How To Develop a QI Plan
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.
Choose a step below to learn more about how it contributes to this process.
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. 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.
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 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:
- 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)
The Public Health Practice Section has made the following survey tools available to all CHBs:
Organizational QI Maturity (PDF)
This 50-question survey was developed to evaluate the Robert Wood Johnson Foundation Multi-State Learning Collaborative (MLC). 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 Public Health Practice Section staff.
Organizational QI Maturity: Ten-Question Subset (PDF)
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 Annual Reporting 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 Public Health Practice Section staff.
For more information on the QI Maturity Tool, visit:
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.
Assess Using the QI Roadmap
The National Association of County and City Health Officials (NACCHO) developed the QI Roadmap 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. CHBs 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 website and/or contact the Public Health Practice Section staff.
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. Each community health board submitted this deliverable to MDH in March 2015.
The PHAB standards and measures also provide a very detailed list of what should be included in a QI plan:
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.
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, 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:
The QI plan should be reviewed, evaluated and updated annually by the QI oversight team. As Public Health Practice Section identifies and/or develops tools to help with this step, we will post them to this page.
Visit Quality Improvement: More Information, and click on "Examples: Quality Improvement Plans."