Population Health Lean"We will be the best at getting better!"

Tomás J. Aragón, MD, DrPHFebruary 28, 2017

Health Officer, City & County of San FranciscoDirector, Population Health Division (PHD)San Francisco Department of Public Healthhttp://phlean.org (quality improvement)http://phds.io (data science blog)tomas.aragon@sfdph.org (email)

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Introduction

Population health lean

Lean thinking (2017 theme!)

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Introduction

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Human core cognitive-behavioral processes

Humans have three core cognitive-behavioral processes:

1. decisions2. actions3. learning

Adaptation comes from adjusting our decisions and actions based onwhat we learn. Improvements are adaptations that make thingsbetter. These processes—deciding, acting, learning—arefundamental to all human activities, and form the basis forinnovation and continuous improvement.

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Organizational core cognitive-behavioral processes

To fulfill its potential as a learning organization, effectiveorganization and unit leaders ensure the following areas are fullypromoted, developed, trained on, and deployed:

1. decision quality (team decision-making and data science1)2. project management (actions, especially agile methods)3. performance improvement (learning, innovation, adaptation)

1“The art and science of transforming data into actionable knowledge.”

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Population health lean

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Population health lean: definitions

Population health2

is “a systems framework for studying and improving the health ofpopulations through collective action and learning.”

Lean thinking and practice3

is “systematically developing people to solve problems andconsuming the fewest possible resources while continuouslyimproving processes to provide value to community members andprosperity to society.”

2source: http://phds.io3source: http://lean.org

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Population health lean is a performance and innovationmanagement system (PIMS)

Figure 1: Population health lean builds upon lean thinking and practice(PDSA problem solving, validated learning, and A3 reporting)

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Population health lean leadership philosophy

Figure 2: PHL leadership philosophy. Leader standard work is, startingwith self, develop people to solve problems and improve performance.

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Population health lean values

Respect for people

1. humility,4

2. respect, and3. teamwork

Continuous improvement

1. challenge,5

2. genchi genbutsu,6 and3. kaizen.7

4includes cultural humility. Humility is the noble choice to forgo your status,and to use your influence for the good of others before yourself5need, problem, opportunity, goal, or assignment6"go and see" to empathize and understand7continuous improvement

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Population health lean mindset

The lean mindset is developed by embracing universal, coherentprinciples that apply always and that drive behaviors and attitude:

1. Placing customers at the center (empathy, human-centered)2. Intellectual honesty and courage3. Mindfulness, sound reasoning, and reflection (hansei)4. PDSA thinking (scientific thinking → daily experiments)5. Embracing and learning from mistakes and failures6. Focusing on processes that align with vision and purpose7. Leading with humility and leader standard work

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Population health lean skillset

The population health lean skillset includes core skills andmethodologies that drive learning, innovation, and improvement.We recognize that lean production is strengthened by integratingmethods from complementary frameworks. We recommend focusingon skills 1 to 3, especially on lean thinking, and developing othercompetencies as needed (“learning in the work”).

1. Staff as daily PDSA problem-solvers2. Managers as coaches and teachers3. Lean thinking (PDSA, validated learning, A3 reporting)4. Design thinking and lean startup5. Collective impact (results-based) methods6. Project management and agile development7. Decision quality and data science

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Lean thinking (2017 theme!)

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Lean thinking and practice (“learning in the work”)

Lean thinking

1. PDSA problem solving2. Validated learning3. A3 reporting

"Learning in the work"The objective of lean practice isto learn how to improve. Thebest way to learn lean is to findand solve real needs andproblems at work.

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PDSA problem solving

PDSA 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 methodis only for scientists. By recognizing that we are already scientificthinkers we can improve decision-making, problem-solving,innovation, and performance.

PDSA is both simple and profound. PDSA is a learning cycle basedon experiments. PDSA has two distinct, but related, purposes:

1. knowledge deployment: experiments to test a new practice2. knowledge discovery: experiments to test a new theory

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PDSA problem solving: Exercise

ScenarioYou are the new health educator for the local school district. Thesuperintendant wants to increase student vaccination rates. Yousurvey the parents about their level of concern regarding vaccines(adverse events, “autism”, etc.). You hypothesize that you canincrease vaccination rates by providing scientific facts aboutvaccine safety, including debunking myths such as “vaccines causeautism.” After an extensive vaccine safety campaign you aresurprised to see vaccination rates significantly decline among“concerned” parents, yet moderately increase among“nonconcerned” parents.

Discussion questions

1. What might explain these observations?2. What is your next experiment? 16

PDSA problem solving: single and double-loop learning

Figure 3: PDSA single and double-loop learning. A theory is acause-effect model (also called schema) which may be expressed, hidden(e.g., cultural norm), or unconscious (e.g., implicit racial bias).

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PDSA problem solving: single and double-loop learning

Figure 4: Example: PDSA single vs. double-loop learning (source:Harvard Business Review, Jan-Feb, 2011) 18

PDSA problem solving

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

PDSA Core activity PDSA variants

Design thinking Lean Startup

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

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

Study Learnb → Learn

Act Improvec → →a Predict, Experiment, and Measureb Mindfulness, Reasoning, and Reflectionc Adopt, adapt, or abandon (“pivot or persevere”) 19

Validated learning is PDSA with a purposeful goal (1/3)

Figure 5: Validated learning is “PDSA with a purposeful goal” (cartoonadapted from http://thedoghousediaries.com/5468) 20

Validated learning is also called “improvement kata” (2/3)

The validated learning can be described as purposeful, goal-drivenrapid cycle PDSA experiments, and it has four 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.

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Validated learning enables leaders to coach (3/3)

The coaching questions are askedwith humility and genuinecuriosity (“humble inquiry”).

Here are the five coachingquestions:

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?

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A3 reporting: PDSA problem solving on A3 paper

PDSA Core activity

Plan1. Problem Statement Define2. Background ⇓3. Current Condition ⇓4. Goal & next Target Condition Design5. Analysis ⇓6. Proposed Solution(s) 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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Questions? Preguntas? Mga katanungan? Des questions?

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