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Public Health Quality

The Public Health Quality Forum (PHQF) defined public health quality for the first time in the 2008 Consensus Statement on Quality in the Public Health System [PDF - 82 KB] as, “The degree to which policies, programs, services, and research for the population increase desired health outcomes and conditions in which the population can be healthy.” Following a review of The Institute of Medicine’s definition of health care quality, the PHQF expanded on that to define public health quality. The definition is applicable beyond governmental public health agencies and includes others that have a public health mission as well (tax-exempt hospitals, NGOs, academia).

The HHS vision for public health quality, as defined by the Assistant Secretary for Health, is: to build better systems to give all people what they need to reach their full potential for health. This definition and vision, along with public health quality aims and priority areas for improvement of quality provide a comprehensive National Framework for Public Health Quality.


National Framework for Public Health Quality

The figure above provides details about the National Framework for Public Health Quality. It includes the definition, aims, priority areas and a vision for public health quality. Public health quality is defined as, ‘The degree to which policies, programs, services and research for the population increase desired health outcomes and conditions in which the population can be healthy.’ The nine public health quality aims are: population-centered, equitable, proactive, health-promoting, risk-reducing, vigilant, transparent, effective and efficient. The six priority areas are population-health metrics and information technology, evidence-based practices, research and evaluation, systems thinking, sustainability and stewardship, policy and workforce and education. The vision of public health quality is, ‘Building better systems to give all people what they need to reach their full potential for health.’ This is an overarching framework of quality for the overall public health system. The framework provides the integral components needed in a Quality Management System (QMS) to monitor, assess and improve the quality functions and services provided that translate into improved health outcomes. QMS includes quality assessment, quality improvement, quality control and quality assurance.

National Framework Aims and Priority Areas

Aims for Public Health Quality

Priority Areas for Improvement of Quality in Public Health (Primary Drivers of Quality)

Practical Application of the Framework

Basic Driver of Quality Diagram

Secondary Drivers of Quality

Aims for Public Health Quality

Based on specific recommendations made in the 1998 report, Quality First: Better Health Care for All Americans to identify aims for quality that guide strategic decision making, the PHQF selected nine aims to give a description of characteristics that clearly articulate what quality should look like in public health. The nine aims aid in guiding public health practices across the entire system to ensure quality for improving population health outcomes. They are aspirational characteristics to guide quality goals throughout all aspects and sectors (for example, program design and implementation, management and governance, policy research, education, healthcare) when fulfilling a public health mission. The nine aims help guide public health practices across the entire system to ensure quality for increasing positive population health outcomes.

  • Population-centered: Protecting and promoting healthy conditions and the health for the entire population
  • Equitable: Working to achieve health equity
  • Proactive: Formulating policies and sustainable practices in a timely manner, while mobilizing rapidly to address new and emerging threats and vulnerabilities
  • Health promoting: Ensuring policies and strategies that advance safe practices by providers and the population and increase the probability of positive health behaviors and outcomes
  • Risk reducing: Diminishing adverse environmental and social events by implementing policies and strategies to reduce the probability of preventable injuries and illness or negative outcomes
  • Vigilant: Intensifying practices and enacting policies to support enhancements to surveillance activities
  • Transparency: Ensuring openness in the delivery of services and practices with particular emphasis on valid, reliable, accessible, timely and meaningful data that is readily available to stakeholders, including the public
  • Effective: Justifying investments by using evidence, science and best practices to achieve optimal results is areas of greatest need
  • Efficient: Understanding costs and benefits of public health interventions and to facilitate the optimal use of resources to achieve desired outcomes

See the Public Health Quality Aims Bibliography [PDF - 367 KB] of documented literature that connects each aim for improvement of quality in public health to supporting evidence on the value to advancing system improvements.

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Priority Areas for Improvement of Quality in Public Health (Primary Drivers of Quality)

The PHQF convened again in 2010 to identify priority areas for improvement of quality in public health. The Forum members surveyed their agencies to develop an initial list of priority areas. Six were selected after an initial list of 26 priority areas were identified. The six priority areas represent areas of greatest need where the public health system should improve quality to achieve improved population health outcomes. The following three criteria guided the selection of the priority areas:

Impact – the extent of significant improvements in population health, health equity, quality, and safety that could result from changes in this area.

Improvability – the potential for changes that could lead to desired health, process, or given changes in system outcomes.

Practice Variability – the potential for standardizing areas where wide variability in practices exist and where gaps between current practices and knowledge, evidence, or best practices can be closed without hindering innovation.  Based on concepts developed at the Institute of Healthcare Improvement1, the priority areas are considered primary drivers of quality.

Based on concepts developed at the Institute of Healthcare Improvement1, the priority areas are actually considered as primary drivers of quality. The six priority areas reflect the complex interactive nature of the public health system as lack of quality in one area can potentially negatively impact quality in another.  They function interactively as system-level drivers that have an impact across the entire public health system, and synergistically integrate strategies to advance improvements in quality and population health outcomes.

These are the six priority areas (primary drivers):

  1. Population Health Metrics and Information Technology
  2. Evidenced-based Practices, Research and Evaluation
  3. Systems Thinking
  4. Sustainability and Stewardship
  5. Policy
  6. Public Health Workforce and Education

1. Population Health Metrics and Information Technology

Improve methods and analytical capacity to collect, evaluate and disseminate data that can be translated into actionable information and outcomes in population health the local, state and national level. Make the improvement of data collection for population subgroups a core value of public health. The informed use of health care quality data can serve as a catalyst to build population-based public health programs as a strategy to improve population health, eliminate health inequities, and bridge gaps between health care and public health.

2. Evidence-based Practices, Research and Evaluation

Bridge research and practice and institutionalize evidence-based approaches to achieve results-based accountability. Support effective and safe practices that can be used by practitioners.

3. Systems Thinking

Advance systems thinking in public health. Foster systems integration strategies by analyzing problems using systems science methodologies (network analysis) while taking into account the complex adaptive nature of the public health system. Complex adaptive systems are described as those based on relationships of diverse and interconnected agents that have the capacity to learn, change, and evolve (hospitals, emergency medical services systems, educational systems, emergency preparedness and response systems).

4. Sustainability and Stewardship

Strengthen system sustainability and stewardship through valid measures and reporting of performance and quality. Ensure efficient funding methodologies that align resources with goals, demonstrated need, responsibilities, measurable results, and ethical practices.

5. Policy

Strengthen policy development and analysis processes and advocacy to ensure that evidence is integrated into policymaking to improve population health.

6. Public Health Workforce and Education

Develop and sustain a competent workforce by ensuring that educational and skills content are appropriately aligned with core and discipline-specific competencies. Assure that public health education is accessible at all academic levels, and that life-long learning is encouraged and valued.

Basic Driver of Quality Diagram

Developing a driver diagram begins with identifying an outcome and works backwards to identify primary drivers and a set of activities as secondary drivers, which lead to achieving a change in the health outcome. The public health quality priority areas serve as the primary drivers, which influence reaching the desired outcome.  The quality aims are secondary drivers as they support the primary drivers and strengthen them.

Driver diagrams explore activities and factors that influence achieving a specific outcome, demonstrate how the activities and primary drivers are connected with each other, and serve as the basis for a framework of measurement. Organizations also develop driver diagrams to identify key barriers to implementation and develop measures to track process improvements. The following figure, is a demonstration of a basic driver diagram, illustrating the generalized theory of change.


 Basic Driver Diagram Illustrating the Generalized Theory of Change 4, 5


The figure above is of a basic driver diagram illustrating the generalized theory of change. The desired outcome is influenced by primary drivers of changes A, B and C. Secondary drivers provide necessary support to strengthen the primary drivers. Secondary drivers A1 and A2 support the primary driver of change A. Similarly Secondary driver B1 supports the primary driver of change B, while secondary drivers C1, C2 and C3 support the primary driver of change C.

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The following table builds on the basic driver diagram in the context of public health quality. An outcome of ‘National Goals for Population Health Improvements’ has been identified and the priority areas are the Primary drivers of quality.

Institute for Healthcare Improvement’s Applied Concept of Primary and Secondary Drivers

Outcome Public Health
Primary Drivers of Quality
Public Health
Secondary Drivers of Quality

National Goals for
Population Health

  • Population Health Metrics and Information Technology
  • Evidence-Based Practices, Research, and Evaluation
  • Systems Thinking
  • Sustainability and Stewardship
  • Policy
  • Workforce and Education

Portfolio of initiatives and
activities to support and
strengthen the priority set of
primary drivers

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Secondary Drivers of Quality

Consistent with the Institute for Healthcare Improvementexit disclaimer model, secondary drivers play an important role in supporting the priority areas (primary drivers) to drive improvements. The secondary drivers help support critical elements of the primary drivers, increase the likelihood of achieving improved outcomes and also strengthen the public health infrastructure. Aligning secondary driver activities with the public health quality aims is the suggested tactic for achieving strategic improvements.

Interactive Models Demonstrating Use of Priority Areas: