Designing a Learning Health Organization for Collective Impact

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

Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 1 / 18

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


Overview

1 Problem statement

2 Project description

3 Goal and objectives

4 Outputs and outcomes

5 Lessons learned


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


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.


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


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.


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.


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



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



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



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



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



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


http://www.barhii.org

http://www.uctv.tv/shows/Tackling-the-Root-Causes-of-Health-DisparitiesLeNoir-NMA-Pediatric-Lecture-27738


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.



Outcome: Peer-reviewed publication (in press), 2014Journal of Public Health Management and Practice

TJA affiliation includes CHCF Health Care Leadership Program!



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)


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).


Health & Medicine

Designing a Learning Health Organization for Collective Impact