Context: Evidence of the effect of continuous quality improvement (CQI) in public health and valid tools to judge that such effects are not fully formed.

Objective: The objective was to adapt and apply Shortell et al.'s (1998) four dimensions of CQI in an examination of a public health accountability and performance management initiative in Ontario, Canada.

Methods: In total, 24 semi-structured, in-depth interviews were conducted with informants from public health units and the Ministry of Health and Long-Term Care. A web survey of public health managers in the province was also carried out.

Results: A mix of facilitators and barriers was identified. Leadership and organizational cultures, conducive to CQI success were evident. However, limitations in performance measurement and managerial discretion were key barriers.

Conclusion: The four dimensions of CQI provided insight into both facilitators and barriers of CQI adoption in public health. Future research should compare the outcomes of public health CQI initiatives to the framework's stated facilitators and barriers.