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Introduction: This practice-based research study capitalized on the statewide implementation of a comprehensive, locally-driven initiative to implement evidence-based policy, system and environmental changes related to obesity and tobacco use. The study examined local health department (LHD) performance and factors such as organizational quality improvement (QI) maturity, structure and governance. Methods: State health department staff reviewed grant reports and documentation pertaining to all LHD grantees, which collectively represented all 87 counties and 4 cities in Minnesota (MN), in order to designate grantees as either: "Exceeds Expectations," "Meets Expectations" or "Approaching Expectations." A study team of state, local and academic partners then used select measures from the QI Maturity Tool to calculate a QI Maturity Score, and subsequently place grantees into three levels of QI maturity: low, medium and high. Multivariate regression was performed to examine the potential relationship between grantee performance and QI maturity, as well as other covariates. Results: Of the final sample of 91 counties/cities, 87 had complete data for multivariate analysis. The distribution of grantee performance was: exceeds expectations (29.7%), meets expectations (55.0%) and approaching expectations (15.3%). Organizational QI maturity was strongly, positively associated with grantee performance comparing the "exceeds expectations" to those who "met or approached expectations" (OR=4.29, 95 % CI: 1.90-9.73, p=0.0005). Implications: Organizational QI maturity was strongly associated with LHD performance. More research is needed to determine whether a more mature approach to quality improvement is merely a marker for overall LHD capacity or has its own unique contribution to performance. Findings have been used to inform the next funding cycle of this initiative and provide support to implementing annual assessment of QI maturity in MN. [ABSTRACT FROM AUTHOR]