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Root Cause Organizational Realignment

State: KY Type: Model Practice Year: 2020

The Louisville Metro Department of Public Health and Wellness (LMPHW) is an independent, academic health department in Louisville (Jefferson County), Kentucky, under the leadership of Dr. Sarah Moyer. The department's 215 employees serve the 771,000 residents of Louisville Metro within its consolidated city/county boundaries. About 19.4% of the population lives in 84 small cities, such as Shively and Jeffersontown, some of which have separate tax systems, governance, and services. Louisville Metro itself is slowly changing; the White population continues to decline while people of color, immigrants, refugees, and others contribute to the growing diversity of our community. 

In June 2006, LMPHW established the Center for Health Equity (CHE)—the first of its kind within a municipal government. CHE was created to advocate for a Louisville Metro where everyone has a fair and justice opportunity to be healthy and reach their full human potential. CHE, under the direction of T Benicio Gonzales, works to advance equity through prioritization of policy change, meaningful partnerships, and transformational practice to address the root causes of health and the systems of power that shape them. For most of its history, CHE has been a smaller departmental division with an average of five staff.  

The Louisville Metro Department of Public Health and Wellness is transforming its public health practice to align with the Public Health 3.0 framework and address the social determinants of health. To that end, in January 2018 Dr. Moyer directed LMPHW to undertake a new strategy and organizational alignment to achieve better health outcomes in the community. This new alignment created an expanded Center for Health Equity staff and organized those staff members into Root Cause Teams (RCT) and Skillset Labs (SSL). 

A 7-month workplan was designed to bolster the new strategy and structure by framing our daily work to be clearly focused on advancing the principles of Public Health 3.0, including a deeper focus on addressing the root causes of health and achieving health equity. Six Root Cause Teams were created, including: Early Childhood Development, Criminal Justice, Housing & Economic Development, Food & the Built Environment, Environmental Equity, and Social/Cultural Capital. The goals of the workplan included improving the skill and ease of communicating expertise on root causes of health and health equity through formal and informal communication mediums and increasing staff's ability to work collaboratively across the department, other local government agencies, and the greater Louisville community.  

The workplan was divided into five phases for the Root Cause Teams to carry out, and included: 

  1. Foundations of Health Equity & Root Causes: deepening our understanding of health equity and the root causes of health  

    1. Completing shared weekly readings,  

    2. Developing and delivering a health equity elevator speech 

  2. Defining Root Causes: understanding the specific root causes by RCT 

    1. Conducting a literature review 

    2. Root cause specific elevator speech 

    3. 2-page brief on specific root cause

  3. Root Causes & Health Equity: identifying the connections between the root cause and health outcomes, using a health equity lens 

    1. Causal diagram training and causal diagram development  

    2. Intersectionality training 

    3. 2-page brief on root cause relationship to health outcomes 

  4. Our Louisville Context: examining Louisville's local context related to health equity and root causes 

    1. Story Map training 

    2. Gathering data on relevant metrics  

    3. Identifying community and strategic partners addressing root causes and current local issues 

    4. Identifying historical and policy issues 

    5. Developing a story map with graphs, tables, and narrative to communicate about health and the RCT's specific root cause 

  5. Plan of Action: planning for addressing the identified root cause using an equity lens 

    1. Developing a written plan of action presented to colleagues across the department 

The objectives of the workplan were met with extended timelines for some deliverables; RCT deliverables were shared through CHE staff section gatherings hosted at the end of each phase of the workplan. The plan was able to be carried out because department leadership continued to champion organizational realignment efforts to address root causes of health and advance health equity. Training efforts were organized to meet identified gaps in knowledge and skills of staff making the transition to their daily work addressing health equity. This workplan and practice provides guidance for preparing and transitioning LHD staff to public health equity practices and addressing the root causes of health. The department's Community Health Improvement Plan is now shaped to address root causes through this organizational alignment and completion of this workplan. More can be learned about our department at www.louisvilleky.gov/health and www.healthequityreport.com

Local health departments focused on advancing health equity must devise strategies to transition their staff from the more traditional public health education and promotion activities of the past several decades to daily work focused on advancing health equity. This work may consist of policy development, data collection and analysis, strategic community engagement, and an explicit focus on addressing root causes of health instead of health outcome-based programming. LHDs are challenged to address stubborn chronic disease outcomes which have not significantly improved in the past several decades and other barriers to health and wellness which prevent opportunities for optimum community health. These challenges are shaped by increasingly stressful budgetary constraints which dictate practice opportunities. The model put forth in Public Health 3.0: A Call to Action to Create a 21st Century Public Health Infrastructure encourages local health departments to take on the role of Chief Health Strategist, address the root causes of health, and use collaboration and strategic partnerships to advance health equity.  

A 7-month Root Cause Team and Skillset Lab workplan, which in practice took the majority of 2018 to complete, was created by the historical (pre-realignment) CHE staff; these staff used their knowledge of public health and health equity research to establish the workplan framework to include key terminology, research, skill and strategy development opportunities, and practice opportunities for department staff. The shift from programs focused on health outcomes to root causes of health requires committed effort and training. An entire month was spent laying the foundation of the health equity framework. Additionally, given that many ongoing grants were health outcomes focused, discussions were had with grantors to improve flexibility of employee time.  

This organizational shift offered new opportunities for strategic partnerships and community engagement, and also allowed LMPHW to reexamine professional development opportunities and leadership expectations.? Trainings were offered to build staff knowledge and capacity and lay the foundation for new work moving forward. Training offerings were created by CHE staff—including through the newly formed Skillset Labs—and department partners on numerous topics. Skillset Lab goals included enriching knowledge and expertise of the skillset through professional development plans and improving the ability to effectively communicate expertise and share skills with non-experts. Skillset Lab staff members were key drivers of these topics as they worked with their colleagues to determine training needs. These trainings covered a wide range of topics, including: developing talking points and delivering an elevator speech, conducting a literature review, intersectionality, causal diagrams, basic GIS, ArcGIS Online, creating surveys, policy development, and community engagement strategies.  

The target population for the development and delivery of this workplan was the newly realigned staff of the Center for Health Equity at the Louisville Metro Department of Public Health & Wellness. Prior to this realignment, CHE was comprised of three frontline staff and the Center's director; after the alignment there were 40 staff members within CHE. In addition to CHE staff, there were a handful of LMPHW staff from the Health Operations section of the department who participated in the RCTs and the completion of the workplan. Each CHE staff was required to participate in the workplan as part of their work responsibilities. Positions and projects were shifted to align with root cause teams that could focus on the deep drivers of health, such as housing, food systems, environmental quality, and early childhood development. These root cause teams were based on the Center for Health Equity's 2017 Health Equity Report available at www.healthequityreport.com. ?  

Restructuring a department can be challenging and complex, but with appropriate planning and capacity building for staff, the realignment can maximize resources and improve a department's ability to address health equity.  While educational trainings exist to teach about health equity concepts, there exists a gap in transition plans to move existing public health staff from traditional health education and promotion strategies to a Public Health 3.0 model directly focused on the root causes of health and using health equity strategies to improve community health. This new structure—facilitated by a 7-month long workplan—increased collaboration and reduced?siloing?across the department as new expectations around communication were instituted. In order for LHDs to make the transition to Public Health 3.0, new organizational practices will need to be implemented and workforce development strategies used to build staff and departmental capacity to advance health equity. 

In July 2017, Louisville Metro Department of Public Health and Wellness (LMPHW) welcomed Dr. Sarah Moyer as the new Director. Dr. Moyer used the opportunity to assess LMPHW's activities and how well they aligned with the foundational principles of Public Health 3.0 and advancing health equity. The goal was to maximize the department's staff and resources to have a more meaningful impact on reducing health inequities in the community of Louisville.? The department was restructured so an entire section could focus on root causes of health and health equity while mandatory functions such as clinical services and health inspections could continue in an operations division.?This realignment resulted in the development of six Root Cause Teams (RCT) and three Skillset Labs (SSL) to which all Center for Health Equity staff were assigned.  


The purpose of developing and implementing this workplan was for the department to undertake a new strategy and organizational structure to achieve better health outcomes in the community by framing our daily work to be clearly focused on advancing the principles of Public Health 3.0.? The planned outcome of the work plan was that CHE team members would be better positioned to advance the foundational principles of Public Health 3.0. Each stage of the plan had identified deliverables culminating in a completed Plan of Action presentation and proposal for each of the six Root Cause Teams and professional development plans for each of the three Skillset Labs.? The workplan process created opportunities for staff to learn, build, and demonstrate skills together in each of the RCTs and SSLs. All Center for Health Equity staff—now 40 staff—and additional staff from Health Operations participated in the completion of the workplan.  

This work plan established 6 Root Cause Teams at a realignment kick-off retreat with the newly aligned Center for Health Equity staff. These Root Cause Teams are informed by root causes of health identified in the department's 2017 Health Equity Report which can be found at healthequityreport.com. The report is the third such report from the Center, and the 2017 report delves deeper into the root causes of health and their connection to health outcomes. These specific root causes were chosen after discussions with department administrators and staff which identified the areas of focus for their work and their passions. 


There were five learning objectives for the RCTs: 1) Gain knowledge of foundation health equity and root cause theory, 2) improve skill and ease of communicating expertise on root cause and health equity through formal and informal communication mediums, 3) increase ability to work collaboratively across LMPHW, Louisville Metro Government (LMG), and the greater Louisville community, 4) Strengthen ability to translate research into action through synthesis of data and detailed action plans, and 5) Team members will be able to present on their root causes and the Health Equity Report. A seven-month work plan was laid out to complete the objectives. The following table gives an overview of each phase's goal, timeframe and expected outcome for the RCTs.?? 

  

Research/Discussion? 

Time Frame? 

Expected Outcomes? 

  1. Foundations of Health Equity & Root Causes: Deepening our Understanding of Health Equity and the Root Causes of Health? 

30 Days? 

  1. Groups will review expectations & set their group working norms? 

  2. Training: Elevator Speech? 

  3. Learning & Skill Building (Weekly meetings)? 

  4. Deliverables at the end of this period? 

  1. Define Root Causes: Understanding the Specific Root Cause (of Focus) and Developing a Working Definition for that Root Cause which can be used across LMPHW? 

60 Days? 

  1. Training: Conducting a Literature Review? 

  2. Learning & Skill Building (Explore theories across disciplines)? 

  3. Deliverables: Elevator Speech, Internal Literature Library Reference, brief 2-page definition/background, & a presentation to CHE? 

  1. Root Causes & Health Equity: Identifying Connections between the Root Causes and Health Outcomes Using a Health Equity Lens? 

45 Days? 

  1. Trainings: Causal diagrams & overview of intersectionality? 

  2. Learning & Skill Building: Health Outcomes in our Community, positive/negative versions of the root cause? 

  3. Deliverables: Causal diagram, elevator speech, 2-page brief on root cause & relationship to health outcome, Presentation to CHE?? 

  1. Our Louisville Context: Examining the Louisville context of the root cause & equity issues?? 

45 Days (SSL joins here to collaborate with RCTs)? 

  1. Training: Developing a Story Map? 

  2. Learning & Skill Building: Data Gathering, Identifying Stakeholders (community engagement, strategic partnerships), & Policy development (historically, brief benchmarking)? 

  3. Deliverables: Graphs, tables, and maps in a story map, Story Map Presentation to CHE? 

  1. Plan of Action? 

30 Days? 

  1. Training: Components of Plan of Action (Uniformity)? 

  2. Learning & Skill Building: A List of Questions Provided Focused around Data, Strategic Partnerships, Policy Development, & Community Engagement? 

  3. Deliverables: Presentation of Plan of Action to CHE and LMPHW? 


Implementation and completion of the workplan utilized the skillset and expertise of staff from across the entire department and department partners. Examples include guidance from communications staff who trained staff on developing talking points and drafting and editing an elevator speech which was used to enhance staff's ability to communicate about health equity to community partners. A local professor provided instruction on conducting a literature review to all staff. Louisville Metro Government staff provided a brief introduction and practice opportunities on understanding and using ArcGIS Online. CHE staff, through their assigned SSLs, provided training to colleagues on developing a plan of action, survey design, causal diagrams, and the concept of intersectionality.    

The SSL's Work Plan had two learning objectives: 1) Enrich knowledge and expertise of skillset through professional development plans and 2) Improve ability to effectively communicate expertise and share skills with non-experts. The following table gives an overview of each of the SSL workplan goals.  


Research/Discussion? 

Time Frame? 

Expected Outcomes? 

  1. Conduct an Analysis of Learning Opportunities? 

30 Days? 

  1. Perform a KWL chart to identify what members know, want to know and learn? 

  2. Conduct a SWOT Analysis to identify?areas of strength, weakness, opportunity, & threat? 

  3. Identify current & possible future resources for professional development opportunities? 

  4. Deliverables: KWL, SWOT, List of resources? 

  1. Develop a Professional Development Plan? 

30 Days? 

  1. Create individual 1-year learning plan with objectives on how to advance expertise in skillset? 

  2. Create group 1-year learning plan to advance whole skillset expertise? 

  3. Collaboratively create list of things you'd like to know/learn from other SSLs? 

  4. Deliverables: Individual PD plan, Group Learning Plan, List from other SSLs? 

  1. Develop Mini-Curriculum from other SSLs? 

30 Days? 

  1. Using list other groups have compiled, create a mini curriculum addressing those questions using several modes of learning (presentations, interactive activities, handouts/case studies)? 

  2. Discuss how your skillset intersects with other skillsets? 

  3. Deliverables: mini curriculum for other SSLs?? 

  1. Knowledge Sharing? 

30 Days?? 

  1. Implement the designed curriculum? 

  2. Deliverables: Presentations of mini?curriculum to other SSLs? 

  1. Ongoing Work of Louisville Begins With RCT? 

~2 months (RCT collaboration; RCT will be dividing work into skillsets as mentioned in Table X)? 

  1. Discuss your work in groups and share ideas on sources of information & ways to work most effectively? 

  2. Deliverables: Dependent upon what is identified by RCTs? 


The results of implementing this organizational realignment and RCT/SSL workplan has led to increased focus on addressing social determinants of health in the department's strategic planning and community health improvement planning. CHE root cause teams are aligned with each of the goals of Louisville's community health improvement plan, Healthy Louisville 2025 (HL2025). Four root cause teams are working on Healthy Louisville 2025 projects which require convening stakeholders and identifying implementation plans; the strategies that emerged are directly addressing the root causes of health. Stakeholder engagement and HL2025 implementation plans will also lead to the development of the next Health Equity Report. This new organizational structure and its alignment to the CHIP allows us to strengthen our ties across the city.?? 

A process evaluation was conducted throughout the workplan; staff were surveyed at the end of each of the five phases of the workplan. Additionally, staff were asked about key health equity concepts, and to provide self-report responses to the surveys provided at the end of each workplan phase.  


Root Cause Team learning objectives were:  


  1. Gain knowledge of foundation health equity and root cause theory.  

  2. Improve skill and ease of communicating expertise on root cause and health equity through formal and informal communication mediums.  

  3. Increase ability to work collaboratively across LMPHW, LMG, and the greater Louisville community.  

  4. Strengthen ability to translate research into action through synthesis of data and detailed action plans.  

  5. Team members will be able to present on their root cause and the Health Equity Report.  


Skillset Lab learning objectives were:  


1. Enrich knowledge and expertise of skillset through professional development plans.  

2. Improve ability to effectively communicate expertise and share skills with non-experts. 


The 40 staff members were asked to provide feedback on the workplan process at the end of each phase. Staff were asked:   


  1. What was clear to them after [end of completed Workplan Phase]. 

  2. What was least clear to them or needed more explanation after [end of completed Workplan Phase] 

  3. To provide any other comments or suggestions for work plans and/or structure. 


Several key insights and themes emerged from the staff surveys; insights included skepticism about organizational impact on the social determinants of health, confusion about leadership structure within the realignment, balancing new responsibilities, and some reluctance to commit to the new organizational strategy.  

  1. Organizational impact—staff expressed skepticism about the department's new direction and what the Root Cause Team realignment would realistically achieve. Staff have experienced various organizational changes over their years within the department that they perceived as not achieving their desired outcomes and reasonably questioned whether there was full support from top department leadership of the workplan. Staff questioned, …are we?actually?going to be trying to change the issues we see in Louisville?” Others wondered how the workplan would move their work from understanding health equity concepts to taking action for health equity and asked how the change would be made real.” Through the development of the RCT plans of action (Phase 5), teams were able to determine actionable steps to address social determinants. Additionally, CHE root cause teams are now aligned with each of the goals of Louisville's community health improvement plan, Healthy Louisville 2025 (HL2025). Four root cause teams are working on Healthy Louisville 2025 projects which require convening stakeholders and identifying implementation plans; the strategies that emerged are directly addressing the root causes of health. 

  2. Organizational structure—the organizational realignment resulted in staff working across (previously defined) divisions to accomplish their RCT workplan objectives; staff continued to report to their supervisors from before realignment. Process surveys from staff revealed confusion about how to prioritize direction from their administrative supervisor which they had an established relationship with, and from the facilitator of the RCT. Instances of this questioning were addressed on an individual basis, and a later policy put forward for CHE staff that the section would operate under a project leadership structure. The project leadership structure has similarities with a matrix management organizational structure; staff are accountable to both an administrative and daily work supervisor while also being responsive to project leaders and RCT facilitators. This model requires significant communication between the administrative supervisor, project leaders, and RCT facilitators.  

  3. Time management—the organizational shift for most staff to focus on addressing the social determinants of health in their daily work resulted in questions about how to integrate the requirements of the RCTs and SSLs and their workplan objectives with existing work requirements—some of which were grant-based. Staff specifically asked, how do I balance my job responsibilities?before the re-org?with my responsibilities?after the re-org?” While others were left with questions regarding the extent to which our daily work/priorities will be shifted to reflect an equity-focused approach.” The workplan process continued on as planned and CHE leadership worked together to develop annual workplans for each staff to outline core public health functions, while incorporating RCT and SSL and other explicit health equity functions into their daily work. These annual workplans are monitored by staff and their supervisor.   

  4. Commitment—while most staff expressed eagerness to increase their knowledge and work advancing health equity, there was some resistance from staff. Staff expressed some anxiety about their role in the organization taking on a Public Health 3.0 strategy addressing the social determinants of health. Evaluations collected at the end of each phase asked for more communication about long-term plans and goals of this shift in strategy and what role staff would play in reaching department priorities. Trainings were provided and input sought on additional learning opportunities needed to aid in skill building for staff, including in policy development, data analysis, and community and partnership engagement.  

Organizational change requires continuous communication about the vision, mission, and values of the organization and how implementing a new strategy is helping to meet those goals. In order to successfully implement the RCT/SSL workplan, staff must have opportunities to provide continuous feedback on new processes and functions. Some of the responsive practice strategies implemented continued to be formed after the RCT/SSL workplan period as feedback from staff continued to be refined and incorporated by CHE administrators. 

The Louisville Metro Department of Public Health & Wellness continues to advance a Public Health 3.0 strategy. The Center for Health Equity operates Root Cause Teams and Skillset Labs to prioritize a focus on the social determinants of health and build staff capacity to enact health equity strategies. The organizational practice is supported by the department's leadership and through administrative practices, including employee annual workplans which incorporate advancing equity, root cause, and skillset development goals.  

Several lessons have been learned through the workplan implementation. It is important to have continuous communication about implementing a Public Health 3.0 strategy and the plan for achieving its goals and objectives. Our written plan and accompanying reading list was made available to all staff and provided to new staff as they were onboarded. The workplan also worked to create a shared vision and language for CHE staff and others participating in the workplan. Establishing this shared vision and understanding of a health equity framework was possible through numerous trainings and skill share opportunities for staff, both in their group and individual daily work. Staff were provided with capacity-building opportunities over the course of the workplan implementation period, including learning (or receiving a refresher) on how to conduct a literature review, citing sources, and communicating about health equity and the 2017 Health Equity Report. 

CHE root cause teams are aligned with each of the goals of Louisville's community health improvement plan, Healthy Louisville 2025 (HL2025). Four root cause teams are working on Healthy Louisville 2025 projects which require convening stakeholders and identifying implementation plans; the strategies that emerged are directly addressing the root causes of health. Stakeholder engagement and HL2025 implementation plans will also lead to the development of the next Health Equity Report. This new organizational structure and its alignment to the CHIP allows us to strengthen our ties across the city. ?? 

Implementing a Public Health 3.0 strategy at LMPHW has been supported by establishing group learning and collaboration structures for staff. Staff have had the opportunity to dialogue with, learn with, and learn from each other through regular Root Cause Team and Skillset Lab meetings, and Center for Health Equity section gatherings. Training and practice opportunities are an important part of cultivating a learning culture within the department. This process has also been supported by encouraging systems thinking which is needed to advance a Public Health 3.0 and health equity strategy. The work plan has provided staff opportunities to explore and understand how root causes are tied together, their impact on health outcomes, and the community and partnership efforts that must come together to address complex issues and improve community health so everyone and every community can thrive. ? 

NACCHO Publication (Connect, Exchange, Public Health Dispatch)