Quality Improvement

NKY Health is committed to systematically obtain feedback, evaluate, improve, monitor and report on the quality of its programs, processes and services in order to achieve a high level of efficiency, effectiveness and customer satisfaction. 

NKY Health commits to a culture of quality, exhibited by:

• Leadership committed to continuous quality improvement.

• The integration of QI into all programs and services, as well as the Health Department’s overall agency policies and operational plans.. 

• Alignment of QI projects with various plans, such as the organizational strategic plan, community health improvement plan, workforce development plan and disaster response plan.

• A focus on improved outcomes.

• The existence of a functioning, formal performance management system.

• The use of an annually updated QI plan for NKY Health.

• The use of an updated organizational strategic plan for NKY Health.

• Active engagement in a comprehensive community health improvement process resulting in a Community Health Assessment (CHA) and Community Health Improvement Plan (CHIP), updated at least every five years.

• The communication of performance improvement and QI activities and outcomes.

• Employee involvement in QI and performance management across all levels and services/programs.

• Organizational learning, including QI and performance management training for all staff, and the sharing of best practices and lessons learned.

• The incorporation of QI competencies and activities in job descriptions and individual performance evaluations.

• A focus on the customer, both external and internal, in all programs and services.

• Resources allocated to ensure QI and performance management.

Quality improvement will be achieved through continuous improvement efforts at district-wide and division levels, as well as at program- or project-specific levels.

• District Director of Health

  • Provides vision for the Health Department and its QI and performance management activities, in alignment with the vision, mission and core values of the Health Department

  • Convenes Senior Staff meetings. Ensures documentation of QI and performance management activities is included in Senior Staff meeting agendas, minutes and action registers

  • Encourages and supports Health Department management and staff in QI and performance management activities

  • Allocates resources for QI and performance management activities

  • Reports QI and performance management activities and outcomes to the District Board of Health

• Performance Improvement Council

  • Supports QI activities and the promotion of a culture of quality, in alignment with the vision, mission and core values of the Health Department and its various plans

  • Assures the Health Department accomplishes QI activities included in annual quality improvement plans

  • Reviews and revises annual quality improvement plans as needed throughout year

  • Monitors status and reviews results of QI projects

  • Supports the development, implementation and ongoing maintenance of the Health Department’s performance management system

  • Annually reviews and provides feedback on any improvements to the performance management system and QI plan, as well as lessons learned

• Division Directors 

  • Provide oversight of quality improvement  plans/QI projects and performance management system within their divisions or district-wide, along with the District Director of Health, and with support from team members

• Planning Manager

  • Implements the QI program and performance management system throughout the organization, in collaboration with the Performance Improvement Council and other management staff

  • Provides technical assistance, support and training to individuals, groups and teams in order to improve staff capacity and skills in QI and performance management; this includes new employee orientation to QI, basic training on the Plan-Do-Check-Act cycle of improvement and QI tools, advanced training for QI champions, and just-in-time QI training and guidance for QI teams, as needed

  • Facilitates formal reporting of QI and performance management activities and outcomes during Performance Improvement Council meetings on a quarterly basis and as needed, and the annual evaluation of the QI plan and performance management system

  • Posts the quarterly reports in a location that enables all staff to access them and encourages the posting of QI storyboards

  • Coordinates the development of the annual quality improvement plan, in collaboration with the Performance Improvement Council and other management staff

  • Coordinates the development of goals and objectives included in the performance management system, in collaboration with the Performance Improvement Council and other management staff

  • Ensures improvements to the performance improvement system and quality improvement plan, as needed

• All management staff

  • Conduct QI efforts 

  • Promote participation in QI processes to staff in their respective division or unit

  • Identify appropriate staff to participate in QI projects

  • Participate in the development, implementation and evaluation of the annual quality improvement plan

  • Participate in the development, implementation and evaluation of goals and objectives in the  performance management system

  • Ensure goals and objectives are measurable and include time frames for measurement

  • Monitor and report on goals/objectives in the quality improvement plan and performance management system

  • Ensure communication of QI activities and outcomes to staff within their division or unit and to other appropriate Health Department staff

• Non-management staff

  • Participate in QI projects as approved by supervisor

  • Understand how unit-level performance measures are relevant to their work affect division-level and/or district-level performance measures

The District Director of Health and members of Senior Staff will serve as members of NKY Health's Performance Improvement Council, which will provide oversight for QI and performance management. 

QI projects are identified by management and non-management staff, and approved through the organizational chain-of-command. QI activities are chosen based on whether they have a direct or indirect influence on the Health Department’s ability to perform mandated public health services and address priority community health needs.

In addition, QI projects and performance objectives are chosen based on their potential to improve health status, improve health behaviors, improve an intervention or program’s effectiveness, and to improve efficiency.

Customer feedback is important to the Health Department. Feedback from both internal and external customers is gathered, analyzed and used to make improvements to services, programs and the organization as a whole. Feedback may be gathered through a variety of methods, including customer satisfaction surveys (in hard copy and electronic formats); group processes, such as focus groups; and informal/impromptu discussions with individuals and groups. QI tools may also be used to gather feedback, as well as to assist in analyzing and prioritizing issues. Results are shared with appropriate parties, including the District Board of Health and Local Boards of Health, as needed. Action steps are then created to improve policies, programs/services and/or interventions.

• Quality Improvement:  Quality improvement in public health is the use of a deliberate and defined improvement process, such as Plan-Do-Check-Act, 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. (Riley, et al. Defining Quality Improvement in Public Health. Journal of Public Health Management and Practice. January/February 2010).

• Quality Improvement Plan: A plan that identifies specific areas of current operational performance targeted for improvement within the organization. A quality improvement plan includes written descriptions of specific, planned QI activities to be carried out within certain timeframes. Quality improvement plans should be broad in scope, reflecting a range of health and service issues relevant to the populations served. Quality improvement plans can and should align with various health department plans. For instance, a QI initiative in the quality improvement plan may be aligned with the organizational strategic plan. (See “Performance Management System” below.)

• Continuous Quality Improvement: A quality philosophy that believes organizations can always make improvements. Continuous quality improvement can also be described as an ongoing effort to increase an agency’s approach to manage performance, motivate improvement and capture lessons learned.

• QI Team: Generally an internal team (but could include members from the community or partner organizations), organized by management, and guided by a problem statement and an aim statement to carry out QI activities through the Plan-Do-Check-Act cycle. QI teams are charged with developing, implementing, evaluating and reporting on QI projects.

• Aim Statement: A concise, specific written statement that defines what a team hopes to accomplish with its QI efforts. It includes a numerical measure for the future target, is time-specific and measurable, and defines the specific population that will be affected. The aim statement answers the following questions: 

  1. 1. • What is the team striving to accomplish? 

        • What is the timeline? 

        • What is the specific numerical measure the team wishes to achieve? 

        • Who is the target population?

• Performance Management System: A fully functioning performance management system that is completely integrated into health department daily practice at all levels includes: (1) setting organizational objectives across all levels of the health department; (2) identifying indicators to measure progress toward achieving objectives on a regular basis; (3) identifying responsibility for monitoring progress and reporting; and (4) identifying areas where achieving objectives requires focused quality improvement processes. (Public Health Accreditation Board. Standards and Measures Version 1.0. Alexandria, VA, May 2011)

NKY Health is committed to improving the quality of its services and programs by annually allocating sufficient resources to support QI, performance management, accreditation and strategic planning activities. In addition, it is an expectation of the District Director of Health that QI competencies and activities be incorporated into the job descriptions of all staff. 

10/3/2022:

• Updated Policy Header information.