Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Environments

Continuous Decision Improvement (CDI): Public HealthDecision Making for Complex Environments

Tomas J. Aragon, MD, DrPHHealth Officer, City & County of San FranciscoDirector, Population Health Division (PHD)San Francisco Department of Public Health

Adjunct Faculty, Division of EpidemiologyUC Berkeley School of Public Health

2014

Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Health[10pt] Adjunct Faculty, Division of Epidemiology UC Berkeley School of Public HealthContinuous Decision Improvement (CDI): Public Health Decision Making for Complex Environments2014 1 / 25

Outline

1 Introduction

2 Continuous Decision Improvement

3 Example—CDI for self-improvement

4 Summary


Introduction

Overview of CDI Training Curriculum

Curriculum and tools for continuous improvement of public health decision making incomplex environmentsIncorporates public health considerations (HELLP = Health, Ethical, Legal, Logistical,Political)Incorporates understanding of dual-process model (intuition vs. deliberation)


Introduction

Complexity and why it matters

What is a complex system?1 A population of diverse agents, all of which are2 connected, with behaviors and actions that are3 interdependent, and that exhibit4 adaptation and learning.

Why do we care? Complex systems . . .are ambiguous, deceptive, unpredictableare difficult to direct and control (adaptive resistance)can evolve along divergent pathways (silos)can produce “tipping points” (e.g., epidemics)


Introduction

Mitigating and harnessing complexity

Mitigating complexityExpect the unexpected and unintended consequencesExpect and prepare to fail (avoid overconfidence)Be humble and practice humble inquiry

Harnessing complexityStrengthen cooperation by building trust and practicing humilityStrengthen decision making processes (requires trust & humility)See every failure as a learning opportunity (requires humility)Balance exploration (learning) and exploitation (execution)Design for agility, adaptability, and responsivenessDevelop/use “simple rules” that can spread


Introduction

What is the Dual-Process model?

DeliberationIntuition


Introduction

Intuition (naturalistic decision making)

Size-up Imagine Do Size-up

DefinitionFramework for studying how people make decisions and perform cognitively complex functionsin demanding, real-world situations. These include situations marked by limited time,uncertainty, high stakes, environmental constraints, unstable conditions, and varying amountsof experience.

ExamplesPanhandler approaches you on the street asking for money.Driving on city street when suddenly you hear a siren.Fighter pilots in heat of aerial battle: Observe-Orient-Decide-Act (OODA) Loop


Introduction

Deliberation (rational decision making)

Analyze Plan Do Re-analyse

Example: 4D Decision Processa,b (a best practice decision process)1 DEFINE Problem (values, objectives)2 DESIGN Alternatives (creative, complete)3 DECIDE Alternatives (consequences, trade-offs)4 DO (action planning)

a. Parnell GS, et al. Handbook of Decision Analysis. Wiley, 2013b. Parnell GS, et al. Decision Making in Systems Engineering and Management, 2nd Edition. Wiley, 2011


Introduction

Dual-process model is Intuition and Deliberation

Observe

Orient

DECIDE

Act

EnvironmentalResponse

EnvironmentalContext

DEFINE Problem(Values, Objectives)

DESIGN Alternatives(Creative, Complete)

DECIDE Alternatives(Consequences, Trade-offs)

DO (action planing)

EnvironmentalResponse

EnvironmentalContext

OODA Loop 4D Decision Process

Intuition Deliberation


Introduction

The 4D Decision Process in more detail

1 DEFINE problem1 Situational awareness (including HELLP: Health, Ethical, Legal, Logistical, Political)2 Clarify problem or opportunity3 Clarify frame and test assumptions4 Clarify values (What is important to us?)5 Set objectives (What do you really need to accomplish?)

2 DESIGN alternatives1 Think into the future: How did we achieve objectives?2 Brainstorm on alternatives3 Be creative and complete

3 DECIDE alternatives1 Assess consequences (consequence table)2 Consider trade-offs3 Prioritize and select alternatives

4 DO decision (implement decision)—traditionally, continuous improvement happens hereTomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Health[10pt] Adjunct Faculty, Division of Epidemiology UC Berkeley School of Public HealthContinuous Decision Improvement (CDI): Public Health Decision Making for Complex Environments2014 10 / 25

Continuous Decision Improvement

What is Continuous Decision Improvement (CDI)?The 4D Decision Process improves decision making, but we aspire to continuously improvedecision making. That’s is continuous decision improvement!

Quality improvement (QI) in public health*A continuous effort to achieve measurable improvements in process performance to improvethe health of the community.

Continuous decision improvement (CDI) in public healthA continuous effort to achieve measurable improvements in the planning and execution ofdecision-making processes to achieve organization goals and to improve the health of thecommunity.

*Riley, Moran, Corso, et al. Defining Quality Improvement in Public Health. J Publ Health Management andPract, Jan/Feb 2010



What kind of decisive leader are you? should you be?

DECISIVE LEADERSHIP

SOLUTION-ORIENTEDWhat should we do?

PROCESS-ORIENTEDHow should we decide?VERSUS

Professor Michael Roberto:“Many leaders focus on finding the right solutions to problems rather than thinking carefullyabout what process they should employ to make key decisions. When confronted with a toughissue, we focus on the question, what decision should I make? We should first ask, how Ishould I go about making this decision?” (Source: The Art of Critical DecisionMaking—Course Guidebook)



The CDI Choice-Mobile—All aboard!Plan Decision → Decision Process → Decision Outcome



Continuous Decision Improvement = PDSA + 4D Decision Process

Define-Design-Decide-Do

Communication

Context

Composition

Control


A Max Cognitive Conflict

B Min Affective Conflict

C Max Shared Understanding

D Max Commitment

E Min Resistance

Quality of Decision Process

- Decision Quality*

- Constructive Conflict (A, B)

- Comprehensive Consensus (C, D, E)

PLANManagerial Levers

DODecision Process

STUDYDecision Process

ACT (learn and improve)Frame, Alternatives, Information, Measurements, and Logical reasoning


Example—CDI for self-improvement

Trust is a decision (see Robert Hurley’s The Decision to Trust, 2012)

Definition of trust“Trust is the degree of confidence you have that another party can be relied on to fulfillcommitments, be fair, be transparent, and not take advantage of your vulnerability.”

FACT: Good team decision making requires cooperation.Good cooperation requires trust and humility.Extending and creating trust are decision problemsHumility improves trust building (giving and creating).

STRONG RECOMMENDATION:Learn and practice individual trust-building CDITrain team members in trust-building CDI



Understanding trust as a decision problem (1/2)

Trustor Trustee

PredispositionsVulnerability

Expectation

Competent*

Commoninterests

Character(integrity)

Consequence Care(benevolence)

DECISIONto Trust?

Probability

Relational Context- Personal security- Power imbalance- Prior history

External Context- Situational security- Uncertainty

Cognitive Biases

INFLUENCEDecision to Trust?

* capable, consistent, continuously improving



Understanding trust as a decision problem (2/2)

Trustor Trustee

PredispositionsVulnerability

Expectation

Competent*

Commoninterests

Character(integrity)

Consequence Care(benevolence)

DECISIONto Trust?

Probability

Relational Context- Personal security- Power imbalance- Prior history

External Context- Situational security- Uncertainty

Cognitive Biases

INFLUENCEDecision to Trust?

* capable, consistent, continuously improvingTomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Health[10pt] Adjunct Faculty, Division of Epidemiology UC Berkeley School of Public HealthContinuous Decision Improvement (CDI): Public Health Decision Making for Complex Environments2014 17 / 25


Scenario—Decision to give and create trust, and to practice humility

Trust is an issue whenwe expose our vulnerabilities, orwe need someone to fulfill a commitment, orwe expect a fair and transparent process when our interests are at stake.

Scenario: Self-improvement through feedbackFor my job, I need to improve my performance. One proven approach is to ask for honestfeedback from my “harshest critics.” Decision problem: From whom do I seek feedback?

CDI Humble inquiry for improvement (HIFI)Humble inquiry is “the gentle art of asking without telling.” Asking for feedback requirespracticing humility, exposing vulnerabilities (extending trust), but it also creates trust(influencing others’ confidence in you). See Edgar Schein’s Humble Inquiry (2013)



Scenario: From whom do I seek feedback for improving in Task A?

1 DEFINE problem1 Situational awareness: work environment2 Clarify problem or opportunity: self-improvement through seeking feedback3 Clarify frame and test assumptions: Improving in Task A will contribute to our mission.4 Clarify values: mission-driven, self-improvement5 Set objectives:

1 maximize technical learning how to improve in Task A2 maximize receiving honest, reliable feedback3 minimize personal, unnecessary attacks4 strengthen relationships (elicit trust [confidence] in me)

2 DESIGN alternatives: generate list of names3 DECIDE alternatives: prioritize and select (consequence table)4 DO decision (use humble inquiry to elicit feedback for self-improvement)



Aside: What is a consequence table?

A consequence table organizes your data:1 Objectives (column 1)2 Alternatives (Options A, B, and, C)3 Measures (cells = consequences of the alternatives on the objectives)



Scenario: From whom do I seek feedback? (Consequence Table)

Objectives Sub-objectives A1 A2 A3 A4Maximize technical learning Competent (-3 to 3) 3 3 0 -3Maximize honest feedback Character (-3 to 3) 3 2 3 -3

Reliable (-3 to 3) 3 2 3 -3Minimize personal attacks Cares about me (-3 to 3) 3 0 0 -3Increase trust in me Vulnerable (-3 to 3) 0 0 -3 0

12 7 3 -12

Scale: -3 = high negative (e.g., very incompetent)-2 = medium negative-1 = low negative0 = neutral1 = low positive2 = medium positive3 = high positive (e.g. very competent)


Summary

Summary of Continuous Decision Improvement as a Consequence Table

Objectives Sub-objectives 4D CDIMaximize quality criteria 1 Frame Y Y

2 Alternatives Y Y3 Information Y Y4 Measurements Y Y5 Logical reasoning Y Y

Maximize constructive conflict 6 Maximize cognitive conflict Y Y7 Minimize emotional conflict Y Y

Maximize comprehensive consensus 8 Maximize shared understanding Y Y9 Maximize commitment Y Y

10 Minimize resistance Y YImprove decision planning 11 Plan-Do-Study-Act (PDSA) cycles YImprove decision process 12 Plan-Do-Study-Act (PDSA) cycles YIncludes HELLP considerations 13 Health, Ethical, Legal, Logistical, Political Y


Summary

Continuous Decision Improvement = PDSA + 4D Decision Process


Communication

Context

Composition

Control


A Max Cognitive Conflict

B Min Affective Conflict

C Max Shared Understanding

D Max Commitment

E Min Resistance

Quality of Decision Process

- Decision Quality*

- Constructive Conflict (A, B)

- Comprehensive Consensus (C, D, E)

PLANManagerial Levers

DODecision Process

STUDYDecision Process

ACT (learn and improve)Frame, Alternatives, Information, Measurements, and Logical reasoning


Summary

Bibliography

1 Why Great Leaders Don’t Take Yes for an Answer: Managing for Conflict and Consensus (2ndEdition), by Michael A. Roberto. Link: http://amzn.com/0133095118

2 Smart Choices: A Practical Guide to Making Better Decisions, by John S. Hammond et al. Link:http://amzn.com/0767908864

3 Handbook of Decision Analysis, by Gregory S. Parnell PhD et al. Link:http://amzn.com/1118173139

4 Decisive: How to Make Better Choices in Life and Work, by Chip Heath et al. Link:http://amzn.com/0307956393

5 The SPEED of Trust: The One Thing That Changes Everything, by Stephen M.R. Covey et al.Link: http://amzn.com/1416549005

6 The Decision to Trust: How Leaders Create High-Trust Organizations, by Robert F. Hurley. Link:http://amzn.com/1118072642

7 Humble Inquiry: The Gentle Art of Asking Instead of Telling, by Edgar H Schein. Link:http://amzn.com/1609949811


http://amzn.com/0133095118







Summary

Acknowledgment

CDC Cooperative Agreement 5P01TP000295This project was supported by the cooperative agreement number 5P01TP000295 from theCenters for Disease Control and Prevention. Its contents are solely the responsibility of theauthors and not necessarily represent the official views of the Centers for Disease Control &Prevention.


Health & Medicine

Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Environments