Thursday, July 14, 2016

What is collective impact?

Here is a presentation given to the San Francisco Health Commission on July 5, 2016.

Slide presentation

Video presentation

The video presentation is here (select Item 9):

Saturday, June 11, 2016

Cultural Humility --- and why it matters!

Cultural Humility

My road to discovering cultural humility was long, complex, and iterative. I have struggled with how to use our technical expertise to address health inequities and reduce health disparities. In April 2014, the San Francisco Department Public Health launched the Black/African American Health Initiative (BAAHI) which required me to question my assumptions and redefine my role. This happened by improving how we listen to our African American staff and communities.

I initially focused on technical solutions, but quickly learned (again!) that technical solutions---no matter how great and well-intentioned---will not take root and spread if we do not address underlying mental models, and explicit and implicit biases. Through an iterative process BAAHI emerged into three components:
  • Cultural humility (focused on racial humility)
  • Workforce development
  • Collective impact for health disparities
Cultural humility brings together and synergizes two important concepts: culture and humility. Culture is a "set of patterns of human activity within a social group and the symbols that give such activity meaning. Customs, laws, dress, architectural style, social standards, religious beliefs, and traditions are all examples of cultural elements. At every level, societies to individuals, culture is multi-dimensional and each individual has their own unique, multi-dimensional expression of culture which is dynamic and changing. Much of culture is hidden: we only see the symbols (behaviors, words, customs, traditions) but not the underlying beliefs, values, assumptions, and thought processes.

Humility is "the noble choice to forgo your status, and to use your influence for the good of others before yourself" (John Dickson). Humility is a universal character virtue because it is positively valued in nearly every society, culture and religion, and throughout modern history. Cultivating humility enables one to seek honest, critical feedback, and to improve relationships, trust building, team performance, and intellectual growth.

In 1998, Melanie Tervalon and Jann Murray-García published a groundbreaking article that challenged the concept of "cultural competency" with the concept of "cultural humility." When you accept cultural humility, by definition, you acknowledge that you can never truly achieve cultural competency. Cultural humility is committing to lifelong learning, critical self-reflection, and continuous personal transformation.

Here is my synthesis of their classic paper on this concept:
  1. Commit to lifelong learning and critical self-reflection
  2. Realize our own power, privilege, and prejudices
  3. Cultivate humility and empathy for respectful partnerships
  4. Acknowledge and validate our common humanity 
  5. Practice humble inquiry and deep listening
  6. Promote institutional accountability
I have come to believe that cultivating humility and practicing humble inquiry is central to leader, team, and organizational learning, performance improvement, and transformation. Organization culture is transformed through relationships (dyads and teams). Prejudices include explicit and implicit biases.

Humility and humble inquiry builds trust. Trust enables cooperation. Cooperation is necessary for shared visioning, shared decision making, and shared learning.

I believe that promoting cultural humility is one path to organizational transformation that will enable continuous improvement internally and externally with the diverse communities we serve.

For a more information on cultural humility visit:

Saturday, May 21, 2016

Population health data science, complexity, and health equity---Reflections from a local health official

I was honored to be invited to speak at the Stanford Center for Population Health Sciences Annual Colloquium on October 26, 2015. They have an exciting new transdisciplinary program to improve the health of populations.

I covered three related areas: population health data science, complex adaptive social systems, and health equity. I ended my talk by focusing on the inter-generational, lifecourse transmission of the effects of trauma to children ages 0 to 5 and how this contributes to racial health inequities.

Here was my thesis:
  1. For the new field of population health data science we must focus on transforming health relevant data into actionable knowledge. To produce actionable knowledge we must integrate methods from the fields of human-centered design, decision sciences, and behavioral economics. In a sense we must start backwards. In the traditional approach we focus on studying populations to discover average solutions ("one size fits most"). Actionable knowledge must be user- and context-centered, and account for individual variation. We use emerging technologies to make this faster, cheaper, better, and actionable.
  2. Human populations are complex adaptive social systems (CASS). To tackle the toughest challenges (e.g., health inequities) requires CASS approaches. How we conceptualize CASS frame how we study and test solutions. To understand CASS we must leverage computational modeling. From this laboratory we learn that simple rules can produce very complex phenomena. We are humbled to know that existing “real world” data are only one realization of many possible realizations. "Off the shelf" solutions do not exist; we must iterate to a solution through community engagement, experimentation, and continuous improvement (e.g., collective impact). 
  3. Our ultimate goal is to mobilize and transform communities. This starts by learning how to transform ourselves, our teams, and our organizations through testing and learning (“continuous improvement”). In public health the approaches we use to transform communities and inform policy decisions include health impact assessment, collective impact, and community-based participatory approaches. These key approaches add capability to our toolbox public health methods. Collective impact for transforming CASS problems has received enormous attention---and deservedly so. Collective impact is continuous improvement methods applied at a social scale for CASS problems. Collective impact embraces the challenges of complexity, and methodically focuses on collaboration and community transformation through a common agenda, shared measurement, mutually-reinforcing activities, continuous communication and improvement, and backbone support.
  4. Our main population health agenda must be to eliminate racial health inequities. Our collective priority must be to interrupt the inter-generational transmission of the effects of trauma (toxic stress) on young children. Toxic stress alters the brains, bodies, and behaviors of young children, thereby permanently affecting memory, judgment, self-regulation, and physiology. This results in higher risk behaviors and adult chronic diseases. Furthermore, Black/African Americans are traumatized throughout their lives by racism and discrimination. This focus---inter-generational transmission of toxic stress---enables us to prioritize and target social policies and social determinants of health with the biggest potential to eliminate the “childhood roots of adult health inequities.”

Summary slide

  1. Population health data science
    1. Start backwards (understand individual and group decision-making!)
    2. Focus on actionable knowledge (Advise--Predict--Discover--Describe)
    3. Focus on human-centered design (“precision public health”)
  2. Transforming complex social systems
    1. Understand complex adaptive systems (requires humility)
    2. Transform self, teams, organizations, communities (in that order:
    3. requires continuous improvement, taking risks, learning from failures)
  3. Tackling population health inequities
    1. Inter-generational transmission of trauma
    2. Toxic stress alters brain, body, and behavior
    3. Life course of trauma, racism, and discrimination
    4. 4Ps of public health: prevent, protect, prepare, promote
    5. 6Ps of complex systems: people, policy, place, program, provider, parents

Slide presentation

Video presentation

Saturday, May 14, 2016

Saturday, May 7, 2016

What Stephen Curry can teach us about the science of improvement

The Golden State Warriors can teach us a few things (actually a lot!) about leadership, organizational culture, teamwork, and performance improvement (also called continuous quality improvement). Performance improvement consists of improving processes to deliver better results. Improvement can be incremental or breakthrough. The science of improvement is best understood by understanding the theory of knowledge creation (plan-do-study-act) and single-loop and double-loop learning (Maccoby 2013).

On April 16, 2016, the New York Times published a graphic (Figure 1) depicting "752 lines---one for each NBA player who finished in the top 20 in 3-point attempts made in each season since 1980. Sitting atop it is the Golden State Warriors's Stephen Curry, who finished the regular season with a record 402 3-pointers" (Aisch, 2016).

Figure 1: Stephan Curry's 3-point record in context is "off the charts." "This chart contains 752 lines --- one for each NBA player who finished in the top 20 in 3-point attempts made in each season since 1980. Sitting atop it is the Golden State Warriors's Stephen Curry, who finished the regular season with a record 402 3-pointers." (Source: [])

Incremental performance improvement occurs by improving practices, and practices are based on accepted theories. A theory is an explanatory (or causal) model that can explain observed phenomena. Theories are not always explicit; they can be assumptions or mental models, sometimes they are hidden. The typical approach is to use PDSA cycles to test and adjust practice improvements (Figure 2). We plan to test a practice innovation, we test (do) the practice innovation, we study the results, and we act on what we learned, leading to incremental improvements.

Figure 2: Plan-Do-Study-Act (PDSA) cycle of experimentation and continuous improvement
Chris Argyris called this single-loop learning (Maccoby, 2013). He recognized that PDSA can also be used for double-loop learning which can lead to new theories and breakthrough performance improvements. Figure 3 depicts PDSA with single-loop and double-loop learning.

Figure 3: PDSA with singe-loop and double-loop learning

For example, when we are dissatisfied with the results of a practice we have two choices:
  1. Improve the practice (single-loop learning; possible incremental improvements), or 
  2. Improve the theory (double-loop learning; possible breakthrough improvements)
Double-loop learning makes these possibilities explicit and encourages innovative (breakthrough) thinking.

I propose that before Stephen Curry, we witnessed primarily single-loop learning and incremental improvements in making 3-pointers. Note that the cumulative improvements over three decades is very impressive! 

Also, I propose that with Stephen Curry (supported by an amazing team and organization), we are witnessing primarily double-loop learning and breakthrough improvements in making 3-pointers. Curry is changing the physics of shooting, and the Warriors are changing how basketball is played. The Warriors are developing new theories of shooting and playing. Many articles have been written about the Warriors's record setting year in basketball.

I often use sports to illustrate continuous improvement. I now use Figure 1 to teach not just PDSA, but also single-loop and double-loop learning. After all, single-loop and double-loop learning makes PDSA much more powerful, practical, and fun. Double-loop learning enables us to always question our assumptions, and is most productive when we use diverse, transdisciplinary teams.


Aisch G and Quealy K. Stephen Curry's 3-point Record in Context: Off the Charts. New York Times. April 16, 2016. Available from:

Maccoby M, Norman CL, Norman CJ, Margolies R. Transforming Health Care Leadership. 1st ed. Jossey-Bass; 2013. Available from:

Sunday, April 24, 2016

Leading public health: A competency framework (book review)

What are the competencies of effective public health leaders? I have had the opportunity to participate in several health leadership fellowships (UCSF/California HealthCare Foundation, NACCHO, and Kresge Foundation). All of them have been great! I have learned a tremendous amount. Leadership training curricula start by identifying desired competencies (knowledge, skills, and abilities) for the participants.

As part of my project in the Kresge Foundation fellowship (Emerging Leaders in Public Health) I discovered, and highly recommend, the book by James Begun and Jan Malcolm: Leading Public Health---A Competency Framework (Springer, 2014). Leadership development is a lifelong, continuous improvement endeavor, and this book has become my competency road map. There are 25 competencies clustered into five sets, which I will summarize here.

Begun & Malcolm define public health leadership as the practice of mobilizing people, organizations, and communities to effectively tackle tough public health challenges.

An overview

Here is useful way to categorize leadership:
  1. How to be
  2. What to know
  3. What to do

How to be---public health values and character traits

“[O]ur framework separates values, traits, knowledge, and competencies. … [W]e call out specific values (beliefs about what ought to be) and traits (patterns of personal characteristics) that are particularly helpful to developing public health leadership.”

Public health values: From Begun and Malcolm: “Personal values are broad preferences concerning appropriate courses of action or outcomes. They represent a person’s sense of right and wrong or what ought to be. They are strongly affected by what we learn from parents, teachers, religious traditions, and peers, as well as life experiences. While deeply ingrained, we can examine and redefine personal values. Indeed, we often carry them subconsciously, unless circumstances allow us or force us to examine or test them.”
  • Social justice
  • Reliance on evidence
  • Interdependence
  • Respect
  • Community self-determination
  • Requisite role of government
  • Transparency

Character traits: From Begun and Malcolm: “[Character] traits … are distinguishing features of the behavioral and mental characteristics that make us unique. Traits are fairly hard-wired and may be harder to change than values—at least they would be hard to change in an authentic manner …”
  • Integrity
  • Initiative
  • Empathy
  • Comfort with ambiguity
  • Passion
  • Courage
  • Persistence

From Begun and Malcolm: “[O]ur framework separates values, traits, knowledge, and competencies. ... [W]e call out specific values (beliefs about what ought to be) and traits (patterns of personal characteristics) that are particularly helpful to developing public health leadership.”

What to know—knowledge areas

  1. Public health science
  2. Understanding people
  3. Understanding complex systems
  4. Changing people, organizations, and communities

What to do—five competency sets

  1. Invigorate bold(er) pursuit of population health
  2. Engage diverse others in public health initiatives
  3. Effectively wield power to increase the influence and impact of public health
  4. Prepare for surprise in public health work
  5. Drive for execution and continuous improvement in public health

Here are some details (mostly definitions)

How to be---public health values and character traits

Public health values
  • Social justice: Acceptance of health as a universal, fundamental human right for all, and a strong commitment to correcting patterns of systematic disadvantage to population subgroups
  • Reliance on evidence: Requirement that evidence informs and challenges decision making, accompanied by a healthy skepticism about existing practices, mindsets, and outcomes; helps mitigate groupthink among like-minded public health practitioners
  • Interdependence: Recognition of the need to work with and in collaboration with diverse individuals and communities rather than independent pursuits; enhanced by the impact of social determinants on population health
  • Respect: At the personal level, a way of regarding another individual that denotes the individual is important; manifested in soliciting input from the individual, listening, and doing so in a way that is sensitive to the individual’s culture and individuality
  • Community self-determination: Respect for the right and ability of communities to define their own issues and interventions; serve as a coalition builder rather than the agenda-setter
  • Requisite role of government: Belief in the value of public service and the role of government action to protect the public’s health
  • Transparency: Public and other stakeholders have the right to information; develops trust and promotes constructive politics

Character traits
  • Integrity: Honesty, truthfulness, and consistent action in accord with one’s values; key to credibility and strength in the face of attack
  • Initiative: Drive to change; willingness to take charge and take risks when necessary
  • Empathy: Interest in and ability to relate to people
  • Comfort with ambiguity: Comfort with lack of clear boundaries and hierarchy in work settings
  • Passion: Deep commitment to values of public health, profession of public health, and service
  • Courage: Willingness to take unpopular stands on high-visibility issues and to push harder, to insist more vigorously, more effectively, and over a longer period of time
  • Persistence: Patience with long-term cultural, social, and multi-generational change

What to know---knowledge areas (a) and key characteristics (b)

a) Knowledge areas

  • Public health science
    • Analytic / assessment
    • Basic public health sciences (biostatistics, epidemiology, environmental health, health policy and management, social and behavioral sciences)
    • Cultural competency
    • Communication
    • Community dimensions of practice
    • Financial planning and management
    • Leadership and systems thinking
    • Policy development / Program planning
  • Understanding people
    • Motivation
    • Social and emotional intelligence
  • Understanding complex systems
    • Systems thinking
    • Focusing on complex adaptive systems
  • Changing people, organizations, and communities
    • Change management
    • Culture of innovation
    • Positive deviance

b) Key characteristics of public health knowledge
  • Evidence-based
    • Correlates with an emphasis on science and scientific research
    • Uses evidence as a key weapon in tackling public health challenges in political arenas
    • Grows largely through the accumulation of scientific evidence-based
    • Empowers societal influence of public health leaders and the field
  • Dynamic
    • Changes frequently, particularly knowledge connected to scientific disciplines
    • Invites an attitude of learning by public health leaders
    • Demands the push for new evidence where it is needed
    • Requires leaders’ openness to change their minds where compelling evidence is identified
  • Prevention-focused
    • Directs most public health knowledge toward preventing the emergence of health problems
    • Compels focus on addressing the root causes of health problems to prevent them
    • Enables a “return-on-investment” mindset that reflects the shard belief in the value of prevention
  • Transdisciplinary
    • Driven by problems rather than traditional boundaries of scientific disciplines
    • Welcomes acceptance of relevant information from other fields and disciplines, as well as their potential limitations
    • Encourages cross-sector collaboration within and outside clinical and scientific fields
  • Value-laden
    • Characterized by strongly political nature of field due to value conflict inherent in most population health issues
    • Raises questions about the allocation of public resources relative to government regulation and intervention, legal and ethical concerns, and political influences
    • Requires political debate over both the means and ends for improving population health

What to do---five competency sets (25 competencies)

  1. Invigorate bold(er) pursuit of population health
    1. Critically assess the current state of your program or organization
    2. Articulate a more compelling agenda
    3. Enlist others in the vision and invigorate them to drive toward it
    4. Pursue the vision with rigor and flexibility
    5. Marshal the needed resources
  2. Engage diverse others in public health initiatives
    1. Assess local conditions, in ways relevant and credible to the local stakeholders
    2. Search widely for the right partners
    3. Apply a social determinants perspective to planning
    4. Take time to build relationships, teamwork, and common understanding
    5. Clarify roles and governance
  3. Effectively wield power to increase the influence and impact of public health
    1. Understand and strategically use both positional authority and informal influence
    2. Analyze a given public health problem and proposed solution in “campaign” terms
    3. Build coalitions of core supporters, new partners, and issue-specific allies
    4. Deal effectively with opponents
    5. Be strategically agile
  4. Prepare for surprise in public health work
    1. Promote resilience in individuals and communities
    2. Develop and critique an emergency response plan
    3. Communicate effectively during surprises
    4. Execute an emergency response plan with flexibility and learning
    5. Learn and improve after surprises
  5. Drive for execution and continuous improvement in public health programs and organizations
    1. Build accountability into public health teams, programs, and organizations
    2. Establish metrics, set targets, monitor progress, and take action
    3. Proactively demonstrate financial stewardship of public health funds
    4. Employ the methods and tools of quality improvement
    5. Encourage innovation and risk-taking


Leading Public Health provides 25 competencies associated with effective public health leadership. The authors reviewed the appropriate literature, and provide further readings and inspiring case stories. This book succinctly summarizes the challenges faced by public health leaders (many of their examples resonated with my personal experience). If you want to become a more effective public health leader, or if you want to learn what public health leaders do (or should be doing), I highly recommend this book!