designing a learning health organization for collective impact
DESCRIPTION
"Designing a Learning Health Organization for Collective Impact" was my presentation given at the California HealthCare Foundation (CHCF) Health Care Leadership Program final seminar and graduation. Congratulations to the amazing fellow graduates!!!TRANSCRIPT
Designing a Learning Health Organization for Collective Impact
Tomas J. Aragon, MD, DrPH
Health Officer, City and County of San FranciscoDirector, Population Health Division (PHD)San Francisco Department of Public Health
University of California, BerkeleySchool of Public Health
October 3, 2014
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Acknowledgments
Barbara A. Garcia, MPA, Director of Health, SFDPH
CHCF Healthcare Leadership Program Staff and Cohort 12!!!
California HealthCare Foundation (CHCF)Healthcare Leadership Program, UC San Francisco
SFDPH Population Health Division staff
SFDPH Quality Improvement Programs
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Overview
1 Problem statement
2 Project description
3 Goal and objectives
4 Outputs and outcomes
5 Lessons learned
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 3 / 18
Problem statement
Challenges and Opportunities
Challenges
Increasing complexity
Public Health Accreditation
Health and socioeconomic inequities
Aging and epidemic of chronic diseases
Patient Protection and Affordable Care Act
Opportunities
Public Health Accreditation
Patient Protection and Affordable Care Act
“Collective impact” for community transformation
Integration of epidemiology, quality improvement, and complexity science
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Problem statement
Problem definition and underlying causes
The San Francisco Department of Public Health, Population Health Division (PHD) is limitedin its ability to fulfill its mission to protect and improve community health and health equity.PHD faces special challenges:
a legacy of categorical funding and autonomous silos,
no system for performance management and continuous quality improvement,
new public health accreditation requirements,
implementation of the Affordable Care Act,
fragmented services, and
limited focus and capability to address complex community health problems and socialdeterminants.
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 5 / 18
Problem statement
San Francisco’s old “public health” division, 2011Population Health and Prevention
Categorical silos
No division training program
No division strategic planning
No division quality improvement
No division performance management
Community Health Promotionand Prevention
Public Health Preparednessand Emergency Response
Environmental Health andOccupational Safety
Public Health Laboratories
Emergency Medical Services
STD Prevention and Control
Tuberculosis Control
Communicable DiseaseControl and Prevention
HIV Prevention
HIV Epidemiology
Bridge HIV (Research)
POPULATION HEALTH & PREVENTIONTomás J. Aragón, MD, DrPHHealth Officer & Director
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Project description
REACH—for Results, Equity, and Accountability for Community Health
Leveraging concepts from
organization development and design,
continuous quality improvement,
leadership and management, and
complexity science,
we reorganized the Population Health Division under a new continuous improvementframework we call REACH—for Results, Equity, and Accountability for Community Health.
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Goal and objectives
Goal
A high performing, learning health organization that successfully implements “collectiveimpact” approaches to complex community health problems.
Output-oriented objectives: By July, 2013:
1 Population Health Division Organization Design Framework (ODF)2 Design and implementation of new REACH framework:
1 Criteria for Performance Excellence (CPE)2 Four Strategic Questions (4SQ)3 Results-based management (RBM)4 Health Equity X (HEX) model
Outcome-oriented objectives: By July, 2014:
The conduct of high-priority health equity projects with continuous improvement in populationhealth (lag) and performance (lead) indicators using the new REACH framework.
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Outputs and outcomes
Output: Population Health Division Organization Design Framework
Public health accreditation
Four P’s of public health
Physiology vs. anatomy(organization chart)
Horizontal integration
DISASTERS(Preparedness)
- - -Emergency
Preparednessand Response
Branch
HEALTHY PLACES(Protection)
- - -EnvironmentalHealth Branch
HEALTHY PEOPLE(Promotion)
- - -Community
Health Equityand Promotion
Branch
DISEASES(Prevention)
- - -Disease
Preventionand Control
Branch
STRATEGIC PLANNING: Office of Policy, Planning, and Quality Improvement
OPERATIONS FOCUS: Office of Operations, Finance, and Grants Management
WORKFORCE FOCUS: Center for Learning and Innovation
KNOWLEDGE MANAGEMENT: Surveillance, Epidemiology, and Research Branch
COMMUNITYPARTNERS
- - -Health Systems
Schoolsetc.
GUIDED BY STRATEGIC VISIONAND ACTION PLANS
1. Safe and Healthy Living Environments
2. Healthy Eating and Physical Activity
3. Access to Quality Care and Services
4. Black / African American Health
5. Maternal, Child, and Adolescent Health
6. Health for People at Risk or Living with HIV
Assessment
Policy Development
Assurance
Governance,Administration,and SystemsManagement
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Outputs and outcomes
Output: Criteria for Performance Excellence—“Baldrige House”
Predictive of high performance
Pillars of leadershp & results
Knowledge integration
Decision support
Guided by Strategic Visionand Action Plans
Supported by Values (respect, continuous improvement, teamwork, excellence)
Influenced by Challenges and Opportunities
1. Leadership 7. Results
2. Strategic Planning& Decision-making
3. CustomerValue
5. WorkforceDevelopment
6. Lean Thinking &Process Innovation
4. Knowledge Integration and Decision Support
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Outputs and outcomes
Outputs: Influence of the Baldrige CPE on the Organization Design
Baldrige Criteria Examples of organization design achievements
1. Leadership Executive team leadership academy2. Strategic planning Result-based strategic planning for accreditation3. Customer focus Community Health Equity and Promotion Branch
Disease Prevention and Control Branch4. Knowledge integration and
decision supportIntegrated surveillance and epidemiology unitIntegrating all disease surveillance systemsContinuous Decision Improvement (CDI) curriculum
5. Workforce focus Center for Learning and Innovation6. Process management Office of Equity and Quality Improvement7. Results Collective impact using results-based management
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Outputs and outcomes
Output: Four Strategic Questions (4SQ)
The practice of asking four strategic questions with all important activities. Promotes aculture of strategy awareness and results-based accountability, but in an accessible way thatvalues staff creativity.
4SQ
1 What are we trying to accomplish and why?(strategic intent)
2 How do we measure success?(scorecard)
3 What other conditions must exist?(assumptions and risks)
4 How do we get there?(action planning)
Example
Daily planning
Planning meetings
Project management
Quality Improvement
Structured decision making
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Outputs and outcomes
Output: Results-based management (RBM) for collective impact
RBM
Results chain
Results matrix
Collective impact
1 Common agenda
2 Shared measurement
3 Continuous improvementof mutually-reinforcingactivities
es)
OutcomesC
OutputsC
1What are we trying to Accomplish and why?
(strategic intent)
2How do we
measure Success?(scorecard)
3What other conditions
must exist?(assumptions & risks)
4How do weget there?
(action planning)
ENDS
Performancemeasures:
Outcomeindicators
Outputindicators
Processindicators
Impactindicators
MEANS
Results-based
planning,working
from endsto means
(a)
(b)
(c)
(d)
4SQ
RBM
FutureState
CurrentState
Inputs C Plan-Do-Study-Act (PDSA)1. Project management2. Continuous improvement3. Test, Learn, Improve, Spread
es)
OutcomesB
OutputsB
Inputs B
es)
OutcomesA
OutputsA
Inputs A
Partner A Partner B Partner C
Goal (common agenda) & Collective Impact
Processes Processes Processes
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Outputs and outcomes
Output: Health Equity X (HEX) model
The HEXa,b model is used for planning and managing efforts to achieveresults for challenges and opportunities embedded in complex socialsystems, including for health equity, quality improvement, and collectiveimpact.
1 People (mental models, belief systems, cultural norms, “isms”)
2 Policy (social, organizational, institutional)
3 Place (neighborhoods, schools, work, open spaces)
4 Program (programs, agencies, or service systems)
5 Provider (teacher, employer, landlord, minister)
6 Patient (student, employee, tenant, follower)
Patient
Program
People
Provider
Place
Policy
Health Equity
a HEX model was inspired by BARHII (http://www.barhii.org) and Dr. Tony Iton
b A hexateron is a geometric object with 6 vertices, 15 edges, 20 triangle faces, 15 tetrahedral cells
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Outputs and outcomes
Outcome: The new Population Health Division!
July 2014: First anniversary of PHD reorganization which was recognized by the NationalAssociation of County and City Health Officials (NACCHO) as a “standout on the issue ofhealth department leadership and transformation in the new public health era” Invited topresent at NACCHO National Conference in Atlanta, Georgia, July 2014.
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Outputs and outcomes
Outcome: Peer-reviewed publication (in press), 2014Journal of Public Health Management and Practice
TJA affiliation includes CHCF Health Care Leadership Program!
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Outputs and outcomes
Outcome: Black/African American Health Initiative launched April, 2014
SF Health Network and Population Health Division
1 Collective impact
2 Workforce development
3 Cultural humility training
Collective impact
1 Heart health — Healthy Hearts San Francisco
2 Behavioral health (focus: alcohol)
3 Women’s Health (focus: breast cancer)
4 Sexual Health (focus: chlamydia)
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Lessons learned
Lessons learned: focus on team-based leadership with . . .
. . . continuous improvement in
1 practice of cultural humility,
2 creation & extension of trust, and
3 practice of shared decision making.
From my research, experience, and practice,the key path to a learning organization is byimproving humility, trust, and shared decisionmaking. With cultural humility we increaseself-awareness of our biases, we engage inself-reflection to put these aside, we redresspower imbalances, and learn from every humaninteraction. Humility and humble inquirycreates trust, enabling shared decision makingwhich requires cooperation (trust andhumility).
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