Grand Rounds McMaster University Department of Pediatrics, December 2nd, 2021
Olaf Kraus de Camargo, @DevPeds
Rachel Martens, @RaeofSunshine79
Keiko ShikakoThomas, @KeikoShikako
Disparities in health outcomes are a result of a myriad of socio-ecological factors that are linked to education, employment, income, discrimination based on race/ethnicity, gender, religion, sexual orientation, geographic location, mental health and/or disability. These factors are commonly referred to as social determinants of health (SDOH). The World Health Organization defines SDOH as the conditions in which people are born, grow up, work and live and the structures and systems that shape the daily conditions of life. There has been a great deal of research focused on SDOH in the past decade that is critical to informing policy and practice necessary to promote health equity. However, it is also important to acknowledge that this concept is not new. Unacceptable health disparities remain despite substantial evidence, over the past century, which shows SDOH are at the root cause of health disparities.
A guide summarizing the main sections of the TCPS-2 in accessible language. It provides a first introduction to research ethics for public servants who have not yet received formal training on the subject.
Patterns, process & action on tribal health: mapping of process & outcomes un...Prashanth N S
Presentation at the India Alliance Conclave 2021 based on the process and outcomes of THETA project. For more on THETA project, see https://wellcomeopenresearch.org/articles/4-202
Revised JAHF strategic plan detailing "downstream shift" from academic capacity building to influencing practice in health care for older Americans. Presented to Foundation Trustees, June 2012
Results from student-facilitated roundtable discussions at PACE Great Streets townhall meeting in Memphis, TN. This project represents an experiential learning activity at The University of Memphis, Health Promotion concentration in the Department of Health and Sport Sciences.
Investigating the impact of curriculum on attitudes by first year occupationa...Anita Hamilton PhD
This was a presentation that I gave during the Graduate Certificate in Higher Education at Deakin University. This pilot study lead to a fourth year honours research study in 2007 by Alison Naughton.
Grand Rounds McMaster University Department of Pediatrics, December 2nd, 2021
Olaf Kraus de Camargo, @DevPeds
Rachel Martens, @RaeofSunshine79
Keiko ShikakoThomas, @KeikoShikako
Disparities in health outcomes are a result of a myriad of socio-ecological factors that are linked to education, employment, income, discrimination based on race/ethnicity, gender, religion, sexual orientation, geographic location, mental health and/or disability. These factors are commonly referred to as social determinants of health (SDOH). The World Health Organization defines SDOH as the conditions in which people are born, grow up, work and live and the structures and systems that shape the daily conditions of life. There has been a great deal of research focused on SDOH in the past decade that is critical to informing policy and practice necessary to promote health equity. However, it is also important to acknowledge that this concept is not new. Unacceptable health disparities remain despite substantial evidence, over the past century, which shows SDOH are at the root cause of health disparities.
A guide summarizing the main sections of the TCPS-2 in accessible language. It provides a first introduction to research ethics for public servants who have not yet received formal training on the subject.
Patterns, process & action on tribal health: mapping of process & outcomes un...Prashanth N S
Presentation at the India Alliance Conclave 2021 based on the process and outcomes of THETA project. For more on THETA project, see https://wellcomeopenresearch.org/articles/4-202
Revised JAHF strategic plan detailing "downstream shift" from academic capacity building to influencing practice in health care for older Americans. Presented to Foundation Trustees, June 2012
Results from student-facilitated roundtable discussions at PACE Great Streets townhall meeting in Memphis, TN. This project represents an experiential learning activity at The University of Memphis, Health Promotion concentration in the Department of Health and Sport Sciences.
Investigating the impact of curriculum on attitudes by first year occupationa...Anita Hamilton PhD
This was a presentation that I gave during the Graduate Certificate in Higher Education at Deakin University. This pilot study lead to a fourth year honours research study in 2007 by Alison Naughton.
Designing a Learning Health Organization for Collective ImpactTomas J. Aragon
"Designing a Learning Health Organization for Collective Impact" was my presentation given at the California HealthCare Foundation (CHCF) Health Care Leadership Program final seminar and graduation. Congratulations to the amazing fellow graduates!!!
This presentation, given as part of a plenary symposium at the 8th World Congress on Promotion of Mental Health and Prevention of Mental and Behavioural Disorders gives an overview of how one area is trying to develop an approach to public mental health, finding frameworks and tools of use
The holy grail: describing the change your charity exists to achieve | Commun...CharityComms
Tracey Pritchard, director of engagement, Prostate Cancer UK
Visit the CharityComms website to view slides from past events, see what events we have coming up and to check out what else we do: www.charitycomms.org.uk
Meet the experts enhancing health through design, learn about quality of life trends and figures through studies and data and how small gestures can make big differences, discover a user guide to fighting hospital-acquired infections and read up on Sodexo News Around the World.
The C. Everett Koop National Health Award recognizes population health promotion and improvement programs. Each year, awards are presented by The Health Project’s leadership to winning organizations as part of the annual HERO Forum each fall. This Thursday Ron Goetzel joins us for an update on the C. Everett Koop National Health Award with information on criteria and how to apply.
Teaching slides from a University College London Partners and National Co-ordinating Centre for Mental Health Public Mental Health Course in February 2015. This session focuses on building local approaches to public mental health
Evidence-Informed Public Health Decisions Made Easier: Take it one Step at a ...Health Evidence™
An afternoon workshop - held in partnership with the National Collaborating Centre for Methods and Tools - at the Ontario Public Health Convention April 7, 2011
+What is the main idea of the story Answer in one paragraph or lo.docxadkinspaige22
+What is the main idea of the story? Answer in one paragraph or longer at least 5-7 sentences)
https://www.youtube.com/watch?v=maCsqrN-irQ
+Go to the following link, and read the article by Michael Bronski, “A Gay Man’s Case Against Gay Marriage”.
https://www.beliefnet.com/news/2004/05/a-gay-mans-case-against-gay-marriage.aspx
Why is Bronski against homosexual marriage? (1 paragraph or longer)
What does Bronski say about his own parents’ marriage? (1 paragraph or longer)
Does Bronski believe in equal rights for homosexuals? (1 paragraph or longer)
Note:
Each paragraph is at least 5-7 sentences, and sentence is not too short
Healthy People 2020
Healthy People was a call to action and an attempt to set health goals for the United States for the next 10 years.
Healthy People 2000 established 3 general goals:
Increase the span of healthy life.
Reduce health disparities.
Create access to preventive services for all.
Healthy People 2010 introduced 2 general goals:
Increase quality and years of healthy life.
Eliminate health disparities.
Practical Policy for Preventive Services
The U.S. health care system faces significant challenges that clearly indicate the urgent need for reform.
There is broad evidence that Americans often do not get the care they need even though the United States spends more money per person on health care than any other nation in the world.
Preventive care is underutilized, resulting in higher spending on complex, advanced diseases.
Practical Policy for Preventive Services
Patients with chronic diseases too often do not receive proven and effective treatments such as drug therapies or self management services to help them more effectively manage their conditions.
These problems are exacerbated by a lack of coordination of care for patients with chronic diseases.
Reforming our health care delivery system to improve the quality and value of care is essential to address escalating costs, poor quality, and increasing numbers of Americans without health insurance coverage.
Why policies need to be developed?
Basic needs are not being met (e.g., People are not receiving the health care they need)
People are not being treated fairly (e.g., People with disabilities do not have access to public places)
Resources are distributed unfairly (e.g., Educational services are more limited in neighborhoods of concentrated poverty)
Why policies need to be developed?
Current policies or laws are not enforced or effective (e.g., The current laws on clean water are neither enforced nor effective)
Proposed changes in policies or laws would be harmful (e.g., A plan to eliminate flextime in a large business would reduce parents' ability to be with their children)
Existing or emerging conditions pose a threat to public health, safety, education, or well-being (e.g., New threats from terrorist activity)
Marjory Gordon’s Functional Health Patterns
Marjory Gordon was a nursing theorist and professor who created a.
Webinar presentation by Susan Pietryzk. Access the webinar recording at http://www.measureevaluation.org/resources/webinars/measuring-impact-qualitatively
Sustainability and Health Systems Strengthening: What Have We Learned?MEASURE Evaluation
Presented by Xavier Alterescu as part of the Brown Bag Series given at USAID on MEASURE Evaluation's contribution to the Global Health Initiative Principles
Population Health Data Science, Complexity, and Health Equity: Reflections fr...Tomas J. Aragon
Annual Population Health Sciences Colloquium at the Stanford Center for Population Health Sciences on October 26, 2015.
This one-day program will showcase population health sciences research from the Stanford community and experts around the world.
This one-day program will showcase population health sciences research from the Stanford community and experts around the world. The PHS Initiative aims to bring together basic, translational and clinical scientists, along with researchers from disciplines across the entire University, to provide resources and facilitate collaborations focused on population-level questions, data and approaches.
We have an exciting full-day session with keynote speakers - Lloyd Minor, Dean of the Stanford School of Medicine; Muin Khoury, Associate Director of Epidemiology and Genomics Research Program at NCI; and Tomas Aragon, Director of Population Health Division at the San Francisco Department of Public Health - and some time to do the vital work of growing our center.
The High Achieving Governmental Health Department in 2020 as the Community Ch...Tomas J. Aragon
This paper was prepared by RESOLVE as part of the Public Health Leadership Forum with funding from the Robert Wood Johnson Foundation. John Auerbach, Director of Northeastern University’s Institute on Urban Health Research, also put substantial time and effort into authoring the document with our staff. The concepts put forth are based on several working group session (See Appendix B for members) and are not attributable to any one participant or his/her organization.
Preparing for Microbial Threats to Health: What Every Professional Should KnowTomas J. Aragon
In this presentation I introduce the "SFDPH Population Health Division Controlling Infectious Diseases Model." This model integrates concepts from understanding transmission mechanisms, transmission dynamics, and transmission containment. The Model is most useful when facing novel microbial threats and we need simple framework for public health action.
Sugar MADNESS: How metabolic syndrome drives obesity and what you can do abou...Tomas J. Aragon
Sugar consumption, especially from sugary drinks, is the single largest and preventable contributor to the global epidemic of diabetes, heart disease, high blood pressure, bad cholesterol, and unhealthy weight gain. Fructose is the part of "sugar" that is the culprit. Fructose in liquid form is worse! Fructose is metabolized by the liver. With repeated exposures, it causes fatty liver, high insulin, insulin resistance, excessive fat storage, and leptin resistance. We call this metabolic syndrome. Our brain is tricked into believing our body is starving. Hence, we eat more and exercise less. It's a complicated, but important story: "Sugar MADNESS" is a memory aid to learning about sugar, metabolic syndrome, and what to do about it.
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Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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[