Continuous Quality Improvement in Ontario’s Pubic Health Sector
Madelyn Law PhD & Ross Graham MSc CHE
PURPOSE
To provide the Public Health Leadership Council with an overview of the role, value and current state of continuous quality
improvement (CQI) and quality improvement (QI) approaches in Ontario’s public health units (PHUs), as well as
recommendations to support the advancement of these approaches. The information provided here stems from our research,
as well as the results of a sector-wide meeting we organized in September 2013.
DEFINITIONS
CQI is both a philosophy and a framework designed to achieve increasing levels of performance (i.e., outcomes of greater and
greater value). As a philosophy, CQI in public health is the “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” (1, p. 5).
When operationalized as an administrative framework, CQI is a “commitment to… execute a continuous flow of
improvements that meets or exceeds the expectations of the [community] and generally includes a link to the organization’s
strategic plan and goals; a quality council made up of the organization’s top leadership; QI training for staff; a mechanism for
prioritizing QI projects based on performance data; and supporting and recognizing staff for their QI activities” (2, p. 5).
Within CQI is the use of QI: “a deliberate and defined improvement process, which is focused on activities that are responsive
to community needs and improving population health” (1, p. 6). In practice, completing “QI projects” commonly involves teams
using a Plan-Do-Check-Act, Lean, Six Sigma, or Model for Improvement methodology to improve the efficiency of a process,
which in turn, improves value for clients, funders and the community. For a more complete definition of these terms see
Randolph and Lea (2012).
ROLE & VALUE OF CQI/QI
CQI/QI can happen at all levels within an organization and have been applied in various ways and at varying levels of
sophistication in public health (see table below). While much of the relevant literature comes from the United States (US), the
increasing adoption of CQI/QI in US local health departments provides an excellent foundation to guide efforts in Ontario. This
being said, while there is limited literature and a lack of consensus on optimal methods and applications, a recent systematic
review determined that QI “could substantially strengthen public health practice” (3, p. S69).
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Types of QI Activities (2)
Organizational QI: Interventions that influence all programs/services.
Program/Service QI: Interventions that focus on improving process within a specific program/service.
Administrative/Management QI: Interventions that focus on an administrative/management process.
Individual QI: At this level, staff focus on improving their individual performance and behaviors.
CQI/QI activities have shown most promise in the clinical and process-oriented areas of public health. For example, one
project was able to increase immunization rates for young children by 21% by using a QI framework (4). Another example was
an increase in postpartum breastfeeding rates from 32% to 49% (4). The application of QI in health promotion has largely
been unexplored, but is seen as an area ripe for innovation. For reviews of QI interventions in public health see Dilley,
Bekemeier and Harris (2012) or the Public Health Quality Improvement Exchange (PHQIX) website (5).
ONTARIO CONTEXT
Elements of CQI philosophy have arguably been a longstanding part of public health practice in Ontario. However, CQI
became a formal priority for the sector when the Capacity Review Committee recommended (a) “that CQI should be the
foundation of an effective performance management system for public health in Ontario” (6, p. 24-25), and (b) that “every
health unit should have a minimum of one quality and performance specialist to lead the implementation of local performance
management activities, coordinate accreditation, manage reporting to the province and the public, and create a culture of CQI”
(6, p. 25).
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CQI then became a component of the provincial Performance Management Framework, the Ontario Public Health
Organizational Standards (standard 6.1), and in 2011 it became a requirement that all Boards of Health “adopt a proactive and
responsive approach to performance improvement” including “a commitment to continuous quality improvement” (section 5.1)
via the Public Health [Funding and] Accountability Agreement.
MEETING TO ADVANCE CQI
Given the mandate for CQI, on September 20th 2013, staff from 34 of 36 PHUs and representatives from Public Health
Ontario (PHO), the Ontario Public Health Association, Health Quality Ontario (HQO), academia, the Ministry of Health & Long
Term Care (MOHLTC), and the Ministry of Children & Youth Services met to (a) learn about CQI/QI excellence in public
health, (b) learn about CQI/QI adoption in healthcare in Ontario, (c) discuss the current state of CQI/QI in public health in
Ontario, and (d) discuss strategies to advance CQI/QI.
Before the meeting, attendees reviewed a primer document (7) and PHU staff completed a survey on their agency’s level of
CQI maturity. The survey results were presented at the meeting in addition to presentations on topics including QI teams, QI
projects in complex environments, as well as the current state of CQI/QI in both the US public health system and Ontario’s
healthcare system. These presentations are freely available online (8). The meeting was generously funded by the MOHLTC
($1,300) and PHO (~$1000).
Meeting to Advance CQI in Ontario’s Public Health Sector
CURRENT STATE
Based on our review of the literature, the results of the QI maturity survey and the meeting discussion themes, there appears
to be various levels of CQI/QI implementation and sophsification in Ontario’s PHUs, yet common challenges and enablers for
CQI/QI advancements.
Within Public Health Units:
 QI was “highly valued” as a strategy to improve service delivery by nearly all the PHUs.
 Approximately half of PHUs had a CQI/QI officer, council, committee, team or plan. Larger PHUs tend to have positions
dedicated to quality-related work. Other PHUs have positions with quality as part of their portfolio, and still others report
quality is largely decentralized or unexplored.
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The most common strategies employed by PHUs to operationalize QI focused on (a) improving leadership support, (b)
training managers and front line staff, and/or (c) establishing an overarching framework and committee.
PHUs reported that senior leaders are receptive and supportive of QI implementation, and that staff are often engaged in
problem-solving and decision-making (a prerequisite for a CQI culture).
The are low levels of CQI/QI engagement and training of both leaders and staff.
At the Sector Level:
 There is low percieved support and clarity of responsibility for CQI/QI at the sector level (specifically from HQO, PHO,
MOHLTC).
 Meeting attendees wanted support from sector stakeholders regarding QI training, resources and tools.
 While the evidence base in the US is growing, there is limited Canadian research in this area. Canadian public health
research has not focused on CQI/QI, and Canadian CQI/QI research has not focused on application of these approaches
in public health.
 PHUs were interested in establishing a network of QI leads to promote knowledge exchange.
 Meeting attendees were interested in establishing sector-wide priority areas for QI (with related indicators).
CQI ADVANCEMENT
The results of our research have identified key opportunities to support the advancement of CQI/QI in public health in Ontario,
which in turn could improve the quality and value of public health service delivery. The following points were the most
consistent ideas/findings on how to advance the field of CQI in public health in Ontario.
The Enablers of CQI/QI are:
 Opportunities for staff to both learn and “do” CQI and QI work.
 Calculation and communication of the cost-savings and service delivery improvements achieved by QI projects (see
Randolph [2013] for examples).
 Organizational, and ideally sector, adoption of a “CQI culture” (with involvement from all PHU staff, but most importantly,
strong support from senior leadership).
 A regional network that (a) promotes knowledge exchange (e.g., sharing sucesses and lessons learned) and (b) has clear
supportive relationship(s) with “backbone” sector-wide organizations.
 Stable resources and incentives that allow PHUs to make longterm commitments to implementing CQI/QI.
 Sector-wide priority areas for QI application (e.g., restaurant inspections) with related metrics to measure improvement
and cost-savings.
Recommendations and Opportunities:
1. Have public health sector leaders actively promote the value and importance of CQI/QI.
Note: The literature as well as advice from experts such a Dr. Greg Randolph from the US Center for Public Health Quality (9)
consistently reinforced that leadership support was the single biggest predictor of CQI advancement.
2. Clarify the role of HQO and PHO in the advancement of CQI/QI in public health (at least regarding supporting
implementation of CQI/QI in PHUs).
Note: There was consensus that both HQO and PHO have significant resources and expertise related to CQI/QI in public
health. However, it appears that neither organization has a mandate to support this work, leaving PHUs feeling unsupported
and confused as to why CQI is a sector priority “on paper,” but not in practice.
3. Fund opportunities for QI leads and PHU staff to learn, practice and exchange information regarding QI projects.
Note: The 2013 meeting was a grassroots, PHU-organized event that met a sector need. While successful, this is a not a
sustainable approach for future CQI/QI learning opportunities. Use of tools such as PHQIX could be a cost-effective strategy
to support continued learning and knowledge exchange.
4. Provide dedicated funding for a QI lead at each PHU, as recommended by the Capacity Review Committee.
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Note: This approach has worked well for the Chief Nursing Officer and Social Determinants nursing positions and would
achieve a recommendation of the Capacity Review Committee.
5. Establish a sector-wide priority area(s) for QI application with metrics that measure improvement and costsavings.
Note: This strategy would (a) emphasize the importance of QI across the sector, (b) achieve performance improvement in one
of the sector’s priority areas, and (c) provide a vehicle/rationale for PHUs to establish practice-sharing communication
pathways. Ideally the priority area would be clinical/process-oriented, in order to facilitate a “quick-win” which have been
shown to promote further adoption of CQI/QI approaches.
6. Advocate for funding for (and/or fund) CQI/QI public health research.
Note: Similar to the organization of the 2013 meeting, the related research was conducted largely “off the side of our desks.”
This is a not a sustainable approach for future research in an area that “could substantially strengthen public health practice”
(3, p. S69).
CURRENT EFFORTS
1. Research Publications: We are currently working towards the submission of a manuscript based on the meeting primer
and the QI maturity tool results. As well, we continue to submit this work to academic and practice-based conferences.
2. CQI Forum Summary Notes: Summary notes from the meeting were circulated to participants in late January 2014.
3. Exploring Research Grant Opportunities: We are actively exploring research granting agencies where we may be able
to apply for funds to support networking opportunities (i.e., meetings, interactive knowledge exchange portal, etc.) as well
as research projects to help advance this work.
REFERENCES
1. Riley, WJ, Moran, JW, Corso, LC, Beitsch, LM, Bialek, R & Cofsky, A. (2010). Defining quality improvement in public
health. Journal of Public Health Management and Practice, 16(1), 5-7.
2. Randolph, GD & Lea, CS. (2012). Quality improvement in public health: moving from knowing the path to walking the
path. Journal of Public Health Management and Practice, 18(1), 4-8.
3. Dilley, JA, Bekemeier, B & Harris, JR. (2012). Quality improvement interventions in public health systems: a systematic
review. American journal of preventive medicine, 42(5), S58-S71.
4. Randolph, G. (2013). The CQI Movement in the US. Presented at the Meeting to Advance CQI in Ontario Public Health.
Toronto, ON. September 20, 2013. Available at https://www.healthunit.com/statistics-and-reports#meeting
5. Public Health Quality Improvement Exchange [website]. Available at: https://www.phqix.org
6. Capacity Review Committee. (2006). Revitalizing Ontario's Public Health Capacity: The Final Report of the Capacity
Review Committee. Available at:
www.health.gov.on.ca/en/common/ministry/publications/reports/capacity_review06/capacity_review06.aspx
7. Law, MP, Graham, R, Bridge, E & Ross, K. (2013). Primer on Quality in Public Health: What is needed to advance CQI in
Ontario Public Health? From the Meeting to Advance CQI in Ontario’s Public Health Sector. September 20, 2013.
Toronto, ON. Available at https://www.healthunit.com/statistics-and-reports#meeting
8. Presentations from the Meeting to Advance CQI in Ontario’s Public Health Sector. September 20, 2013. Toronto, ON.
Available at https://www.healthunit.com/statistics-and-reports#meeting
9. Center for Public Health Quality [website]. Available at: http://www.centerforpublichealthquality.org
AUTHOUR AFFILIATIONS
Madelyn Law is Assistant Professor in the Department of Community Health Sciences at Brock University
Ross Graham is Manager of Strategic Projects at the Middlesex-London Health Unit
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