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.
but first, amid of a lot of discussion about population health, I want to tell you what public health is.
as defined by the World Health Organization, involves organized efforts to
prevent disease, promote health, and prolong life among the population as a
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
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.
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?
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
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.
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
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.
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
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.
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
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
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