A Deliberation on Health Care Access

with

Leadership South Coast and Leaders in Southeastern Massachusetts Health Care

Prepared by

Dr. Thomas Flanagan, PhD. MBA and Kevin Dye

SOUTH COAST COLLABORATIVE COMMUNITY DESIGN STUDIO

an initiative of the

Community Foundation of Southeastern Massachusetts

with sponsorship from

The Community Foundation of Southeastern Massachusetts Healthnet

Senior Whole Health The Urban Initiative at the University of Massachussetts Dartmouth

at the

Advanced Technology & Manufacturing Center, Fall River, MA

May 2010

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ii

South Coast Design is a non-profit organization that builds consensus with community stakeholders.

South Coast Design Studio is a capacity-building initiative of the Community Foundation of Southeastern Massachusetts.

A Deliberation on Health Care Access is a civic engagement event designed for Leadership SouthCoast’s Curriculum for 2010. Leadership SouthCoast’s mission is to provide our region with an ongoing source of diverse leaders, who are prepared and committed to serve as catalysts and sustainers of positive change for the quality of life on the SouthCoast of Massachusetts.

South Coast Design is a member of the Institute of the 21st Century Agoras, a 501(c) (3) non-profit organization, dedicated to the evidence-based practice of the Structured Dialogic Design Process.

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Craig Lindell, founder and Chief Executive Officer of Aquapoint also serves as a Director of the regional Economic Development Council and chairs it's long range planning committed as well as citizen's forum dedicated to capital formation in southeastern Massachusetts.

Craig Dutra is president of the Community Foundation of Southeastern Massachusetts. He serves on the advisory board of the Center for Policy Analysis at UMASS Dartmouth. His previous executive leadership also included posts at the United Way, as one of the Boston Mayor’s Senior Policy Advisers.

Matt Morrissey is Executive Director of the Economic Development Council of New Bedford. Matt improved government effectiveness at the Public Consulting Group, founded a high-tech start-up, and handled legislative, economic development and outreach issues at the UMass Office of the President. He also serves the SouthCoast Learning Network and New Bedford ACTS.

A Letter from the Chairman of South Coast Design,

I believe that regional development must be driven by deliberative dialogue with the community. South Coast Design builds that deliberative capacity here.

Our certitude in this practice derives from our personal experience. My commitment to it is driven by breakthrough experiences.

Promoting applications of this approach to our most pressing regional challenges is the most important work I will do for the rest of my life. It is nothing less than the transformation of the New England Town Meeting. Join me in making this our preferred mode of community engagement.

Craig Lindell Chairman, South Coast Design Advisory Board

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Leadership South Coast 2010

Southeastern Massachussetts demographics are similar to national demographics. Therefore, we have an opportunity to be a national model in how we address issues such as access, cost, and wellness within the reformed system. Towards that end you will rigorously engage the diversity of perspectives about what should be done in a rigorous fashion and network with people that can help make it happen.

Michael Metzler Executive Director of Leadership South Coast

Thank you for your commitment to engage the dilemma of access to health care in our region. This event is a structured dialogue of regional leaders in the health care community and the Leadership South Coast Class of 2010. I selected the structured dialogue approach for this event based on my personal experience with the process and its facilitation team.

To Participants in A Deliberation on Health Care Access,

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Table of Contents A Letter from the Chairman

A Note to the Participants

Executive Summary

The Agenda

Stakeholders in Healthcare

On Access: Urgency & Meaning

A Model of Access

Objectives of Access

Beyond Coverage in Massachusetts

Snapshots of the Situation

Southeast Region Outcome Challenges

State & Regional Barriers: Physician Shortage

Navigating the Labyrinth

Access Disparities

Summary Impressions

Method Case Study: New Bedford’s Creative Economy

Building Capacity

Methodology Overview

Bios

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Executive SummaryA Deliberation on Health Care Access, outlined herein, is a design for synthesizing the voice of regional stakeholders in health care. The outcome of this work addresses the question of what ought to be done to improve access to health care in the region. The first engagement of this deliberation is with Leadership South Coast and area leaders in the health care community of the region. This event is intended to lead to further collaboration on health care access ithe ensuing months.

n

evel e

The selected process of deliberation amplifies the lof engagement of the participants by building trust admidst diversstakeholder perspectives. Ideally, participation in this event will begin networking on systemic improvement of health care access

in the region. The approach of structured dialogue sets forth a collaborative

tone, rather than a politicized atmosphere of debate. In this fashion we hope to launch inter-organizational

collaborative action in a fashion that is inclusive of the plurality of perspectives.

The overall community engagement model convenes stakeholders representing the diverse interests within the health care system. This first event builds on the perspectives of people working in various roles within

the health care system. These invited guests were developed through stakeholder identification of a broader endeavor on health and

wellness in the region in 2009.

We will cultivate the insight of these guests addressing:

• What specific problems in access have they personally experienced?

• How can we learn to address these challenges based on what they know works in other places?

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The Agenda 7:45– 8:30 Reception 8:30– 8:50 Overview 8:50– 9:00 Introductions 9:00–10:00 Problems in Access 1 10:15-10:30 Break 10:30-11:15 Problems in Access 2 11:15-12:15 Solutions to Access 1&2 12:15- 1:00 Lunch & Reflections 1:00- 2:00 Themes & Distinctions 2:00- 2:20 Break 2:20- 4:00 Leadership Directives 4:00- 4:30 Learning & Priorities

Solutions to Access 1&2 – Participants sitting in 7 groups of 7 discuss proven and promising solutions to problems in access which they know about, then share.

Problems in Access 1 – Participants sitting in 12 groups of 4 (2 invited guests and 2 LSC members per group) will articulate and discuss actual experiences of our guests in difficulties with health care access. LSC members will draft statements for the wall and key points of the discussion for a report. Participants then rank which statements to share first.

Problems in Access 2 – The groups share their statements with the whole group. Guests from other groups request clarification.

TThheemmeess && DDiissttiinnccttiioonnss articipants consider similarities ct

Learning & Priorities – We will reflect on what was learned and anticipate what we ought to do.

– Pand differences in the statements. They will also seleones they feel important.

Leadership Directives – Participants investigate the interdependency and leverage of the statements.

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Stakeholders in Health CareA Deliberation on Health Care Access begins by engaging the viewpoints of people within the regional health care system. In this session we primarily enage people within the “provider” box in the diagram below.) The members of Leadership South Coast program are primarily representing “public.” LSC members may also have personal experience or knowledge of access to care issues either from a “patient” perspective, perhaps someone they know. So too, there are LSC members which work within the healthcare system and may be also be able to offer some perspective from the provider’s perspective.

the

Stakeholder Roles & their Interaction from Achieving Health Care Reform in the United States: Toward a Whole-System Understanding

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On Access: Urgency & Meaning On April 15, 2010 Reuters released the results of an online poll which indicated the U.S. ranked 10 . According to a Gallup Poll the concern waccess and cost began to outrank AIDS as the top health concern in the U.S. and as of 2008 access outranks cost. So what does ‘access’ mean?

th ith

In 1993 in Access to Health Care in America, an Institute of Medicine Committee defined access as “the timely use of personal health services to achieve the best possible health outcomes.” The definition combines ‘use’ as well as ‘outcomes’.

Prior to that the IOM report suggests that the most

extensive definitional work on access and the related concept of equity was mounted by the 1983 President's Commission for the Study of Ethical

Problems in Medicine and Biomedicine and Behavioral Science Research. They concluded that society had ‘an

ethical obligation to ensure equitable access to health care which requires that all citizens be able to secure an adequate

level of care without excessive burdens. This social obligation was to be balanced by individual obligation, the burden to be

shared by the public and private sectors, and cost containment not based on access. The positioning as

‘an ethical obligation’ was a step away from the positing of health care as a right set forth in the 1952, the

President’s Commission on the Health Needs of the Nation – taking a ‘moral view.’

6

his

appropriate treament:

ence

Objective 5: Reduce Morbidity/Pain via Timely, Appropriate Treatment

es 10 more specific objectives for access:

Incte reform.)

ventive services.

l emergency medical services.

AHS HP2020–9: …receiving appropriate evidence-based clinical preventive services.

ficulties or delays in

e meframe.

AHS HP2020–10: Increase the proportion of practicing primary care providers.

A Model of Access The 1993 IOM Committee put forth the following model for the pragmatic purpose of developing indicators about access. TCommittee selected 15indicators tracking: 5 objectives around birth, preventable disease, earlyfinding of treatable disease,managing chronic disease, and getting timely and

Objective 1: Promote Successful Birth Outcomes Objective 2: Reduce Vaccine-Preventable Childhood Disease IncidObjective 3: Detection and Diagnosis of Treatable Diseases Early Objective 4: Reduce the Effects of Chronic Disease and Prolong Life

Objectives of Access The Healthy People 2020 initiative outlin

rease the proportion of persons with: AHS HP2020–1: …health insurance. (97% in Massachusetts via staAHS HP2020–2: …persons covered for clinical preAHS HP2020–3: …a usual primary care provider. AHS HP2020–4: …access to rapid response prehospitaAHS HP2020–6: …a specific source of ongoing care.

AHS HP2020–5: Increase number of States with prehospital/hospital pediatric care guidelines. AHS HP2020–7: Reduce the proportion of individuals that experience difobtaining necessary medical care, dental care, or prescription medicines. AHS HP2020–8: Reduce the proportion of hospital emergency department visits in which thwait time to see an emergency department physician exceeds the recommended ti

Beyond CoverageWe’re covered…

“Because of our reform, over 97% of Massachusetts residents are insured—the highest rate of coverage of any state in the nation.”

Governor Deval L. Patrick Massachusetts Is a Health-Reform Model Wall Street Journal Opinion Section October 15, 2009

But… • 1 in 5 adults reported difficulties obtaining

care because providers were not accepting new patients or not accepting their insurance type.

• Early gains in affordability eroded with increasing costs

• 22% with unmet need and worsening trend.

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• Evidence of increased barriers to care as demand increased. Sharon K. Long, Urban Institute

Access and Affordability: Update on Health Reform in MA August 19, 2009

Unmet Need for Health Care for Any Reason

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re ford.

Asthma ER rates (chart at left) and high STD incidences in the Southeast and the top three cities are higher than the state.

Sm king during pregnancy is higher in Fall River, New Bedford, and Taunton.

theast Massachusetts Regional Health Dialogue Department of Public Health, 6/7/2007

Southeast Region Outcomes Challenges Residents of larger communities like Brockton, Fall River, and New Bedford have poorer socio- economic and health outcomes than the state.

• Brockton, Fall River, and New Bedford have poorer birth outcomes and much higher teen birth rates.

Fall River has a higher obesity percentage.

Heart disease (chart at left) and diabetes mortality rates are higher for Brockton, Fall River, and New Bedford.

• Admission rates to substance abuse treatment rates are higher for Brockton, Fall River, and New Bedford. (chart at right)

• Firearm death rates and HIV mortality ahigher for Brockton and New Bed

o

Sou

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Southeast Region Barriers: PhyIn addressing the aforementioned outcomes challeThe New England States, 1996 that Southeastern M e

with ability of . The

Massachusetts Medical Society 2007 Physician Workforce Study indicates that in the ensuing decade the overall situation in Massachussetts became severe.

>50% of physicians in New Bedford, Fall River and Bourne are dissatisfied with the current practice environment, the second worse in the state and the trend is worsening (see chart below).

73% of health system managers in those cities report difficulty filling vacancies and that the applicant pool is inadequate and the trend worsens.

…current physician shortages may have impacted access to care for patients, who reported longer waits for medical appointments…1/3 of physicians altered services or adjusted staff to address patient demand. In particular it is especially difficult in New Bedford (on both accounts.)

• Access to primary care physicians worsens.

• Ability of a physician to refer patients to specialists is more of a problem.

• The number of people who waited more than two months to see a primary care physician jumped from 10 percent in 2005 to 16 percent in 2006. New patients have longer wait times to see a physician.

• “…while there was no uniform effect on specialist wait times, there was a large increase in wait times for primary care providers.” (Healthcare Economist – 6/9/2009)

sician Shortage nges, The Dartmouth Atlas of Health Care:

assachussetts has a comparative disadvantag respect to the New England in avail

primary care physicians (see map left)

Phyisician Dissatisfaction with Practice Environment

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Navigating the Labyrinth This is a diagram of a Hospital System by Marco Barbieri and his associates at Density Design Lab. They specialize in visualizing complexity. This diagram is considered

o a

a simplified view. What map do people new thealth care system use? If there were a map available, can they understand the jargon, thelanguage it is written in, and the seemingly convoluted paths? Does it make sense to them culturally and is the interface at the gateways culturally attuned? How much time does it take to figure out?

How many people must be coordinated to get the care they need? And who will do it?

The complexity of navigating the system itself can be a barrier to access.

djcodrin freedigitalphotos.net

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m_bartoschccc freedigitalphotos.net

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Access Disparities 1998 the President unched the Initiative to liminate Racial and

arities in ealth. Concluding:

Hispanics, Poor worse ff on 90% of access easures.

Blacks, Asians worse off n 33% of access easures.

lthough the Federal osition on access evolved om viewing it as a right a ‘social ethical obligation’ in e context of ethnic and inority disparities the most equent use of “access”, in e 2003 report Unequal reatment, is in the chapter n Civil Rights.

Putting Women’s Health Care Disparities on the Map: Examining Racial and Ethnic Disparities at the State Level, Kaiser Famil

InlaEEthnic DispH

- om

- om

ApfrtothmfrthTo

Foundation y

ns of the Situation

are not insured, but 22% have problems in access. Waiting times are lly Latinos and the poor are worse off on 90% of access measures, blacks

east region is particularly difficult due to a shortage of providers which is ical. 50% of physicians in Southeast cities are dissatisfied with their

75%

blem this country faces" according to Gallup Polls. The most valued re for the sick according to Price Waterhouse Coopers (see chart below.)

fic objectives: good birth outcomes, prevention through vaccination, early es, ameliorating effects of chronic diseases, and reducing morbidity

n.

al outcomethis especially concerns differences in successful pregnancies, heart use, violence, HIV, Asthma, and smoking.

into more regular relationships with care providers by eliminating hnic, racial, gender, andlinguistic differences; affordability, mobility

from poor communication or health literacy.

ccess is ‘moral an

dceivil

ight’.

Summary ImpressioWhat is the situation? In Massachusetts only 3%getting worse. Nationaand asians 33%.

The situation in Southsevere and becoming critwork environment and of people hiring physicians report difficulty in filling positions.

What is access? "The most urgent health proaspect of health ca Access is a set of specidiagnosis of treatable diseasand pain in a timely fashio

Access is targeting specific regionSoutheastern Massachussetts disease, diabetes, substance ab

Access is moving people barriers based on cultural, etor fear, or derive

differences attributable to access disparities. In

Aa st ce’

equal ss a

anac‘CR

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ive, it is impressionistic. The ur deliberation on access.

access. We will address these in a briefing to follow.

l

see them referenced in the methods section. The section concludes with bios on the facilitation essary to read this material in order to participate in the deliberation.

This set of snapshots about the situation in access is not comprehenst the perspectives of the participants in opurpose of it is to elici

We have not yet discussed promising solutions, policies, initiatives. One way of framing approaches is as addressing enabling factors, utilization, equitability, inequitability, effectivenessand efficiency of

The rest of this document provides background on the deliberation experience. We will employ the Structured Dialogue Design (SDD) process for our deliberation. SDD uses proven methodsand software tools two of which are referred to as the CogniScope and CogniSystem. You wil

team. It is not nec

You may be intrigued by taking a minute to glance at a photo-essay covering a local application f the process in New Bedford’s Creative Economy. o

From ImproAmericIndicPamela L. D

ving Access To Care In a: Individual and Contextual

ators, Ronald M. Andersen, avidson in Changing the

U.S. Health Care System: Key Issues in Health Services Policy, Third Edition 2007 By Ronald Andersen, Thomas H. Rice, Gerald F. Kominski.

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Example: Convening New Bedf

AHA! Aquapoint Industries Artworks Broad Reach Advisors, Inc. Buttonwood Park Zoo Charlton College of Business, UMass Dartmouth College of Visual and Performing Arts, UMass Community Foundation of Southeastern Massachusetts Creative Economy Coordinator, City of New BedforDept of Decision and Information Sciences, UMass Downtown New Bedford, Inc. Equity and Diversity, New Bedford Public Schools Habor Development Commission Lafrance Hospitality Co. Mass Cultural Council Mount Vernon Group Mayor’s Office, City of New Bedford Medium Studio Moore and Isherwood New Bedford Art Museum New Bedford Economic Development Council New Bedford Internet New Bedford Whaling Museum No Problemo Preservation Planning, City of New Bedford Reynolds DeWalt Printing Ropeworks SouthCoast Education Compact SQ Design Associates Tatlock Gallery Tourism & Marketing, City of New Bedford Struever Brothers Eccles and Rouse UMass Dartmouth Art Gallery Weekly Compass The Zeiterion Performing Arts Center

ent

of New Bedford’s Creative Economy.

ord’s Creative Economy Committee

d

In the Fall of 2007, forty participants in the New Bedford Creative Economy Committee, representing organizations with diverse interests, achieved a consensus with South Coast Design on key challenges…

…in 12 hours.

having never all met before.

The first coherent leadership agreemaddressing the future

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Forty participants, in twelve hours, roducing a roadmap of twelve key

challenges, and consensus on the three directives – starting with five dozen issues in eight categorie

Learning that their most important, needs would be addressed…

p

s.

…from their collective focuraging direc

s on the tives. most highly leve

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Growing Momentum The great variety of concerns of the stakeholders, as represented by workshop participants, is overwhelming at first.

After completing the influence structuring portion of the group work, they learn where the real leverage points. In so doing, they build a consensus on what the next steps ought to be, and form collaborative action teams.

As a result, the group has also completed a portion of the preparatory work for the follow-up implementation by task specific collaborative action teams. The formation of Social Capital among the participants also lowers the cost of convening participants for follow-on workshops.

ce we can estimate the cost le engagements. Thus there are

economies of scale and scope for the process.

Based on our experienreductions for multip

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Building Capacity

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During the January 2008 South Coast Design conducted two intersessions courses at UMass Dartmouth. Undergraduate tudents were trained in the facilitation methodology, as well as face-to-face and online collaboration technologieEconomic Development Council’s O

s at the ffice.

• Business Systems • Education (

Economy – building a database of keyparticipants. The course mobilizedinterest in local economic developmebusiness people across a wide range oprofessions, from age 24 to 55.

Analyst 3)

• Engineering(2) • Financial Analyst • Information Technology • Insurance / Risk Management • Manufacturing (2) • Sales

The graduate class, above, representing local area businesses (below), focused on identification and analysis of stakeholders in New Bedford’s Creative

nt of f

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he parts of a full Collaborative Action Planning workshop are: Workshop Details T

I Preparation - Discourse Analysis– Identify Stakeholders, Issues, Critical Problems– Design & simulate workshop model

II Collaborative Action Planning Workshop– Structure a Focused, & Open Dialogue– What, How, Which & Why

III Follow Up and Implementation– Who & When?

In our deliberation on access we will address PhaseFurther work and follow up will depend on interest ifirst phase with other groups of stakeholders

I and Phase II. n th

.

the What and How portion ofe community. We may also repeat this

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Action Plan Architecture

ConsensusScenarios

Action Options

Collective Challenges

Critical Problem s

Track I

Track II

Action Plan Architecture

CollaborativeLeadership

Stakeholder’s Issues & Them esForum Intent

Copyright © 1999 - All Rights Reserved

cture uilds an Action Plan

Architecture through a progressive series of inquiries. In this one day session, we will engage a rapid treatment of many, but not all of these sessions. The Orientation session reconfirms and refines the Forum Intent of the client and sponsoring organizations. Stakeholder identification, literature review and interviews elicit issues and themes, assesses the complexity of the situation, determines the collaborative readiness of the participants, and guides the focus and design of inquiry for the workshop. The workshop focuses on investigating deep-seated issues and providing for a diversity of viewpoints and a requisite variety of pertinent themes. The CogniScope™ methodology is employed during the workshop to enable participants to engage in a d deliberation on substantive challenges in the initiative. Alternative solutions are cult e workshop culminates in determination of those actions have the strongest leverage on the situation. The participants internalize these selections through the construction of consensus scenarios. In follow-up to the workshop, organizational commitments to a Collaborative Action Plan are registered and the results packaged in a report and presentation.

Action Plan ArchiteThe process platform employed for our Deliberation on Access b

disciplineivated. Th

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Model

Model Schedule

Task NameStakeholder Identification

Literature Content Analysis

Stakeholder Interviews

Draft White Paper V.1

Review V.1

Design the Conversation

Produce White Paper V.2

Simulations

Pharm Safety Workshop

DELPHI Study

Workshop Report

4/18 4/25 5/2 5/9 5/16 5/23 5/30 6/6 6/13 6/20 6/27 7/4 7/11May June Ju 1 2 3 4 5 6 7 8 9 10 11 12 13

Workshop

Phases, Task Dependency and Minimum Lead Time Constraints

Note that the reason for the comparatively longer duration of Phase I, the preparation, is to enable a very focused, highly structured, rapid completion of the workshop inquiry. This is a key aspect of project management for inter-organizational endeavors. The greatest portion of Total Project Cost is in participant time and logistics and therefore that was the primary target of optimization in the design of the model. This model is designed to optimize participant’s uninterrupted availability, time commitment, and satisfaction with the results.

It is South Coast Design’s experience that the lead-time for setting up the workshop is the most sensitive to securing the availability of the workshop participants rather than that required by South Coast Design.

In follow-on applications of the model, that employs results of the first application in the same arena, the required lead time for South Coast Design in Phase I is reduced to scheduling the time of the facilitation team and assessing progress since the last workshop. South Coast Design’s

ad time for preparation may only require a few weeks. The lead time for the client’s setting the ate, securing the site, and securing participants would be the most time sensitive task on the

critical path.

led

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C ollaborative A ction P laC onsensus ScenarioC H O IC E

n

(1)C riteria

(2)(3)

D EFIN IT IO N D ESIG N

IM PLEM EN TA TIO N

A PPLIC A TIO N STA G ES O F TH E CogniScopeTM SYSTEM

C opyright © 1991 - A ll R ights R eservedIn teractive M anagem ent C onsultantsLTD

.

D . A lternative

A . A lternativeB . A lternativeC . A lternative

C omSitua

uperposition

Scenarios

logy The CogniScope™ Approach to Collaborative

In this section we present a description of the CogniScope™ method of inquiry as customized for Voice of Education Stakeholders Collaborative Action Planning initiatives. The Project is completed in three phases: Preparation, Workshop, and Follow-Up. This description focuses on the workshop format. However, the methodology is also used in the preparation and follow-up phases.

The conversations conducted a CogniScope™ workshop is schematically depicted in the following three figures. The following diagram summarizes the four application stages of the complete process. Note that each stage is color-coded.

MethodoAction Planning

plextion

C hallenges C ategories Influences O ptions C ategories S

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The Definition Stage deter p

Level I

Level II

Level III

Level IV

Seeing a L everage M ap of the Structure of C hallenges

D eep D river

O bviousTarget

T he exam ple show n above is an E N H A N C E M E N T structure. dem onstrates the d irection of influence.

begins with an illustration of the systemic complexity of the situation r

participants. This is

erience, what are the major challenges to improving Renal Safety?” Employing the

.

The influence pattern produced through conversation focusing on the influences among the hallenges enables the participants to discover the “deep rooted” challenges, i.e., those that, if

addressed, would exert leverage in addressing other challenges as shown schematically as a tree ith branches in the figure above. These deep-rooted challenges are located at Level IV, with

arrows propagating upward to less influential challenges located at Level I.

mined from the eparation phase and the collaborative definition of challenges in an initiative to address it. Statements of these challenges are elicited from thedepicted graphically in by overlapping geometric shapes representing the variety of perspectives among the observers. For example, in the case of the Pharmaceutical Safety initiative the number of distinct challenges generated were around 60 in response to roughly over 130 statements about the complexity of the situation. The group of participants responds to a triggering question, such as “...Within the context of current perception of issues and based on your expCogniScope™ the challenges are clarified, prioritized by voting on relative importance, assigned to affinity categories of similar challenges, and structured by means of “influence voting” to show the interrelationship among them. These three process steps are shown graphically in thediagram above on the left side under the title of Definition

c

w

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Level I

Level II

Level III

Level IV

Level V

Illustrating Superposition of A ction O ptions (blue) and C hallenges (red)

L ess Influentia l C hallenge

O ption

A ctions w ith H igh L everage B ecom e A pparent

among

In the Design Stage, participants focus on the identification of options which, if implemented, would help resolve the deep-rooted challenges and contribute to addressing the system of challenges. The options proposed by the participants are clarified, prioritized and assigned to similar categories as shown schematically in the next figure.

This diagram displays a product of the second stage, namely the identification of those options which, if implemented, would address the deep-rooted challenges.

Structural Inquiry of Influence, Dependency, and Leverage The figure above is provided to illustrate, hypothetically, what an “influence” or “enhancement” structure of challenges dealing with a complex design situation might look like after the participants have had the opportunity to engage in focused and open dialogue. Supported by powerful “groupware” decision support system, the CogniSystem, which is an integral component of the CogniScope™ process, the participants are able to explore relationshipsobservations, produce efficiently patterns of relationships among observations (i.e., digraphs), and amend the observations and patterns continuously and automatically with maximum flexibility of thought and structure. The inference engine embedded in the CogniSystem© enables a robust sampling of all possible pairwise influence relationships in 70%-85% less time than manual approaches. The inference engine does not analyze the content of the statements, itsimply tracks the consensus during the deliberation and propagates the emerging logic throughout the system of challenges.

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in Identifying those options (or actions) that, according to the majority of stakeholders engaged the dialogue, appear to have the highest leverage in terms of the system of challenges to be confronted is another benefit of the approach. This kind of design map is generated automatically by the software component of the CogniScope™ system methodology (i.e., CogniSystem©).

Referring again to the Stages figure, the last stage of the conversation provides the participants with an integrated, systemic model of evaluating alternatives and converging on the preferred alternative during the Choice Stage of the CogniScope™ system. Indeed, all things considthis is precisely where such a collaborative decision-making forum ought to be when faced withthe allocation of resources for making progress in the resolution of complex issues confronting most organizations and social systems today. In this way, the clients of South Coast Design are able to develop truly collaborative action plans for dealing with the most pressing orgadesign issues. The products of delibera

ered,

nizational tion at each stage is illustrated below.

he work concludes by reviewing what we learned and how our individual preferences shifted through deliberation. This is illustrated by the example from the Creative Economy case study.

S teps in each S tage of InquiryC om plexSituation

A rticulateO bservations

C larifyM eaning

C lusterInductively

Fram e andFocus on aTriggeringQ uestion

?D evelopShared

L anguage

(a) (b) (c) (d) (e)

(g) (h) (i) (j)(f)V ote &

R ankStructure

A bductivelyEvaluate

C ross-Im pactInterpretLearning

T

Interactive M anagem ent C onsultantsL TD

.

C lassL abel

Type A Type CType B

C opyright © 1999 - A ll R ights R eserved

Influence

Erroneous Priorities vs Findings of High Leverage

This graphic, taken from the workshop onNew Bedford’s Creative Economy, illustrates the “Law of Erroneous Priorities.” In collaborative planning and decision making a common approach to consensus voting is the

26

use of a voting mechanism to establish priorities. South Coast Design has documented that there is almost little correlation of what participants assess as a priority through group voting and what they determine to be the highly leveraging through application of the methodology.

Through a structured deliberation that ltivates consensus on influence,

that cu ap” of leverageinto a “m , managers and

leaders gain confidence in their decision-making efficacy. The process makes the rationale for the priority-setting transparent to stakeholders, and establishes ownership in the consensus plan by the participants.

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he Practitioners and the Practice ur community engagement programs are led by a design management team which the Community oundation of South Eastern Massachusetts extends as a capacity building and enhancement resource r boundary-spanning initiatives. The service is being extended as a pilot program called the South oast Community Collaborative Design Studio (South Coast Design).

The design manag * Managing Director: Dr. Thomas Flanagan * Technical Director: Mr. Kevin Dye The design methodology that we will use has a remarkable Academy of Contemporary Problems run by Battelle MemoInteractive Management. The core of the method is compuemployed have a strong evidence base in behavioral resea work. The overall system paces large groups through idea ghypothesizing, and creative scenario building. During the coassembles individual statements, dialogue, and collective d e results.. The quality of input, scheduling control, and the coassured by best in class practices drawn from hundreds of d The approach, formally called Structured Dialogic Design P the Institute for 21st Century Agoras. Its practice is certified thro e method and CogniSystem software are components employed in the process. These all are tools of the field of Interactive Management approach to collaborative design and planning.

hose wishing to gain a view of the method and its evolution might choose to visit globalagoras.org the 1st Century Agoras – a 501c(3) organization set up to promote the practice internationally.

ou may also read one of two recent books Harnessing Collective Wisdom and T he Talking Point.

TOFfoC

ement team roles consist of:

history. It traces its origins to work within the rial Institute four decades ago known as ter-supported deliberation. The techniques rch for avoiding dysfunctions typical of groupeneration, inductive thinking, abductive urse of the work the process records and ecisions creating a graphic display of thnsistency in the formation of consensus are esign experiences across many domains.

rocess is a registered Service Mark ofugh that organization. The CogniScop

TInstitute for 2Y

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ling ricultural Science, Neuroscience,

nd the Management of Technology. Tom has worked at leading research institutions such as the Cold cal Laboratory in Massachusetts, and the

orroughs Wellcome Company in Research Triangle Park in North Carolina. He has published and es nationally and internationally. Tom's interests in working

ith boundary-spanning technical teams led him into a program on the Management of Technology at erests. Tom returned to the life science arena co-founding a start

p company and recruiting Mr. Dye. Several years later, when the start up had succeeded in recruiting a

gy-

Administration, the US Department of Agriculture, and corporate clients in the life

with groups to help groups construct lists and forge some agreement on what they feel is im ch has shown that when groups are guide almost universally wrong when they first set their priorities erroneous priorities effect

About our Design & Facilitation Team Thomas Flanagan is a design manager with a broad and diverse background in organic, self-assembstructures. His formal training includes degrees in Marine Science, AgaSpring Harbor Laboratory in New York, the Marine BiologiBspoken on technical topics to diverse audiencwMIT, where he and Mr. Dye shared intuseasoned biodiagnostics sales executive to head up US operations, Tom took the opportunity to pilot a new program in life sciences with Dr Christakis' firm. After an extended appointment to lead technolobased economic development activity from within an environmental program at the University of Massachusetts, Tom currently is leading a campaign in the South Coast of New England to cultivate awareness of the power of structured dialogic design as a means for building boundary-spanning collaborations that effectively meet civic goals.

Tom and Kevin have worked together on a range of large-scale design projects including work with the World Health Organization, the US Food and Drug

science and environmental technology fields. Both Tom and Kevin continue towork with Dr. Christakis in support of Dr. Christakis’ most challenging projects. Tom recently published The Talking Point with Dr. Christakis reflecting on the experience in the arena of practice.

"Structured dialogic design shares many of the benefits of more familiar group planning processes and avoids one of their key shortfalls. Everyone works

portant. Our empirical researd to a collective decision, they are

. We call this the ” .”. The reason that we are a is because we have tested group preferences rities in an unstructured list, and then also when they h to build a structure from that list. Our breakthrou eans for folks to connect the dots and capture new i most important. Some are familiar with this as a sys are currently even attempting to construct systems vi of those who are trying this far fewer can actually do thi n guiding a discussion so that groups are prepared to co-cre nd then allowing them to consider that view e, resources, and group confidence by helping groups set their priorities with authentic systems thinking. We are unique in this way."

ble to make this statementwhen they vote for prioave had the opportunity

gh is that we provide a mnsights about what is really

tems view. Very few folks ews with live audiences, and

s well. Our sweet spot is iate a systems view, a

BEFORE they set priorities. We save tim

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Kevin M.C. Dye complements the South Coast Design team with two decades of experience in collaborative strategic planning, decision support, process improvement, and information technology.

ng systems and launch of two Decision

rch

ras. e-building. Kevin provides South Coast Design a

This spans roles in Fortune 20 Corporations in aerospace & buildiSupport Systems companies in finance and health care.. His work with the Interactive Management framework in healthcare has supported large-scale projects for the Elimination of Lymphatic Filariasis with the World Health Organization, designing the National Forums model for the National Patient SafetyFoundation, developing methods for very large scale stakeholder-driven modernization of the the U.S. Food & Drug Administration, leading a transatlantic new technology project for an Economic Development for Peace initiative in the Biotech Sector of Northern Ireland, designing the engagement of Ohio’s Stakeholders for Children with Autism Spectrum Disorder, strategy work with Volunteers in Health, and developing an industry leader summit for Mental Health Standards for the Internet.

An engineer trained at Northeastern University, he was conferred with the Outstanding Student Award. In 1994 he became a Sloan Visiting Fellow at MIT. There he conducted research on the Coordination Science of Interactive Management and was a participant in the Management of Technology program. In 1999 he became Chief Process Scientist for CWA Ltd.. After a role in state government leading reseafor the Massachusetts Office of Dispute Resolution, Kevin became the Senior Research Fellow for theFuture Worlds Center in Cyprus and the Director of Research for the Insitute for 21st Century AgoThere he advances technology for bi-communal peac

change-agent experience and deep insight into methodological foundations.

Mr. Dye’s empirical discoveries on misplaced priorities resulting from group preferences has become codified into a

unique combination of

“law of erroneous priorities", endorsed by the international community of practice of the methodology.”

Kevin Dye (front row, second from left) at the United Nations’ Design Science Lab with the Buckminster Fuller Institute addressing Millennium Development Goals on Health Care.

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Advisor: Alexander N. Christakis, Ph.D. Dr. Christakis is a co-founder of the field of Interactive Management. His experience in designing and facilitating collaborative workshops spans a variety of domains, including: health care systems; medical professional education and development; biomedical product development and compliance; insurance; regulatory agencies; social, economic and cultural development; urban planning; education, environmental and natural resource stewardship; and technology, knowledge and risk management. His career experience includes a wide range of noteworthy achievements in the academic, businessand industrial arenas, both in the United States and internationally. Christakis has served on thefaculties of Yale University, the University of Athens (Greece), the University of Virginia a

,

s Professor of Systems Management, and George Mason University as founder and director of the Center for Interactive Management. A cs, and the Academy of Contemporary Probl r early research and development of thManagement and the later commercia the

ogniScope™. Christakis holds an undergraduate degree in Physics from Princeton University nd a Ph.D. in Theoretical Physics from Yale University. It was his work in Field Theory that ave him insight into creating a mathematical system to support deliberation. He draws on this ackground along with a deep understanding of human behavior and democracy in ongoing evelopment of a systemic approach to “focused and open dialogue” in the resolution of complex ocietal issues. A keynote speaker at several international symposia, he is also the co-author of

ent. Numerous scientific papers written by Dr. Christakis on the management of complexity have been published. He is a member of the Editorial Boards of Systems Research and Behavioral Sciences, Systems: Journal of Transdiscplinary Systems Science, and the Journal of Applied Systems Studies.

co-founder of the Club of Rome, the field of Eikistiems for Battelle Memorial Institute he was responsible foe methodology and technology employed in Interactive lization of the method and software called

Cagbdstwo books on Technology Assessm

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