Q&A with HHS’ Howard Koh: ‘Concepts of public health quality must be embedded into the culture’: Quality improvement efforts advancing under federal leadership ========================================================================================================================================================================= A national movement to improve quality across the public health system is gaining momentum. In 2008, the Public Health Quality Forum convened to release a consensus statement that identifed aims for improving quality in public health. The forum, under the direction of the U.S. Department of Health and Human Services, guides the identification, funding and implementation of quality improvement projects across the public health system. At the helm of the forum is U.S. Assistant Secretary for Health Howard K. Koh, MD, MPH, who last year announced a strategic partnership with APHA to ensure public health leadership is actively engaged in quality improvement. ## As the principal advisor to HHS on quality improvement in the public health system, how are you embracing and advancing quality concepts? As a nation, we can certainly embrace public health quality as a way for helping all people reach their full potential for health, and there has been tremendous momentum on public health quality in recent months. I have had the privilege of establishing a new Office of Health Care Quality within our umbrella of offices here, and that’s where this public health quality program is now positioned. From that locus, we put out a public statement in September 2009, on advancing quality concepts in the public health system. We have posted a number of meetings of our Public Health Quality Forum and we are looking forward to making a presentation at (the APHA Annual Meeting) on the whole topic. So there is a lot of forward movement. ## In September 2009, HHS released a statement, “Quality in the Public Health System,” that discussed ways for building public health’s capacity to improve quality. What are some of the methods that need to be employed? There are multiple steps toward achieving this vision. First is establishing the aims and dimensions of public health quality. Setting priorities, putting forward issues of measurement and sustainability and other themes is very relevant to this process. ![Figure1](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/40/9/4/F1.medium.gif) [Figure1](http://www.thenationshealth.org/content/40/9/4/F1) Howard Koh speaks with HHS Secretary Kathleen Sebelius in July. Koh is at the forefront of public health quality improvement work. Photo by Chip Somodevilla, courtesy Getty Images We are doing this in the context of health reform and there is now the provision to produce a national quality strategy by January. In fact, there is a dedicated group at the department working on that. There are education and training opportunities, of course, and there are also demonstration projects that will be launched by the department, particularly by the Centers for Medicare and Medicaid Services. We are very pleased to be moving all these initiatives forward. ## There is a great deal of momentum to implement quality improvement efforts in health departments. How would you rate the progress? The momentum is accelerating and the department and the public health community at large have certainly rallied around this concept. Also, passage of the Affordable Care Act has advanced the progress substantially, because the whole purpose of the Affordable Care Act is to bring not just coverage but also quality of care and prevention to all people. ## What must leaders do to ensure that quality improvement becomes embedded in their organization’s structure and culture agency-wide? Concepts of public health quality must be embedded into the culture of public health and must be embedded within all the systems that we create to align values of quality within those organizations. Public health leaders are never satisfied with the status quo but always demand quality improvement and demand better systems that help people. Embedding those values into our public health systems, aligning values and resources and measuring outcomes in a continuous fashion is what leadership is all about. ## Other industries have long used quality improvement techniques to improve their services and performance. Why has public health lagged? It’s been only relatively recently that people have understood public health to be a system that needs improvement like other systems. Until now, many have viewed public health as more a collection of problems, but in fact we do have a system that demands attention, that demands improvement and also demands that we measure our progress and report our progress publicly and improve our efforts and then go through that cycle continuously to benefit people’s health. And there are many dimensions of that cycle that have been applied to other systems, particularly in business, and we have recently heard about some pretty high-profile lapses in quality in other industries. So we are learning from those experiences and applying them to public health. We also know that there are areas that we are just beginning to address in a more proactive way in public health, like areas of work force and finance and other related areas. One of the dimensions of public health quality is to be as proactive as possible — to be proactive and vigilant and transparent. Those are three of the nine aims that are particularly important to stress. Public health has now matured to the point that we are embracing those themes as part of advancing public health quality. ![Figure2](http://www.thenationshealth.org/http://www.thenationshealth.org/content/nathealth/40/9/4/F2.medium.gif) [Figure2](http://www.thenationshealth.org/content/40/9/4/F2) Photo courtesy HHS ## How can quality improvement concepts in clinical medicine, which focus primarily on the delivery of care to individuals, create synergy with the public health approach? We and others have convened this forum to help envision a new framework, a broader framework, for public health quality that starts with this foundation that was set at the clinical level. As our statement captures, we have now nine proposed aims for public health quality. For health care quality, there are six of them: Safe, timely, equitable, effective, efficient and patient-centered. For public health quality, we have nine aims that we are proposing: Population-centered, equitable, proactive, health-promoting, risk-reducing, vigilant, transparent, effective and efficient. So there is definite overlap. The clinical quality aims sort of set the foundation and the stage for the public health quality aims, and the two are really very much linked. ## How do U.S. efforts on health reform fit into quality improvement and how important is quality in reform? One of the great transformative features of the Affordable Care Act is that we now have a fighting chance to truly have a system of care and prevention. As part of that, we need a system that has high quality and that measures quality and that gives all people a chance to reach their highest attainable standard of health. The Affordable Care Act moves us toward that goal in so many ways. A national quality strategy is due by January of next year. A national prevention strategy is due by March 2011. Those strategies need to be aligned. So in short, we are developing new systems and new expectations for quality in that system because of the Affordable Care Act. ## What kinds of strategic alliances have been established to advance this work? We are very grateful for the enthusiastic collaboration of so many partner organizations around the country, including APHA, the Association of State and Territorial Health Officials and the National Association of County and City Health Officials. We have other groups also, such as the National Quality Forum and Academy Health. These are just some of the partners who have worked closely with us, and as a result we have moved toward establishing a set of priority areas that will be unveiled at the APHA meeting in Denver this fall. ## What are the next steps in quality improvement at HHS? They include finalizing these priority areas, identifying measures and aligning our efforts with the national quality strategy and national prevention strategy that are going to be unveiled very shortly. Addressing issues of not only continuous improvement but also sustainability of efforts that are going well — and keeping the momentum strong — are all critical themes here. ## Footnotes * The national quality improvement work will be discussed at APHA’s 138th Annual Meeting at session 3193 at 12:30 p.m. on Monday, Nov. 8. * — Interview conducted, edited and condensed by Teddi Dineley Johnson * Copyright The Nation’s Health, American Public Health Association