Systems Research and Behavioral Science - 2016 - Kapp - A Conceptual Framework For A Systems Thinking Approach To US

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Systems Research and Behavioral Science
Syst. Res 34, 686–698 (2017)
Published online 5 September 2016 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/sres.2420
■ Research Paper
A Conceptual Framework for a Systems

Thinking Approach to US Population
Health
Julie M. Kapp1*, Eduardo J. Simoes1, Anne DeBiasi2 and Steven J. Kravet3
1
Department of Health Management and Informatics, University of Missouri School of Medicine, Columbia,
MO USA
2
Trust for America’s Health, Washington, DC USA
3
Johns Hopkins Community Physicians, Division of General Internal Medicine, Johns Hopkins School of
Medicine, Baltimore, MD USA
US health outcomes remain poorer than those of high-income peer countries despite collective
efforts directed at improving health and healthcare. Regarding population health, such collec-
tive impact efforts increasingly come from community-based organizations, as federal bud-
gets have been cut over the years. The Institute of Medicine recently identified core metrics
to facilitate collective efforts and specified the Secretary of Health and Human Services as
the position to lead the nation’s efforts to improve the health of the population. However, in-
tegration across such a complex system requires a clear, deliberate systems approach. We
adapt The Malcolm Baldrige Framework for Performance Excellence as a conceptual model
with which to apply systems thinking to population health improvement. We offer specific
recommendations necessary to build a national systems thinking approach towards improv-
ing the health of communities and populations if we hope to ameliorate the US health disad-
vantage. Copyright © 2016 The Authors Systems Research and Behavioral Science published
by International Federation for Systems Research and John Wiley & Sons Ltd.
Keywords population health; public health systems; system dynamics; health policy; evaluation
‘A system generally goes on being itself, INTRODUCTION

changing only slowly if at all, even with com-
plete substitutions of its elements—as long as The ‘Why’
its interconnections and purposes remain
intact’.‘Changing relationships usually changes A US Population Health Disadvantage
system behavior’.Donella H. Meadows The US has been labelled with a ‘health
disadvantage’ (National Research Council and
* Correspondence to: Julie M. Kapp, Department of Health Manage- Institute of Medicine, 2013). The US lags
ment and Informatics, University of Missouri School of Medicine,
CE717 CS&E Bldg., One Hospital Drive, Columbia, MO 65212, USA.
behind on a number of critical health out-
E-mail: kappj@health.missouri.edu comes compared with its high-income peer
Copyright © 2016 The Authors Systems Research and Behavioral Science published by Received 9 July 2015
International Federation for Systems Research and John Wiley & Sons Ltd. Accepted 24 July 2016
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs Li-
cense, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-
commercial and no modifications or adaptations are made.
10991743a, 2017, 6, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/sres.2420 by INDIAN INSTITUTE OF TECHNOLOGY (NON -EAL), Wiley Online Library on [12/10/2022]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Syst. Res RESEARCH PAPER
countries, including a shorter life expectancy. ‘How?’

This difference in life expectancy has been
growing for the past three decades (National Collective Inter-agency Efforts Are Not Enough
Research Council and Institute of Medicine, The Robert Wood Johnson Foundation and Trust
2013), underscoring the need for reform in for America’s Health emphasized both the need
how the US manages population health. What for federal agencies to increase attention on
complicates our progress is our inability to prevention and health promotion, along with
define, monitor, and improve on modifiable the need to work across agencies external to the
premature mortality, even after 100 years healthcare system in order to have a major
(Kapp, 2013). impact on improving the health of all
Americans (Levi et al., 2014). Hester et al. (2015)
suggested ‘collaborating entities need organiza-
tional structures in order to guide, grow, and
The ‘What’ sustain their joint efforts over time’. Hardcastle
et al. (2011) argued for a fully integrated health
The Affordable Care Act’s Focus on Population system, requiring ‘all government policies reflect
Health the ultimate goal of improving the health of the
The 2010 Patient Protection and Affordable population’.
Care Act (ACA) includes a number of provi- ‘Collective impact’ (Kania and Kramer, 2011) is
sions that attempt to address US population a buzzword among community-based organiza-
health needs. The ACA created a national tions to reflect the inter-agency commitment of
strategy to improve healthcare quality (i.e. the cross-sector organizations towards a common
National Quality Strategy) which includes a goal and is comprised of five conditions for
focus on population health; this focus is rein- success: (i) a common agenda; (ii) a backbone
forced in related frameworks such as the Triple support organization (a highly structured
Aim (Berwick et al., 2008). Section 4001 of the process managed by an umbrella organization);
ACA likewise addresses population health by (iii) shared measurement systems (ways success
establishing the National Prevention, Health will be measured and reported); (iv) mutually re-
Promotion, and Public Health Council, chaired inforcing activities; and (v) continuous communi-
by the Surgeon General, and a provision that cation (Kania and Kramer, 2011).
the National Prevention, Health Promotion, The Strategy’s focus on engaging cross-sector
and Public Health Council establishes the partners in prevention efforts (National Preven-
nation’s first National Prevention Strategy (Na- tion Council, 2011), along with its goals and
tional Prevention Council, 2011; hereafter re- strategies for reducing the US health burden,
ferred to as the ‘Strategy’). This is intended constitutes a collective impact ‘common agenda’
to be the key strategy and vision for managing to which related stakeholders must align. The
US population health. Population health man- idea of collective impact has become increasingly
agement is a nebulous term, the spirit of popular, given the rise in the number of non-
which intends to identify the population health profit organizations and the subsequent increase
needs of a defined service area and align those in public sector (Appleton-Dyer et al., 2012) and
needs with targeted strategies to improve academic partnerships, with the public sector
health outcomes. The Strategy’s core values generally including a range from healthcare,
align with the idea of reducing the US health social services, education, law enforcement,
disadvantage—that Americans live longer and housing, and other local government services.
healthier through an increased emphasis on, The idea of the federal government driving a col-
and investment in, prevention. Yet, even with lective impact model across agencies is not new.
a strategy for ‘what’, there remains many un- For example, in 2009, the American Recovery
certainties about ‘how’ to improve population and Reinvestment Act appropriated $650 million
health. for health promotion (Parekh et al., 2014); the
Copyright © 2016 The Authors Systems Research and Behavioral Science published by Syst. Res 34, 686–698 (2017)
International Federation for Systems Research and John Wiley & Sons Ltd. DOI: 10.1002/sres.2420
Systems Approach to Population Health 687

RESEARCH PAPER Syst. Res
Centers for Disease Control and Prevention then application of system concepts to frame our
funded 10 non-profit organizations to collaborate understanding of the world, and it is also about
with Communities Putting Prevention to Work possible future action—what ought to be or
(Parekh et al., 2014). could be’ (Rajagopalan and Midgley, 2015).
The increased popularity in cross-sector part- What is a system? A system includes at least
nerships and collective impact is challenged by two elements that interact; the elements are all
the increased number of competing stakeholders interdependent (Ackoff, 1999) and are integrated
across sectors. Between fiscal years of 2005 and in ways that continually affect each other in feed-
2013, the Centers for Disease Control and Preven- back loops over time and which operate as a
tion funding had decreased by about 15% ($1.1 whole towards a common purpose (Kim, 1999;
billion; Levi et al., 2014). From 1999 to 2009, Meadows, 2008). Not all systems thinkers agree
501(c)(3) public charities grew from 631 902 on what systems thinking is (Cabrera, 2006).
organizations to 1 006 670, an increase of 59.3% Here, we refer to the ideas of a few scholars as a
(National Center for Charitable Statistics at the starting, not an ending, point (Cabrera, 2006).
Urban Institute, 2010a). During that same The practice of systems thinking does not just
timeframe, 501(c)(3) private foundations grew focus narrowly on a single technical solution
from 77 978 organizations to 120 617, an increase but rather assesses a problem from a comprehen-
of 54.7% (National Center for Charitable Statis- sive holistic view of the overall challenge (Ackoff,
tics at the Urban Institute, 2010a). The total 1981). Organizations are purposeful, with a set of
revenue for public charities in the USA in 2010 goals, objectives, and frequently ideals; organiza-
totalled $1.38 billion (National Center for Chari- tions themselves are part of larger purposeful
table Statistics at the Urban Institute, 2010c), systems with their own goals, objectives, and
and for private foundations, totalled $43 billion frequently ideals (Ackoff, 1974, 1981). Systems
(National Center for Charitable Statistics at the go beyond organizations. Eoyang and Berkas
Urban Institute, 2010b). (1998) identify human organizations as complex
Despite collective impact efforts, US health and adaptive systems, which have characteristics
healthcare activities are often uncoordinated, over all times and at all scales of being: dynamic,
fragmented, misaligned, and lack measurement massively entangled, scale independent, transfor-
to track change that matters most (Institute of mative, and emergent.
Medicine, 2009; Institute of Medicine, 2015).The Through its provisions and strategies, the ACA
Institute of Medicine (IOM) recently reported on has generated attention for programs that drive a
a set of ‘core metrics’ to align and integrate systems engineering approach to healthcare
within and across health and healthcare, recog- services (Cassel and Saunders, 2014; Executive
nizing that measurement is a tool for perfor- Office of the President: President’s Council of
mance improvement. Yet, even a shared Advisors on Science and Technology’s, 2014). In-
measurement system for the status of health deed, a call for re-engineering the US healthcare
and healthcare at the national, state, local, and in- system by using complex adaptive systems
stitutional levels is not enough to enhance the ef- theories is not new (Institute of Medicine and
fectiveness and efficiency of population health Committee on Quality of Health Care, 2001).
performance (Institute of Medicine, 2015). The IOM introduced these concepts in 2001; how-
ever, this was applied to the US healthcare
system (Best, 2011; Fraser and Greenhalgh, 2001;
The Need for a Systems Thinking Framework Plsek and Greenhalgh, 2001; Plsek and Wilson,
‘Systems thinking’ is an approach to a problem 2001; Zimmerman et al., 1998); not population
that considers how components within the larger health, and did not provide a practical approach
structure operate and interact over the lifecycle of to this end.
the system and how to optimize the design, Given that many of the strongest predictors of
implementation, and evaluation of that system. health and well-being fall outside of the tradi-
Systems thinking ‘can best be described as the tional healthcare setting (National Prevention
688 Julie M. Kapp et al.

Council, 2011), applying a systems thinking organizations (National Institute of Standards

approach to population health would be a high- and Technology, 2014). The Baldrige Framework
impact strategy towards reducing the health (Baldrige Performance Excellence Program,
disadvantage. While some articles begin to intro- 2013) is described in a booklet of self-study ques-
duce these concepts (Atun, 2012; Carey et al., tions, which are only briefly explained here. The
2015; Diez Roux, 2011; Leischow and Milstein, Framework centres around two triads and seven
2006; Leischow et al., 2008; Peters, 2014; Peters, criteria of managing and performing as a system:
2014), they do not introduce methodological the Leadership Triad (leadership, strategic plan-
innovations as is needed (Cabrera, 2006) and are ning, and customer focus); measurement, analy-
less applied in their approach. What is needed sis, and knowledge management; and the
is a model or a framework of systems thinking, Results Triad (workforce focus, operations focus,
not [another] theory of systems (Cabrera, 2006). and results). The framework is powerful as it
We argue beyond examining programs that drive creates the expectation that a system’s leadership
a systems engineering approach to re-defining considers all of the criteria comprehensively. We
the system itself. will hereafter refer to Baldrige terms in italics.
No studies have yet applied a systems thinking The Leadership Triad establishes a knowledge and
framework to US population health. We first information system interwoven with process
propose a significant contribution not only to improvement. This ultimately drives results
the literature but also to the traditional manage- explicitly reflective of the defined strategic goals.
ment of US population health in adapting The The seven criteria exist within the larger frame-
Malcolm Baldrige Framework for Performance work of what Baldrige calls the organizational
Excellence (www.nist.gov/baldrige/) for use as profile, which considers the greater context of en-
a unifying conceptual systems thinking frame- vironment, relationships, and the larger strategic
work. This framework uses a systems thinking situation. Through this alignment, the Baldrige
approach already established by the US govern- Framework for Performance Excellence could
ment to drive global competitiveness, making it provide the nation the necessary systems struc-
appropriate for addressing the US health disad- ture to better assure desired results, where stake-
vantage. We then make recommendations about holders’ goals are specifically aligned towards
‘how’ to implement this systems framework. the broader collective scope.
METHODS Baldrige as a Systems Approach
The Malcolm Baldrige Framework The Baldrige Framework is founded on being an

integrated and aligned systems model (Borawski
In 1987, Public Law 100–107 created the Malcolm and Brennan, 2008). The Baldrige Framework can
Baldrige National Quality Improvement Act and be used not only within organizations but also
the Malcolm Baldrige National Quality Award to within systems (Communities of Excellence,
support US companies in becoming more glob- 2015; Kruse and Norling, 2014). The Baldrige
ally competitive through focusing on quality Framework meets the system criteria definition:
(The National Institute of Standards and Technol- (i) its seven criteria are the elements; (ii) the
ogy, 2010). The Baldrige Framework is an inte- criteria are interdependent and interconnected,
grated and aligned systems model to hard wire given their focus on alignment and integration;
performance by setting direction, by using a and (iii) the organizational profile, strategic plan-
fact-based decision process, aligning incentives, ning, and the results criteria drive the purpose of
and driving value (Borawski and Brennan, the system.
2008). In 1999, the scope of the Baldrige Frame- We use systems thinking to apply the Baldrige
work was expanded to education and healthcare, Framework to US population health. We consider
and in 2005, to non-profit and governmental US population health as a supra-system,

containing many subsystems at federal, state, progress in health and healthcare, as well as align
and local levels. We recognize that the applica- functions across federal agencies (Institute of
tion of the Baldrige Framework to US population Medicine, 2015):
health is an idealized design. As an idealized
It is the HHS secretary who directs the agen-
design, it is believed to be unattainable but
cies most involved in the collection and use
towards which progress is believed to be possi-
of health data; who signs off on reporting re-
ble, and is ideal-seeking in its purpose while also
quirements and responsibilities; who is cen-
being (i) technologically feasible; (ii) operation-
trally positioned to convene and work with
ally viable; and (iii) capable of rapid learning
the key stakeholders; and who, as the leader
and adaptation (Ackoff, 1977, 1981, 1999).
most responsible for the nation’s effectiveness
and efficiency in delivering better health at
lower cost, has the greatest potential to unlock
RESULTS
the capabilities of the core measure set.
Applying the Baldrige Framework to Strategic planning includes policy and legisla-
Population Health tion created by leadership with the intention of
improving and protecting the health of the US
Figure 1 outlines our US Population Health population. This includes the ACA and the
Systems Framework, adapted from the Baldrige Strategy.
model. If US population health is our organiza- A customer focus, geared towards the US popu-
tion, its organizational profile would include under- lation, generates questions about identifying
standing key population health characteristics, individuals and communities at high risk for
concepts relating to health, and key health premature mortality and reduced quality of life.
challenges, including competitors to population It also implies the need for evidence-based ways
health (Ackoff, 1981). The Strategy already con- to engage these high-risk individuals and com-
tains elements of an organizational profile, in- munities in tailored and targeted long-term
cluding the nation’s purpose, vision, values, and health promotion behaviours to improve their
mission towards population health improvement. health and reduce premature mortality.
Leadership would be supported by the Execu- The US measurement efforts are uncoordi-
tive Office of the President and Congress, but as nated, vertically and horizontally, at the national,
described in the recent IOM report, the Secretary state, local, and institutional levels (Institute of
of Health and Human Services (HHS) is the most Medicine, 2015). In practice, organizations con-
appropriate entity to provide leadership towards ceptualize their own definitions of the problems,
Figure 1 A conceptual framework for a systems thinking approach to US population health

outcomes, and the ultimate impact goal. Even practice. The Baldrige Results Triad (workforce
definitions of ‘population health’ vary (Stoto, focus, operations focus, and results) is a composite
2013). Similarly, implementation scientists lack of product and process and the performance
consensus on measures (Rabin et al., 2012). There results they yield (Baldrige Performance Excel-
is a call for a set of standardized measures for lence Program, 2013).
assessing the intrinsic health of communities in
and of themselves; a set of standardized health
outcome indicators for national, state, and local OPERATIONALIZING THE FRAMEWORK
use; and a summary measure of population
health for estimating and tracking health- How to Implement a Systems Thinking
adjusted life expectancy nationally (IOM, 2011). Approach to Population Health
After considering a broad range of sources, the
IOM recently identified a recommended set of Logic models are widely used in public health
metrics for widespread implementation for organizations as a useful roadmap to align stake-
health and healthcare in the US (Institute of holders and make the infrastructure visible in
Medicine, 2015). This report also identifies the order to understand the intended pathway to
HHS secretary as the ‘appropriate person to move from activities to outcomes. Logic models
steward the eventual process of amending the are intended to represent a theory of change
core measure set’. through a series of ‘if–then’ statements across
Measurement, analysis, and knowledge manage- constructs of activities, outputs, outcomes, and
ment is the system foundation and is critical not impacts (or some variation thereof), as operation-
only to managing effectively but also to aligning alized in Figure 2. For example, we generally
stakeholders and improving performance and expect improvement in an individual’s knowl-
competitiveness by creating a fact-based, edge and understanding (at least of how to
knowledge-driven system (Baldrige Performance operationalize behaviour change, if not a better
Excellence Program, 2013). The system foundation understanding of the circumstances) to precede
links the Leadership Triad to the Results Triad, a change in behaviour; sustainable changes in
assuring alignment and interconnections. This behaviour are then expected to lead to a change
means that the HHS secretary, Congress, and spe- in related outcomes.
cial health committees that implement or create ‘Even less easy to identify are those metrics
legislation could monitor the progress of their which capture possible actions by …systems that
policies on advancing results for the customers might reduce morbidity and mortality at the
by using an evidence-based systems thinking community level. A stronger body of evidence
dashboard, as described below. is needed for innovative clinical and total
The workforce focus includes those who carry community metrics’ (Hester et al., 2015). When
out the Strategy, particularly under the leader- organizations develop their tracking metrics to
ship of the HHS secretary. We define workforce measure progress towards a program’s intended
as national (level 1 workforce), state (level 2 work- outcomes, the metrics rarely represent a theory
force), and local (level 3 workforce) to include of change perspective with leading and lagging
federal, state, and local government agencies, indicators to monitor progress towards success.
community-based and non-profit organizations, ‘Currently, the evidence base to support the
universities and institutions, and Indian tribes, linkage between specific standards for public
consistent with ACA legislation. The workforce health…and improved public health outcomes
needs to align on incorporating the Strategy into is very limited’ (Exploring Accreditation Plan-
their operations and how to assess workforce ning Committee, 2007), arguably one of the
capability, needs, and change management. greatest weaknesses of the current Strategy for
The operations focus becomes a question of how improving population health. Even the IOM’s
to design, align, and integrate processes to incen- core measure set is described as a set of flat
tivize progress towards results for the Strategy, in metrics, rather than in a theory of change format.

Figure 2 Systems thinking logic model to monitor ‘measurement, analysis, and knowledge management’ of population health
efforts
If the core metrics support a theory of change, with definitions). The core metrics sequence
and local, regional, and state-based organizations used here is for illustrative purposes; it would
can pursue evidence-based actions that align need testing and confirmation. The final core
with progress on the metrics, we can better metrics sequence becomes the beginning of the
monitor and manage US population health im- dashboard for US population health, forming
provement. This is an integrated and aligned the centralized, transparent, national ‘shared
purposeful, if not idealized, systems thinking measurement system’ (Kania and Kramer,
approach with interconnected elements. 2011) with which to monitor progress on the
nation’s health.
Second, health and healthcare community-
Recommendation 1: Drive a Strategic based organizations would need to be incentivized
Outcome-oriented Rather than Action-oriented to align and integrate their within-organizational
Approach by Creating an Evidence-based National metrics to the shared metrics. This will help align
Reporting Dashboard and integrate the population health system
First, we organized the core metrics into a towards one focused on activities to one of out-
proposed theory of change sequence based on comes (the systems align with the supra-system).
the IOM’s definitions of the best current The proposed federal and national responsibili-
measures (Institute of Medicine, 2015; ties (level 1 workforce) are represented in boxes
Figure 2). This core metrics’ sequence order below the appropriate theory of change defini-
was based on the standard logic model struc- tion, with bold and underlined text (Figure 2).
ture that activities drive change in knowledge The proposed state and local responsibilities are
which drives change in behaviour which drives represented in boxes with italics text (levels 2 and
change in outcomes which, over a broad- 3 workforce). Funds are a powerful tool to influ-
enough scope, drives impact (rounded boxes ence and incentivize systems thinking and

community–partner engagement beyond simply interactive. This dashboard then also serves as
collaborating or performing activities related to the ‘reinforcing feedback loop’ to foster efficien-
an overarching theme. Therefore, the operations cies and growth in progress over time. In the
focus would require the level 1 workforce to set clear era of big data and informatics, this might be
expectations for federal funds through requests displayed in a fractal design, meaning, clicking
for proposals (RFP) that require organizational on the linkages (e.g. arrows) across components
(levels 2 and 3 workforce) alignment with the met- would allow one to ‘drill down’ through the
rics. This is the ‘how’ of designing, managing, back-end dataset to see the level of evidence for
and improving key products and work processes the linkage, the evidence-based model used,
and ensuring effective management of these what the target population was, the geographic
operations. region, the magnitude of effect, the period of
The operations focus of the RFPs would be non- sustainability, and any number of other required
prescriptive and adaptable for community-based standardized fields of reporting. Levels 2 and 3
agencies, as the RFPs would focus on common workforce end-of-project reports and quantitative
needs (at risk/high need), rather than on com- results could be catalogued through hyperlinks.
mon procedures (Baldrige Performance Excel- In this way, the dashboard also supports ‘expan-
lence Program, 2013). The levels 2 and 3 workforce sionism’, in that understanding proceeds from
can respond to RFPs, Strategy goals, and targets the whole to its parts, and knowledge proceeds
with ‘mutually reinforcing activities’ (Kania and from the parts to the whole (Ackoff, 1981).
Kramer, 2011) that are ‘creative, adaptive, and Finally, over the long term, the dashboard
flexible approaches, fostering incremental and would help leadership and level 1 workforce moni-
major (breakthrough) improvement through tor cross-organizational progress, improve effi-
innovation’ (Baldrige Performance Excellence ciencies, reduce redundancies, and identify gaps
Program, 2013). These RFP directives still leave (feedback loops). If a metric does not improve
organizations the freedom to innovate their after funding multiple organizations over a
activities, but those activities must nonetheless specified period of time, dashboard data (list of
fit into the overarching plan (the Strategy) if com- funded activities and associated organizations
bined efforts are to succeed (Kania and Kramer, and dollars granted towards those organizations)
2011). Levels 2 and 3 activities then become would support decision-making towards an RFP
evidence-based drivers for progress on the core continuous quality improvement process. The
metrics. dashboard would also allow stakeholders to see
Third, as the dashboard evolves, documenta- where certain indicators may have been
tion would need to be available through the underfunded relative to well-funded indicators
dashboard that ensures transparency and clarity that did not improve. This would facilitate
in reporting the evidence-base for the theory of moving away from an optimistic interpretation
change and cross-process linkages. In other of Strategy successes based largely on ecological
words, the dashboard must have indicators for fallacies (National Prevention Council, 2012,
the level of evidence (perhaps a grading mecha- 2013, 2014) towards an evidence-based, data-
nism like the US Preventive Services Task Force driven, causal-path model.
uses; a five-star rating scale; or a red, yellow,
and green level of evidence) connecting the
theory of change constructs for each fundee’s Recommendation 2: Improve Operational
attribution to progress on the outcomes. The Effectiveness of the Workforce
dashboard would be a ‘living’ dashboard (the With the growing number of stakeholders and
HHS secretary may modify the metrics as appro- community-based organizations competing for
priate, although there should be a deliberate federal funds, it is critical to push more within-
process and strategy behind the frequency and organizational effectiveness from community-
type of changes), interoperable, likely housed based partners towards an evidence-based yield
on a government or foundation website, and of performance.

First, the RFPs would require grantees to com- evaluations, community partners often struggle
plete their own organizational profile, providing in performing useful evaluations and using them
a clearer picture of their operating environment for continuous quality improvement, and there is
(key relationships, customers, suppliers, partners, a significant amount of heterogeneity among
and stakeholders) as well as the competitive envi- evaluators (Kane et al., 2013). They lack an under-
ronment, key strategic issues, and the system for standing to tie together organizational effective-
performance improvement. Following this as- ness, programmatic improvement, and impact
sessment, further proposal questions would ask (Liket et al., 2014), likely exacerbated in smaller
not only how governance and leadership guide organizations. For example, frontline workers of
and sustain their organization but also how they non-profit organizations often engage in the
create an environment for engagement, innova- soft-skill relational work with clients, adjusting
tion, ethical behaviour, and societal responsibility. what they do to meet the specific needs of those
The assessments would look at how the organiza- they serve (Benjamin, 2012), resulting in mission
tion (i) develops and implements its strategy; (ii) creep. Consequently, community-based organiza-
engages and obtains information from customers; tions often deviate from their defined program-
(iii) manages information and data to drive per- matic model, which may negate their evidence
formance; (iv) builds an effective workforce envi- of success in working towards a clearly defined
ronment where team members know how they fit set of outcomes. One example of how requiring
and why they matter; and (v) manages to im- evaluations is necessary but not sufficient is with
prove work processes and operations. Most im- non-profit hospitals. Section 9007 of the ACA
portantly, such an assessment would ask how requires that all non-profit hospitals conduct a
the articulated desired results of the organization, community health needs assessment of the com-
including those tied to process effectiveness, munity served by the hospital and adopt strate-
customer-focused performance, leadership and gies to meet those needs. Few community
governance, and financial and marketplace per- benefit programs, as related to the ACA tax-
formance, measurably align with the goals of the exempt hospital mandates, are rigorously evalu-
Strategy and the dashboard (i.e. core metrics). ated or provide evidence of program impact
Second, to be eligible to apply for federal (Burke et al., 2014).
funds, levels 2 and 3 workforce would be required
to complete a government-approved certification
in evaluation, logic model planning, organiza- DISCUSSION
tional capacity, quantitative metrics, and assess-
ment (balancing feedback loop). The positive Requiring an organizational profile and
movement towards voluntary national accredita- improved operational effectiveness would help
tion of public health departments is consistent address the need for levels 2 and 3 workforce to
with this recommendation for improved organi- better design, manage, and improve their
zational and operational effectiveness. However, products and work processes. Implementing the
the current standards and measures for public Baldrige Framework across all criteria, and all
health department accreditation are activities— levels of the workforce is key to driving collabora-
rather than outcomes—focused. It is possible for tion activities, a systems thinking approach, and
an agency to successfully execute the activities accelerating the greater amount of ‘continuous
without driving the necessary systems thinking communication’ (Kania and Kramer, 2011). Creat-
outcomes. ing a common cross-sector vocabulary takes time
Third, RFPs would require levels 2 and 3 (Kania and Kramer, 2011), and implementing the
fundees to demonstrate core competencies in per- Baldrige Framework is a long-term commitment
formance enhancement or continuous quality im- of leadership.
provement processes through effective use of While the workforce is actively engaged in
evaluations. While current federal and founda- many of the right efforts needed for improving
tion grants and contracts often require population health, what is missing is an overall

management framework integrating all of the We address this through the RFP funding mecha-
components into a systems perspective. We nism. ‘Incentives should be tailored to the context
propose a systems thinking approach to popula- and culture of the organization’. We address this
tion health by adapting the Baldrige Framework through the continuous quality improvement
and making two main recommendations. This cycle of leadership to ensure that the RFPs are
systems thinking framework is flexible enough always addressing needed areas and funding
to be adapted as new evidence is produced, the most effective workforce. ‘It is equally impor-
while also providing a working infrastructure tant to remove formal and informal disincentives
for long-term initiatives. Aligning societal goals to results-based management’. In a true system,
across a wide spectrum of organizations would the levels 2 and 3 workforce will ensure that their
be accelerated by a comprehensive framework mission, vision, values, and goals align, integrate,
to assure that resources are being applied and and support the Strategy, which means that the
allocated effectively, maximizing taxpayers’ and Strategy becomes integrated into their operations.
funders’ investments. Our conceptual framework is not result-based,
Implementing result-based management initia- but process- and integration-based.
tives alone are not enough for a systems thinking
approach. The United Nations indicated that
their results-based management initiative was Anticipated Challenges and Future Directions
part of a broader agenda of reforms, and failed,
in part, for a number of reasons (Bester, 2012). We acknowledge that these ideas are conceptual
Included in these reasons, the United Nations and are intended to provide a theoretical basis
states that ‘agencies are good at defining and for the ideas of implementing a systems thinking
measuring results at the output level as outputs approach to US population health by using the
are generally amenable to measurement. Mean- Baldrige Framework, which is entirely innova-
ingful definition and measurement of outcomes tive. We anticipate several major challenges to
is not easy, and many agencies experience diffi- the implementation of these ideas. First, buy-in
culty in developing realistic, technically sound by the office of the Secretary of HHS is clearly a
indicators for these levels of results. Some sug- critical step, as that office is central to defining
gest that vague outcomes are also a way to avoid access to many of the ACA population health
being held accountable’. We wholeheartedly dollars, the largest incentive for state and local
agree. In our recommendation 1, we discuss stakeholders to adopt this approach. Second,
having a set of defined core metrics; allowing some resistance to alignment on the Strategy
the workforce to create additional tailored metrics and core metrics will come from levels 2 and 3
addresses this point. To further support the need workforce, while others will welcome the clarity
for core metrics, ‘many organizations persist in and sense of direction. Our conceptual frame-
their attempts to measure as many things as work lays the groundwork for a long and chal-
possible. This propensity towards complexity is lenging journey to transform the ‘how’ of US
partly driven by multiple reporting demands population health management. The next steps
put on organizations in the public sector. It is also for research involve identifying the right core
driven by lack of clarity about which results are metrics for the logic model and testing their
the most important’. This is also true among if–then sequence in community-based pilot pro-
community-based non-profits. Our core metrics jects. Identifying mandatory reporting metrics
and logic model approach will reduce cross- by levels 2 and 3 workforce to be included in the
sector reporting burdens and inefficiencies; our metrics would then facilitate the creation of a
evidence-based, rating system approach in a prototype (even theoretical) working dashboard.
dashboard format will reveal which activities Implementing a systems approach will take at
are the most important in driving outcomes for- minimum decades. But if the workforce is already
ward. ‘There must be incentives in place for man- investing time and billions of dollars in activities,
agers and staff to use results-based management’. then making calculated, deliberate, incremental

changes that are aligned and integrated within a Ackoff RL. 1977. National development planning
deliberate systems approach offers our best revisited. Operations Research 25: 207–218.
Ackoff RL. 1981. Creating the Corporate Future. Plan or
chance for those activities to move outcomes. Be Planned For. John Wiley & Sons: New York.
Ackoff RL. 1999. Ackoff’s Best. His Classic Writings on
Management. John Wiley & Sons, Inc.: New York.
CONCLUSIONS Appleton-Dyer S, Clinton J, Carswell P, McNeill R.
2012. Understanding evaluation influence within
public sector partnerships: a conceptual model.
Not until we begin to align and integrate and can American Journal of Evaluation 33: 532–545.
visually display health and healthcare organiza- Atun R. 2012. Health systems, systems thinking and
tions’ shared metrics, allocated dollars on shared innovation. Health Policy and Planning 2012/10/04:
metrics, programs and activities on shared iv4–iv8.
metrics, progress reports on shared metrics, and BPEP. 2013. 2013–2014 Criteria for Performance Excellence.
U.S. Department of Commerce, National Institute of
evidence-based and effective practices on shared
Standards and Technology: Gaithersburg, MD.
metrics, will we begin to see system level change Benjamin LM. 2012. Nonprofit organizations and
towards reducing the US health disadvantage. outcome measurement: from tracking program
Most importantly, given our health outcomes’ activities to focusing on frontline work. American
standing among peer countries and our failure Journal of Evaluation 33: 431–447.
to make progress on improving the proportion Berwick DM, Nolan TW, Whittington J. 2008. The
triple aim: care, health, and cost. Health Affairs
who succumb to modifiable premature mortality (Millwood.) 27: 759–769.
after 100 years of awareness (Kapp, 2013), we Best A. 2011. Systems thinking and health promotion.
cannot afford not to consider an aligned and inte- American Journal Of Health Promotion: Ajhp 2011/03/
grated systems thinking perspective for improv- 03: eix–ex.
ing US population health. Bester A. 2012. Results-based management in the
United Nations Development System: progress and
challenges. A report prepared for the United Nations
Department of Economic and Social Affairs, for the
ACKNOWLEDGEMENTS Quadrennial Comprehensive Policy Review.
Borawski P, Brennan M. 2008. The Baldrige Model: An
JMK and SJK were Baldrige Executive Fellows in Integrated and Aligned Systems Approach to Perfor-
mance Excellence. Journal of Association Leadership
the 2014 cohort. JMK is formerly the executive Summer.
director of the Partnership for Evaluation, Assess- Burke JG, Truong S, Albert S et al. 2014. What can be
ment, and Research at the University of Missouri learned from the types of community benefit
—St Louis. We are grateful to the leadership of the programs that hospitals already have in place?
Baldrige Executive Fellows Program for their ex- Journal of Health Care Poor Underserved 25: 165–193.
Cabrera DA. 2006. Systems Thinking. Cornell Univer-
pertise, especially Harry Hertz, Bob Fangmeyer, sity: Ann Arbor.
Bob Barnett, and Patrician Hilton. We thank Keith Carey G, Malbon E, Carey N, Joyce A, Crammond B,
Mandel, MD, formerly of the University of Mis- Carey A. 2015. Systems science and systems think-
souri Health System, for his expert review and ing for public health: a systematic review of the field.
feedback on an early version of this manuscript. BMJ open 2016/01/01 e009002.
We thank Steffani Webb and her insightful team Cassel CK, Saunders RS. 2014. Engineering a better
health care system: a report from the President’s
at the University of Kansas Medical Center for Council of Advisors on Science and Technology.
their feedback. We thank Editor Dale Smith for The Journal of the American Medical Association 312:
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A Conceptual Framework for a Systems

‘A system generally goes on being itself, INTRODUCTION

countries, including a shorter life expectancy. ‘How?’

Systems Approach to Population Health 687

688 Julie M. Kapp et al.

Council, 2011), applying a systems thinking organizations (National Institute of Standards

METHODS Baldrige as a Systems Approach

The Malcolm Baldrige Framework The Baldrige Framework is founded on being an

Systems Approach to Population Health 689

Figure 1 A conceptual framework for a systems thinking approach to US population health

690 Julie M. Kapp et al.

Systems Approach to Population Health 691

692 Julie M. Kapp et al.

Systems Approach to Population Health 693

694 Julie M. Kapp et al.

Systems Approach to Population Health 695

696 Julie M. Kapp et al.

Systems Approach to Population Health 697

698 Julie M. Kapp et al.

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