San Francisco Department of Public HealthPopulation Health Divsion, 2017-05-22

Population Health Lean: An overview v. 2017-05-22

Tomás J. Aragón2,3*, Barbara A. Garcia1 “We will be the best at getting better!”

AbstractFor transforming organizations and communities, the San Francisco Department of Public Health, Population HealthDivision has embraced population health lean—a transdisciplinary management system for learning, adaptation, innova-tion, and continuous improvement based on the Toyota Production System (lean), collective impact and other methods.Our training focus is on lean thinking. Our core values include humility, respect for people, teamwork, embracingchallenges, genchi genbutsu (“go and see” to empathize and understand), and kaizen (continuous improvement).

Keywordspopulation health, quality improvement, lean, lean startup, collective impact, design thinking, decision science

1Director of Health, San Francisco Department of Public Health (SFDPH)2Health Officer, City and County of San Francisco; Director, Population Health Division, SFDPH3Clinical faculty, University of California, Berkeley School of Public Health, Division of Epidemiology* Corresponding email: tomas.aragon@sfdph.org; Population health lean website: http://www.phlean.org

Humans have three core cognitive-behavioral processes: de-ciding, acting, and learning. Adaptation comes from adjusting ourdecisions and actions based on what we learn. Improvements areadaptations that make things better. These processes—mediatedby emotions—are fundamental to all human activities, and formthe basis for innovation and continuous improvement.

To become a learning organization, we must ensure:• decision quality (decisions, supported by data science),• project management (actions, including agile development),• performance improvement (learning, improved results), and• positive and safe environments (emotions, see “NewSmart”)

Population health is “a systems framework for studying andimproving the health of populations through collective actionand learning” [1]. Lean thinking and practice is “systematicallydeveloping people to solve problems and consuming the fewestpossible resources while continuously improving processes to pro-vide value to community members and prosperity to society” [2].Population health lean is a transdisciplinary management systemfor learning, adaptation, innovation, and continuous improvementbased on lean thinking, complementary frameworks, and a leanleadership philosophy (Figures 1 and 2 on the following page).

Figure 1. Population health lean: transdisciplinary managementsystem for learning, adaptation, innovation, and improvement

1. Leadership philosophyThere are three types of values: organization values (What’simportant to us?), customer value (What’s important to our pri-mary customers? What would they be willing to pay for?), andmeasurement values (How do we measure values? How do wemeasure controllable predictors of value?). We must be able tomeasure how well we improve processes, achieve results andgoals, and deliver organization and customer value.

Organization valuesThe value pillars of lean are respect for people and continuous im-provement. Each pillar has three components. Respect for peopleincludes (a) humility, (b) respect, and (c) teamwork. Continuousimprovement includes (a) challenge (need, problem, opportunity,goal, assignment), (b) genchi genbutsu (“go and see” to empathizeand understand), and (c) kaizen (continuous improvement).

Cultivating humility and empathy, and leading with humilityare essential for success. “Humility is the noble choice to forgoyour status, [and to] use your influence for the good of othersbefore yourself” [3]. Humility enables one to seek honest, criticalfeedback, and to improve trust, relationships, team performance,and intellectual growth. Humility fuels the growth mindset [4].

MindsetThe population health lean mindset is developed by embracinguniversal, coherent principles, based on neuroscience, and cogni-tive and positive psychology that drive behaviors and attitudes:1. Placing customers at the center (empathy, human-centered)2. “NewSmart” mindset (intellectual humility, honesty, and courage;

open to testing own ideas; good at not knowing; hyperlearner) [5]3. Humility mindset (humble, forgo status, open-hearted) [3, 5]4. PDSA thinking (scientific thinking→ daily experiments)5. Embracing and learning from mistakes and failures [4]6. Focusing on processes that align with vision and purpose7. Leading with humility [5] and leader standard work (Figure 2)

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Figure 2. Population health lean leadership philosophy

SkillsetThe population health lean skillset includes core skills and method-ologies that drive learning, adaptation, innovation, and improve-ment. Traditional lean production [6–8] is strengthened by inte-grating methods from complementary frameworks (design think-ing, lean startup, Results-Based Accountability [RBA],TM etc.).However, we recommend focusing on skills 1 to 4, especially“NewSmart” behaviors and lean thinking, and developing otherskills as needed (“learning in the work”).1. Staff exhibit “NewSmart” behaviors (see “NewSmart . . . ”)2. Staff as daily PDSA problem-solvers (Figure 2)3. Managers as coaches and teachers (Figure 2)4. Lean thinking (PDSA, validated learning, A3 reporting [9])5. Collective impact (results-based) methods [10, 11]6. Agile project management [12], and other methods [13–16].7. Decision quality [17], supported by data science [1]

ToolsetPopulation health lean emphasizes lean production and manage-ment tools for leadership, people development, continuous im-provement, strategic planning and strategy deployment, visualmanagement, project management, and ensuring team account-ability at all levels:1. Catch-ball (dialogue, feedback, shared decision making)2. 5S (workplace organization for visual management) [18]3. Standard work (including leader standard work) [19, 20]4. Status sheets (monitor) and huddle boards (improve) [19]5. Value-stream mapping (eliminate waste; optimize flow) [21]6. Hoshin kanri [22]; Kanban agile project management [12]7. 3P (“production preparation process”) for new designs

2. “NewSmart” HumilityNewSmart Humility is the heart and mind of population healthlean! The world is changing fast! Disruptive technologies are

emerging at a rapid clip. Automation, machine learning, andartificial intelligence—the Smart Machine Age (SMA)—are dis-placing knowledge-based professionals, and these phenomena areaccelerating [5]. Transdisciplinary teamwork is the new norm.People skills, creativity, adaptability, agility, innovation, and con-tinuous improvement are more important now than ever.

Unfortunately, our native cognitive abilities have not evolvedat the same pace [23]. Our brain is wired to sense “dangers” andreact quickly based on perceived threats and emotions. Our brainis also wired for efficiency, and it defaults to personality traits,fast decisions via nonconscious schemas, or learned mindsets.We resist entertaining new ideas that demand significant cognitiveeffort. Our individual and team decision making is suboptimaldue to cognitive biases and traps [17]: (a) protection of mindset,(b) personality and habits, (c) faulty reasoning, (d) automaticassociations, (e) relative thinking, and (f) social influences.

We can mitigate our cognitive, emotional, and behaviorallimitations by understanding our brain better. Hess argues thatprotecting our egos and reacting to our fears are the primaryimpediments to creativity, receiving honest feedback, critical andinnovative thinking, and emotionally engaging others [5]. There-fore, we need a new definition of “being smart” (“NewSmart”).We must embrace intellectual humility, awareness, honesty, andcourage and develop behaviors and organizations for this modernera. We call this approach NewSmart Humility that consists offour components: (a) NewSmart mindset, (b) Humility mindset,(c) NewSmart behaviors, and (d) NewSmart organization.

“NewSmart” mindsetHess writes “To change our mental model for the SMA, we firstneed to accept a quality-based definition of “being smart”—aNewSmart—that we define as excelling at the highest level ofthinking, learning, and emotionally engaging with others thatone is capable of doing. NewSmart is a measure not of whatyou know or how much you know but of (a) the quality of yourthinking, listening, collaborating, and learning; (b) how good youare at "not" knowing and decoupling your beliefs (not values)from your ego; (c) how good you are at being open to continuallystress-testing your beliefs about how the world works; (d) howgood you are at trying out new ideas and ways to accomplish yourobjectives and learning from those experiments.”

“So what does the high-quality thinking, learning, and emo-tional engagement underlying NewSmart look like in practice?”The NewSmart principles are worth committing to memory:1. “I’m defined not by what I know or how much I know, but by

the quality of my thinking, listening, relating, and collaborat-ing.”

2. “My mental models are not reality—they are only my general-ized stories of how my world works.”

3. “I’m not my ideas, and I must decouple my beliefs (not values)from my ego.”

4. “I must be open-minded and treat my beliefs (not values) ashypotheses to be constantly tested and subject to modificationby better data.”

5. “My mistakes and failures are opportunities to learn.”

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Humility mindsetWe embrace two definitions of humility: (a) Dickson defineshumility as “the noble choice to forgo your status, [and to] useyour influence for the good of others before yourself” [3], and(b) Hess defines “Humility as a mindset about oneself that isopen-minded, self-accurate, and ‘not all about me,’ and that en-ables one to embrace the world as it ‘is’ in the pursuit of humanexcellence” [5].

“Humility is a mindset that results in not being so self-centered,ego defensive, self-enhancing, self-promotional, and closed-minded—all of which the science of learning and cognition shows inhibitexcellence at higher-order thinking and emotionally engagingwith others” [5].

NewSmart behaviorsThe NewSmart and Humility mindsets drive behaviors that aresupported and improved with evidence-based skills. Hess clustersthem into four behavioral categories:(a) Quieting Ego,(b) Managing Self (thinking and emotions),(c) Reflective Listening, and(d) Otherness (emotionally connecting and relating)

Quieting Ego“Quieting Ego is how we can deliberately work to reduce our re-flexive emotional defensiveness; have empathy and open-minded-ness; engage in Reflective Listening; and proactively seek otherpeople’s feedback and perspectives to stress-test our own thinking.Quieting Ego is a way of practicing and operationalizing Humility.To quiet our ego is to perceive others and the world without filter-ing everything through a self-focused lens and to tamp down onnegative or self-protective “inner talk” that is driven consciouslyor subconsciously by our fears and insecurities” [5]. QuietingEgo starts with four evidence-based behaviors: (a) mindfulness,(b) mindfulness meditation, (c) daily Quiet Ego reminders, and(d) practicing gratitude.

Managing Self (thinking and emotions)“Managing Self—our emotions and thinking—aids us in engagingin the higher-level thinking and behavior required . . . . It’s nec-essary to remain open-minded and be willing to test our beliefsand modify our points of view if presented with better data. It’salso how we’re able to overcome our fear of mistakes in order totake ownership of them and learn from them, and helps us moreeffectively relate to and collaborate with others” [5].

“Managing Self comes from the science of ‘self-regulation’and ‘self-control,’ which are broad psychological concepts thatmean to monitor and manage one’s emotions, thoughts, and be-haviors” [5], and start with these practices: (a) slowing down,(b) managing thoughts, (c) managing emotions, and (d) emotionalintelligence.

For managing thoughts Hess’ “thinking toolbox” starts withfamiliar concepts from population health lean (lean thinking, rootcause analysis, decision quality, design thinking, etc.).

For managing emotions Hess writes “We’ve discussed howego and fear are the two big learning inhibitors and explored

our reflexive tendency as humans to be emotionally defensiveand self-protective. We’ve discussed how negative emotions canundermine our behavior and thinking and how positive emotionscan improve them. Stress, anger, and anxiety can cause narrow-mindedness and the fight-flee-or-freeze syndrome. . . . Positiveemotions, on the other hand, have been scientifically linked notjust to higher health and well-being but also to broader attention,open-mindedness, deeper focus, and more flexible thinking, allof which underlie creativity and innovative thinking. Positiveemotions also improve decision making and general cognitiveprocessing.”

Hess’ “managing emotions toolbox” includes effective tech-niques such as (a) psychological distancing, (b) reframing, (c) pos-itive memories, (d) positive self-talk, and (e) if-then implementa-tion plans. See Hess book [5] for illustrative examples.

Emotional intelligence (EI) is “the ability to monitor one’sown and others’ feelings and emotions, to discriminate amongthem and to use this information to guide one’s thinking andactions. . . . Sensitivity to other people’s emotions has been foundto be a key to effective collaboration.” The EI model includesthese abilities:1. Perceive emotions (and differentiate) in self and others.2. Use emotions to facilitate reasoning, aid judgment and mem-

ory processes, problem solve, communicate with others, andfacilitate open-mindedness.

3. Understand emotions by analyzing the emotions of yourselfand others.

4. Manage emotions.

Reflective Listening“Reflective Listening is so important because it underlies all [otherskills]. Why? Because your thinking and learning are limitedby cognitive biases, emotional defensiveness, ego, and fear. Youneed, then, to truly listen to others to open your mind, push pastyour biases and mental models, and mitigate self-absorption inorder to collaborate and build better relationships. [We knowfrom] evidence that it’s hard for any of us to critique our ownthinking and truly think critically. We’re just too wired to confirmwhat we already believe, and we feel too comfortable having acohesive simple story of how our world works. We need to havethinking “partners” who force us to confront those biases, and weneed to listen to them” [5].

Reflective Listening starts the following practices:(a) preparing to listen reflectively,(b) listening with a Quiet Ego and an open mind, and(c) humble inquiry (asking with humility and genuine curiosity).

Here is a preparation checklist for listening reflectively:1. Is my mind clear? If not, take several deep, slow breaths.2. Am I calm emotionally? If not, take a few more deep breaths,

focusing on breathing in for four seconds and very, very slowlybreathing out for four seconds.

3. Say to yourself a couple of times: (a) “I am not my ideas.”(b) “It’s not all about me.” (c) “Don’t be defensive.” (d) “Askquestions before telling.” (e) “Don’t interrupt.” (f) “Stayfocused.” (g) “Critique ideas, not people.” (h) “Listen tounderstand, not to confirm.”

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Otherness (emotionally connecting and relating)Hess writes “We need others because we can’t think, innovate, orrelate at our best alone. To relate to other people you first haveto make a connection with them. It is by building a relationshipover time that you build trust, and when you have caring trust,you have set the stage for the highest level of human engagement.. . . So how do you get better at connecting and relating? It’squite obvious that connecting and relating to people is inhibitedby arrogance, self-absorption, self-centeredness, not listening,closed-mindedness, lack of empathy, emotional defensiveness,and the ego protection and fear that flow from the Old Smartmental model. Accepting NewSmart and Humility as well aspracticing Quieting Ego, Managing Self, and Reflective Listeninglays the groundwork for relationship building with others.”

Otherness behaviors include: (a) fives keys to connecting,(b) building trust and caring (see p. 20), (c) preparing for meetings,(d) choose words wisely. The five keys to connecting are (a) bepresent, (b) be genuine, (c) communicate affirmation, (d) listeneffectively, and (e) communicate support.

Prepare for meetings with this checklist: (a) be really present;(b) genuinely smile—a big smile; (c) make eye contact; (d) bepositive; (e) listen reflectively; (f) stay fully present; and (g) dono harm. Choose your words wisely: use “Yes, and” instead of“Yes, but” to build on the ideas of others; use “I believe” insteadof “I think” to acknowledge your ideas are hypotheses open tocritique and testing; use “I want to” instead of “I have to” and “Iwon’t” instead of “I can’t” to emphasize the power of choice.

NewSmart organizationFinally, design your organization culture and environment forlearning, adaptation, innovation, and improvement leveraging es-tablished psychological concepts: (a) positivity (promote positiveemotions, minimize negative emotions); (b) self-determinationtheory (promote intrinsic motivation by supporting innate humandrives for autonomy, relatedness, and competence); and (c) psy-chological safety (feeling safe to speak freely; to experiment, fail,and learn; to seek and give constructive feedback; to challengeothers’ thinking, including the “boss”). Embracing NewSmartHumility is at the heart and mind of population health lean!

3. Lean thinkingLean thinking is the foundation of Population Health Lean, andconsists of three components:1. PDSA problem-solving2. Validated learning3. A3 reporting

PDSA (scientific) problem-solvingPDSA stands for Plan-Do-Study-Act. PDSA is the scientificmethod and we have been using it all of our lives. PDSA thinkingand problem solving is part of human nature: it is how we trythings, learn, and adapt. Unfortunately, many believe, mistakenly,that the scientific method is only for scientists. By recognizingthat we are already scientific thinkers we can improve our dailydecision-making, problem-solving, innovation, and performance.

PDSA is both simple and profound. In practice, PDSA isan improvement and learning cycle based on experiments. Thisdiffers from Plan-Do-Check-Act (PDCA) which is primarily animprovement cycle. PDSA has two distinct, but related, purposes:• knowledge deployment: experiments to test a new practice• knowledge discovery: experiments to test a new theory

A theory is an explanatory (cause-effect) model which maybe explicit, invisible (e.g., cultural norm), or unconscious (e.g.,implicit racial bias). In knowledge deployment we experimentto test a new practice idea without challenging or testing theunderlying theory. We hypothesize the new practice is betterthan the old. Our intent is to improve practice. In knowledgediscovery we experiment to test a new theory. We hypothesize thenew theory is valid (or invalid). Our intent is to improve theory.Linking knowledge discovery to deployment encourages researchthat is more likely to lead to breakthroughs in practice and impact.

Table 1 displays PDSA for daily problem-solving. PDSAactivities are listed: (a) define the problem (or opportunity) andset objectives; (b) design a process to discover root causes andpossible solution options, and to develop criteria for selectingoptions; (c) decide on options for testing (experiments); (d) pre-dict the results (outputs, outcomes); (e) conduct the experiment;(f) learn by observing results with mindfulness (total focus, freeof bias and prejudgment); by reasoning using sound logic; andby reflection (looking for deeper meaning); and (g) improve byadopting, adapting, or abandoning the option for the next iteration.Also included in Table 1 are PDSA variants from two enormouslyeffective, complementary, and popular approaches called designthinking (human-centered design) [13] and lean startup [14–16].

The secret to PDSA is prediction: “People learn better whenthey predict. Making a prediction forces us to think ahead aboutthe outcomes. Making a prediction also causes us to examinemore deeply the system, question or theory we have in mind”[24]. “We will learn much more if we write down our prediction.Otherwise we often just think (after the fact), ‘yeah that is prettymuch what I expected’ (even if it wasn’t)” [25]. We learn byexperimenting to narrow the knowledge gap between predictionand results. We improve by using what we learn to narrow theperformance gap between current and desired results.

Table 1. PDSA for daily problem-solving (and variants)

PDSA Coreactivity

Design thinking(see p. 15)

Lean startup(see p. 16)

Plan Define Empathize ↓Design Define ↓Decide Ideate (Ideas)

Do Experimenta Prototype Build (product)↓ Test Measure (data)

Study Learnb (learn) Learn

Act Improvec (improve) (improve)a Predict, Experiment, and Measureb Mindfulness, Reasoning, and Reflectionc Adopt, adapt, or abandon (“pivot or persevere”)

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Figure 3. PDSA single and double-loop learning

PDSA single and double-loop learningIncremental performance improvement occurs by improving prac-tices, and practices are based on accepted theories. A theory isan explanatory (cause-effect) model that can explain observedphenomena. Theories are not always explicit; they can be as-sumptions or mental models, sometimes they are hidden. Thetypical approach is to use PDSA cycles to test and adjust practiceimprovements. We plan to test a practice innovation, we test (do)the practice innovation, we study the results, and we act on whatwe learned, leading to incremental improvements.

Chris Argyris called this single-loop learning [26]. He recog-nized that PDSA can also be used for double-loop learning whichcan lead to new theories and breakthrough performance improve-ments. Figure 3 depicts PDSA with single-loop and double-looplearning. For example, when efforts to improve a practice arefailing (unsatisfactory results), we have two choices:1. continue attempts to improve the practice (single-loop learn-

ing; possible incremental improvements), or2. consider improving the theory (double-loop learning; possible

breakthrough improvements)Double-loop learning makes these possibilities explicit and en-courages innovative (breakthrough) thinking.

Double-loop learning is groundbreaking for practitioners pur-suing performance improvements. Double-loop learning (a) pro-vides an alternative learning path when attempts to improve cur-rent practices are failing; (b) raises awareness of hidden cause-ef-fect assumptions that may be driving poor results but not explicitlyacknowledged (e.g., implicit racial bias); (c) provides opportuni-ties for discovering new theories leading to breakthrough improve-ments; and (d) promotes the discovery of novel “practiced-basedevidence,” in contrast to just deploying and incrementally improv-ing “evidence-based practice.”

By itself, PDSA is powerful. However, connected to vision,purpose, and strategy PDSA unleashes profound and far-reachingpotential for achieving aspirational goals in the community andthe organization. Professor Mike Rother calls this the “improve-ment kata” [27] and Eric Ries calls this “validated learning” [14]

Validated learning: “PDSA with a purposeful goal”Professor Mike Rother, University of Michigan scholar of the Toy-ota Production System, acknowledges that many organizationallean transformations fail primarily because they adopt lean toolswithout transforming the culture [27]. Based on cognitive, andbehavioral science research he developed the improvement kata—a standardized approach to purpose-driven scientific problem-solving that drives behavior and transforms organizational culture.To align with lean startup (p. 16) we call this validated learning.

PDSA thinking, by itself, is not sufficient unless it (a) mo-tivates daily experiments, (b) improves performance, (c) movesthe organization towards its goals, (d) promotes coaching andteaching, and (e) creates a learning culture.

The validated learning (Figures 4–5) can be described aspurposeful, goal-driven rapid cycle PDSA experiments, and it hasfour clear sequential steps:1. embrace a challenge and set a goal,2. grasp the current condition,3. establish your next target condition, and4. conduct PDSA experiments to get there (Figure 6).A challenge is a problem, need, opportunity, goal, or assignment.Validated learning (Figure 6 on the next page) supports rapidPDSA cycle prediction, learning, and improvement.

These short YouTube training videos are must viewing:• https://www.youtube.com/watch?v=3f5wxRO7EYM• https://www.youtube.com/watch?v=4VwrUzIS9m8• https://www.youtube.com/watch?v=uqZOu1D639Q

Coaching validated learning (5 coaching questions)The coaching questions are asked with humility and genuinecuriosity (“humble inquiry”). Here are preliminary questions:(a) Which True North metric? (strategic direction); (b) What is thechallenge? (problem, opportunity, assignment); and (c) What isthe goal? (yours or assigned) Here are the five coaching questions:1. What is the (next) target condition?2. What is the current (actual) condition?3. What obstacles do you think are preventing you from reaching

the target condition?4. What is your next step (experiment)? What do you expect?5. How quickly can we go and see what we have learned from

taking that step?These questions have been validated with adults and children, andare effective for developing scientific daily problem solvers.

Figure 4. Validated learning (adapted from [14, 27])

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Figure 5. Validated learning is “PDSA with a purpose” (cartoon adapted from http://thedoghousediaries.com/5468)

Figure 6. Validated learning (improvement kata) can be used alone or inserted into A3 reports at the Do-Study-Act steps.

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A3 reporting: Problem solving on A3 paperFor needs or problems that are complex, or involve multiplestakeholders, we summarize the problem solving process on A3paper (Table 2). Sections 1–5 are on the left side, and steps 6–8 are on the right side. A3 sections can be worked on in anyorder with one exception: the left side (sections 1–5) must becompleted before the right side (sections 6–8). This ensures thatproposed actions (“countermeasures”) are not proposed until thereis a thorough shared understanding of the current state, gap, andkey drivers (causes). The PDSA activities from Table 1 (define,design, decide, predict, etc.) still apply, and in fact, they apply toall problem-solving frameworks, including design thinking, leanstartup, decision making, etc.

The Problem Statement is a concise description of (a) a cus-tomer need, (b) a gap between a current and desired future state,or (c) a gap between current performance and a standard. Theproblem statement is a conjecture1 of what could be better, andan estimate of the size of the need or gap. The problem statementis updated—and may change significantly—as more is learned,especially after gaining an understanding of the current state.A problem statement should be specific and not state causes orsolutions (e.g., “We are unproductive because we lack funding.”).

The Background section is a summary of the context, andhealth and/or business rationale: (a) Why, why now, why shouldwe care? (b) Who are the key stakeholders? (c) How does solvingthis problem align with vision, purpose, True North? (d) Does thisA3 connect to a parent or children A3s? (e) What other analysessupport this A3 (e.g., business case).

The Current Condition is a descriptive summary of the cur-rent state of the problem area. For qualitative data go to theGemba to see and understand (genchi genbutsu). For quantita-tive data review process and results indicators from Table 6 onpage 11, including trends and forecasts. Indicators will likelycome from the True North metrics.2 For population and/or perfor-mance indicators,3 start with result indicators: (a) How much didwe do? (quantity of outputs) (b) How well did we do it? (qualityof outputs) (c) Is anyone better off? (outcomes of customers) Uselean tools4 to describe, measure, and understand the value streamprocesses that drive results.

The Goal and next Target Condition section states the goalsand targets, but focuses on the next target condition. The GoldenState Warriors goal is to win the NBA Finals. Their first targetcondition is to earn a spot in the NBA playoffs. To get there theymust play 80 regular season games. Each games is a PDSA cycleof prediction, learning, and improvement.

If a shared goal does not exist—which is very common—thenwe must design an inclusive, participatory, creative process togenerate a goal (“common agenda”) that everyone will support.Starting without a goal occurs when we are assigned a general“direction” without specific goals or targets. That’s why this is thefirst step in the validated learning and results-based methods.

The Analysis section summarizes the necessary analysesand/or syntheses to determine the proposed actions, and includes,

1an opinion or conclusion formed on the basis of incomplete information2 (a) equity, (b) safety, (c) performance, (d) customer experience, (e) develop-

Table 2. A3 report: Problem solving on A3 paper

PDSA Activity(Table 1)

Plan1. Problem Statement Define2. Background ⇓3. Current Condition ⇓4. Goal & next Target Condition Design5. Analysis ⇓6. Proposed Actions (countermeasures) Decide

Do ⇓7. Action Plan Experimentsa

Study and Act Learnb

8. Validated Learning (PDSA cycles) Improvec

a Prediction, Experimentation, and Measurementb Mindfulness, Reasoning, and Reflectionc Adoption, adaptation, or abandonment (“pivot or persevere”)

but is not limited to: (a) gap analysis; (b) causal analysis: 5 whys,fish-bone diagram, driver diagram, force field, causal models;and (c) decision quality (DQ): influence diagram, strategy table,decision analysis. Gap analysis measures the magnitude of theproblem. Causal analysis must lead to a “theory of change” inorder to design a “theory of action” (proposed actions). We useDQ methods when decision-making is the focus of the A3.

The Proposed Actions (“countermeasures”)5 section summa-rizes the interventions (theory of action) that are hypothesized toactivate a theory of change (underlying causal model of change).A very useful approach is to draw a driver diagram that is aleft-to-right expanding tree with the following nodes connectedby right-to-left arrows: (a) outcome(s), (b) primary drivers (the-ory of causation), (c) secondary drivers (theory of change), and(d) proposed actions (theory of action). In contrast, for decisionproblems, the proposed actions would be the alternatives (choices)selected. Figure 7 on the following page displays a conceptualdriver diagram from a review article worth reading [28].

The Action Plan section is the high-level project schedule(e.g., kaizen workshops). For traditional projects it should be aGantt chart, and for agile projects list proposed project phasesrecognizing that the specifics of the phases will change and evolveand as more is learned and integrated at each iterations. Whileproject managers may keep detailed project plans, project teamsmay huddle at kanban project management boards [12].

The Validated Learning table (PDSA cycles) (Figure 6) canbe used alone for experiments, or can fit as the Do-Study-Actsection of an A3 report. Validated learning explicitly includesprediction, learning, and improvement cycles.

This A3 report and should be collaborative with diverse input.For A3 reports we recommend this Stanford training video: https://www.youtube.com/watch?v=rtyia0ci12I.

ing people, and (f) financial stewardship.3See Results-Based AccountabilityTM (Section 4 on the next page)4value stream, cross-functional, process, or spaghetti diagrams, etc.5Using lean jargon. We prefer common language.

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Figure 7. Driver Diagram [28]: think of “primary drivers” as theroot causes (theory of causation), “secondary drivers” as thetheory of change, “change concepts” as the theory of action, and“specific change ideas” as PDSA experiments. Use validated,double-loop learning for continuous improvements. Together,theory of causation, change, and action is program theory.

4. Collective impact (results-based) methodsLean evolved out of production systems. In contrast, results-based methods (RBMs) are frameworks for mobilizing partnersto tackle community health challenges [10, 11]. RBMs start byconvening stakeholders and building a shared vision and settinggoals. Using ends-to-means causal-thinking, we design strategiesthat are informed by gap and root-cause analyses, evidence-basedsolutions, and community voice. By aligning, coordinating, andimproving existing efforts we pursue collective impact.

Collective impact frameworkCollective impact is a collaborative, multi-sector approach toaddress complex social problems [29–32]. FSG.org defines col-lective impact as “the commitment of a group of important actorsfrom different sectors to a common agenda for addressing a spe-cific social problem at scale.” (See Table 3 for collective impactmindset.)

Collective impact fulfills five conditions [29]:1. common agenda (goals),2. shared measurement (results and process indicators),3. mutually-reinforcing activities (operational processes),4. continuous communication (relational processes), and5. backbone support (strategic project management).

Principles of PracticeCollective impact promotes the Principles of Practice:6

1. Design and implement with a priority placed on equity.2. Include community members in the collaborative.3. Recruit and co-create with cross-sector partners.

6https://collectiveimpactforum.org/

Table 3. Complex social change requires a shift in mindset fromtechnical (complicated) to adaptive (complex) problem-solving

Technical problem-solving Adaptive problem-solving

Technical solutions Adaptive solutionsEvidence Evidence and relationshipsContent expertise Content and context expertiseOne solution Many coordinated solutionsCredit is concentrated Credit as shared currency

4. Use data to continuously learn, adapt, and improve.5. Cultivate leaders with unique system leadership skills.6. Focus on program and system strategies.7. Build a culture that fosters relationships, trust, and respect.8. Customize for local context.

Five core conditions of collective impact[1] Common agenda A common agenda is having a sharedvision and common goals. The prerequisite to a common agendais having trust between community partners. This takes time andcannot be rushed.

[2] Shared measurement A shared measurement system enablespartners to answer: How do we measure and predict success?They must select common result indicators. The real innovationoccurs when they use value stream mapping, and other lean tools,to improve cross-cutting, interdependent processes that touchmultiple organizations.

[3] Mutually-reinforcing activities Partners come to the table withactivities that are inspired by their organizational purpose andmission. They come already inspired! We do not ask them tostop what they are doing, but rather to start by aligning andcoordinating their activities.

[4] Continuous communication Continuous communication isfocused on building trust and cooperation among diverse partnersand communities. This requires deploying team building skills(see Appendix A: Building Effective Teams on p. 20).

[5] Backbone support Collective impact requires a robust back-bone support infrastructure. The backbone is a multidisciplinaryteam skilled in strategic project management, neutral facilitation,collective decision-making, and continuous improvement. Hereare the key functions from [31]: (a) guide vision and strategy,(b) support aligned activities, (c) establish shared measurementpractices, (d) cultivate community engagement and ownership,(e) advance policy, and (f) mobilize resources. We believe back-bones should have support in strategic, agile project management,performance improvement, data science, and program evaluation.

Backbones must balance the tension between coordinatingand maintaining accountability, while staying “behind the scenes”to promote collective ownership. The backbone does not setagendas, drive solutions, receive all the funding, or appoint it-self. However, for the initiative to succeed, backbones must beadequately funded, supported, and continuously trained.

Population Health Lean: An overview v. 2017-05-22 — 9/30

Figure 8. An evaluation framework for a collective impact initiative (source: http://collectiveimpactforum.org)

Collective impact embraces complexityCollective impact embraces complexity: community health andsocial problems and solutions emerge from complex adaptive so-cial systems. Complex systems are defined as diverse entities thatare connected, interdependent, and adapting [33]. Communitiesand organizations are complex systems, and they are dynamicand often unpredictable. Off-the-shelf solutions do not exist forcomplex social problems: stakeholders experiment and iterate tosolutions that work in their local context. Failure and learningare the rule. Table 4 summarizes the difference between simple,complicated, and complex problems. Complex problems do nothave known and agreed-upon root causes and/or solutions.

The role of evaluationCollective impact uses both shared measurement and evaluationto understand their effectiveness and impact. Evaluation includesdevelopmental, formative, and summative methods. The sharedmeasurement system (SMS) uses a common set of indicators tomonitor an initiative’s performance and track progress. SMS canbe both an input to evaluation (by providing data and/or shapingevaluation questions) and an object of evaluation (Figure 8).

Table 4. Simple, complicated, and complex problems

Problem Known andagreed-uponroot cause

Known andagreed-upon

solution

Solution feasiblewithout externalexpert assistance

Simple Yes Yes YesComplicated Yes Yes NoComplex Yes or No No No

Results-Based AccountabilityTM

Collective impact is continuous improvement applied at a socialscale. The continuous improvement approach we recommend isResults-Based AccountabilityTM (RBA) [11]—a results-basedframework for improving communities for families and children.RBA is an epidemiologic framework for guiding a collectiveimpact initiative. RBA complements lean. RBA emphasizes:• Outcomes focus (“Is anyone better off?”)• Criteria for designing and selecting indicators• Root cause analysis (“What’s the story behind the curve?”)• Criteria for selecting evidence-based strategies

In public health the goal is to improve the health of commu-nities (population accountability) by “ensuring the conditionsin which people can be healthy” [34]. When we directly servea customer (in a program, agency, or service system) the goal,again, is to improve their health (performance accountability).Therefore, performance improvement contributes to populationhealth improvement, but they are not the same (Figure 9).

Figure 9. Results-Based AccountabilityTM

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In collective impact, population accountability is shared bypartners, each of whom have direct performance accountabilityfor their program, agency, or service system.

We start by engaging collective impact partners with 7 strate-gic questions (7SQ).7 These 7SQ apply to both community health(population accountability) and client health (performance ac-countability).1. What are we trying to accomplish and why? (goals)2. How do we measure and predict success? (a) How are we

doing with result indicators (population and performance: out-puts, outcomes); (b) How are we doing with process indica-tors?; and (c) For both, what are the trends and forecasts?

3. What are the drivers? (gap and root cause analysis)4. What partners can help? (collective action / impact)5. What other conditions must exist? (assumptions and risks)6. What strategies work? (science and community evidence)7. How do we get there? (action plan; validated learning)

Mark Friedman [11] uses slightly different questions (Table 5)where questions 4–7 apply to both columns. The RBA Guide [36]contains a 6-question set and criteria for selecting indicators andstrategies. Use whichever set of questions that work for youraudience; they cover the same territory.

Table 5. Collective impact questions from Results-BasedAccountability.TM Questions 4–7 apply to both. (Source: [11])

Population Accountability(see Figure 10)

Performance Accountability(see Figure 11)

1 What are the quality of lifeconditions we want for thechildren, adults, andfamilies who live in ourcommunity?

Who are our customers?(clients, patients,businesses, staff)

2 What would theseconditions look like if wecould see them?

How can we measure if ourcustomers are better off?

3 How can we measurethese conditions?

How can we measure if weare delivering services well?

4 How are we doing on the most important of thesemeasures? What is the story behind the curve?

5 Who are the partners that have a role to play in doingbetter?

6 What works to do better, including no-cost and low-costideas?

7 What do we propose to do?

RBA has three simple questions for developing and monitor-ing performance improvement indicators: (a) How much did wedo? (b) How well did we do it? and (c) Is anyone better off ?For nontechnical audiences, use these questions for classifyingprocess and result indicators (Table 6 on the following page).Figure 12 on the next page displays the “results matrix” [35] viewof collective impact. Carefully study Table 6 and Figure 12.

7The 7SQ were derived from the “4 Critical Strategic Questions” [35].

Figure 10. Population accountability [11] is applied to acollaborative partnership of programs, agencies, or servicesystems working collectively to impact population healthimprovement. Performance accountability (Figure 11)contributes to population accountability.

Figure 11. Performance accountability [11] is applied to a singleprogram, agency, or service system. Performance improvementcontributes to population health improvement (Figure 10).Figure 12 on the next page displays how performanceaccountability connects to population accountability.

Population Health Lean: An overview v. 2017-05-22 — 11/30

Table 6. Population health, epidemiologic indicator framework for lean and collective impact (results-based) methods (e.g.,Results-Based AccountabilityTM). Focus on, act on, and improve lead indicators (processes and outputs) to improve lag indicators(outcomes). Lead indicators reflect processes under our control and are causally predictive of the outcomes.

Performance indicators (partner, program, agency, or service system level)

Population health indicators (community level)

Lead indicators (effort) Lag indicators (effect)

Processes Results (outputs, outcomes)

Outputs Outcomes (Is anyone better off?)

Quantity How much did we do? Circumstances (social & physical environments)Cycle and lead timesValue- & non-value-added timesVariation and mura (unevenness)Muda (waste),a muri (overburden)

average wait# on schedule# services met standard# clients served at standard

Knowledge, attitudes, beliefs, skills, satisfactionRisk and protective factorsHealth and wellness measuresDisease, injury, or death measures

Quality How well did we do it? Circumstances (social & physical environments)Cycle and lead times% Value- & non-value-added timesVariation and mura (unevenness)Muda (waste),a muri (overburden)

average wait% on schedule% services met standard% clients served at standard

Knowledge, attitudes, beliefs, skills, satisfactionRisk and protective factorsHealth and wellness measuresDisease, injury, or death measures

a For 8 wastes in lean remember TRIM WOOD: transport, resource mismatch, inventory, motion, waiting, over-processing, overproduction, and defect. Resourcemismatch occurs when a human or technical resource capability does not match its intended purpose. For example, a physician doing data entry, or using an expensivesoftware “solution” when a manual, low-cost, process is sufficient. Untapped staff talent or potential is an example of resource mismatch.

Figure 12. Results matrix: An epidemiologic, results-based systems framework for collective impact (e.g., Partners A, B, and C). The4SQ depicts an overview; however, use 7SQ and validated to implement RBMs. Partners’ performance improvements—by improvingprocesses that improve outputs that influence immediate outcomes—contribute to population health improvements in the community.Dotted-lined box outlines components under our full control: inputs, processes, and outputs. Use “What other conditions must exist?”to assess and challenge assumptions and risks, and to plan risk management.

Population Health Lean: An overview v. 2017-05-22 — 12/30

Using the 7 Strategic QuestionsFor collective impact, the 7SQ can be summarized in an A3report (Table 7). Define the population to be impacted by thecollective impact initiative: community, client, or both. Popula-tion accountability applies to a community population that is notwell enumerated and not served directly (e.g., men-who-have-sex-with-men (MSM) exposed to an HIV prevention social marketingcampaign). Performance accountability applies to a client popu-lation served directly in a program, agency, or service system. Abackbone facilitator poses the 7SQ (or equivalent) to a group ofstakeholders. Preliminary planning questions include: Who arethe primary customers? Who is the target population?

[7SQ-1] What are we trying to accomplish and why? (goal)The “why” refers to the strategic intent that is usually communi-cated by the vision, purpose, mission, or true north. Our GoalStatement8 is “what” we are trying to accomplish: it is a positive,aspirational statement of health and well-being for communityor client population. Try asking “What are the quality of lifeconditions we want for the children, adults, and families who livein our community?”

[7SQ-2] How do we measure and predict success? (current state)If the goals were realized, what would it look like? Try asking“What would these conditions look like if we could see them?”“How can we measure if our customers are better off?” Our objec-tives are to (a) select process and result indicators, (b) evaluatepast and current trends, and (c) and forecast future trends.

We must distinguish between process, output, and outcomeindicators. Communities are inspired and mobilized by improvingresults (outcomes and outputs)—hence, the power of RBA. How-ever, to achieve results, we must improve processes—hence thepower of lean. Process and output indicators are also called leadindicators because they are (a) causally predictive of outcomes,and (b) under our control. Outcomes are lag indicators.9

The key to improving outcomes (lag indicators) is toimprove processes and outputs (lead indicators).

CAUTION: Lean experts are quick to warn us of the dangersof focusing solely on results (outputs and outcomes). To improveoutcomes we increase the quantity and quality of our outputs(How much did we do? How well did we do it?). This seemsso logical and, in fact, leads to improved outcomes. Results-oriented behaviors and successes are incentived and rewarded.However, this can come at a great expense: when we are overlyfocused on results we are more likely to lose focus on improvingprocesses. This leads to waste and inefficiencies. We focus onworking harder, not necessarily smarter. We work longer hoursand weekends, we hire more staff, we hire more consultants,we “troubleshoot” instead of problem-solve root causes, and we

8In RBA, this is called the “Results Statement.” For us, achieving results(outputs, outcomes) does not guarantee achieving goals.

9Sometimes immediate outcomes are used as lead indicators; for example,“test of cure” in the antibiotic treatment of female chlamydia infections. The lagindicators would be rates of pelvic inflammatory disease and infertility (longerterm outcomes).

Table 7. A3-CI: Results-based collective impact on A3 paper

7 Strategic Questions Activity (Table 1)

Plan1. Goal statement (common agenda) Define2. Current state (shared measurement) ⇓3. Drivers (theory of causation) ⇓4. Partners (collective action) Design5. Assumptions (external risks) ⇓6. Strategies (theory of change) Decide

Do ⇓7. Action Plan (theory of action) Experimenta

Study and Act Learnb

8. Validated Learning (PDSA cycles) Improvec

a Prediction, Experimentation, and Measurementb Mindfulness, Reasoning, and Reflectionc Adoption, adaptation, or abandonment (“pivot or persevere”)

advocate for more resources and funding. We “throw money atthe problem.” We “do whatever it takes” to deliver results. Thisapproach is not sustainable, especially when resources are scarceor others have a competitive advantage.

Figure 13. The 4 Disciplines of Execution (4DX) (source: [37])

Why does this occur? First, focusing on “achieving results”is highly valued by everyone—it’s hard to argue with achieve-ment! Second, key terms and concepts may be confusing becausedefinitions overlap (see Table 6 on the preceding page). Popu-lation health lean embraces a balanced approach by focusingon lead and lag indicators. This is an established best practicepopularized by Chris McChesney’s best selling book The 4 Disci-plines of Execution (Figure 13) [37]. Discipline 1 is “focus on thewildly important” (7SQ-1), Discipline 2 is “act on lead indicators”(7SQ-2), Discipline 3 is “keep a compelling scoreboard” (7SQ-2:lead and lag indicators), and Discipline 4 is “create a cadence ofaccountability” (lean tools: validate learning, daily management,

Population Health Lean: An overview v. 2017-05-22 — 13/30

Table 8. Comparison of performance improvement approaches

“SIPOC”indicators

RBA Lean 4DX PHL

Suppliers +++ ++++Inputs + ++++ ++++Processes ++ ++++ Lead ++++Outputs +++ ++++ Lead ++++Early Outcomesa ++++ +++ Lagb ++++Late Outcomesa ++++ + Lag ++++a Primary customer (the "C" in SIPOC)b or lead (e.g., “test of cure” in STD treatments)

visual controls, kanban project management, etc.).Table 8 compares how different improvement approaches

focus their methods across the “SIPOC” indicators. RBA focuseson “results” using an epidemiologic framework, but it does nothave the process improvement tools of lean. Lean evolved fromproduction systems and is organization-focused with technicaljargon (Gemba, kaizen, genchi genbutsu, kanban, hansei, hoshinkanri, etc.) and tools. The 4DX provides a business perspectivepromoting the focus on lead indicators. From an organizationand community health perspective, these approaches complementeach other nicely—hence, the emergence of population healthlean.

In collective impact, the early objectives are to inspire and mo-bilize cross-sector community partners to tackle a complex socialproblem. Collaboratives are motivated by pursuing aspirationalresults with evidence-based strategies and improvement; hencethe popularity of RBA. In contrast, the Toyota Production System(and its lean descendants) evolved to eliminate waste and improveproduction processes within organizations (e.g., manufacturing,health care). Lean evolved into comprehensive management andproduction systems for organizations. Population health lean usesthe best of both approaches.

Select lag indicators Improvements in lag indicators (outcomes)answers the question “Is anyone better off?” Therefore, the se-lection lag indicators always inspire and mobilize stakeholderswhether they are collaborative members or clinic staff. RBA usesthe following criteria for selecting outcome (lag) indicators:• Communication power (inspires, motivates, mobilizes)• Proxy power (causally linked to key or multiple outcomes)• Data power (high quality and availability)For the details, see the RBA Guide [36] or Friedman’s book [11].

Select lead indicators In contrast, lead indicators answer thequestions “How much did we do?” and “How well did we doit?” This includes processes (e.g., STD partner notification times),outputs (e.g., partner located, counseled, screened, and treated),and possibly early outcomes (e.g., STD cure rates). We use thefollowing criteria for selecting lead indicators:• causally predictive of outcomes, and• under our control.If the proposed lead indicator reflects a process and output notunder our control, then it becomes a proposed lag indicator—an

outcome—that we will try to influence by acting on processesand outputs that we do control (our new proposed lead indicator).Again, we act on lead indicators to causally affect and improvelag indicators. Here is the key selection message:

We use different selection criteria for lead and lag in-dicators. Lag indicators must be meaningful health-related outcomes that inspire and mobilize stakehold-ers. In contrast, lead indicators should be causaland controllable, even if they are “boring” and donot inspire anyone. However, you must engage andempower front-line staff to select and improve leadindicators.

Data development agenda for indicators (DDAI) Sometimes indi-cators need research, development, or investment. If the indicatoris important but not available, do not eliminate it: it goes in thedata development agenda for further consideration and work bythe DDA Team, possibly the backbone or outside consultant.

How are we doing? (current state) Using the lead and lag indi-cators, describe the current state. For the lag (outcome) indicatorsinclude the following:• Times series trend curve• Projection forecastFor the lag indicators ask: How are we doing on the most im-portant of these measures? Forecasts are important because theycommunicate what we expect to happen if the status quo contin-ues. Is the status quo acceptable? Usually it is not. Forecastshave communication power.

[7SQ-3] What are the drivers? (root causes)This section is analogous to the “causal analysis” section of an A3problem solving report (see Table 2 on page 7). Between the goalstatement (desired future state) and the current state there is a gap.Why does this gap exist, how big is it, and what are the barriersto closing it? (gap analysis) Look at the time trend curve. Whatforces are pushing the curve up, and what forces are pushing thecurve down? (force field analysis) For problems that must besolved, what are the root causes? (root cause analysis) Try asking“why” five times (5 Whys) or drawing a fish-bone (Ishikawa)diagram. Is there a program theory (theory of causation, change,and action) to guide you based on a review of the literature? Hereare key questions to consider (program theory):1. What are the root causes? (theory of causation: causal model

of the core problem without interventions: literature, experts,common sense)

2. What is the theory of change? (causal model that includeschange theories; e.g., shaping social norms)

3. What in the theory of action? (causal model that includesactions that activate theory of change)

Ask the questions. Important, unanswered causal questions aremoved to the data development agenda for causes (next).

Data development agenda for causes (DDAC) The DDA Teamreviews the literature and conducts key interviews of experts,including community residents. The DDA Team develops a causal

Population Health Lean: An overview v. 2017-05-22 — 14/30

model of the most important cause-effect processes. A causalmodel informs and guides theories of change and action that arenecessary to develop strategies. In general, considering usingthese types of causal maps: driver diagrams [28], causal-loopdiagrams10 that contain feedback loops, or directed acyclic graphs(DAGs)11 that do not have feedback loops. Start with driverdiagrams. Epidemiologists should be using DAGs [38, 39].

[7SQ-4] What partners can help? (partners)From Friedman: [11]: “Who are the partners who have a role toplay in doing better? . . . no one program or agency can do it alone.The work requires contributions from a wide array of partners,public and private, across the community. . . . However, the workof adding partners is never finished. At each pass through thedecision process, it is important to consider who is still needed atthe table. The action plan should always have a component thataddresses the recruitment and engagement of new partners. . . .[I]n practice, you never have everyone at the table. Processes thatcan’t do anything until everyone is at the table typically don’t doanything. Inclusion is a process not an endpoint.”

[7SQ-5] What other conditions must exist? (assumptions)This question was developed by systems engineers that recog-nized that we operate in complex systems where external forcesoutside of our control may be supporting or opposing our efforts.Unexpected changes in these forces may threaten or derail ourefforts. Sometimes we are unaware of these forces because theyare hidden from us or we take them for granted. A best practicein risk management planning is to brainstorm and identify keyassumptions that, if one or more of them becomes invalid, wouldthreaten the success of a project.

Causal logic provides a simple, disciplined, systems approachto risk and consequence management planning for external risks.Here’s how: Review column 3 of the results matrix (Figure 12),and then we can make the following IF-THEN (cause-effect)statements. Collect these assumptions and use them in planning.

IF inputs + valid assumptions 1 THEN processes are executedIF processes + valid assumptions 2 THEN outputs are producedIF outputs + valid assumptions 3 THEN outcomes are achievedIF outcomes + valid assumptions 4 THEN goals are achieved

[7SQ-6] What strategies work? (proposed actions)Friedman defines strategy as “a coherent set of actions that has areasoned change of improving results. Strategies are made up ofour best thinking about what works, and include the contributionof many partners. Strategies operate at both the population andperformance levels” [11]. By “reasoned chance” he means theoryof change (see Figure 7 on page 8).

For prioritizing and selecting strategies Clear Impact recom-mends the following criteria [36]:Values “Is the strategy consistent with the values of the commu-

nity and/or agency?”Leverage (effectiveness: theory of change) “How strongly will

the proposed strategy impact progress as measured by the10https://en.wikipedia.org/wiki/Causal_loop_diagram11https://en.wikipedia.org/wiki/Directed_acyclic_graph

[indicator] baselines?” The strategy should be evidence-based. Bottom-line: does it work?

Specificity (theory of action) “ Is the strategy specific enough tobe implemented? Is there a time line with deliverables thatanswers the questions: Who? What? When? Where? How?There should be budget detail for the strategy, includingimplications for future budgets.”

Feasibility “Is the proposed strategy feasible?” “No-cost andlow-cost actions will rate higher here.”

Friedman recommends rating each strategy “high,” “medium,” or“low” for each criteria. This decision making process should beinclusive and participatory with key stakeholders.

The Strategies (proposed actions) section should be summa-rized with a driver diagram (Figure 7 on page 8) that includestheories of change and action. A driver diagram ensures rigor inour causal thinking and planning.

For more guidance on team decision making, or designingstrategies, see Section 7 on page 17 on decision quality.

Data development agenda for solutions (DDAS) 7SQ-7 focuseson identifying and selecting evidence-based, cost-effective strate-gies. Sometimes more research is required to identify evidence-based strategies. Sometimes more information gathering is re-quired to guide priority-setting. Consulting subject matter experts,epidemiologists, or decision analysts may be necessary.

[7SQ-7] How do we get there? (action plan)The A3 action plan consist of two components:1. Project schedule (what, who, when) (e.g., Gantt chart)2. Validated learning (PDSA cycles) (“Study and Act”)

Additionally, teams can huddle in front of a kanban agileproject management board [12]. A kanban board is a large whiteboard with three or more columns with task sticky notes that flowfrom left to right. A typical kanban board has three headings:

Backlog (“To do”) Doing Donetask 3 task 2 task 1task 4

Rows can be added to stratify by project, staff, or other use-ful category. ThedaCare created a “Daily Huddle Board” fordaily improvement activities that has become very popular andis described in their best-selling book Beyond Heroes: A LeanManagement System for Healthcare [19]. Here is a depiction oftheir kanban huddle board (columns: backlog, doing, done):

Ideas “Just do its” Implementedpost ideas easy fixes sustain improvements!

PICK charta A3 reports Celebrations!select ideas complex projects celebrate staff!

a see Figure 20 on page 17

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Figure 14. Design thinking as depicted by Empathy design consultants (http://designthinking.co.nz/design-thinking-in-a-day/)

5. Design thinking (human-centered design)

Because of its importance, design thinking (Figure 14) was intro-duced in Table 1 on page 4. Design thinking is a creative, needand problem-finding process for designing products, services, orenvironments that delight humans and fulfill their needs. Recallfrom Figure 3 on page 5 this relationship: Theory + Practice→Results. Traditional PDSA focuses on improving practice (knowl-edge deployment) or improving theory (knowledge discovery) inexisting operational processes. Performance improvements comefrom process innovations that improve results (Figure 15).

However, we can do better: “What results (value) do ourcustomers care about that we could deliver?” Humans value ex-periences that are emotionally fulfilling and solve their problems.Using design thinking (Figure 14) we can discover, prototype,and test new solutions that are process, functional, and emotionalinnovations (i.e., human experience innovations in Figure 15).

Figure 15. Design thinking: innovations in human experiences

Design thinking is a creative, systematic framework that isespecially valuable for discovering new solutions where bestpractices are scarce, customer engagement and behavioral changeis essential, or data and analytic methods are not available.

Design thinking has five phases that are either in a creative,divergent phase, or in a focused, convergent phase. Designerscycle back to whatever step improves insight and learning. Designthinking should become a natural part of population health leanthinking (PDSA, validated learning, and A3 reports).

Design thinkers have the following mindset: human centered-

ness, bias towards action, show don’t tell, radical collaboration,culture of prototyping, and mindfulness of process. In the Toy-ota Production System genchi genbutsu meant going to whereworkers created value (i.e., on the shop floor). However, in popu-lation health lean we embrace human-centered design and priori-tize going to where population health is created, protected, andpromoted—in the community using a family-centered, life courselens! Here are the five phases:

[1] Empathy Seek understanding and insight by observing andinterviewing primary customers (preferably) in their natural so-cial and community context. This usually involves ethnographicmethods, including recognizing and setting aside our own culturaland cognitive biases. The objective is to understand what mattersmost to them? What are their unfulfilled needs? Beyond whatthey say and do, how do they think and feel?

[2] Define Empathy leads to creating a “point of view” (problemdefinition and/or new opportunity identification) that is based oncustomer needs and insights, defining the current condition, andsetting a vision and goals.

[3] Ideate Ideation is structured brainstorming to generate andselect creative solution ideas. Good brainstorming requires open-mindedness and embracing a few rules that promote creativity:(a) framing the problem, (b) warming up, (c) brainstorming, and(d) grouping and selecting ideas. Here are the rules: (a) Deferjudgment. (b) Go for volume (many!). (c) One conversation at atime. (d) Be visual. (e) Headline your idea. (f) Build on the ideasof others. (g) Stay on topic. (h) Encourage wild ideas.

[4] Prototype Prototype means building quickly a low resolutionrepresentation of one or more ideas to show others. The purposeis to test customers’ and our understanding of needs and solutionideas, and not necessarily to test specific solutions.

[5] Test Begin to test the product or service with customers. Pro-totyping and testing are similar to PDSA cycles in their embraceof experimentation with the intention of learning and improving.

Design thinking has spread beyond technology innovations,and is now used for strategy innovations. There are many re-sources for learning design thinking [13, 40–43]. Start by doingand experimenting with free materials from Stanford.12

12http://dschool.stanford.edu/

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6. Lean startup

Lean is based on the Toyota Production System and has trans-formed manufacturing and health care. In 2011, Eric Ries, soft-ware engineer turned entrepreneur, published The Lean Startup—a bestselling book that described the application of lean conceptsto technology startup companies [14]. Not obvious to everyone isthat every startup is an experiment! So what is a startup?

A startup is a human institution designed to create anew product or service under conditions of extremeuncertainty.

“Anyone who is creating a new product or business under condi-tions of extreme uncertainty is an entrepreneur whether he or sheknows it or not and whether working in a government agency,a venture-backed company, a nonprofit, or a decidely for-profitcompany with financial investors” [14]. Lean startup is transform-ing nonprofits and government agencies with the realization thatmuch of what we do is entrepreneurship. Lean startup has cat-alyzed a mindset shift in the public and social impact sector [15].

Ries studied and experimented applying lean principles tostartup companies. He developed these five principles of the leanstartup: (1) Entrepreneurs are everywhere; (2) Entrepreneurshipis management; (3) Validated learning; (4) Innovation accounting;and (5) Build-Learn-Measure (Figure 16).

Startups have a unique role beyond serving customers: they“exist to learn how to build a sustainable business.” Lean startupstest a hypothesis by quickly (and cheaply) building a minimumviable product (MVP) to test with their customers. MVPs testsneeds and solutions. Startups rapidly experiment (“fail fast”),learn, and change course when indicated (“pivot or persevere”).

Therefore, entrepreneurs (that’s us!) must experiment andinnovate in these core areas:1. Customer development (understand needs and problems)2. Agile development (discover, design, test, and build solutions)3. Business model design (discover, sustain, scale, and partner)In summary, validated learning is just “PDSA with a purposefulor strategic goal” where the goal is to innovate successfully incustomer, solution, and business model development.

Figure 16. Build-Measure-Learn cycle is a PDSA variant thatpromotes experimentation, validated learning, and innovation.

Table 9. Lean startup uses PDSA variant: Build-Measure-Learn

PDSA Activity Design thinking Lean startup

Plan Define Empathize ↓Design Define ↓Decide Ideate (Ideas)

Do Experimenta Prototype Build (product)↓ Test Measure (data)

Study Learnb (learn) Learn

Act Improvec (improve) (improve)a Predict, Experiment, and Measureb Mindfulness, Reasoning, and Reflectionc Adopt, adapt, or abandon (“pivot or persevere”)

Innovation accounting is a shared measurement system withactionable metrics designed to monitor progress, and to guidedecision-making, priority-setting, and accountability. Action-able metrics are lead indicators (see Table 6 on page 11) thatare causally linked to the outcome hypothesis (customer, solu-tion, business model). A shared measurement system was firstintroduced in collective impact methods (e.g., Results-BasedAccountabilityTM). Without such a system it is impossible tomake data-driven decisions. “Vanity metrics” are lag indicatorstrending positive but misleading because they are not causallylinked to experiments.

Table 9 displays how the lean startup Build-Measure-Learncycle is a PDSA variant, and how it is complemented by designthinking (human-centered design). Lean startup concepts are notnew: they are established lean principles successfully applied tothe unique circumstance facing startups, and even nonprofits.

Putting it all together: design thinking to collective impactPopulation health lean builds on lean production, integrating thebest practices from complementary frameworks. Figure 17 de-picts how it all fits together. Design thinking always applies. Fordeveloping new products or services in the face of extreme uncer-tainty, lean startup promotes radical experimentation, adaptation,and innovation. Finally, collective impact transforms communityhealth through radical collaboration and adaptation, and relent-lessly asking “Is anyone better off?”

Figure 17. Population health lean builds upon lean thinking(PDSA problem solving, validated learning, and A3 reporting)

Population Health Lean: An overview v. 2017-05-22 — 17/30

7. Decision quality: better team decisions

Humans have three core cognitive-behavioral processes:1. deciding2. acting3. learningAdaptation comes from adjusting our decisions and actions basedon what we learn. Improvements are adaptations that make thingsbetter. These processes—deciding, acting, learning—are funda-mental to all human activities, and form the basis for continuousimprovement.

At the organizational level these core processes are so impor-tant that every organization should have a program or office thatincludes the following expertise and training capabilities:• decision quality (decisions, including budget priority-setting)• project management (actions, especially agile methods)• performance improvement (learning, innovation, adaptation)If an organization does not focus on all three foundational areas,then it cannot realize its full potential as a learning organization.

Front and center is the art and science of decision-making.Yet most of us have not received any training in decision-making.This is probably because we have been making intuitive deci-sions all of our lives. Naturally, we conclude that “successful”people, by definition, must be “good” decision makers. Andsome are; however, research shows that we have a lot of room forimprovement—so why not get better! Fortunately, the decisionsciences has progressed significantly and we have practical toolsfor improving individual and team decision making.

What is a decision? “A decision is a choice between twoor more alternatives that involves an irrevocable allocation ofresources” [44]. For important, high stakes, or high costs issues,do not rely on gut decisions—deliberate! Here’s why: decisionchallenges include: (a) uncertainty; (b) competing objectives;(c) values and preferences; (d) time and resource constraints;(e) multiple decision parties; and (f) organizational, environmen-tal, and analytical complexity (Figure 18).

Figure 18. Decision approaches for different levels ofcomplexity [17]

Figure 19. Fist to Five voting for building consensus

Facilitative leadershipConsensus using Fist to Five votingConsensus means building, through discussion, acceptable sharedunderstanding and commitment to action. When building teamconsensus is important try Fist to Five voting (Figure 19). Eachperson votes by holding up 0 to 5 fingers, where 0 is a fist: 0:“No way, terrible choice, I will not go along with it” (fist blocksconsensus); 1: “I have serious reservations with this idea, butI vote to move forward, but I’d prefer to resolve the concernsbefore supporting it.” 2: “I have some concerns, but I’ll go alongand try it.” 3: “I will support the idea.” 4: “I like this idea, soundsgood.” 5: “Absolutely, best idea ever! I’ll champion it.” Continuediscussion until everyone is voting 3 or above.

PICK chart to “pick” improvement projectsIn daily huddles teams use the PICK chart (Figure 20) to prior-itize and select improvement ideas. The PICK chart introducesteams to multi-criteria, deliberative decision-making. Ideas withhigher effect-to-effort ratios are moved closer to the top-left cor-ner. For an excellent discussion read Mark Graban’s blog here:http://www.leanblog.org/2014/07/picking-on-the-pick-chart/.

Figure 20. PICK Chart: a multi-criteria decision tool

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Figure 21. Decision quality requirements: A decision is only asstrong as its weakest link (source: http://sdg.com)

.

Decision quality (DQ) appraisal cycleFor important decisions, we must ensure decision quality (DQ)(Figure 21). A good decision requires quality at each link, and theoverall quality of a decision is no better than the weakest link [17].As before, use A3 paper for DQ appraisal cycle (Table 11).

Starting with the appropriate frame, ask the following:1. What are we deciding and why? (frame)2. What choices do we have? (alternatives)3. What do we need to know? (information)4. What consequences do we care about? (values & trade-offs)5. Are we thinking straight? (sound reasoning)6. Is there commitment to action? (group consensus)

DQ-1. Frame (What are we deciding and why?)1. Purpose: What problem are we trying to solve? What oppor-

tunity are we addressing? Why are we doing it? What do weintend to achieve? Why now? How will we know if we’resuccessful? How could we fail?

2. Perspective: Who are the primary customers? What otherperspectives will help? (see Table 10); and

3. Scope: What decisions are “Taken as Given,” “Focus On,” and“Decide Later” (called Decision Hierarchy). The “Focus On”questions become columns in the Strategy Table (Figure 22).Public health decisions involve multiple considerations and

stakeholders. Use the (HELP)2 Checklist (Table 10) to designand improve decision making processes (source: TJA):

Table 10. The (HELP)2 Checklist for improving decision quality

Health benefits (outcomes) Health equityEthical issues (see p. 20) Efficiency issuesa

Legal exposures Logistical issuesPublic trust Political support

a For example, cost-effective analysis ratios: maximize health outcomes in thenumerator and minimize costs in the denominator by eliminating waste using lean.

Figure 22. Strategy Table example based on an office movedecision [17]

DQ-2. Alternatives (What choices do we have?)1. What are the alternatives (or strategies) under consideration?2. Are the alternatives consistent with organizational strategy?3. Do the alternative fit the frame?4. Are the alternatives well-defined? creative? doable? com-

pelling? comprehensive range? significantly different?One creative approach is to build a Strategy Table (Table 22)

from the “Focus On” key decisions from the Decision Hierarchy.Use these decisions as column headings. Under each key decisioncolumn have a set of choices that are reasonably comprehensiveand mutually exclusive. Design strategy themes by selecting a setof choices (not more than one per column). The strategies shouldrange from the least aggressive to the most aggressive strategy.

Table 11. A3-DQ: Decision quality on A3 paper

Decision quality Activity(Table 1)

Plan1. Frame (What are we deciding and why?) Define2. Alternatives (What are our choices?) ⇓3. Information (What do we need to know?) ⇓4. Values and trade-offs (What do we want?) Design5. Reasoning (analysis) ⇓6. Decisions (selected alternatives) Decide

Do ⇓7. Action Plan Experimenta

Study and Act Learnb

8. Validated Learning (PDSA cycles) Improvec

a Prediction, Experimentation, and Measurementb Mindfulness, Reasoning, and Reflectionc Adoption, adaptation, or abandonment (“pivot or persevere”)

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DQ-3. Information (What do we need to know?)1. Do we have the information needed to make the decision?2. What are the major uncertainties? Have quantified the uncer-

tainties with ranges and probabilities?3. What are the most critical factors that drive value and risk?4. Does our information correctly reflect the judgment of experts

we trust?5. Are we focusing on getting the right additional information

(i.e., where the benefits outweigh the costs)?6. How are we accounting for intangibles?

DQ-4. Values and trade-offs (What do we want?)1. What consequences do we care about?2. What are the criteria we will use to compare the alternatives?3. How are we making the trade-offs among multiple criteria?4. What are the “intangibles” that are important in this decision?

How are quantifying these effects and relating them to theoverall value?

5. If the consequences of choices could seriously harm the orga-nization, has leadership risk attitude been considered?

6. Are the values and trade-offs clearly stated, well understood,and easy to communicate?

DQ-5. Reasoning1. Are we thinking straight about this?2. How does our evaluation model work?3. For each alternative, what are the key sources of value?4. For each alternative, what are the primary drivers of risk?5. How do the alternates compare?6. Is the reasoning easy to understand and communicate?

DQ-6. Commitment1. Do we have a consensus to take action?2. Are we willing to commit the resources?3. Is best choice clear? What/who could change our minds?4. Does our choice have broad support with the organization?5. Do the people implementing the action have the authority,

ability, resources, motivation, and discipline required?6. What is the plan and time frame for implementation and com-

munication?

Decision analysisDecision analysis (DA) is the applied discipline “that addressesthe complexities of making decisions in the face of uncertainty,dynamics (multiple rounds of deciding and learning), and mul-tiple factors that affect value [17].” The field was pioneered byRonald A. Howard at Stanford University [44], and has beenvery influential in the fields of health and medical decision mak-ing [45, 46]. DA tackles uncertainty head-on using probabilitytheory, especially Bayes Theorem. DA methods include decisiontrees, Monte Carlo simulations, Markov modeling, relevance dia-grams (also called influence diagrams or value maps), Bayesiannetworks, etc. DA is beyond the scope of this handout.

Dialog Decision Process (DDP)When decisions have high stakes, high costs, and high uncer-tainty (i.e., high organizational and analytical complexity) we

Figure 23. Dialog Decision Process (source: http://sdg.com)

need a rigorous deliberative process involving a decision boardand a project team. The decision board is the individual or boardcharged with making a final decision (or recommending a finaldecision) that achieves DQ. The decision board is trained in andhas responsibility for ensuring DQ. The project team includesindividuals who (a) are trusted by board members to executetheir roles in the DDP, (b) are important stakeholders in the de-cision and its eventual implementation, and (c) are competent indecision-making methods.

The Dialogue Decision Process (Figure 23) has four-stages:1. define frame,2. design alternatives,3. decide among evaluated alternatives, and4. do action planthat guides decision makers to execute high quality decisionsthrough dialogue with a project team, creating alignment andcommitment to the highest value choice along the way. TheDDP is designed to avoid cognitive biases and to satisfy therequirements for DQ.

“The project team’s job is to assess the situation, proposea frame, develop alternatives, build a decision model, gathernecessary information, apply sound reasoning to evaluate thealternative, present clear comparisons of the alternative, and rec-ommend a course of action to the decision board, whose job it isto make the decision” [17].

Here are the Decision Maker’s Bill of Rights [17]: “Everydecision maker has the right to decision quality, achieved through:1. A decision frame that structures the decision in the most rele-

vant context.2. Creative alternatives that enable a selection among viable and

distinct choices.3. Relevant and reliable information upon which to base a deci-

sion, incorporating the inherent uncertainty.4. An understanding of potential outcomes of each alternative

described in terms of the decision maker’s values.5. Sound reasoning and analysis that allow decision makers to

draw meaningful conclusions and choose the best alternative.6. An effect decision project leader who can achieve alignment

and commitment to the best action.”

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Public health ethicsIn public health we incorporate ethics into our decision making.We start with key definitions. “Public health is what we, as a so-ciety, do collectively to assure the conditions in which people canbe healthy” [34]. Morality refers to social institution or practice—what people believe, value, and do [47]. Ethics is the reflectivetask of interpreting, understanding, and criticizing morality. Inpublic health ethics we evaluate and weigh how public healthactions promote or infringe on moral considerations (norms):

Moral considerations (norms)1. Producing benefits2. Avoiding, preventing, and removing harms3. Producing the maximal balance of benefits over harms and

other costs (often called utility)4. Distributing benefits and burdens fairly (distributive justice)

and ensuring public participation, including the participationof affected parties (procedural justice)

5. Respecting autonomy, including liberty of action6. Protecting privacy and confidentiality7. Keeping promises and commitments8. Disclosing information as well as speaking honestly and truth-

fully (often grouped under transparency)9. Building and maintaining trust

Justificatory conditionsHow do we justify infringing on moral norms such as liberty,privacy, and confidentiality in the selection of public health inter-ventions? To be ethical, we use the following criteria to designand select public health actions:1. Effectiveness: Is the action likely to accomplish the public

health goal?2. Necessity: Is the action necessary to override the conflicting

ethical claims to achieve the public health goal?3. Least infringement: Is the action the least restrictive and least

intrusive?4. Proportionality: Will the probable benefits of the action out-

weigh the infringed moral norms and any negative effects?5. Impartiality: Are all potentially affected stakeholders treated

impartially?6. Public justification: Can public health officials offer public

justification that citizens, and in particular those most affected,could find acceptable in principle?

Intervention LadderInterventions are listed from least to most intrusive [47]:1. Do nothing2. Monitor (e.g., surveillance)3. Provide information (e.g., health education)4. Enable choice5. Guide choice by changing the default policy6. Guide choice by incentives7. Guide choice by disincentives8. Restrict choice9. Eliminate choice

8. Building effective teams

In today’s world, teams must be agile, adaptive, responsive, andimproving. High-performing teams are quickly convened anddeployed. Teams must master the following areas:1. building trust and celebrating courage2. promoting humility and accountability3. improving leadership, decisions, and ethical behaviors4. managing “crucial conversations”

Living cultural humilityIn 1998, Melanie Tervalon and Jann Murray-García publisheda groundbreaking article [48] that challenged the concept of“cultural competency” with the concept of “cultural humility.”Cultural humility is committing to lifelong learning, criticalself-reflection, and personal and institutional transformation. Ac-cepting cultural humility means accepting that we can never befully culturally competent. Cultural humility is the foundation forestablishing trust and respectful relationships, and for managingdifferences and conflict.1. Commit to lifelong learning and critical self-reflection.2. Cultivate humility, opening our hearts to transformation.3. Realize our own power, privilege, and prejudices.4. Redress power imbalances for respectful partnerships.5. Recognize and validate our common humanity.6. Promote institutional accountability.

Building trustIn organizations with high levels of trust staff engage in honest,vigorous deliberations about the most important and sensitivetopics, including strategy, budget cuts, ethics, equity, racism,discrimination, power, privilege, prejudice, interpersonal conflict,etc.

The word trust is used often but rarely defined. The wordis thrown around as if everyone understands exactly what wemean. We attend countless meetings where “building trust” isemphasized. Building and restoring trust requires a thought-ful, systematic approach. To understand trust we must defineit precisely. Trust is an aspect of relationships; it varies withinand across relationships. Organizational trust researcher, RogerMayer, defines trust as follows:

“Trust is the willingness of a party [trustor] to bevulnerable to the actions of another party [trustee]based on the expectation that the other party willperform a particular action important to the trustor,irrespective of the ability to monitor or control thatother party. . . . Making oneself vulnerable is takinga risk. Trust is not taking a risk per se, but rather itis a willingness to take risk.”

In short, trust is the willingness to be vulnerable to anotherparty. Therefore, trust is a state of readiness to take risk in arelationship. Trust is the willingness to assume risk; behavioraltrust (or a trusting action) is the assuming of risk. Our focus ison trust as a state of readiness (“willingness”). An organizational

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culture of trust is a culture where staff feel safe to tackle andvigorously debate the most challenging, sensitive topics in serviceof the organizational purpose.

Not appreciated by many is that trust is a decision [49]. As anintuitive (gut) decision we experience trust as a feeling of safety.As an deliberative decision we experience trust as a feeling ofconfidence. In short, our objective is to influence others to trust us,our teams, and our organization. Therefore, our job as managersis (a) to be trustworthy, (b) to behave in ways that inspire trust,and (c) to design systems that promote a culture of trust.

Building a culture of trust improves team and organizationdecision making, execution, accountability, continuous improve-ment, and performance. Here is standard work for BuildingTrust—these behaviors apply always, with anyone, and in anysituation:1. Show you care (readily help without expecting anything in

return; “acts of kindness” [see https://www.kindness.org/])2. Be competent (capable, consistent, and continuously improv-

ing)3. Have character (integrity, honesty, fairness, loyalty, and trans-

parency)4. Live cultural humility (see p. 20)5. Communicate clarity (intent [what], motive [why], and agenda

[how: who, when, where])6. Ensure safety (psychological, emotional and physical)

The trustor’s propensity to trust is the predisposition or gen-eral willingness to trust before any information about the trusteeis considered. At one extreme, a very high propensity to trustcan result in extending trust even when it is not warranted (“blindtrust”). At the other extreme, a very low propensity to trust canresult in not extending trust even when it is warranted (“blinddistrust”).

Celebrating courageHumility and trust are based in human relationships and involvevulnerability. Brené Brown defines vulnerability “as uncertainty,risk, and emotional exposure.” “Vulnerability is the core of allemotions and feelings. To feel is to be vulnerable” [50]. Anytime someone risks vulnerability to get better, build trust, protectothers, or behave ethically they are courageous!. Therefore,we are surrounded by daily acts of unrecognized courage! Wemust recognize and celebrate our courageous staff, clients, andcommunities!

Promoting accountabilityThe Center for Creative Leadership defines accountability:

Whereas responsibility is generally delegated by theboss, the organization, or by virtue of position, ac-countability is having an intrinsic sense of ownershipof the task and the willingness to face the conse-quences that come with success or failure.

Accountable managers “look out the window to apportioncredit . . . when things go well, [and] they look in the mirror toapportion responsibility . . . when things go poorly” [51]. In other

words, when failures occur, we should actively seek full responsi-bility for our part—we do not seek blame, blame others, or lookto “hold someone accountable”—we problem-solve and ask “howcan I (or we) make things better?” Lean leaders promote a cultureof trust, humility, and respect, and deploy a lean managementsystem that engages and promotes accountability for individualsand teams at every level.

Managing crucial conversationsTeams built on trust are high-performing: members engage in con-structive conflict—vigorous debates of ideas, concepts, strate-gies, and decision trade-offs [52]. However, affective (emotional)conflict is unproductive and may be destructive to relationshipsand team performance. Patterson recommends engaging in a“crucial conversation” when we recognize affective conflict [53]:• high stakes,• opposing opinions, and• strong emotions.We must recognize how our cognitive, emotional, and behavioralprocesses are tightly coupled but—ultimately—under our controlthrough our awareness and management of self and others. In ourPath to Action (Figure 24), we1. see and hear others’ behaviors (from their Path to Action)2. tell a story (to ourselves, or recall a rumor we heard),3. feel (an emotion triggered by the story or rumor), and4. act (based on an intuitive, rather than deliberative, decision).

Figure 24 depicts the Crucial Conversions model. First, studyand understand the model components. Second, study Table 12on the following page. (If possible, read the book [53].) Steps1–3 are the most important:1. Start with heart (know what you really want for you & others)2. Learn to look (crucial conversation, safety, silence, violence)3. Make is safe (ensure or restore safety to move forward)

Be aware that a crucial conversation can emerge quickly andunexpectedly. Therefore, we must be mindful of our emotionsand the “story” that may be activating our emotions. Also, beaware that our implicit (unconscious) biases may be the cause.

Figure 24. Crucial conversations: Focus on understanding Pathsto Actions, ensuring emotional and physical safety, enlarging thePool of Shared Meaning (e.g., common agenda; shared vision,collective problem solving, shared decision making). We wantthe circle of silence and violence to shrink and disappear.

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Table 12. Coaching for Crucial Conversations (source: [53])

Principle Skill Crucial question(s)

1 Start with heart Focus on what you really want.Refuse the “Sucker’s Choice.” (false choicebetween “violence” or “silence.”)

What am I acting like I really want? What do I reallywant? For me? For others? For the relationship? Howwould I behave if I really did want this?

2 Learn to look Look for when the conversation becomescrucial.Look for safety problems.Look for your own Style Under Stress.

Am I going to silence or violence?Are others going to silence or violence?

3 Make it safe Apologize when appropriate.Contrast to fix misunderstanding.CRIB to get to Mutual Purpose.- Commit to seek Mutual Purpose- Recognize the purpose behind the strategy- Invent a Mutual Purpose- Brainstorm new strategies

Why is safety at risk?(a) Have I established Mutual Purpose?(b) Am I maintaining Mutual Respect?What will I do to rebuild safety?

4 Master my stories Retrace my Path to Action.Separate fact from story.Watch for the Three Clever Stories.Tell the rest of the story.

What is my story?What I am pretending not to know about my role inthe problem?Why would a reasonable, rational, and decent persondo this?What should I do right now to move toward what Ireally want?

5 STATE my path Share your facts.Tell your story.Ask for others’ pathsTalk tentatively.Encourage testing.

Am I really open to others’ views?Am I talking about the real issue?Am I confidently expressing my own views?

6 Explore others’ paths Ask – Mirror – Paraphrase – PrimeAgree – Build – Compare.

Am I actively exploring others’ views?Am I avoiding unnecessary disagreement?

7 Move to action Decide how you’ll decide.Document decisions and follow up.

How will we make decisions?Who will do what by when?How will we follow up?

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9. Population health leadership

Leaders are people that others follow [26, 54]. If no one follows,one cannot be a leader. Leadership is a relationship. Goodleadership means people willingly follow a leader who is workingto further the common good. Leadership is a relationship thatcannot be handed off to anyone else. In contrast, management isa collection of functional tasks to carry out, monitor, and achievestrategic objectives. Unlike leadership, management functionscan be delegated.

Global leadership scholar Roger Gill argues that leadershippractice boils down to six core themes of leadership [55]:1. Values (What’s important to us?)2. Vision (What does the desirable future look like?)3. Purpose (Why do we exist?), or Mission (What do we do?)4. Strategy (How will we get there?)5. Engagement (Involve staff at every step (e.g., visioning))6. Empowerment (Give staff the training and tools to succeed.)Based on this, here is a longer definition of leadership:

Leadership is modeling the way of inspiring a sharedvision of the future; promoting clear purpose andmission, core and supportive values, and intelligentstrategies; and engaging and empowering all thoseconcerned to pursue this vision.

Building on this, and consistent with the Leadership Chal-lenge (see glossary), public health leadership is “the practice ofmobilizing people, organizations, and communities to effectivelytackle tough public health challenges” [56]. A competency isdefined as the “effective application of values, traits, knowledge,and skills in complex situations” [56]. Leadership competenciescan be divided into three categories: how to be, what to know,what to do.

How to be: values and character traitsThe values of effective public health leaders include [56]: socialjustice, reliance on evidence, interdependence, respect, commu-nity self-determination, requisite role of government, and trans-parency. The character traits of effective public health leadersinclude [56]: integrity, initiative, empathy, comfort with ambigu-ity, passion, courage, and persistence.

What to know: knowledge basePublic health knowledge is evidence-based, dynamic, prevention-focused, trans-disciplinary, and value-laden. The public healthknowledge base of effective public health leaders includes [56]:• Public health science: analytic / assessment; basic public health

sciences (biostatistics, epidemiology, environmental health,health policy and management, social and behavioral sciences);cultural competency (see cultural humility); communication;community dimensions of practice; financial planning and man-agement; leadership and systems thinking; policy developmentand program planning• Understanding people: motivation, and social and emotional

intelligence

• Understanding complex systems: systems thinking, and com-plex adaptive social systems.

• Changing people, organizations, and communities: changemanagement, culture of innovation, and positive deviance.

What to do: five competency sets (25 competencies)1. Invigorate bold pursuit of population health: assess the current

state of your program or organization; articulate a compellingagenda; enlist others in the vision and invigorate them to drivetoward it; pursue the vision with rigor and flexibility; andmarshal the needed resources

2. Engage diverse others in public health initiatives: assess localconditions, in ways relevant and credible to the local stake-holders; search widely for the right partners; apply a socialdeterminants perspective to planning; take time to build rela-tionships, teamwork, and common understanding; and clarifyroles and governance

3. Effectively wield power to increase the influence and impact ofpublic health: understand and strategically use positional au-thority and informal influence; analyze public health problemsand proposed solution in “campaign” terms; build coalitionsof core supporters, new partners, and issue-specific allies; dealeffectively with opponents; and be strategically agile

4. Prepare for surprise in public health work (e.g., disasters):promote resilience in individuals and communities; developand critique an emergency response plan; communicate ef-fectively during surprises; execute emergency response planswith flexibility; and learn and improve after surprises

5. Drive for execution and continuous improvement: build ac-countability into public health teams; establish metrics, settargets, monitor progress, and take action; proactively demon-strate financial stewardship of public health funds; employthe methods and tools of quality improvement; and encourageinnovation and risk-taking

Skill path to becoming a FAST LEADERLeadership is getting results in a way that inspires trust.

. . . Stephen MR Covey [57]

Leadership development is a lifelong endeavor that requiresrelentless focus and learning. To accelerate leadership develop-ment, we have found the FAST LEADER model [1] and acronymvery helpful (Table 13 on the next page). The acronym is easyto remember and share, and supports professional development,coaching, and teaching. The Leading Population Health (LPH)framework (Figure 26 on page 25) provides a roadmap.

Kresge-inspired LEAD initiativePublic health leaders promote organization and community trans-formation. The San Francisco Department of Public Health hascommitted to four areas of continuous transformation (Figure 25on the next page):1. Trauma-informed systems (designing a healing organization)2. Cultural humility (transforming workforce)3. Continuous improvement (designing a learning organization)4. Collective impact (transforming community)

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Table 13. Skills for becoming a FAST LEADER for Leading Population Health (Figure 26 on the next page)

Acronym Focus on these skills

Facilitative leadership Mastering neutral facilitation skills for teams and groupsAdaptive leadership Leading change differently for technical (complicated) versus adaptive

(complex) challenges and solutions (see Heifetz [58])Servant leadership Cultivating humility, empathy, compassion, and serviceTransformational leadership Developing a new generation of leaders through coaching and teaching

Learning Mastering innovation and performance improvement with lean thinking andpractice, and leader standard worka (see Figure 2 on page 2)

Empathy Seeking empathy and emotional intelligence;b ensuring staff engagement(see NewsSmart Humility, p. 2 ; and Building Effective Teams, p. 20)

Accountability Ensuring an organizational culture and a lean management system thatpromotes self and team accountability

Decisions Ensuring high quality, ethical decisions, including priority-setting andresource allocation, in the setting of uncertainty and competing objectives

Execution Ensuring visual project management and agile development systems [12]Results Ensuring results that matter: “Is anyone better off?” (esp. health equity)

a Starting with self, develop people to solve problems and improve performanceb Emotional intelligence is subsumed by an integrated model called personal intelligence (see Mayer [59]).

Figure 25. Kresge Foundation Emerging Leaders in Public Health-inspired SFDPH LEAD Initiative—core training intrauma-informed systems (designing a healing organization), cultural humility (transforming workforce), continuous improvement(designing a learning organization), and collective impact (transforming communities). Graphic adapted from the LeanTransformation Framework (http://www.lean.org/WhatsLean/TransformationFramework.cfm)

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Figure 26. The Leading Population Health Framework (LPHF): The essential goals include (1) protecting and promoting healthand equity; (2) transforming people and place; (3) ensuring a healthy planet; and (4) achieving health equity. At center is the leanleadership philosophy that promotes scientific (Plan-Do-Study-Act [PDSA]) problem-solving, leader standard work, and alignment topurpose. Leader standard work is, starting with self, developing people to solve problems and improve performance. The bottom lefttriangle is transforming self and interpersonal relationships. At center is the core human cognitive-behavioral processes of deciding,acting, and learning. The heart represents the powerful role of emotions. Based on Hess & Ludwig’s book “Humility is the NewSmart,” NewSmart Humility is quieting the ego (intellectual humility and mindfulness), managing self (thinking and emotions),reflective listening, and connecting and relating to others. W. Edwards Deming’s System of Profound knowledge is the understanding(a) complex systems (systems thinking), (b) variation (statistical thinking), (c) theory of knowledge (PDSA), and (d) psychology.Strategic intelligence is having foresight, building a shared vision, building effective partnerships, and motivating and inspiring people.The bottom right triangle is transforming teams and collaboratives. At center is lean thinking. And, the top triangle is transformingorganizations and communities. Pioneered in San Francisco, the Community Action Model (CAM) is a community-based participatoryapproach that changes social policy through youth development and policy action. At center of the top triangle is data science—the artand science of transforming data into actionable knowledge. Actionable knowledge is designed to influence, inform, or optimizestakeholder decision-making. A NewSmart organization is designed for optimal learning, adaptation, innovation, and continuousimprovement by using the following psychological concepts: Positivity, Self-Determination Theory, and Psychological Safety.

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10. Population health data sciencePopulation health data science (PHDS) is the art and scienceof transforming data into actionable knowledge to improve health.Actionable knowledge is knowledge that influences, informs, oroptimizes decision making. PHDS supports decision quality.

PHDS is categorized into five analytic domains (Figure 27):(1) description: measuring the burden of risk factors and out-comes; (2) prediction: early targeting of prevention and responsestrategies; (3) discovery: testing causal pathways for designingprevention strategies, and discovering and testing new causalpathways; (4) simulation: modeling processes for epidemiologicand decision insights; and (5) optimization: optimizing decision-making, priority-setting, and resource allocation. Discovery, sim-ulation, and optimization support causal and evidential reasoningthat guide decisions, design, deployment, learning, and continu-ous improvement.

PDHS is a rapidly growing field that emerged from solvingpublic health problems. In public health practice, we need toinfluence, guide, and advise decision makers in a relevant andtimely way. Decision makers include patients, providers, policymakers, colleagues, and community stakeholders. When possi-ble, timeliness should be in real time. Peer-reviewed scientificpublications are often ineffective and too slow. The bottom linechallenge is this: the transformation of data into to actionableknowledge means improving decision-making in the setting ofcomplex environments, uncertainty, limited information, multipleobjectives, competing trade-offs, and time constraints.

PHDS integrates the expertise from public health , epidemi-ology, medicine, statistics, computer science, decision sciences,health and behavioral economics, and human-centered design.PHDS is the future of public health data analysis and synthesis,and knowledge integration. Knowledge integration is the man-agement, synthesis, and translation of knowledge into decisionsupport systems to improve policy, practice, and—ultimately—population health.

Figure 27 summarizes the data science landscape. The gen-eral idea is to design human-centered decision support systemsand practices to improve and optimize decision-making fromcommunity residents to policy makers. Examples of PHDS ap-proaches familiar to public health include: (a) health impactassessment, (b) decision analysis, (c) cost-effectiveness analy-sis, and (d) cost-benefit analysis. Less familiar to public healthinclude the following: (a) operations research, (b) Bayesian net-works, (c) machining learning, and (d) artificial intelligence.

“Big data” are the availability of huge data systems with multi-dimensional, longitudinal data on individuals and their environ-ments that enable us (through computer algorithms) to describe,predict, explain, and optimize the human experience—primarilyby influencing human choices (decisions), by targeting publichealth interventions, and by conducting causal research.

Biostatistics and epidemiology, the foundational quantitativesciences of public health, are the essential components of PHDS.Epidemiologists are deploying advancements in causal inference,risk assessment, decision analysis, and Bayesian networks [38,39,44]; and joining or leading data science teams. Biostatisticians

contribute through statistical learning methods and research.

Figure 27. The data science landscape strengthens lean thinkingand decision quality (source: http://www.bayesia.com/)

Glossary3P is the production preparation process. Creative process for

designing new products, services, systems, or environments.See also human-centered design.

5S is for organizing a workplace for visual management: sort, setin order, shine, standardize (standard work), and sustain.

actionable metrics In lean startup, actionable metrics are leadindicators (see Table 6 on page 11) that are causally linkedto the outcome hypothesis (customer, product, growth), andare used in innovation accounting.

catch-ball is practiced by anyone initiating an improvementproject: that person articulates the purpose, objectives, andother ideas and concerns and then “throws” them to theother stakeholders for feedback, support, shared decisionmaking, consensus, and action.

consensus means the discussion group has achieved a sufficientlevel of shared understanding and commitment to action tomove forward.

Deming, W. Edwards was a quality improvement scholar whodeveloped the System of Profound Knowledge: apprecia-tion for a system (systems thinking), knowledge of varia-tion (statistical thinking), theory of knowledge (learningand adaptation), and psychology (understanding people).For details see https://deming.org/.

data science is the art and science of transforming data intoactionable knowledge.

design thinking See “human-centered design.”evaluation, developmental is an approach to understanding the

activities of a program operating in dynamic, novel environ-ments with complex interactions. It focuses on innovationand strategic learning rather than standard outcomes and isas much a way of thinking about programs-in-context andthe feedback they produce.

evaluation, formative is an evaluation that takes place before orduring a project’s implementation with the aim of improv-ing the project’s design and performance. The evaluation

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complements summative evaluation and is essential for un-derstanding why a program works or doesn’t, and whatother factors (internal and external) are at work during aproject’s life.

ego is best understood as “self-concept” which is a collection ofbeliefs about oneself, including our many identities (gender,racial, professional, etc.) [60]. “Self-concept is made upof one’s self-schemas, and interacts with self-esteem, self-knowledge, and the social self to form the self as whole.. . . The temporal self-appraisal theory argues that peoplehave a tendency to maintain a positive self-evaluation bydistancing themselves from their negative self and payingmore attention to their positive one” [60].

emotional intelligence (EI) is the “the ability to monitor one’sown and others’ feelings and emotions, to discriminateamong them and to use this information to guide one’sthinking and actions” [5]. The EI model includes the abili-ties to perceive, use, understand, and manage emotions ofself and with others. EI has been subsumed by an integratedmodel called personal intelligence [59].

evaluation, summative looks at the impact of an interventionon the target group. It can take place during the projectimplementation, but is most often undertaken at the end ofa project.

five whys In lean startup, “The Five Whys” was adapted fromlean production and used for problem solving and rootcause analysis.

goal is a specific end result desired or expected to occur as aconsequence, at least in part, of an intervention or activity.

growth mindset is embracing the fact that talents can developedthrough hard work and continuous improvement. A fixedmindset believes that talents are innate gifts and cannot bedeveloped [4].

hansei is Japanese for self-reflection and is a central idea inJapanese culture, meaning to acknowledge one’s own mis-take and to pledge improvement.

hoshin kanri (also called policy deployment) is a managementsystem for ensuring that organization strategic goals driveprogress and action at every level. Hoshin kanri aligns orga-nizational goals (strategy) with middle management plans(tactics) and the work performed by all staff (operations).

human-centered design (design thinking) is the creative designof products, services, or environments to delight, fulfillneeds, and exceed the expectations of end-users.

humility is “the noble choice to forgo your status, [and to] useyour influence for the good of others before yourself” [3]and is “a mindset about oneself that is open-minded, self-accurate, and ‘not all about me,’ and that enables one toembrace the world as it ‘is’ in the pursuit of human excel-lence” [5].

hyperlearning “is learning that’s agile, rapid, energizing, en-gaged, determined, continual, and eager. For humans, thatlearning is both cognitive and emotional. . . . [A hyper-learner addresses] the emotionally challenging parts ofeffective learning–the emotional parts of critical thinking,

creativity, innovation, collaborating, and engaging withothers” [5].

improvement kata is a synonym for validated learning, and rep-resents sequential PDSA cycles with a purposeful goal. Theterm and concept of “improvement kata” was developed byMike Rother.

innovation accounting In lean startup, innovation accounting isa visual measurement system with actionable metrics de-signed to monitor progress, and to guide decision-making,priority-setting, and accountability.

leader standard work is standard work (including a schedule)for a manager’s regular activities to develop people (startingwith self) to solve problems and improve performance.

lean startup is a methodology for developing businesses andproducts. It aims to shorten product development cycles byadopting a combination of hypothesis-driven experimenta-tion, iterative product releases, and validated learning.

impact is an estimate of effectiveness. What outcomes can be at-tributed to a program, agency, service system, or collectiveimpact? For example, “number of deaths averted.”

leadership challenge Kouzes and Barry have organized leader-ship into five evidence-based practices: (1) Model the Way,(2) Inspire a Shared Vision, (3) Challenge the Process, (4)Enable Others to Act, and (5) Encourage the Heart. (seehttp://www.leadershipchallenge.com/)

lean thinking has three components that build on each other: (1)PDSA, (2) validated learning (“PDSA with a purpose”),and (3) A3 reports (for problem solving, collective impact,or decision quality).

mindfulness is being fully presence without judgment or expec-tation; it enables moment-by-moment self-awareness andemotional intelligence.

minimum viable product (MVP) In lean startup, the MVP isthe “version of a new product which allows a team to col-lect the maximum amount of validated learning about cus-tomers with the least effort” [14].

NewSmart behaviors are (1) Quieting the ego (mindfulness, re-flection, minimizing defensiveness and fear), (2) Managingself (thinking and emotions), (3) Reflective listening, and(4) Otherness (emotionally connecting and relating) [5].

NewSmart mindset is a measure not of what you know or howmuch you know but of (1) the quality of your thinking,listening, collaborating, and learning; (2) how good you areat “not” knowing and decoupling your beliefs (not values)from your ego; (3) how good you are at being open tocontinually stress-testing your beliefs about how the worldworks; and (4) how good you are at trying out new ideasand ways to accomplish your objectives and learning fromthose experiments.

outcomes represent changes in the institutional and behavioralcapacities that occur between the completion of outputsand the achievement of goals.

outputs are changes in skills or abilities and capacities of indi-viduals or institutions, or the availability of new productsand services that result from the completion of activities

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within the control of the organization.pivot In lean startup, a pivot is the decision to change course

based your innovation accounting system and actionablemetrics.

population health is a systems framework for studying and im-proving the health of populations through collective actionand learning.

population health data science is the art and science of trans-forming data into actionable knowledge to improve health.

reasoning is short for causal and evidential reasoning. This isthe discipline of applying logic and Bayesian reasoning todraw inferences and improve decisions.

results are changes in a state or condition that derive from acause-and-effect relationship. There are three types of suchchanges: outputs, outcomes and impact. The changes canbe intended or unintended, positive and/or negative.

Results-Based AccountabilityTM (RBA) is a result-based ap-proached popularized by Mark Friedman [11]. RBA re-sources are available from http://www.clearimpact.com.

standard work (SW) is an “agreed-upon, best-known, least-waste way today” of doing something. SW defines thedesired sequence of steps and the time required to performeach step. Leader standard work: starting with self, de-velop people to solve problems and improve performance.

theory of action are the ways in which programs or interven-tions are constructed to activate theories of change; e.g.,health promotion programs might use peer mentor, socialmarketing, or some other strategy to change perceptions ofsocial norms [61].

theory of change are the central processes or drivers by whichchange comes about for individuals, groups, or commu-nities; e.g., psychological, social, physical, or economicprocesses. A theory of change can be developed from aformal, research-based theory or an unstated, tacit under-standing about how things work [61].

validated learning is sequential PDSA cycles with a purposefulgoal. In lean startup, “Startups . . . exist to learn how tobuild a sustainable business. This learning can be validatedscientifically by running frequent experiments that allowentrepreneurs to test each element of their vision” [14].

transdisciplinary is a strategy that crosses disciplinary bound-aries to create a holistic approach.

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Contents

1 Leadership philosophy 1

2 “NewSmart” Humility 2

3 Lean thinking 4

4 Collective impact (results-based) methods 8

5 Design thinking (human-centered design) 15

6 Lean startup 16

7 Decision quality: better team decisions 17

8 Building effective teams 20

9 Population health leadership 23

10 Population health data science 26

Glossary 26

References 28

AcknowledgmentsSpecial thanks and enormous gratitude to the following visionaries:• Kresge Foundation Emerging Leaders in Public Health fellowship• Mike Rona, Rona Consulting (https://www.ronaconsulting.com/)• Kim Barnas and John Toussaint, Catalysis (https://createvalue.org/)13

• Eric Ries, The Lean Startup (http://theleanstartup.com/)• Mike Rother, The Toyota Kata (http://www-personal.umich.edu/~mrother/

Homepage.html)• Deitre Epps, ClearImpact (https://clearimpact.com/)• Population Health Division staff, especially Dara Geckler, Priscilla

Chu, Gretchen Paule, Janine Young, Paula Stewart, Dale Gluth, IsraelNieves-Rivera, and Rita Nguyen

• San Francisco Health Network, San Francisco Department of PublicHealth, lean quality improvement leaders: Roland Pickens, SusanEhrlich, Lisa Golden, Ellen Chen, and Alice Chen

• Marc Hebert, Design Anthropologist, Innovation Office, San Fran-cisco Health Services Agency

13Formerly ThedaCare Center for Healthcare Value