The Leading Population Health Framework

Transforming self, teams, organizations, and communities

Toms J. Aragn, MD, DrPH

Tuesday, May 2, 2017; Presentation to Ukraine Ministry of Health Delegation
Health Officer, City & County of San Francisco
Director, Population Health Division (PHD)
San Francisco Department of Public Health
http://www.tomas.pro (my home page)

PDF slides produced in Rmarkdown LATEX BeamerMetropolis theme

1
1 What is population health?

2 The Leading Population Health FrameworkAn overview

3 Population health leadershipCore competencies

2
1 What is population health?

3
Some definitions

Health is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity (World Health Organization, 1946).
Public health is what we, as a society, do collectively to assure the conditions in which
people can be healthy (Institute of Medicine, 1988).
Population health1 is a systems2 framework for studying and improving the health of
populations through collective action and learning (Aragon & Garcia, 2017).3

1
Essential population health goals include (1) protecting and promoting health and equity, (2)
transforming people and place, (3) ensuring a healthy planet, and (4) achieving health equity.
2
Complex adaptive socioecological systems (CASES)
3
For discussion of the term "population health" see http://www.phdata.science/p/about.html
4
Health includes the 8 dimensions of wellness

Source: http://www.samhsa.gov/wellness-initiative
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Population health socioecological framework

Source: California Department of Public Health, Office of Health Equity

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San Francisco residents do not have equitable opportunities for good health
Unevenly distributed obstacles to health (left); Health inequities (right)

Source: San Francisco Community Health Needs Assessment, 2016 (http://sfhip.org)

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Structural trauma and toxic stressThe roots of racial health inequities
Foundational themes

Individual and communities suffer from the effects of trauma

Life-course of toxic stress, structural racism, and discrimination
Trauma effects are transmitted across generations socially and biologically
Toxic stress effects a childs learning, behavior, and health for life
Policy, systems, structural priorities must reach the most vulnerable
Community- and family-centered life-course focus is essential4

4
With a relentless focus on prioritizing social policy that aims to always reach the most
vulnerablechildren ages pre-conception to 5 years.
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Childhood adversities and mental health outcomes in homeless adults
San Francisco, 2016 (Am J Geriatr Psychiatry 2016)

Source: http://www.centerforyouthwellness.org/
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2 The Leading Population Health
FrameworkAn overview

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The Leading Population Health Framework
Transforming self, teams, organizations, and communities

Source: http://www.phlean.org 11
A. Transforming self and interpersonal relationships5

1. Think!a
2. Decide!b
3. Connect!c
4. Lead!d
a
Leadership thinking competencies
b
Decisions, emotions, actions, and learning (DEAL)
are the core human processes that drive innovation
and improvement.
c
Building relationships with empathy, trust, and
cultural humility (ETCH).
d
Leader standard work
5
For details see http://www.phlean.org/p/resources.html.
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A.3 Think! Leadership thinking competencies10

1. NewSmart Humility6 is embracing intellectual humility, honesty, and courage in

the "smart machine age"7 for improving mindfulness, managing self (thinking and
emotions), reflective listening, and connecting and relating to others.
2. Profound knowledge8 is understanding complex systems (systems thinking);
variation (statistical thinking); theory of knowledge creation (PDSA); and
psychology of self, teams, and organizations.
3. Strategic intelligence9 is having foresight, building a shared vision, building
effective partnerships, and motivating and inspiring people.
6
Hess & Ludwig: ISBN 978-1626568754
7
Disruptive era of increasing automation, machine learning, and artificial intelligence
8
W. Edwards Deming Institute (https://deming.org/)
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Michael Maccoby, et al.: ISBNs 978-1118505632 and 978-0199682386
10
Sources and citations see http://www.phlean.org/p/resources.html.
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B. Population health lean leadership philosophy (1/4)

Population health lean is a transdisciplinary11 management system for contin- uous

learning, adaptation, innovation, and improvement. Lean thinking is the foundation of
population health lean, and is the primary focus of our training efforts.

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Strategy that crosses disciplinary boundaries to create a holistic approach.
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B. Population health lean leadership philosophy (2/4)
Lean thinking and practicea is
systematically developing people to solve
problems and consuming the fewest possible
resources while continuously improving
processes to provide value to community
members and prosperity to society.
Population health lean thinking:
1. PDSA problem-solving
2. Validated learning
3. A3 reporting

a
Lean Enterprise Institute (https://www.lean.org/)
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B. Population health lean leadership philosophy (3/4)

1. Valuesa
2. Behaviorsb
3. People developmentc
4. Scientific reasoningd
5. Managemente
6. Leading changef
a
Respect for people, continuous improvement, etc.
b
Behaviors that demonstrate values and purpose
c
Developing people is at the core of everything!
d
Culture of scientific reasoning and experimentation
e
Strategic alignment, visual management, etc.
f
Leading with humility and leaders standard work

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B. Population health lean leadership philosophy (4/4)
Population health lean values

Respect for people

1. humility,a a
Noble choice to forgo your status, and to use your
2. respect, and influence for the good of others before yourself.
3. teamwork Cultural humility extends this concept; for details
see Aragn & Garcia (2017) at
Continuous improvement http://www.phlean.org/p/resources.html.
b
1. challenge,b need, problem, opportunity, goal, or assignment
c
"go and see" to empathize and understand
2. genchi genbutsu,c and d
continuous improvement
3. kaizen.d

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C. Transforming teams and collaboratives12

1. Lean thinking!a
2. Build teams!
3. Solve problems!
4. Achieve impacts!
a
Lean thinking is (1) PDSA problem-solving, (2)
validated learning is conducting rapid PDSA cycles
with a purposeful or strategic goal (also called
improvement kata), and (3) A3 reporting.

12
For details Aragn & Garcia (2017) at http://www.phlean.org/p/resources.html.
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D. Transforming organizations and communities13

1. Transform organizationsa
2. Transform communities
3. Achieved goalsb
4. Data sciencec
a
Designing a healing (trauma-informed) and
learning (improving) organization
b
Essential population health goals (see Figure).
c
Learn more at http://www.phdata.science/.

13
For details Aragn & Garcia (2017) at http://www.phlean.org/p/resources.html.
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The Leading Population Health FrameworkPutting it all together!

Leadership is getter results in a

way that inspires trust.
. . . Stephen M.R. Covey

Population health goals:

1. Protecting and promoting
health and equity
2. Transforming people and place;
3. Ensuring a healthy planet; and
4. Achieving health equity.

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3 Population health
leadershipCore competencies

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What is leadership?14
"Leaders are people that others follow."

If no one follows, one cannot be a leader. Leadership is a relationship. Good leadership

means people willingly follow a leader who is working to further the common good.
Leadership is a relationship that cannot be handed off to anyone else. In contrast,
management is a collection of functional tasks to carry out, monitor, and achieve
strategic objectives. Unlike leadership, management functions can be delegated.

14
Adapted from Michael Maccoby: ISBNs 978-1118505632 and 978-0199682386
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Six core themes of leadership15

1. Values (Whats important to our customer? Whats important to you and 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 stakeholders at every step (e.g., visioning))
6. Empowerment (Give stakeholders the training and tools to succeed.)

Based on this, here is a longer definition of leadership:

Leadership is modeling the way of inspiring a shared vision of the future; pro-
moting clear purpose and mission, core and supportive values, and intelligent
strategies; and engaging and empowering all those concerned to pursue this
vision.
15
Source and citations see http://www.phlean.org/p/resources.html.
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What is population health leadership?16

Population health leadership is the practice of mobilizing people, organizations, and

communities to effectively tackle tough population health challenges. A competency is
defined as the effective application of values, traits, knowledge, and skills in complex
situations. Leadership competencies can be divided into three categories:

how to be,
what to know, and
what to do.

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Adapted from Begun & Malcolm (2014). Leading Public Health: A Competency Framework. ISBN
978-0826199065; for details see http://www.phlean.org/p/resources.html.
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How to be: values and character traits17

The values of effective population health leaders include: social justice, reliance on
evidence, interdependence, respect, community self-determination, requisite role of
government, and transparency.
The character traits of effective population health leaders include: integrity, initiative,
empathy, comfort with ambiguity, passion, courage, and persistence.

17
Adapted from Begun & Malcolm (2014). Leading Public Health: A Competency Framework. ISBN
978-0826199065; for details see http://www.phlean.org/p/resources.html.
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What to know: knowledge base18

Population health knowledge is evidence-based, dynamic, prevention-focused,

trans-disciplinary, and value-laden. The population health knowledge base of effective
population health leaders includes:

Population health science

Understanding people
Understanding complex systems
Changing people, organizations, and communities

18
Adapted from Begun & Malcolm (2014). Leading Public Health: A Competency Framework. ISBN
978-0826199065; for details see http://www.phlean.org/p/resources.html.
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What to do: five competency sets19

1. Invigorate bold pursuit of population health

2. Engage diverse others in population health initiatives
3. Effectively wield power to increase the influence and impact of population health
4. Prepare for surprise in population health work (e.g., disasters)
5. Drive for execution and continuous improvement

19
Adapted from Begun & Malcolm (2014). Leading Public Health: A Competency Framework. ISBN
978-0826199065; for details see http://www.phlean.org/p/resources.html.
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FAST LEADERa model for all-purpose leadership skill development

Acronym Focus on these skills

Facilitative leadership
Adaptive leadership
Servant leadership
Transformational leadership
Mastering neutral and directive facilitation skills for teams and groups
Leading change differently for technical (complicated) versus adaptive
(complex) challenges and solutions
Cultivating humility, empathy, compassion, and service
Developing a new generation of leaders through coaching and teaching

Learning Mastering innovation and performance improvement with lean thinking and
practice, and leader standard work
Empathy Seeking empathy and emotional intelligence; ensuring staff engagement
Accountability Ensuring an organizational culture and a lean management system that
promotes self and team accountability
Decisions Ensuring high quality, ethical decisions, including priority-setting and
resource allocation, in the setting of uncertainty and competing objectives
Execution Ensuring visual project management and agile development systems
Results Ensuring results that matter: Is anyone better off? (esp. health equity)

a
Developed by Aragon; for details see http://www.phlean.org/p/resources.html.
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Questions? Preguntas? Mga katanungan? Des questions?
Acknowledgments (in alphabetical order)

Abbie Yant, Alice Chen, Amor Santiago, Anda Kuo, Aneeka Chaudhry, Ayanna Bennett, Barbara
A Garcia, Barry Lawlor, Belle Taylor-McGhee, Brittney Doyle, Cecilia Thomas, Christine Siador,
Cindy Garcia, Colleen Chawla, Colleen Matthews, Curtis Chan, Darlene Daevu, David Serrano
Sewell, Deborah Sherwood, Deena Lahn, Dianne M. Easton, Ellen Chen, Estela Garcia, Greg
Wagner, Guliana Martinez, Hali Hammer, Iman Nazeeri-Simmons, Isela Ford, Israel
Nieves-Rivera, Jacque McCright, James Illig, Jeannie Balido, Jenee Johnson, Jessica Wolin, John
Grimes, Jonathan Butler, Jonathan Fuchs, Judith Martin, Karen Pierce, Karen Strickland,
Kavoos Ghane Bassiri, Kenneth Epstein, Kenneth Hardy, Kevin Grumbach, Kim Shine, Kirsten
Bibbins-Domingo, Leigh Kimberg, Lisa Golden, Maria X Martinez, Marlo Simmons, Mary Hansell,
Maximilian Rocha, Michelle A. Albert, Michelle Kirian, Michelle Long, Muntu Davis, Nadine
Burke Harris, Neal Halfon, Patricia Erwin, Paula Fleisher, Paula Jones, Perry Lang, Rachael
Kagan, Rhea Bailey, Rhonda Simmons, Roberto Vargas, Robin George, Roland Pickens, Ron
Weigelt, Stuart Fong, Susan Ehrlich, Susan Philip, Tessa Rouverol Collejo, Thomas Boyce,
Tracey Packer, Veronica Shepard, Wanda Materre, Wanetta Davis, Wilma Wooten, Wylie Liu 29
Key online resources

Population Health Lean

http://www.phlean.org/
Center for Lean Engagement And Research (CLEAR) in Healthcare
http://clear.berkeley.edu/
The Lean Startup
http://theleanstartup.com/
Results-Based Accountability (RBA)
http://clearimpact.com
Collective Impact Forum
https://collectiveimpactforum.org/
Population Health Data Science
http://www.phdata.science/

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