"Designing a Learning Health Organization for Collective Impact" was my presentation given at the California HealthCare Foundation (CHCF) Health Care Leadership Program final seminar and graduation. Congratulations to the amazing fellow graduates!!!

1. Designing a Learning Health Organization for Collective Impact
Tomas J. Aragon, MD, DrPH
Health Ocer, City and County of San Francisco
Director, Population Health Division (PHD)
San Francisco Department of Public Health
University of California, Berkeley
School of Public Health
October 3, 2014
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 1 / 18

2. Acknowledgments
Barbara A. Garcia, MPA, Director of Health, SFDPH
CHCF Healthcare Leadership Program Sta and Cohort 12!!!
California HealthCare Foundation (CHCF)
Healthcare Leadership Program, UC San Francisco
SFDPH Population Health Division sta
SFDPH Quality Improvement Programs
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 2 / 18

3. Overview
1 Problem statement
2 Project description
3 Goal and objectives
4 Outputs and outcomes
5 Lessons learned
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 3 / 18

4. Problem statement
Challenges and Opportunities
Challenges
Increasing complexity
Public Health Accreditation
Health and socioeconomic inequities
Aging and epidemic of chronic diseases
Patient Protection and Aordable Care Act
Opportunities
Public Health Accreditation
Patient Protection and Aordable Care Act
Collective impact for community transformation
Integration of epidemiology, quality improvement, and complexity science
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 4 / 18

5. Problem statement
Problem de

6. nition and underlying causes
The San Francisco Department of Public Health, Population Health Division (PHD) is limited
in its ability to ful

7. ll its mission to protect and improve community health and health equity.
PHD faces special challenges:
a legacy of categorical funding and autonomous silos,
no system for performance management and continuous quality improvement,
new public health accreditation requirements,
implementation of the Aordable Care Act,
fragmented services, and
limited focus and capability to address complex community health problems and social
determinants.
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 5 / 18

8. Problem statement
San Francisco's old public health division, 2011
Population Health and Prevention
Categorical silos
No division training program
No division strategic planning
No division quality improvement
No division performance management
POPULATION HEALTH PREVENTION
Community Health Promotion
and Prevention
Public Health Preparedness
and Emergency Response
Environmental Health and
Occupational Safety
Public Health Laboratories
Emergency Medical Services
STD Prevention and Control
Tuberculosis Control
Communicable Disease
Control and Prevention
HIV Prevention
HIV Epidemiology
Bridge HIV (Research)
Tomás J. Aragón, MD, DrPH
Health Officer Director
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 6 / 18

9. Project description
REACH|for Results, Equity, and Accountability for Community Health
Leveraging concepts from
organization development and design,
continuous quality improvement,
leadership and management, and
complexity science,
we reorganized the Population Health Division under a new continuous improvement
framework we call REACH|for Results, Equity, and Accountability for Community Health.
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 7 / 18

10. Goal and objectives
Goal
A high performing, learning health organization that successfully implements collective
impact approaches to complex community health problems.
Output-oriented objectives: By July, 2013:
1 Population Health Division Organization Design Framework (ODF)
2 Design and implementation of new REACH framework:
1 Criteria for Performance Excellence (CPE)
2 Four Strategic Questions (4SQ)
3 Results-based management (RBM)
4 Health Equity X (HEX) model
Outcome-oriented objectives: By July, 2014:
The conduct of high-priority health equity projects with continuous improvement in population
health (lag) and performance (lead) indicators using the new REACH framework.
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 8 / 18

11. Outputs and outcomes
Output: Population Health Division Organization Design Framework
Public health accreditation
Four P's of public health
Physiology vs. anatomy
(organization chart)
Horizontal integration
KNOWLEDGE MANAGEMENT: Surveillance, Epidemiology, and Research Branch
STRATEGIC PLANNING: Office of Policy, Planning, and Quality Improvement
DISASTERS
(Preparedness)
- - -
Emergency
Preparedness
and Response
Branch
HEALTHY PLACES
(Protection)
- - -
Environmental
Health Branch
HEALTHY PEOPLE
(Promotion)
- - -
Community
Health Equity
and Promotion
Branch
DISEASES
(Prevention)
- - -
Disease
Prevention
and Control
Branch
OPERATIONS FOCUS: Office of Operations, Finance, and Grants Management
WORKFORCE FOCUS: Center for Learning and Innovation
COMMUNITY
PARTNERS
- - -
Health Systems
Schools
etc.
GUIDED BY STRATEGIC VISION
AND ACTION PLANS
1. Safe and Healthy Living Environments
2. Healthy Eating and Physical Activity
3. Access to Quality Care and Services
4. Black / African American Health
5. Maternal, Child, and Adolescent Health
6. Health for People at Risk or Living with HIV
Assessment
Policy Development
Assurance
Governance,
Administration,
and Systems
Management
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12. Outputs and outcomes
Output: Criteria for Performance Excellence|Baldrige House
Predictive of high performance
Pillars of leadershp results
Knowledge integration
Decision support
Guided by Strategic Vision
and Action Plans
Influenced by Challenges and Opportunities
2. Strategic Planning
Decision-making
5. Workforce
Development
1. Leadership 7. Results
3. Customer
Value
6. Lean Thinking
Process Innovation
4. Knowledge Integration and Decision Support
Supported by Values (respect, continuous improvement, teamwork, excellence)
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13. Outputs and outcomes
Outputs: In
uence of the Baldrige CPE on the Organization Design
Baldrige Criteria Examples of organization design achievements
1. Leadership Executive team leadership academy
2. Strategic planning Result-based strategic planning for accreditation
3. Customer focus Community Health Equity and Promotion Branch
Disease Prevention and Control Branch
4. Knowledge integration and
decision support
Integrated surveillance and epidemiology unit
Integrating all disease surveillance systems
Continuous Decision Improvement (CDI) curriculum
5. Workforce focus Center for Learning and Innovation
6. Process management Oce of Equity and Quality Improvement
7. Results Collective impact using results-based management
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14. Outputs and outcomes
Output: Four Strategic Questions (4SQ)
The practice of asking four strategic questions with all important activities. Promotes a
culture of strategy awareness and results-based accountability, but in an accessible way that
values sta creativity.
4SQ
1 What are we trying to accomplish and why?
(strategic intent)
2 How do we measure success?
(scorecard)
3 What other conditions must exist?
(assumptions and risks)
4 How do we get there?
(action planning)
Example
Daily planning
Planning meetings
Project management
Quality Improvement
Structured decision making
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15. Outputs and outcomes
Output: Results-based management (RBM) for collective impact
RBM
Results chain
Results matrix
Collective impact
1 Common agenda
2 Shared measurement
3 Continuous improvement
of mutually-reinforcing
activities
Outcomes
C
Outputs
C
es)
1
What are we trying to Accomplish and why?
(strategic intent)
2
How do we
measure Success?
(scorecard)
3
What other conditions
must exist?
(assumptions risks)
4
How do we
get there?
(action planning)
ENDS
Impact
indicators
Performance
measures:
Outcome
indicators
Output
indicators
Process
indicators
MEANS
Results-based
planning,
working
from ends
to means
(a)
(b)
(c)
(d)
4SQ
RBM
Future
State
Current
State
Processes Processes Processes
Inputs C Plan-Do-Study-Act (PDSA)
1. Project management
2. Continuous improvement
3. Test, Learn, Improve, Spread
Goal (common agenda)
Collective Impact
Outcomes
B
Outputs
B
es)
Inputs B
Outcomes
A
Outputs
A
es)
Inputs A
Partner A Partner B Partner C
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16. Outputs and outcomes
Output: Health Equity X (HEX) model
The HEXa;b model is used for planning and managing eorts to achieve
results for challenges and opportunities embedded in complex social
systems, including for health equity, quality improvement, and collective
impact.
1 People (mental models, belief systems, cultural norms, isms)
2 Policy (social, organizational, institutional)
3 Place (neighborhoods, schools, work, open spaces)
4 Program (programs, agencies, or service systems)
5 Provider (teacher, employer, landlord, minister)
6 Patient (student, employee, tenant, follower)
Patient
Program
People
Provider
Place
Policy
Health
Equity
a HEX model was inspired by BARHII (http://www.barhii.org) and Dr. Tony Iton
b A hexateron is a geometric object with 6 vertices, 15 edges, 20 triangle faces, 15 tetrahedral cells
Tomas J. Aragon, MD, DrPH (SFDPH) Designing a Learning Health Organization October 3, 2014 14 / 18

17. Outputs and outcomes
Outcome: The new Population Health Division!
July 2014: First anniversary of PHD reorganization which was recognized by the National
Association of County and City Health Ocials (NACCHO) as a standout on the issue of
health department leadership and transformation in the new public health era Invited to
present at NACCHO National Conference in Atlanta, Georgia, July 2014.
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18. Outputs and outcomes
Outcome: Peer-reviewed publication (in press), 2014
Journal of Public Health Management and Practice
TJA aliation includes CHCF Health Care Leadership Program!
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19. Outputs and outcomes
Outcome: Black/African American Health Initiative launched April, 2014
SF Health Network and Population Health Division
1 Collective impact
2 Workforce development
3 Cultural humility training
Collective impact
1 Heart health | Healthy Hearts San Francisco
2 Behavioral health (focus: alcohol)
3 Women's Health (focus: breast cancer)
4 Sexual Health (focus: chlamydia)
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20. Lessons learned
Lessons learned: focus on team-based leadership with . . .
. . . continuous improvement in
1 practice of cultural humility,
2 creation extension of trust, and
3 practice of shared decision making.
From my research, experience, and practice,
the key path to a learning organization is by
improving humility, trust, and shared decision
making. With cultural humility we increase
self-awareness of our biases, we engage in
self-re
ection to put these aside, we redress
power imbalances, and learn from every human
interaction. Humility and humble inquiry
creates trust, enabling shared decision making
which requires cooperation (trust and
humility).
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