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Using Town Planning to Make a Breakthrough in Community Engagement: The CAS Theme for the Month

2010/08/01

In this post we begin a new practice for the Center for Adaptive Solutions: sharing our various perspectives throughout the month to provide analysis, insight, and examples of actions which can help communities move forward, and to make breakthroughs on problems they have previously been unable solve.   The arena for our posts this month, town planning, is well-known for its requirement to bring together multiple participants with both divergent and convergent interests to work together toward a common goal and vision.  Our mission (as CAS) is to assist whole systems to come together, make good decisions, and reach levels of performance which were previously unattainable.  In our posts this month, we will use several examples of towns, communities, and regions faced with challenging, and apparently intractable problems- in making decisions about building schools and raising taxes; in helping a parents’ advocacy group work better with the local school system; and in achieving sufficient cooperation among competing interests to solve problems that cross boundaries and require some entities to accept short-term losses in return for the hope of longer-term gains for the entire community.  There are common features across these specific examples—they require individuals to consider subordinating their local interests in order to support the common good; they involve complex, multidimensional challenges for which durable solutions require bringing the whole system into the room; and they require engagement among people and subgroups who may have conflicting interests and may not come together for any other purpose.

This introduction to the series will provide a framework for the month’s discussion and will highlight some elements of the CAS approach to generating common sense solutions to systemic problems.  We will focus on ways of identifying the system of concern, bringing the whole system into the room, and fostering collaborative inquiry when the stakes are high.  From this we will derive principles of community engagement, collective decision-making, and brining about long-lasting, durable changes in this kind of system.  After providing an example, we will generalize the learning to form rules of thumb regarding whole-system breakthroughs in areas which have not been solvable before.

To start with, I want to build on my recent post, “Self-Interest and the Common Good,” which featured the perennial challenge of democracies to rise above self-interest in order to preserve larger goals which may go against one’s own self-interest.  That post highlighted a meeting of several hundred people in one of Ontario’s fourteen LHINs (Local Health Integration Networks) to promote system integration, imagine healthcare models of the future, and find ways to move toward that vision.   This meeting was part of a larger movement in the Province to deal with budget shortfalls and “bend the cost curve” by improving quality, reliability, and coordination of care.   Participants in this meeting were urged by the team of consultants and facilitators to “think system” and rise above their local interests.  But in working groups organized to envision the future of various program areas (such as cancer care, chronic disease management, primary care, and several others), the hardest issues to resolve involved competition between hospitals and provider groups over who would retain major clinical programs and where these programs would be located.  At a meeting of Governors (local Board members of hospitals and other service providers), probably the majority sentiment was expressed by a Board member who said, “I have to be candid—I am here to represent my local hospital and community; I know we have a system, but it is secondary for me.”  For our purposes, this comment raises several key questions: What do we mean by a healthcare “system,” and why should people care about it?  Why should they give it credence, or standing, in relation to their local and individual interests?  How can they determine its relative value or benefit?  And how does this discussion relate to town planning?

Approaches to healthcare reform generally succeed or fail based on how well they approach the question of who comprises the “whole system” that should be “in the room” when decisions are made.  If we include providers, hospitals, insurors, and government, we leave out suppliers, communities, citizens, patients, and families.   The resulting solutions often fall short of what is needed because they have left out too many of the stakeholders who will be crucial for lasting reform.  On the other hand, when efforts are made to be inclusive, for instance by bringing in patients and families as influencers and even decision-makers, experts feel their advice and knowledge is being overlooked or discounted.  Furthermore, the process runs greater risk of bogging down, generating delays, and otherwise losing momentum instead of providing hope for a better way.  Ideally, one would hope to obtain the best elements of both paradigms—broad participation with deep expertise, focused conversations with systemic impacts, “early wins” with lasting gains.   Are there approaches which can engage all stakeholders in making decision that generate a new, durable, and systemic healthcare solution, while maintaining momentum, leveraging knowledge and expertise, and creating a synthesis of the views of the “experts” with those of “the common man?”

The LHIN in question is trying to take this kind of approach.  In their system integration initiative (called Care Connections), they are including the entire community as stakeholders and decision makers.  This includes a much broader circle of involvement than in the past (thus a kickoff meeting with hundreds of invitees rather than a much smaller advisory council to meet with the LHIN management team to do program planning for the future).   Yet the LHIN faces a parallel problem in carrying out a more inclusive approach- the tendency of all decision-making, as well as all politics, to be local.  The LHIN in question includes 77 local Boards of healthcare entities, including (but by no means limited to) hospitals.  These entities include hospices, community mental health agencies, and community care access centers (which coordinate resources and care mainly for the elderly).  Thus the project of creating a higher-quality, lower-cost, more integrated healthcare system for the region is also, by implication, a regional and multi-town planning effort.  By raising the question, “What should the model of care look like for the region 5-10-20 years from now?” the initiative indirectly raises many related questions which directly affect the towns and cities within the region.  These questions include: What will be the roles of the hospital, providers, patients and families in the system of the future?  What clinical programs will remain in a given area?  Which ones will be cut back or consolidated with others in the region?  Will any programs be added?  If so, how will this and other key decisions be made, including those affecting of resource allocation and access to care in specific towns and cities?  Very quickly we move into questions of conflict, competition, compromise, and diverging vision for the future.

Questions like these can, and often do, cause a process like the one just described to have a promising start but then bog down in a morass of competing local interests with no way to work them through, in a timely but satisfying way, for all concerned.  This is the challenge addressed successfully by the author of the second post in this series, Dr. Rick Lent, in a successful town planning effort for which he was the facilitator.  Before turning things over to him, however, let me add a closing thought: thinking of a system in terms of innovation strategy can be useful when designing, leading, and facilitating change, for example in town, municipal, and regional  planning efforts.    For our purposes, the innovation being promoted in the Ontario case is the ability for local actors (such as Board members) to consider the needs and interests of the wider “system” or region, or Province) as they consider and make decisions at the local level.  Indeed, it means the ability to subordinate local interests to those of the region or Province, and thus to accept funding cuts in specific local programs in order to maintain, sustain, and create new capacities for the region.  At the moment, this ability is rare, but it does have Early Adopters, or those for whom it is intuitively obvious (use aboriginal quote).  Others who are Late Adopters will take a long time to convince; the gentleman quoted above would probably be in this category.  A third category is the Pragmatists; in this case, the third speaker in the Governance session (Sean) provided a way forward.  We can use the categories of Early Adopters, Pragmatists, and Late Adopters to gain a closer understanding of “what’s in it?” for each of these groups if they commit to the system integration goals of the LHIN.  In doing so, we can see a new pathway forward for pursuing the goals of the Care Connections initiative while increasing the odds that a prevailing majority of the human “system” will carry on the gains made during the early stages of this process.

In upcoming posts in this series, we will have contributions from Rick Lent, Clarissa Sawyer, David Morf, Paul Hutchinson, and Joseph Carrabis.

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