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

1. Continuous Decision Improvement (CDI): Public Health
Decision Making for Complex Environments
Tomas J. Aragon, MD, DrPH
Health Officer, City & County of San Francisco
Director, Population Health Division (PHD)
San Francisco Department of Public Health
Adjunct Faculty, Division of Epidemiology
UC 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 Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Envir2o0n1m4ents 1 /H2e5alth[

2. Outline
1 Introduction
2 Continuous Decision Improvement
3 Example—CDI for self-improvement
4 Summary
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Envir2o0n1m4ents 2 /H2e5alth[

3. Introduction
Overview of CDI Training Curriculum
Curriculum and tools for continuous improvement of public health decision making in
complex environments
Incorporates public health considerations (HELLP = Health, Ethical, Legal, Logistical,
Political)
Incorporates understanding of dual-process model (intuition vs. deliberation)
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Envir2o0n1m4ents 3 /H2e5alth[

4. Introduction
Complexity and why it matters
What is a complex system?
1 A population of diverse agents, all of which are
2 connected, with behaviors and actions that are
3 interdependent, and that exhibit
4 adaptation and learning.
Why do we care? Complex systems . . .
are ambiguous, deceptive, unpredictable
are difficult to direct and control (adaptive resistance)
can evolve along divergent pathways (silos)
can produce “tipping points” (e.g., epidemics)
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Envir2o0n1m4ents 4 /H2e5alth[

5. Introduction
Mitigating and harnessing complexity
Mitigating complexity
Expect the unexpected and unintended consequences
Expect and prepare to fail (avoid overconfidence)
Be humble and practice humble inquiry
Harnessing complexity
Strengthen cooperation by building trust and practicing humility
Strengthen 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 responsiveness
Develop/use “simple rules” that can spread
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Envir2o0n1m4ents 5 /H2e5alth[

6. Introduction
What is the Dual-Process model?
Intuition Deliberation
Tomas J. Aragon, MD, DrPH Health Officer, City & CoCuonnttyinoufoSusanDFercaisniocinscIomDpriorevcetmore,nPt o(pCuDlaIt)i:oPnuHbeliacltHheDalitvhisDioenc(isPioHnDM) aSkaingFrfoarncCisocmopDleexpaErntvmir2eo0nn1tm4oefnPtsub6lic/H2e5alth[

7. Introduction
Intuition (naturalistic decision making)
Size-up Imagine Do Size-up
Definition
Framework for studying how people make decisions and perform cognitively complex functions
in demanding, real-world situations. These include situations marked by limited time,
uncertainty, high stakes, environmental constraints, unstable conditions, and varying amounts
of experience.
Examples
Panhandler 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
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Envir2o0n1m4ents 7 /H2e5alth[

8. 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, 2013
b. Parnell GS, et al. Decision Making in Systems Engineering and Management, 2nd Edition. Wiley, 2011
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Envir2o0n1m4ents 8 /H2e5alth[

9. Introduction
Dual-process model is Intuition and Deliberation
OODA Loop 4D Decision Process
Environmental
Context
Observe
Orient
DECIDE
Act
Environmental
Response
Environmental
Context
DEFINE Problem
(Values, Objectives)
DESIGN Alternatives
(Creative, Complete)
DECIDE Alternatives
(Consequences, Trade-offs)
DO (action planing)
Environmental
Response
Intuition Deliberation
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Envir2o0n1m4ents 9 /H2e5alth[

10. Introduction
The 4D Decision Process in more detail
1 DEFINE problem
1 Situational awareness (including HELLP: Health, Ethical, Legal, Logistical, Political)
2 Clarify problem or opportunity
3 Clarify frame and test assumptions
4 Clarify values (What is important to us?)
5 Set objectives (What do you really need to accomplish?)
2 DESIGN alternatives
1 Think into the future: How did we achieve objectives?
2 Brainstorm on alternatives
3 Be creative and complete
3 DECIDE alternatives
1 Assess consequences (consequence table)
2 Consider trade-offs
3 Prioritize and select alternatives
4 DO decision (implement decision)—traditionally, continuous improvement happens here
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments10 /H2e5alth[

11. Continuous Decision Improvement
What is Continuous Decision Improvement (CDI)?
The 4D Decision Process improves decision making, but we aspire to continuously improve
decision making. That’s is continuous decision improvement!
Quality improvement (QI) in public health*
A continuous effort to achieve measurable improvements in process performance to improve
the health of the community.
Continuous decision improvement (CDI) in public health
A continuous effort to achieve measurable improvements in the planning and execution of
decision-making processes to achieve organization goals and to improve the health of the
community.
*Riley, Moran, Corso, et al. Defining Quality Improvement in Public Health. J Publ Health Management and
Pract, Jan/Feb 2010
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4moefnPtsu1b1lic/H2e5alth[

12. Continuous Decision Improvement
What kind of decisive leader are you? should you be?
DECISIVE LEADERSHIP
SOLUTION-ORIENTED
What should we do?
PROCESS-ORIENTED
How should we decide? VERSUS
Professor Michael Roberto:
“Many leaders focus on finding the right solutions to problems rather than thinking carefully
about what process they should employ to make key decisions. When confronted with a tough
issue, we focus on the question, what decision should I make? We should first ask, how I
should I go about making this decision?” (Source: The Art of Critical Decision
Making—Course Guidebook)
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments12 /H2e5alth[

13. Continuous Decision Improvement
The CDI Choice-Mobile—All aboard!
Plan Decision ! Decision Process ! Decision Outcome
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments13 /H2e5alth[

14. Continuous Decision Improvement
Continuous Decision Improvement = PDSA + 4D Decision Process
Define-Design-Decide-Do
Composition
Context
Communication
Control
Define-Design-Decide-Do
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)
PLAN
Managerial Levers
DO
Decision Process
STUDY
Decision Process
ACT (learn and improve)
Frame, Alternatives, Information, Measurements, and Logical reasoning
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments14 /H2e5alth[

15. 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 fulfill
commitments, 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 problems
Humility improves trust building (giving and creating).
STRONG RECOMMENDATION:
Learn and practice individual trust-building CDI
Train team members in trust-building CDI
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4moefnPtsu1b5lic/H2e5alth[

16. Example—CDI for self-improvement
Understanding trust as a decision problem (1/2)
External Context
- Situational security
- Uncertainty
Consequence Care
Trustor Trustee
Expectation
Vulnerability Predispositions
(benevolence)
Competent*
Character
(integrity)
Common
interests
DECISION
to Trust?
Probability
Relational Context
- Personal security
- Power imbalance
- Prior history
Cognitive Biases
INFLUENCE
Decision to Trust?
* capable, consistent, continuously improving
Tomas J. Aragon, MD, DrPH Health Officer, City & CoCuonnttyinoufoSusanDFercaisniocinscIomDpriorevcetmore,nPt o(pCuDlaIt)i:oPnuHbeliacltHheDalitvhisDioenc(isPioHnDM) aSkaingFrfoarncCisocmopDleexpaErntvm2ir0eo1nn4tmoefnPtsu1b6lic/H2e5alth[

17. Example—CDI for self-improvement
Understanding trust as a decision problem (2/2)
External Context
- Situational security
- Uncertainty
Consequence Care
Trustor Trustee
Expectation
Vulnerability Predispositions
(benevolence)
Competent*
Character
(integrity)
Common
interests
DECISION
to Trust?
Probability
Relational Context
- Personal security
- Power imbalance
- Prior history
Cognitive Biases
INFLUENCE
Decision to Trust?
* capable, consistent, continuously improving
Tomas J. Aragon, MD, DrPH Health Officer, City & CoCuonnttyinoufoSusanDFercaisniocinscIomDpriorevcetmore,nPt o(pCuDlaIt)i:oPnuHbeliacltHheDalitvhisDioenc(isPioHnDM) aSkaingFrfoarncCisocmopDleexpaErntvm2ir0eo1nn4tmoefnPtsu1b7lic/H2e5alth[

18. Example—CDI for self-improvement
Scenario—Decision to give and create trust, and to practice humility
Trust is an issue when
we expose our vulnerabilities, or
we need someone to fulfill a commitment, or
we expect a fair and transparent process when our interests are at stake.
Scenario: Self-improvement through feedback
For my job, I need to improve my performance. One proven approach is to ask for honest
feedback 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 requires
practicing humility, exposing vulnerabilities (extending trust), but it also creates trust
(influencing others’ confidence in you). See Edgar Schein’s Humble Inquiry (2013)
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4moefnPtsu1b8lic/H2e5alth[

19. Example—CDI for self-improvement
Scenario: From whom do I seek feedback for improving in Task A?
1 DEFINE problem
1 Situational awareness: work environment
2 Clarify problem or opportunity: self-improvement through seeking feedback
3 Clarify frame and test assumptions: Improving in Task A will contribute to our mission.
4 Clarify values: mission-driven, self-improvement
5 Set objectives:
1 maximize technical learning how to improve in Task A
2 maximize receiving honest, reliable feedback
3 minimize personal, unnecessary attacks
4 strengthen relationships (elicit trust [confidence] in me)
2 DESIGN alternatives: generate list of names
3 DECIDE alternatives: prioritize and select (consequence table)
4 DO decision (use humble inquiry to elicit feedback for self-improvement)
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments19 /H2e5alth[

20. Example—CDI 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)
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments20 /H2e5alth[

21. Example—CDI for self-improvement
Scenario: From whom do I seek feedback? (Consequence Table)
Objectives Sub-objectives A1 A2 A3 A4
Maximize technical learning Competent (-3 to 3) 3 3 0 -3
Maximize honest feedback Character (-3 to 3) 3 2 3 -3
Reliable (-3 to 3) 3 2 3 -3
Minimize personal attacks Cares about me (-3 to 3) 3 0 0 -3
Increase 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 negative
0 = neutral
1 = low positive
2 = medium positive
3 = high positive (e.g. very competent)
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments21 /H2e5alth[

22. Summary
Summary of Continuous Decision Improvement as a Consequence Table
Objectives Sub-objectives 4D CDI
Maximize quality criteria 1 Frame Y Y
2 Alternatives Y Y
3 Information Y Y
4 Measurements Y Y
5 Logical reasoning Y Y
Maximize constructive conflict 6 Maximize cognitive conflict Y Y
7 Minimize emotional conflict Y Y
Maximize comprehensive consensus 8 Maximize shared understanding Y Y
9 Maximize commitment Y Y
10 Minimize resistance Y Y
Improve decision planning 11 Plan-Do-Study-Act (PDSA) cycles Y
Improve decision process 12 Plan-Do-Study-Act (PDSA) cycles Y
Includes HELLP considerations 13 Health, Ethical, Legal, Logistical, Political Y
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments22 /H2e5alth[

23. Summary
Continuous Decision Improvement = PDSA + 4D Decision Process
Define-Design-Decide-Do
Composition
Context
Communication
Control
Define-Design-Decide-Do
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)
PLAN
Managerial Levers
DO
Decision Process
STUDY
Decision Process
ACT (learn and improve)
Frame, Alternatives, Information, Measurements, and Logical reasoning
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments23 /H2e5alth[

24. Summary
Bibliography
1 Why Great Leaders Don’t Take Yes for an Answer: Managing for Conflict and Consensus (2nd
Edition), 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
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments24 /H2e5alth[

25. Summary
Acknowledgment
CDC Cooperative Agreement 5P01TP000295
This project was supported by the cooperative agreement number 5P01TP000295 from the
Centers for Disease Control and Prevention. Its contents are solely the responsibility of the
authors and not necessarily represent the official views of the Centers for Disease Control &
Prevention.
Tomas J. Aragon, MD, DrPH Health Officer, City & County of San Francisco Director, Population Health Division (PHD) San Francisco Department of Public Continuous Decision Improvement (CDI): Public Health Decision Making for Complex Env2ir0o1n4ments25 /H2e5alth[