Quality improvement methods have spread rapidly through health care in the last two decades, and health professions schools are integrating this training more and more each year. But the field of public health has been much slower to adopt a quality methods, even as more health systems are taking on population health through the IHI Triple Aim. In this blog post, Erica Bridge, BPH, MA, former Open School Chapter Leader at Brock University in Ontario, Canada, explains why she believes quality improvement is necessary, yet undervalued, in public health.

I believe that quality improvement approaches are absolutely necessary in public health.

Public health, as defined by the World Health Organization, involves organized efforts to prevent disease, promote health, and prolong life among the population as a whole.

Public health activities aim to provide conditions in which people can be healthy. Unlike traditional health care, they focus on entire populations, not on individual patients or diseases. Public health affects us all, every minute of every day. For example, the fluoride in your water is the result of public health efforts to prevent dental decay.   

In the last decade, quality improvement has been popular in health care, in both acute and primary care settings. But public health has been slow to adopt these approaches, outside of pockets of excellence across the United States and Canada. So, you might wonder, “How is quality improvement relevant to public health?” Here are four ways quality improvement can improve public health interventions. 

1. Large Scale vs. Rapid Cycle

In public health, interventions happen on a much larger scale than in health care. It’s not unusual for efforts to include multiple interventions occurring over years. Evaluation takes place both before and after the intervention.

For example, imagine that public health professionals implement a two-year smoking cessation program focusing on young adults between the ages of 18-24 years, with smoking cessation aids, group counselling, and informational pamphlets. Public health evaluators analyze smoking rates before and after the program, and measure the number of participants in the program. At the end of the program, the results show that smoking rates have not significantly changed, and very few people participated. The program leaders conclude it was a failed effort and discontinue the program.

If you’ve ever worked in public health, I’m sure you can relate to this scenario. But, consider this “failed attempt” from a different perspective. Was the intervention itself ineffective, or was it the implementation?

Quality improvement uses rapid cycles of implementation and testing. In other words, program teams continuously improve their work with PDSA cycles (plan, do, study and act). In this way, health care professionals are able to identify and resolve problems in real time, instead of waiting years after the program’s start to recognize inefficiencies or failures. They can also recognize interventions that have the greatest success and largest impact.

2. The “Quick Win” Theory

Some public health programs last even longer than a couple of years — some span even decades. For instance, in the United States, public health practitioners have been working to decrease deaths from coronary heart disease since the 1990s, and heart disease remains the first leading cause of death among Americans. Even in a successful program, it can be hard to see the finish line. When this happens, public health professionals may lose momentum.

Nothing motivates more than success. Quality improvement and PDSA cycles allow teams to set short-term goals, in addition to the long-term goals, that allow quick wins to motivate employees. Teams can continue building on the changes and set new targets, leading to further improvements and small victories.

3. Collaborate, Collaborate, Collaborate

Around the world, health systems have become focused on quality since the Institute of Medicine set its six aims for health systems and declared that “between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.” Quality improvement and the Model for Improvement are everywhere in health care.

But many organizations with the same goals working in different sectors have too often fragmented their impact. To build cross-organizational and cross-sector partnerships, all organizations, including public health, must adopt the quality improvement language and methods being used across the system. An initiative called the Lead States in Public Health Quality Improvement is an excellent example of how public health departments can learn and apply QI methods to improve the performance of their interventions.

4. Achieving the Triple Aim

Last but not least, quality improvement activities in public health are crucial to achieving the IHI Triple Aim. The Triple Aim consists of 1) improving the experience of care, 2) improving the health of populations, and 3) reducing per capita costs of health care. If health systems want to achieve the Triple Aim — which requires health care organizations to work with communities to improve the health of populations — they must work with public health organizations. And vice versa.

Although the benefits are clear, public health remains a laggard in adopting quality improvement. So, what to do about this gap?

One of the main barriers is training and knowledge exchange. While many have reported the need for medical education and nursing programs to integrate quality training into their programs, the majority of public health programs have not integrated this training. Universities and colleges need to address this skill gap through courses and hands-on projects before students enter the workforce.

But just because public health professionals didn’t receive this training in school doesn’t mean it’s too late to start. Public health organizations should invest in quality improvement training for their employees. Public health is one of the most important areas in health care, and for that reason, it should draw on the quality improvement successes of other health sectors.

If you’re a public health professional or academic, I’m asking you to invest in quality improvement skills, for the sake of improving public health services and the health of our communities now, and for future generations.

Learn more about integrating quality improvement skills into the curriculum.

Browse and take the Open School courses, including a free course, QI 102: The Model for Improvement.

Learn essential quality improvement methods through the IHI Open School whiteboard videos.