Designing a Learning Health Organization for Collective Impact

In May 2014, the Public Health Leadership Forum published “The High Achieving Governmental Health Department in 2020 as the Community Chief Health Strategist.”1 This groundbreaking paper started with the following statement: Local and state health departments need to adapt and evolve if governmental public health is to address emerging health demands, minimize current as well as looming pitfalls, and take advantage of new and promising opportunities. To succeed requires a view into the future. In November 2011, the San Francisco Department of Public Health (SFDPH), Population Health Division embarked on this journey to reorganize the public health division into a high-achieving governmental health department for the future. We used public health accreditation as the catalyst to reorganize, and the new organization structure launched on July 1, 2013. For the staff in the SFDPH, public health accreditation is about the humble and passionate pursuit of results, equity, and accountability for improving community health. This inspired us to call our framework for public health accreditation and improvement REACH (Results, Equity and Accountability for Community Health). Staff are focused on achieving results (impacts, goals, and outcomes); integrating equity into quality improvement efforts; designing accountability into our activities, including community-based evidence (local voice, wisdom, and knowledge) with science- and practice-based evidence; and protecting and promoting population health. REACH was developed after the SFDPH leadership embraced the idea that public health accreditation could be used as a vehicle to protect and promote the health of all San Franciscans. The San Francisco Health Commission—the governing health body—passed a resolution declaring public health accreditation a top strategic health priority for San Francisco. With this support, the SFDPH embarked on an extensive reorganization of its public health services into a new Population Health Division. The overarching goal was to design a community-centered, responsive, and agile health organization that could adapt quickly to current and emerging public health challenges and opportunities. Strategic objectives included the following: provide leadership in health protection, health promotion, disease and injury prevention, and disaster preparedness; expand our focus to community wellness, beyond disease events; promote healthy and sustainable environments; integrate health equity into quality improvement efforts; strengthen service excellence to communities, clients, and providers; ensure a culture of trust and innovation; strengthen our culture of finding, translating, and implementing science-based solutions to problems; and achieve and maintain public health accreditation. An organization design team consisting of leaders, managers, and staff was convened. Because there is limited collective knowledge and funding for developing organizational structures in local health departments, a new structure was designed using existing local experience and published resources. The design team members reviewed public health accreditation domains and standards, population health models,2,3 the Baldrige Criteria for Performance Excellence (CPE),4 key public health texts,5,6 and modern organization design books.7,8 The design team actively engaged the staff, the affected community, and other stakeholders to bring in and build connections of trust and understanding. By pulling together all those sources of input, the design team developed a strategic map and then created an organization design framework and staffing chart. With that foundation, the REACH framework evolved after reviewing and testing several quality improvement models.9–16 Finally, the SFDPH was able to leverage funding and technical assistance from the Centers for Disease Control and Prevention and the National Association of County & City Health Officials, which supported preparation for public health accreditation and funding for program collaboration and service integration.17 The purpose of this commentary is to review how the SFDPH used organization design concepts and continuous improvement frameworks to reorganize from autonomous, categorical silos of public health services to an integrated, community-centered Population Health Division. We believe that these concepts and methods can be adapted to many health organizations.