Armbruster also brought her expertise to the Missoula City-County Health Department in Montana, which sought technical assistance to build QI capacity and improve overall department performance. PHF delivered a two-day training. Subsequent QI projects included a breastfeeding outreach initiative which was recently highlighted by the Public Healt​h Quality Improvement Exchange (PHQIX). Ellen Leahy, Director and Health Officer for the department located in the second most populous county in the state, said, "While preparing for accreditation, the Missoula City-County Health Department took full advantage of resources from the Public Health Foundation (PHF). When we came to a point when we could not break through the chicken and egg dilemma of where to focus limited training money -- performance management or quality improvement -- I sought PHF for advice. Their technical assistance in sorting out that question with our department was as integral to our accreditation success as the quality improvement training that PHF subsequently provided." 

Department-wide impact was not unique to Missoula's experience. The New Orleans Health Department chose to use part of its grant from the National Association of County and City Health Officials (NACCHO) to provide QI training to staff. The health department had a performance management system that did not yet include a QI component. And while its PHAB prerequisites were complete, staff saw QI as a gap in its current practice and readiness for accreditation. PHF Senior Quality Advisor Jack Moran delivered a one-day training, after which staff completed several QI projects, including its most recent one focused on improving grant applications.