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Design for Care

We Tried to Warn You

Team Design

Co-designing for power balance in social systems

Power remains a hugely unresolved issue in strategic design, “systems change,” OD, and progressive management.

Healthcare, like other public and social sector institutions (education, social welfare, government) is organized by what Jane Jacobs in Systems of Survival calls Guardian systems, the moral syndrome of ruling.  As in government, the values of authority, prowess, rank, restraints on trading, and “deceit for the task” are important in these sectors, though we don’t like to admit it. Even democratic governments are not democratic in values or style, they inherit the mantle of the warrior class, which makes a living by “taking”. In some ways, business – even corporate America – is fairer and more open. In Jacobs’ model, business (or merchant systems) tends to care about collaboration, honesty, results and of course customers – this leads to power toward winning joint ends and achievement, rather than winning process (or means) struggles.

Power manifests in many ways – so in design processes, we adapt and deal with power issues in different ways, according to different environments.  Design practices tend to deal with power differentials obliquely, since designers tend to only have soft power, referent or expert. Since we are positioned externally to power centres, our influence isn’t a threat to legitimate power. We will eventually go away. And designers like to avoid conflict that isn’t creative.

Because I want to attract new audiences for Design for Care, (its an “early” book in the field), I pull many critical punches. I don’t want to give the impression to healthcare decision makers that designers want to “change the system” in ways that may appear naïve (or appearing uniformed from a clinical point of view). These issues are highly contested within the spheres of legitimate medical power and decision making, so coming from a design text, its precarious to even raise these issues.

Yes, design practices can lead to interesting outcomes with power conflicts. We can structure design engagement to proceed over multiple iterations of research and mutual learning. We can build multiple team structures within organizations, and encourage a mix of disciplines, personal styles, and affiliations within each team. We employ forms of dialogue to get to creative tensions, which can relieve the social tension around power to decide.

Typically, we advocate design methods that lead to innovative (high novelty) outcomes with high degrees of agreement. The creative process itself references the common design theory of power, which is that “everyone is creative.” Therefore if we are inclusive and participatory, power differences are minimized. So we include a wide range of participants and seduce them with creative engagement to generate sufficient depth and breadth to maximize the outcomes of enhanced design outcomes, higher utility and social adoption.

However, in many collaborative and team decision processes power (especially between levels of hierarchy and top-dog disciplines) emerges as a significant dimension. In the chapter (8) on systemic design practices in healthcare institutions and systems, I suggest the dialogic design methods (as indicated in the influence map) from the Romanow Report case study.

Romanow

Influence map generated by Cognisystem for recommended actions from the Romanow Report (Challenges in Canadian Healthcare)

Dialogic design been in continuous development since the 1970′s (Interactive management) and appears in hundreds of journal articles. We teach this practice to our Strategic Foresight & Innovation grad students. It balances in-session power dynamics and post-engagement power (deciding final outcomes) in several ways:

  • We take “the whole system in the room” very seriously. That means the containing system for the organization, not just the organization itself, if possible.
  • Set the expectations for democratic process, and frame the focus question, issues, and context very carefully. We spend weeks getting to the right question for a stakeholder engagement sometimes.
  • Select stakeholders using a very disciplined rule of “requisite variety” to the outcome decision. Include diversity, all affected organizations and levels, and include those vulnerable to a bad decision
  • Use a structured dialogue process that ensures principles of autonomy and authenticity are met. SDD has well-defined methods for ensuring this.
  • Facilitate processes with an aim of neutrality. Ensure all participants recognize they are co-designers in the process, and share investment and ownership in the outcome.
  • Have good sponsors and organizational brokers that mediate power relationships in advance of holding a workshop, and can mediate results in the org setting when we, the hired social design team, leave!

We might call the principle requisite access to power, since the value we’re seeking is not to minimize the strong but to give those with unequal access an equal chance for advocacy. We aim to ensure all stakeholders recognize their capacity to act on power within their responsibilities for action. Since all members of a dialogue have power, all forms of power should be ethically recognized, not neutralized. (Its the Reconciliation of Power in axiom #7 in our development of Dialogic Design Science).

Yes, design practice has practical ways to navigate power dynamics in stakeholder engagements and co-creation workshops, but design theory has very little to say about the influence of power.  Power in the act and activity of design is a pervasive fact of life. Whether in product or service design (Design 2.0, which is in service to sponsors and product managers), organizational process design (Design 3.0, where the decision rights of managers hang in the balance), or certainly social transformation (Design 4.0) there are different modes of power, means to exert and follow power, and – if we choose – there are systemic design methods to both balance and emancipate requisite power to change organizations, societies, and worlds for the better.

What is a “Problem,” Really? The Wickedness of Problem Systems

Adapted from a new article:  Jones, P.H. (2014). Systemic design principles for complex social systems. In G. Metcalf (ed.), Social Systems and Design, Volume 1 of the Translational Systems Science Series, pp 91-128. Springer Japan.

“Problems,” as we naively designate them, are essentially social agreements to name a salient concern shared within a culture. We learn to describe an observed phenomenon or anticipated possible outcome as a normative deficiency, and we expect a listener to accept the “problem” as a shared object of concern.  But what is a “problem” really?  The designation of concern (Latour, 2008) reflects a thoughtful presentation of the social value of the meaning ascribed to problems as experienced. Latour distinguishes between matters of fact (believed to be objectively determined) and matters of concern (about which we share associated values, and experience care, entanglement, and investment).   Matters of concern are issues relevant to our motivation for design for social betterment. Design theorists often prefer “fuzzy” or “ill-formed situation” as a rhetorical means to distanciate the social concerns embedded in the situation that could inhibit generative ideation or creative resolution. In other words, better design results when we keep ourselves from becoming too attached to the “problem as stated” or the desired sponsor outcomes.

I will adhere to the common meaning of problem as a perceived deficiency or negative value state sufficiently significant to compel social agreement to repair or restore the source at issue. And I will attempt to shed light on the meaning of “problem” itself, as many have done before.

Significant societal or global problems (such as global poverty, hunger, sociopolitical violence, climate change) originally emerge from multiple root causes and become interconnected over time. As with designed systems, “problems” are situations that favor some constituents and cause unforeseen consequences to others. Problems are maintained by social agreement and tend to reinforce conditions over time, and they begin to resemble autonomous, complex adaptive systems. These co-occurring problematic manifestations can be termed problem systems. Problem systems demonstrate the whole-part identity of a system of systems, the interdependency of component systems, and the endurance of ultra-stable systems.

Problems Exist in Language

It is incorrect to speak of solving wicked problems, as there are no agreed or effective evaluation measures that would justify the claim. The idea of dissolving wicked problems by design thinking has a popular resonance, but little empirical meaning. According to social systems theorists, the so-called wicked problem does not exist in the world with definable boundaries. Warfield (2001) asserted that all problems we define, as human constructs, can be described as problem sets, with each distinct problem merely a component of a set or problem system.

Warfield (2001) stated that all complexity exists in the minds of perceivers, not in the system believed to be the subject of description. The frustration that occurs when observers find themselves unable to define and understand a situation leads to the explanation that the system is inherently complex. Stakeholders are unable to recognize that their own cognitive limitations explain the majority of the complexity. Also, most socially complex problem constructions contain objectively complex subsystems, multiple relationships and feedback interactions that require analysis and domain expertise to unravel. Likewise, in any problem definition stakeholders underconceptualize the factors and therefore the field of designable options (or possibilities for innovation).

While this feature of complexity has been considered an argument for systems thinking, the necessity for variety and multiple reasoning pathways strengthens the argument for a strong design approach instead. Warfield’s axiom, taken seriously, reveals the flaws of a hard systems analysis for optimization and problem definition. Design, or effective intervention, in complex systems requires deliberate variety enhancement and refraining from early closure. System designers identify and reconfigure boundaries as ways of sensemaking with others, to evaluate design strategies, and to produce descriptive scenarios.

A Problematic Identity

Problems only “exist” when declared by social agreement. The identity of a problem does not exist until expressed in language, communicated in some way. The notion of deficiency is normative and a matter of shared understanding, not an objective fact. Even a devastating, and observable measurable situation such as “ocean acidification” is not registered as a problem until expressed as a deficiency, and with agreement from others that such is the case. The pH levels and measures may exist otherwise, but not a “problem” unless languaged.

For design in a systemic context, we are not only handed problems as matters of fact, but are given complex, socially-contested issues which may be descriptions of deficiencies we can only begin to make sense of. These don’t “exist” in a real sense, they are socially constructed and the designation of problem is a way in which we organize meaning and move toward appropriate action.

Every stakeholder invested in a situation will be primarily concerned with relationships that occur within the problem system perceived as significant to their interests or values. This differentiation of care results in agreements not based on common understanding of a social system, but on individual concerns for possible outcomes and opportunities understood as individually meaningful.  Different stakeholders will find salience in aspects of the situation they care about, which are compelling to their experience, giving them an actual stake in the problem, a motive for taking action. Returning to Latour for a moment, his recent Inquiry into Modes of Existence discriminates up to 15 modes or lifeworlds, each which might carry completely different sets of values and concerns relevant to the facts of a case. To frame a problem such as “climate change impacts” we face difficulties in understanding each other’s lifeworld or mode of existing and values, before we might self-organize toward actually effective action on systemic problem systems.

Social methods are necessary for enabling people to discover experienced phenomena and to reach understanding, if not consensus, about possible paths of action. Social methods are not necessarily democratic by design, but must be to facilitate substantive and invested participation from the range of stakeholders in a problem system. Social methods are necessarily processes of design, not only ideation and deliberation.  The most efficacious courses of action in a complex social system are not determined analytically, or by consensus of a group, but through the interactive co-creation and assessment of stakeholder proposals that synthesize a whole intervention or actionable strategy.  (The methods for which are included in such works as Design for Care.)

Relating Systems Thinking to Design 3 – Call for Contributions

The 3rd annual symposium is organized  the Systemic Design Research Network and hosted by the Institute of Design, Oslo School of Architecture and Design (AHO)

The emerging renaissance of systems thinking in design responds to the increasing complexity in all challenges faced by designers, strategists, and transdisciplinary innovators. We are facing deeply entangled problematics in natural, social, economic, and political systems. Our professional and organizational worlds have become too complex for linear goal-driven management, and the solution of conventional design thinking is insufficient to address complexity across domains, scales, and networks. New thinking, new knowledge, and new forms of intervention are required to take on this web of interconnected challenges.

The theme for Relating Systems Thinking and Design 3, to be held at AHO in Oslo 15th to 17th October 2014, is: Knowledge of Forms and Forms of Knowledge.

Birger-sm

The Systemic Design Research Network invites systemic designers to think BIG for this year’s symposium. How might systemic design help to:

  • Promote a transition towards flourishing enterprises and sustainable prosperity?
  • Engage value conflicts between economic, social, and environmental paradigms?
  • Address systemic causes of escalating costs and complexity in the health, legal, taxation, financial, security, and other sectors?
  • Empower citizens to mobilize local responses to global problematics and democratically engage within their cities, municipalities, provinces, and states?
  • Shift government approaches to citizen engagement, policy design, and policy assurance?
  • Catalyze systemic changes and innovations in the relationships between architecture, the built environment, and the social and natural systems they interact with?
  • Reframe approaches to education and professional practice to exploit complexity?
  • Increase the resilience of social systems to cumulative effects and systemic risk by rethinking and redesigning them?
  • Accelerate learning and adaptation at organizational and societal scales?
  • Provoke transformation and innovation in today’s legacy social systems?
  • Advance a deeper and more critical theoretical foundation for designing at scale?

We are interested in proposals that draw from recent case studies from fieldwork, design inquiry and research, and mixed methods in systems-oriented design. Design practices found effective in fields such as healthcare, governance, environmental stewardship, organizational transformation and social change are of particular interest for cases and discussion within the conference.

We invite you to submit an abstract of no more than 1000 words. Accepted abstracts will be invited to submit a presentation and working paper to the symposium. The process for publication of selected full papers in an international peer reviewed journal will be announced at a later date.

Submissions should be through the Easychair submission system April 1, 2014.

The Healthcare Innovator’s Challenge

Adapted from Design for Care (page 253 )

The innovator’s challenge in healthcare is not a technological fix – it is more to understand and preserve core values of human care while changing practices for durable social and economic benefit. Although economic value is often a pivotal driver of innovation adoption, cost management is not itself a core value but a sustainability factor to be evaluated in decision making. The related social innovation challenge is a macro policy problem, not a design issue.  An immediate challenge is convincing organizations that accessible patient-centred, value-based care is actually possible with a business model change. (Then new care service models can be designed). It will be the rare organization with the cost buffers and patience that reconfigures care models in advance of a new business model.

HC Shared Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Using a simple Business Model Canvas model, a shared value healthcare business model (based on Porter & Lee’s value-based care) is outlined.  The model suggests a significant trans-valuation of the “offer” of clinical care, which is not service for fee, but to attain personalized health outcomes that matter to people.

Such a shift may seem impossible in today’s lean, cost-contained, time-sliced organizations. Yet surmounting the impossible is the chief purpose of business model design. Significant social impacts from cost savings could be invested in by transferring the earned value from a high-profit sector of care to a high throughput, low-profitability but essential function. Rather than accommodating the demands of every specialty and department, a core strategic purpose would be formulated – such as to facilitate universal community access to health services and to improve primary care.

Healthcare is a social and public good that can be provided universally, in some form, as in most developed countries. In the United States, this would require a truly disruptive change to public policy and the insurance payer model of the healthcare system. A recent New England Journal of Medicine article declared:

“It is hard to ignore that in 2006, the United States was number 1 in terms of health care spending per capita but ranked 39th for infant mortality, 43rd for adult female mortality, 42nd for adult male mortality, and 36th for life expectancy. These facts have fueled a question now being discussed in academic circles, as well as by government and the public: Why do we spend so much to get so little?”*

Was there ever a clearer innovation challenge in any sector or business? Healthcare as an industry faces multiple crises that beg for systemic solutions, not piecemeal fixes. System interventions aim for the root issues most closely related to the perpetuation of critical problems. Sustainable solutions are those that economically scale across institutions and regions.

Systemic redesign requires agreement on a shared vision of the future value state. Any project aiming to satisfy multiple stakeholders (not just users or owners) requires a systemic approach, rather than the mere negotiation of service functions. We might reframe the purposes of “disruptive innovation” in institutional healthcare from economic and technical value to that of co-creating significant service transformations that benefit all stakeholders.

*Murray, C. J., & Frenk, J. (2010). Ranking 37th—measuring the performance of the US health care system. New England Journal of Medicine, 362(2), 98-99.