How To Do It
There is no standard process or requirement for how to develop a Quality Improvement (QI) Plan. Steps 1-3 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.
- Create Quality Improvement Oversight Team
- Gather Information and Assess QI Culture
- Write Quality Improvement Plan
- Implement and Evaluate
- Examples: QI Plans
|1. Create Quality Improvement Oversight Team|
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. If training is needed, visit Schedule: Training and Technical Assistance for available training opportunities from MDH.
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.
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.
- Kitsap Public Health District (PDF: 83KB / 5 pages)
- Fillmore-Houston Community Health Service (PDF: 282KB / 7 pages)
- Kandiyohi County Public Health (PDF: 163KB / 6 pages)
|2. Gather Information and Assess QI Maturity|
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 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:
- Key leader(s) at health department completes assessment survey
- QI oversight team completes assessment survey
- 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)
OPI has made the following survey questions available to all CHBs:
- Organizational QI Maturity (PDF: 198KB / 4 pages): This 50-question survey was developed to evaluate the Robert Wood Johnson Foundation Multi-State Learning Collaborative (MLC) [Attn: Non-MDH link]. In 2009, 2010, and 2011, the University of Southern Maine administered this survey to top officials in all sixteen participating states (including Minnesota). Since that time, the survey has been used repeatedly in Minnesota at the state and local levels. If you need assistance with administering this survey, please contact OPI staff.
- Organizational QI Maturity: Ten-Question Subset
(PDF: 139KB / 1 page): An alternative option is to complete the QI maturity index, which is a 10-item subset of the full QI Maturity Tool. This shorter list of questions was developed by the Minnesota’s Public Health Research to Action Network to represent the key domains of QI maturity. These questions have been incorporated into PPMRS as Local Public Health Act performance measures. CHBs will report on them annually beginning 2013. This will enable the SCHSAC Performance Improvement Steering Committee to monitor the QI maturity of Minnesota’s local public health system. The 10-question index could also be used to create a QI maturity score for an individual health department or CHB. If you need assistance with administering this survey, please contact OPI staff.
For more information on the QI Maturity Tool, visit:
- Assessing quality improvement in local health departments: results from the Multi-State Learning Collaborative (Journal of Public Health Management and Practice, June 2012)
- Measuring quality improvement in public health: the development and psychometric testing of a QI Maturity Tool (Evaluation and the Health Professions, Jan.-Feb. 2012)
To view issue briefs describing current organizational QI maturity in Minnesota’s state and local health departments, visit:
- Minnesota Public Health Research to Action Network: Publications
[Note: This link will open in a new window.]
This assessment can also be used as baseline data to measure the change in the culture of QI at the health department if tracked over time. It is recommended that the health department tracks progress on an annual basis.
The health department’s QI Plan should be relevant to the size, capacity, and readiness of the staff to take on the efforts outlined in the plan. In the previous step, information regarding current practices was gathered and culture of QI at the health department was assessed. Through this, areas of improvement were likely identified, but not all of them can be addressed at the same time. The following questions will use the information you gathered and looked at in the previous steps, and help focus the scope of the QI plan. Therefore, the next step is to prioritize focus areas for the 12-month period of implementation of the plan. (i.e. how many QI projects the health department will undertake, communication with staff and key stakeholders, training of staff and leadership, process for monitoring and evaluating progress towards goals, etc.)
During the prioritization step, some key questions to ask include the following:
- What does your health department want to focus on and accomplish during the next 12 months?
- Considering our current capacity, what can we take on and accomplish in the next 12 months?
- What efforts, if addressed first, would help with the others?
- Looking at our QI culture assessment results, what questions/measures do we want to focus on improving first?
There are many prioritization tools available to help with this step. For examples of prioritization tools including those below, visit the MDH Quality Improvement Resource Toolbox.
- Tool: Interrelationship Digraph
Identifies and analyzes relationships among critical factors that impact an issue, so as to hone in on key drivers and outcomes.
- Technique: Nominal Group Technique (Multivoting)
A way of coming to a consensus based on the relative importance of issues or solutions.
- Tool: Prioritization Matrix
A tool that can help an organization make decisions by narrowing options down by systematically comparing choices through the selection, weighing, and application of criteria.
Quality Improvement is not a stand-alone area of work but should be linked with the everyday work of your health department, as well as greater planning efforts. To help guide QI efforts, the QI oversight team should look at existing assessments, plans, and reports, such as the following:
- Strategic plan
- Community Health Assessment
- Community Health Improvement Plan
- Program or grant reports
- Performance measure data/reports
- Staff knowledge of program areas
These documents will give the team ideas on what areas to focus improvement efforts and identify what data is already gathered and can be used to assist with QI efforts.
|4. Write Quality Improvement Plan|
The previous steps have provided the foundation of information needed for the content of a Quality Improvement 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.
- Deliverable to MDH: Quality Improvement Plan
The PHAB standards and measures provide a very detailed list of what should be included in a QI Plan:
- More Information: Standard 9.2: Requirements for QI Plans
(PDF: 175KB / 2 pages)
Write a QI Plan, which will outline the process and foundation for quality improvement within your organization. The QI Plan Outline provides a basic structure you can follow to write your QI Plan, which incorporates the requirements from PHAB standards.
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.
For examples of QI plans, skip down to Examples: QI Plans.
|5. 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, CHB). 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:
- Template: Storyboard (PPT: 102KB / 1 slide)
The QI Plan should be reviewed, evaluated and updated annually by the QI oversight team. As OPI identifies and/or develops tools to help with this step, we will post them to this page.
|Examples: Quality Improvement Plans|
Note: These examples have not been reviewed by PHAB and are not guaranteed to meet PHAB standards. Please use the PHAB requirements list and the QI Plan Outline as tools to ensure that your QI Plan meets PHAB requirements if you plan to apply for PHAB accreditation.
Washington County (MN)
- Washington Co. Quality Improvement Plan (PDF: 577KB / 16 pages)
- QI Process Map (PDF: 212KB / 1 page)
- QI Project Proposal (PDF: 291KB / 1 page)
- QI Project Worksheet (PDF: 195KB / 2 pages)
- QI Storyboard (PDF: 200KB / 1 page)
- PIT Consultant Checklist (PDF: 193KB / 1 page)
Fillmore-Houston CHB (MN)
- Fillmore-Houston Quality Improvement Plan (PDF: 311KB / 4 pages)
- Appendix A: QI Organizational Structure (PDF: 187KB / 1 page)
- Appendix B: QI Council Charter (PDF: 282KB / 7 pages)
- Appendix C: QI Calendar (PDF: 215KB / 2 pages)
- Appendix D: QI Project Submission and Reporting Form
(PDF: 161KB / 2 pages)
- Note: Appendices E and F are purposely omitted.
- Appendix G: QI Glossary of Terms (PDF: 284KB / 2 pages)