled ACHD to improve services to better meet community needs. The QI team sought to increase the percentage of ACHD’s programs that implement the department-wide survey process from 33% to 75% to give clients and stakeholders an opportunity for input. A total of 347 surveys were returned during the 4-month project period. As a result of this initiative, 90% of ACHD programs had surveys returned, and the percentage of all team members who adhered to the survey process increased from 33% to 81%.

Clackamas County (Oregon) Public Health Department (CCPHD)
During a 4-day Kaizen event, the team at CCPHD designed and implemented a division-wide customer feedback system. The aim of the project was to increase the number of client feedback forms (from 8 to 43 per month) submitted across all programs and services. The Clackamas County team also wanted clients to gain confidence in the customer feedback system and raise staff awareness about the process to solicit feedback from the individuals they serve. Although the project team did not achieve its target number of 43 completed feedback forms per month, they did almost triple the number of forms returned. The initial project raised staff awareness about customer satisfaction, and staff members continued to be engaged and committed to increasing the number of completed customer feedback forms, then acting on customer feedback recommendations. Additionally, staff and managers within the organization continue to review customer feedback to identify opportunities to make process improvements.

5. Resources

Association of State and Territorial Health Officials (ASTHO). (2014, April). Measuring customer satisfaction: Nine steps to success. Retrieved from http://www.astho.org/Accreditation-and-Performance/Measuring-Customer-Satisfaction/Home/

Tews, D. S., Heany, J., Jones, J., VanDerMoere, R., & Madamala, K. (2012, January). Customers, clients, and stakeholders. In Embracing quality in public health: A practitioner’s quality improvement guidebook (2nd ed.) (pp. 17–23). Retrieved from https://www.mphiaccredandqi.org/wp-content/uploads/2013/12/2012_02_28_Guidebook_web_v2.pdf



Kane, T. Using Customer Satisfaction Surveys to Assess the Quality of Programs and Services. Sat, 05/20/2017. Available at https://www.phqix.org/content/using-customer-satisfaction-surveys-assess-quality-programs-and-services.





QI Spotlight icon

Many quality improvement (QI) projects start as simple ideas, and although objectives may have been set to achieve specific goals, the objectives are often vague. A successful QI project, regardless of how small or large, consists of well-defined goals and objectives. Goals are high-level statements of what an organization hopes to achieve (Terris, 2015). Objectives are created by breaking down goals; thus, objectives are more detailed and limited in scope than goals (Terris, 2015). Although goals and objectives are both essential in framing the work involved in the project, objectives provide a roadmap to the activities that need to occur.

Within the makings of a QI project, once the goal statement is complete (see the first QI Spotlight article: What are goal and aim statements and why are they important), defining SMART objectives will help move the idea into action. This transition from planning to action occurs because objectives provide the project with a direction so that a clear process improvement can be planned. The clearer the objectives, the more successful the project will be.

Gurleen Roberts, author
Gurleen Roberts

What are SMART objectives?

SMART is an acronym for:

  • Specific: focused, detailed, and defined so that the direction of the project is obvious and resources can be allocated appropriately. The language used needs to be clearly defined so that anyone reading the objective can understand exactly what the writer meant.
  • Measurable: quantifiable and/or descriptive values addressing issues such as quantity, quality, cost, satisfaction scores, and percentage of improvement (Terris, 2015). This part of the objective will allow everyone to know exactly what is intended to be measured and compared from baseline to post-implementation.
  • Achievable: feasible and within reach of current roles, responsibilities, and available resources. If you don’t have control of or influence on the suggested improvement, don’t waste your time because it will demotivate those involved in the project. Objectives should be challenging enough to inspire people, but not too challenging that they are out of reach (Zahorsky, 2014).
  • Relevant: related to the goal the project is trying to achieve, and linked to the organization’s mission (Terris, 2015). By directly linking the objective back to the goal statement, the project is strengthening its foundation for success. It’s important to make sure that the project aligns with the organization’s overall mission so that the impact from the project can potentially affect other parts of the organization, and resources and leadership support can be maximized.
  • Time-bound: specific time frame to create project boundaries and help keep the project on track (Centers for Disease Control and Prevention, 2011). This piece keeps the project focused and can range from a few days to a few months. Having a start and end date can also help the project move into the evaluation phase so that it’s not stuck in the planning and implementation phases.

Why use SMART objectives?

SMART objectives provide a plan. Writing a SMART objective on paper is the first step toward achieving that objective; this means that the team is on the same page and the project can now move forward. SMART objectives can also provide transparency for individuals outside of the project to understand the focus of the improvement. In addition, SMART objectives can direct future projects in order to reduce repetition and foster continuous quality improvement.

How do you write a SMART objective?

Keep it simple! The purpose of SMART objectives is to avoid writing vague objectives. Although each objective should consider all five components, it does not have to fit into one sentence. The SMART format helps others who are reading your objectives to know exactly what you are planning to do.

Here are some example objectives:

Not so SMART: We want to decrease patient wait times in our health department.
SMART: Over the next 30 days, we want to decrease patient wait times by 25% in our health department by allowing the front-desk clerk to check patient IDs and insurance cards immediately upon check-in.

Not so SMART: We want to increase the number of customer satisfaction surveys collected.
SMART: By allowing customer satisfaction surveys to be completed online and/or on a health department tablet before check-out, in addition to existing paper-based surveys, we hope to increase the number of surveys collected by 30% in the second quarter of fiscal year 2015. The health department clerks will remind and assist customers in completing this survey.

Here is a list of questions to assist in molding simple objectives into SMART ones. Keep in mind that not all of these questions have to be answered in your objective; they are simply listed to help guide your thought process.

Objective Transforming Questions
Specific What do you want to accomplish?
Who is going to help?
How do you plan to do this?
Measurable How will you know a change occurred?
Can these measurements be done?
Achievable Do you have the resources needed to succeed?
Who is going to help?
Is leadership approval needed?
Is the goal set too high or too low?
Are there any barriers?
Relevant Do you know the boundaries related to this objective?
Is this related to the goal we are trying to achieve?
Will the organization benefit from this?
Time-bound When do you plan to do this?
For how long?
When will you stop to evaluate?

What do you do with a SMART objective once it is developed?

Now that SMART objectives have been developed, they can be used to create activities for the project. Each objective commonly has between one and three activities.

For example, activities for previous SMART objectives are listed below:

SMART objective: Over the next 30 days, we want to decrease patient wait times by 25% in our health department by allowing the front-desk clerk to check patient IDs and insurance cards immediately upon check-in.

Activities: train the front-desk clerk on the new process, display signs to educate patients on the new process, ensure that the front-desk clerk has the tools needed to succeed in improving the new process, and so on.

SMART objective: By allowing customer satisfaction surveys to be completed online and/or on a health department tablet before check-out, in addition to existing paper-based surveys, we hope to increase the number of surveys collected by 30% in the second quarter of fiscal year 2015. The health department clerks will remind and assist customers in completing this survey.

Activities: create an online survey that can be accessible, ensure that the health department has a tablet for patients to use, ensure that the tablet is secure so it doesn’t get stolen, train clerks on the new process, ensure that the health department has wireless Internet access so the survey can be accessed through the tablet, and so on.

Examples of SMART objectives in action

Many QI projects using SMART objectives have been submitted to the PHQIX website. Although the submissions do not have a specific "SMART objectives" section, objectives can be found in the aim statement section of most submissions. Listed below are a variety of different types of SMART objectives used in various QI projects.

Electrifying the Adolescent Pregnancy Prevention Program Evaluation

SMART objective: Reduce the number of process steps by 50% by May 31, 2018.
  • This is a good SMART objective because it has a time frame and is simple, specific, and measurable.

SMART objective: Decrease the turnaround time to 6 months or fewer for 90% of first draft evaluation reports by December 31, 2016.

  • This SMART objective is achievable because it has a set goal for 6 months, and it guides the project to reduce the time to even fewer than 6 months, if possible.

Increasing Enrollment in the Early Intervention Program

SMART objective: Increase the percentage of completed mini-applications from 80% to 85% by July 1, 2013, and to 95% by January 1, 2014.
  • This is a great SMART objective because it has incremental mini-objectives within the larger objective. These mini-objectives help guide the project over a longer period so that momentum is continuous.

SMART objective: Decrease the staff time necessary at the Early Intervention Program and the Evergreen Health Insurance Program to monitor data exchange from 40 hours per month to 10 hours per month by April 1, 2014.

  • This SMART objective provides a great example of how to use a different type of measurement: the number of hours spent per month.

The Cleveland County QI Collaborative in Increased Community Engagement

This is another format for writing a SMART objective, with multiple objectives within the same time frame.

SMART objective: By March 2011, the Cleveland County Health Department will improve community engagement and health improvement planning processes, as evidenced by the following:
  • An increase in average score from 3.8 to 4.0 on the Meeting Effectiveness Survey
    • This SMART objective asks for a change in the average survey score (measurement) and specifies a survey tool to be used within the time frame listed above.
  • An improvement from 0% to 100% of a local strategic plan completed through the Step UP performance management web-based system
    • This is a unique way to write a SMART objective to create a strategic plan from scratch: going from 0% to 100% and using a specific system for the strategic planning process.

Women, Infants, and Children (WIC) Program Patient Flow Analysis

The following SMART objectives are all well-written examples of various ways to reduce wait time. They all list specific locations and criteria, have a time frame, and are measurable.

SMART objective: Ellis Shipp Clinic: By December 2013, WIC staff will decrease the waiting time for a nutritionist by 30%.
SMART objective: Rose Park Clinic: Reduce the average gross waiting time by 15% for WIC participants by December 1, 2013.
SMART objective: Salt Lake City Clinic: Reduce overall appointment time from 59 minutes to 50 minutes by December 31, 2013.
SMART objective: South Main Clinic: Food instrument appointments will decrease from 24.1 to 18 minutes.


Centers for Disease Control and Prevention. (2011). Public Health Information Network Communities of Practice: Develop SMART Objectives. Atlanta, GA. Retrieved from http://www.cdc.gov/phcommunities/resourcekit/evaluate/smart_objectives.html

Terris, D. D. (2015, September). Building a Toolkit for Success in Quality Improvement. Watkinsville, GA: SudOrd Consulting.

Zahorsky, D. (2014, December). The 5 steps to setting SMART business goals. About Money. Retrieved from http://sbinformation.about.com/od/businessmanagemen1/a/businessgoals.htm



Roberts, G. Developing and Using SMART Objectives. Thu, 03/03/2016. Available at https://www.phqix.org/content/developing-and-using-smart-objectives.






QI Spotlight icon

Quality leaders at all levels of the organizational chart are needed to build and sustain quality improvement (QI) culture. For example, at the organization level, QI leaders must execute strategies to weave QI into the fabric of the organization (e.g., QI plans and policies), whereas at the program level, QI leaders are relied on to lead improvement projects in the face of adversity.

Two important QI leadership roles, the QI coach and QI champion, are often referred to in public health circles. This article will describe the role and necessity of QI coaches and champions and will provide examples from PHQIX submissions, highlighting examples of QI leaders in action.

Ty Kane, author
Ty Kane

Although important distinctions can be drawn between coaches and champions, what is most important is that the roles and responsibilities of both are carried out in every agency.


QI coaches use a variety of skills and tools to facilitate meetings, help teams set goals, establish measures, design improvement tests of change, and study results. Coaches may be asked to support the project from start to finish or provide support as needed. The role of a coach will also vary based on the skills, abilities, and experience of other individuals involved and the scope of the improvement project. (1)

QI champions cultivate a spirit of QI within the organization that encourages continuous improvement of services and programs by providing a strong endorsement for QI and participating in QI activities (training, projects, etc.). QI champions are the organization's QI cheerleaders or inspirational leaders! According to the Minnesota Department of Health: "Ideally, (champions) should have training, knowledge and experience with QI, but at a minimum they need to be committed to leading QI efforts and helping others get involved and interested." (2)


QI coaches have the knowledge, ability, and experience to support QI project teams as they navigate through the steps of a defined improvement process such as Plan, Do, Study, Act. A proposed set of prerequisite knowledge and experience for a QI coach may include QI methods and tools, leadership and team building, change management, performance management, and group facilitation. Coaches should also have the time and budget to support the demands of QI project teams. QI coaches should also have access to QI resources such as books, journals, and a network of other QI leaders or coaches. (1)

QI champions are people who inspire others to adopt QI practices and bring a spirit of QI to the organization. Special training and experience are not typically required of QI champions. Because the QI champion role does not require advanced training, skills, or time, QI champions may be found at any level of the organizational chart. In fact, if you’re reading this article, there’s a good chance you’re a QI champion, too!


Recent publications from national public health QI leaders point to the need for QI coaches and champions:

  • Key ingredients that contribute to successful QI endeavors include selecting experienced, objective facilitators and identifying internal champions, teams, and team leaders. (5)
  • Training agency leaders in change management and how to be a QI champion will advance QI use in local health departments. (6)
  • Building a culture that supports QI includes several factors, including leadership, application of a proven QI method, and champions. If you want quality to be in the fabric of your organization, your organization must have the capacity to use proven QI methods. (7)
  • QI coaching has been shown to play a critical role in the change process—one that helps organizations harness the knowledge and creativity of front-line teams to make lasting improvements in core processes. (1)

Coaches and Champions


Some organizations have filled the role of QI coach internally by identifying qualified candidates and investing in the development of their QI knowledge and skills through training. Others have looked externally to a public health system partner or consultant. The National Association of County and City Health Officials (NACCHO) has developed a resource to help identify a QI consultant, found below. A consultant can help expedite the process to train staff and leaders or develop internal training capacity by training the trainer. Agencies have hired QI consultants from national or private organizations or have partnered with universities or public health institutes with QI or performance management expertise. (3)

QI champions, unlike QI coaches, are usually found within the organization. To find organizational QI champions, NACCHO encourages local health departments to identify staff with existing QI knowledge, experience, or expertise and engage them as QI champions. If existing staff members do not have these characteristics, seek staff members who exhibit characteristics of natural QI champions: those who have an established reputation as early adopters, innovators, natural leaders, and analytical thinkers. (4)


The following examples are intended to highlight the role and necessity of quality leaders to carry out effective improvement projects.

Agency: Tacoma-Pierce County Health Department (TPCHD)

Year: 2010

How did the team from TPCHD use a QI coach or champion?
The main driver of success in this project was having a consistent process champion to support elements of the initiative. The agency QI coordinator provided technical assistance on group process and QI methods and tools throughout the project period.

Why is this important?
By using a skilled QI coach for technical assistance throughout the project, TPCHD achieved an increase in average quarterly billings of Medicaid administrative match dollars of around 300% (from about $250,000 to $750,000) in average quarterly billings.

Improving the Appropriate Collection of Revenue at a Local Health Department: The Medicaid Title XIX Match QI Project

Agency: Cabarrus Health Alliance (CHA)

Year: 2010–2011

How did the team from CHA use a QI coach or champion?
CHA benefited from technical assistance and training from a partner organization (North Carolina State University), as well as an internal QI project champion.

Why is this important?
With internal (QI champion) and external (QI coach) support, the QI team reduced the average cycle time for the complete Women, Infants, and Children Program visit by 25%. Also, as a result of this unique partnership, staff received valuable training and experience in the Lean Kaizen methodology and learned how to use different QI tools, such as the Gemba walk and value-stream map.

Improving WIC Open Access Appointment System

Agency: Sullivan County Public Health Services (SCPHS)

Year: 2012–2013

How did the team from SCPHS use a QI coach or champion?
The agency's public health nurse supervisor had been tracking maternal-child health (MCH) referrals for years and tried multiple strategies to increase referrals. She convinced the management team that a QI initiative could harness additional resources to achieve measurable improvement in this area. The agency applied for and received training through a Community of Practice for Public Health Improvement grant.

Why is this important?
With the knowledge and skills gained through training, the public health nursing supervisor led a team that achieved measurable improvement related to MCH referrals from community providers.

Increasing Prenatal Referrals for Home Care Maternal and Child Health Nursing Services in Sullivan County

For more information, consider reviewing some of the resources cited in this article:

  1. Weitzman Institute. (2013, August). Quality improvement coaching (website). Retrieved from http://quality.chc1.com/echo/coaching/
  2. Minnesota Department of Health. (n.d.). How to develop a QI plan (website). Retrieved from http://www.health.state.mn.us/divs/opi/pm/lphap/qiplan/howto.html
  3. National Association of County and City Health Officials. (n.d.). Engaging a quality improvement consultant. Retrieved from http://www.naccho.org/topics/infrastructure/accreditation/upload/Engaging-a-QI-consultant-FINAL.pdf
  4. National Association of County and City Health Officials. (2012). Roadmap to a culture of quality improvement. Retrieved from http://qiroadmap.org/wp-content/uploads/2013/01/QIRoadmap.pdf
  5. Public Health Foundation. (2014, June). Key ingredients in public health QI. Retrieved from http://www.phf.org/resourcestools/Documents/Key_Ingredients_for_QI_Success.pdf
  6. Davis, M. V. (2012, June). Building theory: Creating a QI culture. Presented at AcademyHealth Public Health Systems Research Interest Group Annual Meeting. Retrieved from http://www.academyhealth.org/files/phsr/4-Davis.pdf
  7. Tews, D. S., Heany, J., Jones, J., VanDerMoere, R., & Kusuma, M. (2012, January). Embracing quality in public health: A quality improvement practitioner's guidebook (2nd ed.). Retrieved from https://www.mphiaccredandqi.org/wp-content/uploads/2013/12/2012_02_28_Guidebook_web_v2.pdf




Kane, T. The Role and Necessity of Quality Leaders in Public Health. Fri, 02/05/2016. Available at https://www.phqix.org/content/role-and-necessity-quality-leaders-public-health.




QI Spotlight IconAre you frustrated by improvement actions that don’t create the level of improvement you expected? Do the problems you’ve tackled continue after the quality improvement (QI) project is completed? One answer to your frustration and disappointment is to understand and apply the concepts and tools of root cause analysis to your problem!

W. Edwards Deming, considered the father of QI, transformed quality control processes by applying his beliefs about root cause analysis (Bialek, Duffy, & Moran, 2009, p. 22). 1 His belief was that just measuring outputs and/or outcomes at the end of a work process ignores the root cause of the problems and lingering challenges. Quality can be improved indefinitely and future problems avoided if these root causes are discovered and addressed through ongoing evaluation and QI. All the procedures in an organization should be part of an ongoing measurement process using feedback loops.

QI Spotlight Icon
Marni Mason
A QI team can use root cause analysis concepts and tools, such as the fishbone diagram and the 5-Whys tool, to identify, explore and display the root causes of organizational problems. The fishbone diagram is the most common tool used to generate potential root causes of a specific problem through brainstorming if no data are available or if the results are based on data collected before building the fishbone diagram.

The process of building a fishbone diagram enables the QI team to focus on the content of the problem rather than its history or the differing personal interests of team members. In effect, it creates a snapshot of the collective knowledge and consensus of a team around a problem, which builds support for the resulting solutions to the problem.

To construct a fishbone diagram:

  • Use a large writing surface such as a flip chart, butcher paper, or a white board.
  • Draw a rectangle in the middle of the right-hand side.
  • Write the problem statement in the rectangle (not a solution!).
  • Draw a horizontal line across the middle of the writing surface from the left-hand side to the middle of the rectangle (like a backbone).
  • Draw four to five angled lines outward from the backbone (like ribs).
  • Label each rib with a major cause category (see page 25 of Brassard, Ritter, and Oddo [1994] for suggested categories). 2
  • Place the brainstormed or data-driven causes in the categories
  • Ask repeatedly, for each cause, “Why does that happen?” or “What could happen?”

Following is an example of a fishbone diagram created to identify potential root causes for physical inactivity in adolescents.

Fishbone diagram to identify potential root causes

Once the fishbone diagram has been constructed, the team should interpret or test for root causes by doing one or more of the following:

  • Look for causes that appear more than once within or across categories.
  • Choose the most likely root causes through an unstructured consensus or a more formal process like multivoting or nominal group process.
  • Collect data on selected causes to determine relative frequencies.
  • Use an analysis tool, like a Pareto chart, to identify root causes.

Another good tool for finding root causes is called the 5-Whys. This tool is simple to use and is often used in conjunction with the fishbone diagram to delve deeper into a category in the fishbone diagram. The 5-Whys process involves asking “Why?” at least five times in a row and is best used when people do not truly understand the situation or when a deeper understanding is necessary. This tool helps people use higher-order thinking skills to cut through layers of bureaucracy, and encourages people to challenge their current situation or problem.

Although these two tools are commonly used to identify the root cause of a problem, several other tools can be used to approach the problem differently and provide good information for the QI team. These tools include the tree diagram, the affinity diagram, and the interrelationship digraph. Some examples of QI projects on PHQIX that successfully used root cause analysis are described as follows:

Examples from PHQIX

NNPHI Kaizen Program: Processing Low-Priority Chlamydia and Gonorrhea Reports
During the Kaizen event, the Chicago Department of Public Health conducted a cause-and-effect analysis, which included a fishbone diagram, prioritization of issues, root cause analysis (5-Whys), brainstorming of solutions, and finally, prioritization of solutions. Multiple issues, root causes, and solutions were identified. Briefly, the root causes for the amount of time the reports were waiting to be entered by data entry staff were (1) the assigned batches of work to the senior data entry operators from the program director were too large, and (2) the perpetual backlog of reports was being carried over year after year.

Improving Referral for Hepatitis C Testing in Kittitas County
The bulk of the hepatitis C testing and counseling clients were previously accessed at the local jail. For a variety of reasons, the jail was no longer available to the Kittitas County Public Health Department for hepatitis C testing, and the health department looked to other referral partners to see if it could increase referrals from other sources. A number of barriers to testing were identified and classified using an affinity diagram. Three root causes were identified as a result of the affinity diagram: (1) lack of client readiness, (2) client fear, and (3) lack of education for referring staff and clients about hepatitis C.

Integrating Chronic Disease and Environmental Health Education into Home Visiting Programs
Using a tree diagram, a cause-and-effect analysis tool, staff highlighted a chain of causes and ultimately found the root cause of the problem. The effect is identified first, along with major groups of causes. The diagram then asks “why” for each branch. One issue that staff identified was “multiple home safety assessments being used by home visiting programs.” They determined the root cause to be that assessment tools were developed by home visiting programs in silos because they were being funded by different sources and created years apart.

All of the root cause analysis tools mentioned in this article can be found in QI resources such as The Public Health Memory Jogger, the Public Health Quality Improvement Encyclopedia, The Public Health Quality Improvement Handbook, and “Ridding Root Cause Analysis of Defects” (a 50-minute video from ASQ).

1 Bialek, R. G., Duffy, G. L., & Moran, J. W. (2009). The public health quality improvement handbook. Milwaukee, WI: American Society for Quality, Quality Press.

2 Brassard, M., Ritter, D., & Oddo, F. (1994). The memory jogger II: A pocket guide of tools for continuous improvement and effective planning. Salem, NH: GOAL/QPC.


Mason, M. Root Cause: The Foundation of Successful Improvement. Sat, 08/24/2015, Available at https://www.phqix.org/content/root-cause-foundation-successful-improvement.





QI Spotlight icon A good goal statement is a basic starting point for teams or individuals to plan their work and identify whether it is successful—goal statements are fundamental for success. A properly detailed and documented goal statement completely defines the result that an organization seeks to produce. It describes the purpose, outcome, or activity that must be accomplished.

Public health has used a form of goal statement, known as an "aim statement," as a starting point for its improvement cycle (Plan, Do, Study, Act) and improvement projects for many years. Different formats exist with various prompting questions and comprehensiveness of content.

These formats have generally prompted users to investigate

  1. What do you seek to accomplish?
  2. Who is the target population?
  3. How will you know that an improvement has been made (or, what is the specific measure you seek to achieve)?
  4. What changes can you make that will result in improvement?

What are the components of a complete goal and aim statements?


Puzzle pieces: To, For, By, So That, Standards, Conditions
The result that the goal must produce: This always begins with "TO" and identifies the object to be transformed and the final state it should be in when the goal is realized. It determines what result, purpose, or outcome is desired.
The beneficiaries of the goal: Who benefits from the results? What is the scope?
How will you achieve the desired results? What is the approach you will use to solve the problem (not the solutions)?
The benefits the result will produce for each beneficiary of the goal: This identifies how a beneficiary will be better off once "TO" is achieved. What are the benefits from achieving the goal?
How will you judge whether an improvement has been made? What will be measured? How will it be measured? What is the target? Always include the date or time by which the improvement is to be achieved.
What requirements or limitations exist? Is the availability of resources restricted? Does the goal have to be completed by a certain date? Does it require certain actions (e.g., use of an existing computer system)? Does it have an existing protocol that must be followed?

How are good goal and aim statements developed?

Chris Bujak portrait
Chris Bujak

Plan: Before you start to draft a goal statement, it often helps to first understand what prompted the opportunity. How is this goal linked to the organization’s strategy or a larger goal? Linkage to a larger purpose can often be found in the organization’s quality improvement plan or via interviews with leadership.

Do: Draft your goal statement (six components) using the previously described guidance and attached template.

Study: Once you have drafted your goal statement, test it.

Act: Document, communicate, and start to use your goal statement during each phase of the improvement process.

Examples from PHQIX

Many examples of well-focused QI Initiatives have been submitted to PHQIX. The following table lists examples of initiatives on which PHQIX Expert Panel reviewers have remarked about the clarity of the aim statement and the extent that the initiative was well-focused. The aim statements presented in these initiatives are not all structured exactly the same; however, they all contain the components of good goal/aim statements described above.

Project Title
NNPHI Kaizen Program: Death Certificate Filing
Operation Chuck Wagon: Permitting Unlicensed Mobile Food Vendors
Preventing Unintended Secondary Pregnancies in Women Receiving Women, Infants and Children (WIC) Services
Improving the Retention Rate of the Special Supplemental Nutrition Program for Women, Infants, and Children Clients in Yellowstone County, Montana
NNPHI Kaizen Program: Processing Low-Priority Chlamydia and Gonorrhea Reports
Reducing Tobacco Use Among Pregnant WIC Clients by Increasing Enrollment in Tobacco Cessation Programs

Think about the goal/aim statements that you have created. Do they address all of the items covered in the examples? Take advantage of learning from others. What will you improve for the next one?



Bujak, C. & Vecellio, P. What are goal and aim statements and why are they important? Wed, 08/12/2015. Available at https://www.phqix.org/content/what-are-goal-and-aim-statements-and-why-are-they-important.




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