Pathways to Healthy Communities

The following comes from a presentation on, “Developing a Systems Thinking Perspective of a National Deliberation Project on Healthcare Costs” as part of the “How Can We Reduce Costs and Still Get the Care We Need?” Kumu project which was featured in the last blog post, “Using Deliberation and Systems Thinking to Address Healthcare Costs”. They are the three concluding statements arrived at after the completion of a systematic inquiry into the NIFI forum on healthcare costs.

1. We should not approach issues of Healthcare Costs in terms of "Cost Savings". Instead, we should approach it in terms of "Reinvesting and getting a Better Return”.
2. We should endeavor to bring Healthcare concerns, both health, and costs, closer to community-based approaches. The positive aspect of such an approach is that there are already numerous efforts going on. These need to be prioritized to a far greater degree. (and made to have a Collective Impact)
3. Community-based efforts should focus first on health then find cost-efficient means of implementing programs, not the other way around. 

The salient point for this post is, “The positive aspect of such an approach is that there are already numerous efforts going on. These need to be prioritized to a far greater degree.” This means moving our attention away from the deliberative process of deciding issues of healthcare costs to creating and implementing programs in a community based on those decisions.

This then would be a part of a process of creating what will be called Healthy Communities (wiki-tag). Below are several new websites recently added to the New Community Paradigms Wiki, all of which have some focus on health and community.

Healthy Communities involves building Healthy Cities (wiki-page) as well as focusing on Community Design (wiki-page), Geographic Based (wiki-page) community change agencies, and rethinking our Streets (wiki-page).

Healthy Cities approaches working toward community health from a variety of different perspectives and levels. Some are more functional and could be applied in a variety of settings, like a toolbox. This particular Community Tool Box | Table of Contents is a service of the Work Group for Community Health and Development at the University of Kansas.

“The Community Tool Box is a free, online resource for those working to build healthier communities and bring about social change. Our mission is to promote community health and development by connecting people, ideas, and resources.”
Others like the Gallup-Healthways Well-Being Index provide important health data.

“The Gallup-Healthways Well-Being Index® is the first-ever daily assessment of U.S. residents' health and well-being. By interviewing at least 1,000 U.S. adults every day, the Well-Being Index provides real-time measurement and insights needed to improve health, increase productivity, and lower healthcare costs. Public and private sector leaders use data on life evaluation, physical health, emotional health, healthy behavior, work environment, and basic access to develop and prioritize strategies to help their communities thrive and grow. Journalists, academics, and medical experts benefit from this unprecedented resource of health statistics and behavioral economic data to inform their research and reporting.”

Another similar site is Rankings | County Health Rankings & Roadmaps, sponsored by the Robert Wood Johnson Foundation, which "allows you to Look up your county’s Rankings, learn about their methods, and download the data you need."

An example at a local city level of a community focusing on health is Davidson Design for Life.

“Davidson Design for Life (DD4L) is an initiative of the Town of Davidson to foster healthy community design through the use of health impact assessments (HIA), public participation, and collaborative efforts in Davidson, the Charlotte-Mecklenburg region, and North Carolina.”
Even though a small community of 11,750 people (2013) with Davidson College nearby with 1,920 students, the site provides information on Health Impact Assessment: What is it?, for the surrounding region and information on HIA in the US.

At a state level for Minnesotans is Alliance for Healthy Homes and Communities.

“All Minnesotans should have the opportunity to make choices that allow them to live a long, healthy life, regardless of their income, education, or ethnic background. Everyone wants good health to be productive at work and to succeed in school and to have affordable medical and housing costs. To make this opportunity a choice for all Minnesotans, we all have to do our part in creating and maintaining healthy homes and communities. Every person and every organization have a role to play, small or large.”
Closer to home is LA2050 - Shaping the future of Los Angeles, which involves though a major city with a population of over 3.8 million and a focus that expands beyond healthcare concerns to other areas, so it has been placed under Geographic Based community change agencies.

“LA2050 is a community-owned mechanism to create a shared vision of success for Los Angeles in 2050 and to track progress toward that vision.”
At a state level is The California Endowment which is also involved in the Creating Health Collaborative and in the related Stanford Social Innovation Review presentation on “Organizing Communities to Create Health”.

"The California Endowment was established in 1996 as a result of Blue Cross of California's creation of its for-profit subsidiary, WellPoint Health Networks. Since then, we've invested in health broadly, from strengthening the safety net for families struggling with poverty to diversifying the health care workforce. The lessons learned from early investments were the genesis for Health Happens Here and the 10-year, $1 billion Building Healthy Communities plan, in which residents in 14 places are working to transform their neighborhoods."

The sites cited above involve data and organizations. There is also a need to consider at a more foundational physical level in the promotion of health through design, which is what the Center for Active Design does.

“The Center for Active Design is a nonprofit resource for design professionals, policymakers, real estate developers and community advocates, committed to promoting and expanding the Active Design Guidelines published by New York City in 2010. We maintain a multi-disciplinary perspective in the translation of health research into design solutions that amplify the role of architecture and urban planning in improving public health and well-being.”

"Rethinking the Automobile", a project created to raise awareness around the negative impact of the automobile on our world by livable streets advocate Mark Gorton no longer seems to exist. The presentation, associated with the site, still exists on Vimeo. 

Elsewhere, from a more creating health perspective, is the StreetFilms video Carmaggeddon Averted as Broadway Comes to Life, in which "Mark Gorton takes us on a tour of Broadway's car-free squares and boulevard-style blocks, where conditions have improved dramatically for pedestrians, cyclists, and, yes, delivery truck drivers," putting forward the counterintuitive truth that taking away space for cars improves traffic and makes the city safer and more enjoyable for everyone on foot, based on established theories like traffic shrinkage and Braess's paradox that help to explain why this happens.

These are not the only websites in the NCP wiki related to health or healthcare, in fact, most can be related, at least indirectly. They are the most recent and have not been featured previously.

Laying out a few possible pathways to creating Healthy Communities does not lay out the entire required journey. Moving from the primarily deliberative process to actual implementation of programs still, means overcoming any fundamental differences in perspectives or mindsets within the community (which will exist even if everyone is familiar and adept at systems thinking) and crossing the Knowing-Doing Gap by Jeffrey Pfeffer and Robert I Sutton as discussed in previous posts. There is still lots more work to do but this does make it all the more possible. 

Using Deliberation and Systems Thinking to Address Healthcare Costs

This blog post is another in a continuing effort to integrate systems thinking with a system of both deliberative and participatory (or direct) democracy while recognizing the limitations of such attempts so as to learn more for the future. The focus this time is on healthcare costs.

These efforts to justify systems thinking as a means of scaffolding for systems of direct democracy have ranged from the more abstract approach to Deliberation and Democracy, a Kumu mapping of the article Deliberation, Democracy and the Systemic Turn co-authored by David Owen and Graham Smith and the Better Deliberative and Participatory Democratic Community Based Governance through Systems Thinking model that sought to demonstrate how systems thinking might be incorporated into a process of deliberative and participatory governance of a community to the more direct involvement approach with the DDST Community made through participation in the Dialogue, Deliberation, and Systemic Transformation Community and through another opportunity for exploration with the NCDD Overcome the Lack of Trust in Our Democracy, Leaders, and One Another project.

What they all have in common is that they are limited, not only in terms of George Box’s principle, "All models (or maps) are wrong, Some models are useful” but also in terms of applicability. They are narrowly focused experiments in applying systems thinking to questions of direct community governance. An analogy might be to see them as attempts to match the work of Erasmus Darwin, and others, in the natural sciences prior to his famous grandson’s theory of evolution. They are opportunities for trial and learning.

Just prior to finishing off with the Collective Impact series of blog posts, Kumu maps and presentations and then spending the last two posts on making up on some past good intentions, another opportunity to explore the integration of systems thinking and systems of direct democracy through Kumu mapping arose through the NCDD (National Coalition for Dialogue and Deliberation.

Back in September, the NCDD Community News announced an opportunity to Join the National Deliberation on Health Care Costs. The NIFI (National Issues Forum Institute), in cooperation with the Kettering Foundation and Public Agenda, was sending out, “You're Invited - Join a National Deliberation Project about Healthcare Costs - FREE materials available” notices.

The NIFI forum on a National Deliberation on Healthcare Costs provided another opportunity for direct involvement. A lengthy period of lead time before the NIFI process would finish in May 2016 provided time to build a Kumu relational map from the materials that were made freely available. Building the maps was a fairly extensive endeavor. At the conclusion, another limitation became increasingly apparent.

Healthcare, as well as a more focused examination of healthcare costs, is a complex, wicked problem. The applicability of the Kumu relational project on this topic was shown to be limited because of a notable difficulty in moving to a state of what has been called coherent complexity. There was no expectation to make the topic in its full range and depth simple. There was evidence that a deliberative inquiry on its own did not go deep enough to adequately vet the topic. It was also recognized that incorporating a deliberative process with the systems thinking inquiry provided more meaningful breadth. The two modes were better together.

Combining the two modes of thinking though required of others an overly large shift in their thinking, particularly if one or both mode were new to them. On the first impression, the proposed cure seems as complex as the wicked problem it is designed to address. In an ideal world, both modes would have been part of the K-12 curriculum becoming more second nature in being applied. It might be different if built with a group from the start but this was a solo effort. The Kumu mapping project was not designed to provide a set of specific answers but rather provide the ability to build templates for deliberation on various recommendations and the issues behind them.

To assist in this matter two Kumu presentations were created. The first Deliberative Discussions and Systems Thinking provided a general overview of combining systems thinking with a system of deliberation. It was a means of letting people know what they were getting into. The second presentation was more extensive, providing a guided tour as opposed to the former’s tour highlights. Developing a Systems Thinking Perspective of a National Deliberation Project on Healthcare Costs moved from the deliberative perspective to incorporate a systems thinking perspective and potentially provide a platform to move beyond. The full project, including both presentations, is here, How Can We Reduce Costs and Still Get the Care We Need?

In it, the untested but still strongly held hypothesis is made that most would be able to acquire the essential insights if they went through the entire presentation despite limited exposure to systems thinking. It could perhaps require that others are available to help but then a deliberative process can be said to be based on such a foundation. Having one person knowing something about systems thinking acting as a facilitator would no doubt be exceedingly helpful but there is no necessity that everyone is certified in systems thinking. The bigger obstacle would be getting everyone to give up their old mental models of political competition and conflict.

My own perspective is especially slanted having built the Kumu project from the ground up. As someone said before, “Everybody thinks that their own models are beautiful”. There were though two real world instances by which the viability of insights of the Kumu Healthcare Costs project was upheld at least to some extent.

The first was an opportunity to participate in an online forum on the topic hosted by the Kettering Foundation and NIFI. The deliberation forum used the NIFI Common Ground for Action featuring the Conteneo Collaboration Cloud. Having completed the system thinking maps on the topic, I had a strong foundation. Interestingly, the group seemed to gravitate to my way of thinking though to be truthful this cannot be shown to be correlated as the others had no knowledge of the Kumu project and I had no means to directly influence them. What might be surmised is that systems thinking provided the deepest perspective in the context of what people felt that they needed.

The second instance was the surprising correlation between the Kumu Healthcare Costs project and the Stanford Social Innovation Review presentation on “Organizing Communities to Create Health” despite having completed the systems thinking Kumu project before seeing the presentation. It could be asserted that the Kumu project was a “watch works” justification through systems thinking for the vision of the Creating Health Collaborative.

The concept of Communities Creating Health as a means of transforming our system of health in the Twenty-first Century begins creating a bridge with systems thinking between the resources found at the Healthy Cities wiki-page to the Direct Democracy and Systems Thinking wiki-page through Collaborating to Create a Healthy Cities from the earliest days of NCP.

This undoubtedly means enhancing complexity but hopefully, by being open and endeavoring to take a pathway of trial and learning, it will become both more coherent and more insightful for us all in creating new community paradigms.

New Community Paradigms and More Belated Good Intentions

CommunityMatters, cited in the previous blog post, has also hosted a number of other organizations that are of interest to NCP but despite ‘good intentions’ have never been featured in either the blog or wiki up to this point. These newly found resources have now been placed under a variety of different NCP wiki-pages.

The greatest number of additions were under Governance through Community. The concept of Slow Democracy took the longest to be incorporated though it is arguably a necessary addition for New Community Paradigms to be viable, recognizing the difference between government administration and democratic governance.

"It describes how citizens around the country are breathing new life into their communities. Large institutions, centralized governments, and top-down thinking are no longer society’s drivers. New decision-making techniques are ensuring that local communities—and the citizens who live there—are uniquely suited to meet today’s challenges. In Slow Democracy, readers learn the stories of residents who gain community control of water systems and local forests, parents who find creative solutions to divisive and seemingly irreconcilable school-redistricting issues, and a host of other citizen-led actions that are reinvigorating local democracy and decision making."
Other new additions ranged from highly localized such as the Right Question Institute - A Catalyst for Microdemocracy.

“The robustness of the Right Question Strategy is demonstrated in how it is used to address such a wide range of challenges in so many communities around the country and the world and what happens when the RQ Strategy is taught to people who have never had the opportunity to learn to ask their own questions and focus on key decisions that affect them.”
Governance through Community is also home for Resident Learning Exchange featuring Resident-Centered Community Building:

“In June 2012, forty-one leaders of community building efforts came together to share strategies and discuss lessons they have learned about how to improve conditions in disadvantaged communities. While gatherings like these happen regularly, this one was unusual; it was designed by and for community residents.”
Other examples are much broader based.

The Center for Communication and Civic Engagement,

“The center is located in the Department of Communication at the University of Washington, and co-sponsored by the Department of Political Science is dedicated to understanding communication processes and media technologies that facilitate positive citizen involvement in politics and social life through original research, new educational programs, policy recommendations, and Web-based citizen resources.”
The Journal of Public Deliberation | Public Deliberation

“(The) International Journal for Public Participation (2007 - 2010) merged with the Journal for Public Deliberation as a joint venture between DDC and IAP2 in November 2010. In announcing the joint venture in November 2010, IAP2 President Desley Renton said, ‘this initiative builds on the foundations of both journals and will extend the discourse in the field with readers benefiting from firsthand experience of public participation practitioners’.”
Newly placed under Community Places, the NCP wiki home for Project for Public Spaces (PPS), is the National Consortium for Creative Placemaking and its related blog, created to build capacity for sustainable and cost-effective creative placemaking, a new way of making communities more livable and prosperous through the arts. By going beyond public art and performing arts centers it is making them better places for not only the arts, it is making places better for everyone.

“Creative placemaking starts with building effective partnerships. Our approach to creative placemaking is based on six key elements: Building diverse and productive partnerships in communities and with local leadership to implement ideas. Enhancing quality of life for more people in communities Increasing economic opportunity for more stakeholders in communities Building healthier climates for creativity and cultural expression Engaging existing assets (both physical and human) as much as possible Promoting the best and distinct qualities of a place Our work is guided by the teachings of reflective practice, double-loop learning, asset-based community development, fifth level leadership, arts-based community development, communicative practice, environmental justice, and other current and cutting-edge philosophies of practice.”

There is a connection through the wiki-focus page, Community Design to Greater Places | The Community for Urban Design, a crowdsourced “How-To” manual for creating great communities – cities, suburbs and rural areas.

“Think of a Pinterest or Houzz for community design. WHAT IS COMMUNITY DESIGN? Community design is about people, the places we live, and the spaces we share. Community design is also about how we come together and make decisions that affect our communities and neighbors: from crossroads in the country to homeowners’ associations in the suburbs to new apartments in the city.”

There is also now a shared related wiki-page for Community Places and Community Design through Community Arts.

Under Innovation in Governance has been placed the Harvard - ASH Center for Democratic Governance and Innovation and their Project on Social Innovation which provide a virtual knowledge hub for social innovation in cities and municipalities.

“Its purpose is to provide a practical platform for sharing the stories and lessons of exciting innovators from the nonprofit, philanthropic and public sectors. The Project on Social Innovation accomplishes this purpose through an innovator's toolkit, relevant news updates, profiles of best practices, regular blogging, and links to other online resources. The site is an initiative of the Ash Center for Democratic Governance and Innovation at the Harvard Kennedy School of Government.”

Change Management and Processes is a newly created wiki-bridge page connecting Systems Thinking Applications and Organizational, Online and Technology Base  Community Change Agencies. These are the tools, processes, community algorithms that can be used by any community change agency, ranging from the organizational to the personal.

The Change Management Toolbook - Home

"Welcome to the Change Management Toolbook! This site has been around since 1997, and we remain focused on the founding vision of offering really useful and free change management content to our web visitors. This is the fourth (and we believe the best!) major revision of the website - it's a lot simpler and much prettier, and we think you will find that it is easier and quicker to get to the information you want. The changes are not limited to the "look and feel" - we've added some really good additional content, and we look forward to ongoing high-quality contributions by our growing global network of contributors."
The Process Arts site is “a living story of the process arts”.

"Processes can relate to the individual (such as meditation), interpersonal dynamics (for example Nonviolent Communication), group processes (e.g. Open Space, World Cafe, unconference and wiki), on up to very large scale systems, such as economic, legal and political structures (e.g. Threebles, Restorative Circles, or Citizen Deliberative Councils). Even more than a list of particular processes though, the process arts are about an awareness that however we are doing something, that is simply one particular way, and we can and often do experiment with doing it any number of other ways."
Finally, New America is an organization which asserts that it is dedicated to the renewal of American politics, prosperity, and purpose in the Digital Age.

“We carry out our mission as a nonprofit civic enterprise: an intellectual venture capital fund, think tank, technology laboratory, public forum, and media platform. Our hallmarks are big ideas, impartial analysis, pragmatic policy solutions, technological innovation, next generation politics, and creative engagement with broad audiences.”