Try This “Secret Weapon” for Quality Improvement

We've all seen it happen. A health department decides to pursue PHAB accreditation, dives headfirst into documentation, and six months later realizes they've built their performance management system on a shaky foundation. Or worse, they make it all the way to their site visit only to discover fundamental gaps in their quality culture that can't be fixed with better documentation.

The financial and emotional costs are real. Staff burnout from chasing moving targets. Consultant fees for multiple course corrections. Delayed accreditation timelines that impact funding opportunities. And perhaps most damaging: the erosion of staff confidence in leadership's ability to guide transformational change.

The most successful health departments we’ve worked with share a common thread: they invested time upfront in understanding their organizational culture before building their systems – and one tool is particularly helpful.

Why the NACCHO Assessment Changes Everything

The NACCHO Culture of Quality Self-Assessment is a diagnostic tool that reveals the hidden dynamics that can make or break your accreditation efforts. The assessment examines six foundational elements:

1. Leadership commitment to quality improvement
2. QI infrastructure and resources
3. Employee empowerment and engagement
4. Customer focus in service delivery
5. Teamwork and collaboration across programs
6. Continuous improvement mindset

All of these elements are integral to quality improvement. To give just two examples: Leadership commitment isn’t merely about stating support for quality improvement – it’s about allocating budget, time, and staff to QI efforts. Employee empowerment means staff can propose and lead improvement projects, not just implement top-down initiatives.

Here's what makes the assessment powerful: The assessment doesn't just identify gaps – it reveals the interconnections between them. For example, if your assessment shows strong leadership commitment but weak employee empowerment, this suggests communication gaps between leadership intentions and frontline implementation.

From Assessment to Action: A Success Story

In a recent engagement with a mid-sized health department in the eastern United States, we started with the NACCHO assessment before developing their performance management and quality improvement plans. What we discovered transformed their entire approach.

The assessment revealed something surprising. While this department had pockets of excellence in quality improvement that staff could identify, only a few staff members could explain how those efforts connected to strategic priorities or performance metrics. Staff in different programs were essentially speaking different languages when it came to quality.

This insight became the cornerstone of their transformation. Instead of building separate systems for performance management and quality improvement, we designed an integrated approach where:

• Every QI project linked directly to strategic objectives
• Performance data automatically flagged improvement opportunities
• Staff at all levels could see how their daily work connected to department-wide goals

The result? Two PHAB-compliant plans that actually work in practice, not just on paper. Six months after implementation, the department was already reporting improved staff engagement and measurable progress on key health indicators.

Three Steps to Get Started

If you are struggling to set performance goals, measure progress, or prove your value to stakeholders, consider completing the NACCHO assessment as the first step in a performance management/quality improvement effort.

Here are a few tips to ensure maximum impact:

1. Complete the Assessment Honestly: Resist the temptation to paint a rosier picture than reality. The assessment's value lies in surfacing uncomfortable truths before they become accreditation obstacles.
2. Engage Your Full Team: Don't limit participation to leadership. Include staff at all levels to get a complete picture of your culture. The disconnects between leadership perception and frontline reality are often the most revealing.
3. Act on the Findings: An assessment without action is just an expensive mirror. Work with experts who can translate findings into practical strategies that move you toward accreditation while improving daily operations.

Three Pitfalls to Avoid

While the NACCHO assessment is a powerful tool, we've seen health departments make predictable mistakes that limit its value. Avoid these common pitfalls to maximize your investment:

1. Treating it as a One-Time Exercise: The assessment should be repeated annually for the most impact.
2. Focusing Only on Low Scores: Sometimes high scores in isolation signal bigger problems with misalignment or communication strategies.
3. Assuming Leadership Scores Reflect Organizational Reality: The biggest gaps often exist between leadership perception and staff experience.

Conclusion

The bottom line is that quality improvement is a journey, not a destination. Success requires more than good documentation – it demands a culture that embraces continuous improvement at every level.

Think of the NACCHO Culture of Quality Self-Assessment as your roadmap for that journey.