Assessing Continuous Quality Improvement in Public Health: Adapting Lessons from Healthcare

Price, Alex; Schwartz, Robert; Cohen, Joanna; Manson, Heather; Scott, Fran

This study shows a mix of facilitators and barriers to CQI best-practice in Ontario, according to Shortell et al.' s (1998) four-dimensions framework. Evidence of strong leadership interest and involvement in quality improvement at both local and provincial levels was clear. Strong developmental and/or group cultures were also evident at public health unit interview sites, which reflected leadership efforts to foster high performance and provided additional insight into their CQI capacity. The importance of senior and managerial leadership engagement cannot be over-emphasized, as previous reviews of public health quality improvement initiatives have shown (Dilley et al. 2012; Randolph et al. 2012) . However, Ontario' s quality improvement initiative also featured limitations placed on the meaningful influence of local leadership in decision-making by provincial stakeholders, which was reflected by misalignments in priorities, even though agreement on the principle of quality improvement was mutual. A part of this phenomenon may be because of the split emphasis that Ontario' s system of accountability and performance management has between quality assurance and quality improvement. Assurance of legislative and service requirements promotes top-down decision-making and control, whereas a focus on improving outcomes requires local leadership and discretion. Similar misalignments were highlighted in the work of Degroff et al. (2010) who argued that many of the challenges to applying performance measurement to national public health programs in the US were due, in part, to the competing interests of quality improvement and public accountability (DeGroff et al. 2010) .