How can we improve program planning and evaluation in public health?

Use Continuous Quality Improvement techniques.

One of the most important issues to address in the public health profession is how we effectively work to change practice, behavior and policy through programming on every level of the Spectrum of Prevention. The application of continuous quality improvement techniques to public health practice is one of the most useful – and flexible – change strategies to employ when developing and managing programs primarily because the process is iterative, and necessitates evaluation of the process at every step. It also has the added benefit of using a common language that is can be consistently used across the industry.

Designing an effective program to address any aspect of public health (a particular chronic disease, inequity in access to care, disparities in breast cancer screening rates) requires that a practitioner ask a set of particular questions - questions that may seem overly simplistic, but can be difficult to answer:

(1) where are we?
(2) where do we want to be?
(3) should we do something?
(4) what should we do, and how?
(5) how will we know it’s working?

These questions focus a practitioner's work at each step of the process. However, a fundamental aspect of program planning is that it is a necessarily continuous process; which may be a detail that is easy to neglect as program managers and other stakeholders become invested in the programs they design and implement. Nonetheless, a judiciously applied quality improvement approach to program planning may actually be effective in ensuring that program goals are prioritized, and that the program is feasible! Continuous quality improvement (CQI) also encourages program evaluation and therefore can improve the effective allocation of resources within a local, state or federal public health department.

Presently, continuous quality improvement (CQI) techniques, such as the “Plan Do Study Act” cycle, are used in many areas of the health care system in the United States, to both improve quality of care and address issues of patient safety and health inequities. These techniques have shown a great deal of promise at the individual program level, as well as within individual health care facilities (hospitals and nursing homes, for example). However, the challenges remains to use these techniques to create lasting system-wide change. At present, resources are mostly devoted to CQI programming that is focused on improvement at the individual facility level. A great deal of of pressure exists to focus the work of public health practitioners on individual medical services which we perceive to be related to health outcomes. However, we must move beyond the present focus of CQI programs to address the improvement of individual programs or facility performance alone. While CQI techniques have been used widely to address patient safety concerns in the hospital setting, these programs fail to translate to systems-wide improvements which address the root causes of the identified problem. Therefore, while a program may be effective on a facility level, it appears difficult to translate this approach across the spectrum of care in a public health system. To address this issue, the aspects of program planning that emphasize evaluation and revisiting program goals should be applied more rigorously, especially if the program is attempting to address an issue (like obesity) that is by definition beyond the scope of an individual health care facility.

To learn more about Continuous Quality Improvement, visit the Institute for Healthcare Improvement at www.ihi.org.