摘要：Objectives. We conducted case studies of 10 agencies that participated in early quality improvement efforts. Methods. The agencies participated in a project conducted by the National Association of County and City Health Officials (2007–2008). Case study participants included health directors and quality improvement team leaders and members. We implemented multiple qualitative analysis processes, including cross-case analysis and logic modeling. We categorized agencies according to the extent to which they had developed a quality improvement culture. Results. Agencies were conducting informal quality improvement projects (n = 4), conducting formal quality improvement projects (n = 3), or creating a quality improvement culture (n = 4). Agencies conducting formal quality improvement and creating a quality improvement culture had leadership support for quality improvement, participated in national quality improvement initiatives, had a greater number of staff trained in quality improvement and quality improvement teams that met regularly with decision-making authority. Agencies conducting informal quality improvement were likely to report that accreditation is the major driver for quality improvement work. Agencies creating a quality improvement culture were more likely to have a history of evidence-based decision-making and use quality improvement to address emerging issues. Conclusions. Our findings support previous research and add the roles of national public health accreditation and emerging issues as factors in agencies’ ability to create and sustain a quality improvement culture. Increasingly, local public health agencies are implementing quality improvement projects. 1–6 According to results from the 2010 National Association of County and City Health Officials (NACCHO) profile survey, 84% of local public health agencies reported implementing some form of quality improvement effort, 7 with 15% conducting agency-wide quality improvement. These efforts build on foundational initiatives designed to improve agency performance and create a culture of continuous quality improvement. 8–11 However, agency efforts to move from sporadic projects to creating a quality improvement culture and sustaining the improvement of performance have been challenging. 12 Barriers include perceptions about lack of relevance, time, and financial resources to conduct quality improvement activities; inexperience and insufficient training about the use quality improvement tools and concepts; lack of leadership commitment to quality improvement; the need to create a manageable scope and appropriate measures for a quality improvement project; and public health crises. 2–4,6,13 Furthermore, agencies that serve larger populations are more likely to conduct quality improvement projects, and small agencies may be more likely to consider quality improvement an add-on activity. 14,15 Facilitators to conducting quality improvement and creating a quality improvement culture include a commitment from senior managers who empower employees closest to the issue to make changes, the creation of activities with clear performance criteria, and the institutionalization of continuous improvement into everything the organization does. 12 Specific strategies include involving more staff in quality improvement efforts and providing training to spread quality improvement competence. Quality improvement becomes part of the agency culture through a process of repetition, saturation, and spread. Agency development of advanced quality improvement maturity occurs when administrators take active roles and agencies use a specific quality improvement framework and performance data. 6 Experience from health care supports these findings, particularly the need for leadership support to transfer quality improvement efforts to the whole organization. 16,17 Building on the literature, we examine why, in what respects, and under what circumstances select agencies develop a quality improvement culture. We explore the factors that support or hinder development of such a culture and propose a logic model for quality improvement culture development in public health agencies.
