The Affordable Care Act1 upholds a major goal to improve quality and population health. To date, major advances have pushed forward concepts and measures in health care quality, focusing primarily on clinical settings.2 However, the development of such quality concepts and measures in the broader arena of public health has lagged behind those in the narrower world of health care. Closing that "quality chasm" first requires developing a basic definition of public health quality as well as identifying aims and priority areas. Recently, we have begun to narrow that gap to move closer toward a public health quality vision of "Building better systems to give all people what they need to reach their full potential for health."3

The Vision of Building Better Systems

The need to apply uniform concepts for quality that advance population health started with the 1998 report, Quality First: Better Health Care for Americans.4 This landmark document recommended developing a national culture where quality is valued and supported with a national consensus for aims, priorities, and shared system goals across all sectors of health care. Quality First: Better Health Care for Americans recommended that such elements be embedded into the daily practices of public health and health care organizations. Integrating such systems-thinking approaches could link quality, prevention, treatment, and access to care,3 with a special emphasis on ensuring "equality in quality,"5 as a foundational and not merely an aspirational goal.

In that spirit, in 2008, the US Department of Health and Human Services (HHS) established the Public Health Quality Forum (Forum) under the direction of the Assistant Secretary for Health. The Forum charged directors of HHS agencies, with input from external stakeholders, to develop basic definitions, aims, and priorities for quality in the public health system as recommended in Quality First: Better Health Care for Americans. Subsequently, the Consensus Statement on Quality in the Public Health System,6 the initial work released by the Forum, offered a formal definition of public health quality as

Quality in the public health system is 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.

Included also in the Consensus Statement are the following 9 aims representing characteristics of quality required for public health systems:

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 other negative outcomes

Vigilant: Intensifying practices and enacting policies to support enhancements to surveillance activities (eg, technology, standardization, systems thinking/modeling)

Transparent: Ensuring openness in the delivery of services and practices with particular emphasis on valid, reliable, accessible, timely, and meaningful data that are readily available to stakeholders, including the public

Effective: Justifying investments by utilizing evidence, science, and best practices to achieve optimal results in areas of greatest need

Efficient: Understanding costs and benefits of public health interventions and to facilitate the optimal utilization of resources to achieve desired outcomes

This unified set of quality principles provides a common foundation for advancing quality efforts moving forward.

Bridging Public Health and Health Care Quality

The Consensus Statement can serve as an initial catalyst for broad engagement of any organization engaged in population-based activities. As an example, the Catholic Health Association recently recognized the applicability of these public health quality concepts to the community benefit and community building activities of tax exempt hospitals.7 Such activities strengthen the bridge between public health and health care.

Furthermore, Rust et al8 noted that linking public health and clinical practices helped achieve major reductions in deaths over a 50-year period. As an example, they show that the 56% reduction in heart disease from 1950 to 2000 can be attributed, in part, to both public health interventions such as blood pressure education and awareness campaigns combined with clinical practices for the treatment of blood pressure in primary care settings. Such heart disease awareness and prevention campaigns, involving both public health agencies and groups such as tax exempt hospitals through community benefit and community building activities, provide evidence of proactive, health-promoting, and risk-reducing activities exemplifying public health quality aims. Effectiveness, a characteristic of public health quality and of patient care as defined by the Institute of Medicine,9 is achieved through these combined activities in public health and health care. Also, the HHS National Strategy for Quality Improvement in Healthcare, released in 2011, also reinforced the value of promoting quality in broad public health arenas as well as in health care.

Another major advance is identifying priority areas that function as primary drivers of public health quality. In November 2010, the Forum released the report Priority Areas for Improvement of Quality in Public Health,2 which are listed as follows:

* population health metrics and information technology;

* evidence-based practices, research, and evaluation;

* policy;

* systems thinking;

* sustainability and stewardship; and

* workforce and education.

With this publication, the field of public health quality has evolved in reaching a common definition, aims, and priority areas. Together, they provide an early framework for identifying and eliminating gaps between public health and health care, and for aligning organizational, local, state, and national goals for public health.3

Progress

Sustaining forward momentum in public health quality now requires the development of quality management systems that include methods for quality assessment, assurance, and improvement. This special issue of the Journal of Public Health Management and Practice begins to explore these issues by reporting and analyzing key quality improvement efforts in state and local health departments across the nation. These efforts document how public health organizations around the country are beginning to make progress. The application of quality concepts to such improvement activities ensures capacity across the system to

* recognize the value of public health quality,

* develop and implement standards,

* set goals consistent with the public health quality aims,

* increase transparency and stewardship,

* collect and analyze valid data across all levels of the system,

* identify weaknesses, and

* make measurable improvements.

In this issue, some investigators (Harrison et al, Wright et al, Davis et al, Cornett et al, Ramaswamy et al, Randolph et al, Morrow et al, and Joly et al) provide further insight on the quality aims and priority areas (ie, effective, research, risk reducing, sustainability, workforce training) and focus on the need to advance the culture of quality and build better systems. Still others (Madamala et al and Matthews et al) analyze system readiness and policies for agency accreditation as a mechanism to improve quality.

Moving Forward

Advancing this new field involves furthering research, making these public health quality concepts concrete, useful, and applicable. Organizations that achieve success when the concepts are applied to improve health outcomes must be publicly recognized and rewarded. Tying the quality concepts to appropriate HHS public health funding opportunities is also a high priority. Equally important is the development of tools where professionals can access evidence-based strategies and quality measures linked to the concepts. Ongoing efforts include an upcoming book describing the concepts and demonstrating the value to public health and health care as well as teaching materials being developed for wide distribution.

The US Department of Health and Human Services is pleased to be part of these efforts. In collaboration with many other stakeholders and both traditional and nontraditional partners, we all share the goals to bridge the quality gap between health care and public health, further health quality for all people, and make the nation healthier in the future.

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