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.