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Quality improvement plans 101
Based on PHAB Guidance v1.0 for a QI Plan (Measure 9.2.1) and materials created by Marni Mason of
MarMason Consulting.
March 2017
Overview
Quality improvement (QI) in public health is the use of a deliberate and defined improvement process like
Plan-Do-Study-Act (or PDSA), which is focused on activities that are responsive to community needs and
improving population health. It refers to a continuous and ongoing effort to achieve measurable
improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators
of quality in services or processes which achieve equity and improve the health of the community.
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A quality improvement plan is a basic guidance document that describes how a health department will
manage, deploy, and review quality. It also serves to inform staff and stakeholders of the direction,
timeline, activities, and importance of quality and quality improvement.
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Purpose
The quality improvement plan describes what a health department is planning to accomplish, and
should be updated regularly to reflect what is currently happening in QI at your health department. The
quality improvement plan provides written credibility to the entire Quality Improvement process, and is
a visible sign of management support and commitment to quality throughout the health department.
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The Public Health Accreditation Board (or PHAB) writes in its standards and measures guide that “to
make and sustain quality improvement gains, a sound quality improvement infrastructure is needed.
Part of creating this infrastructure involves writing, updating, and implementing a health department
quality improvement plan. This plan is guided by the health department’s policies and strategic direction
found in its mission and vision statements, in its strategic plan, and in its health improvement plan.”
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Participants
The quality improvement plan is typically developed and implemented by an internal oversight team of
7-10 members who serve as QI leaders for the organization, often called a Quality Council or QI Advisory
Team. There is no specific requirement on who is on this team from the organization, but it often is
comprised of both senior leaders and front-line staff. This helps to ensure that the organization has both
a top-down and bottom-up approach to QI. Members of this team should be well-versed in QI principles,
methods and tools and are expected to serve as QI champions for the organization and will be
responsible for the development, implementation, monitoring, and evaluation of the QI plan.
MDH support for process
Staff from the QI Unit in the Public Health Practice Section at MDH are available to provide consultation
and technical assistance for community health boards as they form their QI teams, write and implement
their QI plans, initiate QI projects, and monitor and evaluate their QI efforts. Tools, templates, and other
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supporting materials are available below. All guidance has been designed to assist community health
boards meet the national public health standards developed by PHAB.
How to do it
There is no standard process or requirement for how to develop a quality improvement (QI) plan. Steps
1-2 listed below are suggested steps to help prepare for writing a QI plan. Step 4 provides the national
public health guidance for what should be included in a QI plan.
1. Create QI oversight team [pre-plan preparation]
Identify key leaders and staff to be Quality Improvement (QI) champions for the health department.
Ideally, these individuals 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.
The typical size of this group is 5-10 members and it may be an ongoing leadership team, or a mix of
leaders, managers, and front line staff. It is encouraged that this team be comprised of representatives
from both leadership and front line staff to allow for the engagement of staff and to facilitate the reach
of QI throughout the health department.
Primary responsibilities may include:
▪ Learning QI methods and tools and modeling for others at agency
▪ Reviewing, evaluating, and approving the agency QI plan annually
▪ Encouraging and fostering a supportive QI environment
▪ Championing QI activities, tools, and techniques
▪ Selecting and supporting agency QI projects
Develop a charter outlining the structure, roles, and responsibilities of this team. The charter will be a
central piece of the QI plan.
Tips
In order to build organizational expertise and engage staff members, it can be helpful to have terms for
team members (anywhere from one to three years) and stagger when members leave the team.
You may have staff with QI experience from another county department, local company, or community
college—have them participate on the team.
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2. Gather information and assess QI maturity [pre-plan preparation]
Gather information on what QI activities, efforts, and work have previously been implemented at the
health department. These do not have to be formal QI projects, but can be other efforts to improve the
work of the health department. The purpose of this step is to assess where the health department
currently is in terms of QI efforts and process. This will help with the writing of the QI plan by outlining
the structures and processes that are currently in place and can for formalized.
Assess QI maturity at the health department
It is important that the oversight team have a sense of the department’s commitment to quality
improvement and how it relates to organizational goals. Developing a culture of quality in the
organization goes beyond conducting individual QI projects, and typically takes place over time. An
assessment can help the team identify key areas for quality improvement and determine if staff and
leadership need additional education or training around the concept of QI.
This assessment is not required, but can help guide the QI oversight team in identifying key areas to
focus efforts and set organizational goals around QI. If the QI oversight team or health department
leadership decides to do this assessment, there are a few options:
1. Key leader(s) at health department completes assessment survey
2. QI oversight team completes assessment survey
3. Assessment survey given to all staff at health department (this option is recommended to give the
best data regarding the health department’s culture of quality)
Assess using the QI roadmap
The National Association of County and City Health Officials (NACCHO) developed the Roadmap to a
culture of quality improvement (https://qiroadmap.org/qi-roadmap/qi-home) in partnership with local
health departments and QI consultants who worked with local health departments, in 2011.
The Roadmap describes six elements of a QI culture. Included with the Roadmap is guidance for moving
through the six elements to the goal of a comprehensive quality culture within the health department.
There are specific strategies and resources for moving from one phase to the next phase. Community
health boards could use the Roadmap to assess their current culture around QI individually, or within
the QI council, leadership team, or advisory group.
If you need assistance on how to use this tool, please review the QI Roadmap website and/or contact
staff from the MDH Center for Public Health Practice.
3. Develop Quality Improvement Plan
The previous steps have provided the foundation of information needed for the content of a QI plan.
The next step is to take the information gathered and write a QI plan, which will outline the process and
foundation for QI at the health department.
The Public Health Accreditation Board (PHAB) (https://phaboard.org/)
standards and measures also
provide a very detailed list of what should be included in a QI plan.
Tips
Remember to start where your health department is at. If you have the capacity to do one QI project
each year, start with that. Your QI plan should be useful and relevant to your health department and you
can work to build off of it during the next year, as you will update it annually.
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4. Implement and Evaluate
Within the written QI plan, the health department should have developed a work plan or action plan for
how to implement the work needed to meet the goals. Within the QI plan examples linked on this
website, there are various ways shown that health departments monitor and track their progress. It is
important to remember to track progress in all areas (e.g., training, communication, QI culture), not just
related to specific QI projects.
As progress is monitored, report to key stakeholders as needed or desired (e.g., staff, customers,
general public, community health board). Outline how this will be done in the communication plan.
Along with this, share lessons learned and celebrate successes. This can be done through storyboards or
other similar formats:
Quality improvement storyboard
(https://www.health.state.mn.us/communities/practice/resources/phqitoolbox/qistoryboard.html).
The QI plan should be reviewed, evaluated, and updated annually by the QI oversight team.
Review checklist
▪ Plan is dated within the past year
▪ Describes the current culture of quality and/or the desired future state of quality in the organization
and how this culture aligns with the organization's mission/vision
▪ Notes key elements of the QI team's governance structure
▪ Includes glossary of key quality terms (common vocabulary)
▪ Describes employee QI training
▪ Outlines how organizational QI initiatives and results will be communicated to staff
▪ Describes how improvement initiatives are to be identified and/or prioritized
▪ Describes goals, objectives and measures with responsible person(s)/team(s) and time-framed
targets identified for the various components of the plan
▪ Describes monitoring of plan: Data collection and analysis process
▪ Describes monitoring of plan: How actions will be taken to make improvements based on progress reports
▪ Describes monitoring of plan: How progress will be reported on the stated goals and objectives
▪ Describes process to assess effectiveness of the plan
The review checklists for the strategic plan, community health improvement plan (CHIP) and quality
improvement (QI) plan are based on the PHAB standards and other state and national resources. MDH
recommends that, whether or not a community health board is actively considering accreditation, they
consult the PHAB standards as a point of reference as they engage in the assessment and planning process.
The standards serve as a guide for demonstrating accountability to stakeholders, improving the quality of
work, enhancing credibility, and increasing staff morale. Fulfilling the MDH assessment and planning
requirements, however, is not a guarantee of meeting the PHAB standards for the purposes of accreditation.
The checklists for the strategic plan, community health improvement plan (CHIP) and quality
improvement (QI) plan are based primarily on the PHAB standards, as well as NACCHO guidance and
MDH local assessment and planning guidance.
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QI glossary
For more QI tools and terms, visit: Public health and QI toolbox
(https://www.health.state.mn.us/communities/practice/resources/phqitoolbox/index.html).
Minnesota Department of Health
Center for Public Health Practice
651-201-3880
health.ophp@state.mn.us
www.health.state.mn.us
March 2017
To obtain this information in a different format, call: 651-201-3880.
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Riley WJ, Moran JW, Corso LC, Beitsch LM, Bialek R, & Cofsky A. (2010). Defining quality improvement in public
health. Journal of Public Health Management and Practice 16(1), 5-7. Online:
https://journals.lww.com/jphmp/Abstract/2010/01000/Defining_Quality_Improvement_in_Public_Health.3.aspx
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Kane T, Moran J, & Armbruster S. (2011). Developing a health department quality improvement plan.
Washington, DC: Public Health Foundation. Online:
http://www.phf.org/resourcestools/Pages/Developing_a_Health_Department_Quality_Improvement_Plan.aspx
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Kane, Moran, & Armbruster.
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Public Health Accreditation Board. (2011). Guide to national public health department accreditation version 1.0.
Measure 9.2.1. Online: https://phaboard.org/
