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Introduction
It has been said by many that quality drives innovation and vice-versa. This is evidenced by the growing literature on the utilization of Six Sigma methodology within health care institutions (7, 6, and 9). In contrast, the local public health community may have been slow to respond to innovative quality methods often utilized by the private sector, due to a barrage of legal and ethical considerations regarding the distinction between the actual practice and research. As medical communities begin to confront quality improvement with increased vigor, so should the public health community. This study will examine the difference between public health practice and research; and why it may be appropriate for local health departments to embrace Six Sigma methodology in their respective operations.

The Dilemma of Public Health Practice
Public health refers to the organized efforts of society, both government and others, to assure the population's health (12). Local public health practice is quite complex. Understanding the difference between public health practice and research has perplexed the local public health community for years. Local (in the context of this article) will be defined as relating to a city, town or distinct rather than larger area. What drives this unique distinction, are primarily three features: Common Rule, Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Tenth Ammendment. Common Rule refers to how the federal government interprets the utilization of human subject research. HIPAA another federal mandate protects how the use and privacy of health information. "The provision of public health services in the United States has its basis in the U.S. Constitution 11 (p22)." What this means, is that ultimately, states have the primary responsibility of protecting its public health and the Tenth Amendment allows states to exercise this broad and extensive power. Further, as states define their scope and definition of public health. The comprehensive "Model State Public Health Act" (11, 4) recently completed the "Turning Point Statutory Modernization Collaborative" (11, 4) which continues to build a universal definition of public health. As a result, local public health practice refers to protecting the public's health in a city or town. Local public health officials have questioned whether a certain activity may be defined as research or activity, but this is where states have influence on determining what is a

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