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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


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


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. ii

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


Leadership South Coast 2010

To Participants in A Deliberation on Health Care Access, 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. 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 iv

Table of Contents A Letter from the Chairman A Note to the Participants Executive Summary

Snapshots of the Situation

The Agenda

Southeast Region Outcome Challenges

Stakeholders in Healthcare

State & Regional Barriers: Physician Shortage

On Access: Urgency & Meaning

Navigating the Labyrinth

A Model of Access

Access Disparities

Objectives of Access

Summary Impressions

Beyond Coverage in Massachusetts

Method Case Study: New Bedford’s Creative Economy Building Capacity Methodology Overview Bios


Executive Summary A 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 in the ensuing months. The selected process of deliberation amplifies the level of engagement of the participants by building trust admidst diverse stakeholder 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?

The Agenda 7:45– 8:30 8:30– 8:50 8:50– 9:00 9:00–10:00 10:15-10:30 10:30-11:15 11:15-12:15 12:15- 1:00 1:00- 2:00 2:00- 2:20 2:20- 4:00 4:00- 4:30

Reception Overview Introductions Problems in Access 1 Break Problems in Access 2 Solutions to Access 1&2 Lunch & Reflections Themes & Distinctions Break Leadership Directives Learning & Priorities

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. 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. Themes & Distinctions – Participants consider similarities and differences in the statements. They will also select ones they feel important. Leadership Directives – Participants investigate the interdependency and leverage of the statements. Learning & Priorities – We will reflect on what was learned and anticipate what we ought to do.


Stakeholders in Health Care A 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 “the 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.

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


On Access: Urgency & Meaning On April 15, 2010 Reuters released the results of an online poll which indicated the U.S. ranked 10th . According to a Gallup Poll the concern with access 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? 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.’


A Model of Access The 1993 IOM Committee put forth the following model for the pragmatic purpose of developing indicators about access. This Committee selected 15 indicators tracking: 5 objectives around birth, preventable disease, early finding of treatable disease, managing chronic disease, and getting timely and appropriate treament: Objective 1: Promote Successful Birth Outcomes Objective 2: Reduce Vaccine-Preventable Childhood Disease Incidence Objective 3: Detection and Diagnosis of Treatable Diseases Early Objective 4: Reduce the Effects of Chronic Disease and Prolong Life Objective 5: Reduce Morbidity/Pain via Timely, Appropriate Treatment

Objectives of Access The Healthy People 2020 initiative outlines 10 more specific objectives for access: Increase the proportion of persons with: AHS HP2020–1: …health insurance. 9 (97% in Massachusetts via state reform.) AHS HP2020–2: …persons covered for clinical preventive services. AHS HP2020–3: …a usual primary care provider. AHS HP2020–4: …access to rapid response prehospital emergency medical services. AHS HP2020–6: …a specific source of ongoing care. AHS HP2020–9: …receiving appropriate evidence-based clinical preventive services. AHS HP2020–5: Increase number of States with prehospital/hospital pediatric care guidelines. AHS HP2020–7: Reduce the proportion of individuals that experience difficulties or delays in obtaining necessary medical care, dental care, or prescription medicines. AHS HP2020–8: Reduce the proportion of hospital emergency department visits in which the wait time to see an emergency department physician exceeds the recommended timeframe. AHS HP2020–10: Increase the proportion of practicing primary care providers. 6

Beyond Coverage We’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. •

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


Southeast Region Outcomes Challenges Residents of larger communities like Brockton, Fall River, and New Bedford have poorer socioeconomic 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 are higher for Brockton and New Bedford.

Asthma ER rates (chart at left) and high STD incidences in the Southeast and the top three cities are higher than the state. Smoking during pregnancy is higher in Fall River, New Bedford, and Taunton. Southeast Massachusetts Regional Health Dialogue Department of Public Health, 6/7/2007


Southeast Region Barriers: Physician Shortage In addressing the aforementioned outcomes challenges, The Dartmouth Atlas of Health Care: The New England States, 1996 that Southeastern Massachussetts has a comparative disadvantage with respect to the New England in availability of primary care physicians (see map left). 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. Phyisician Dissatisfaction with Practice Environment • 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) 9

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 a simplified view. What map do people new to a health care system use? If there were a map available, can they understand the jargon, the language 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.





Access Disparities In 1998 the President launched the Initiative to Eliminate Racial and Ethnic Disparities in Health. Concluding: - Hispanics, Poor worse off on 90% of access measures. - Blacks, Asians worse off on 33% of access measures. Although the Federal position on access evolved from viewing it as a right to a ‘social ethical obligation’ in the context of ethnic and minority disparities the most frequent use of “access”, in the 2003 report Unequal Treatment, is in the chapter on Civil Rights.

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


Summary Impressions of the Situation What is the situation? In Massachusetts only 3% are not insured, but 22% have problems in access. Waiting times are getting worse. Nationally Latinos and the poor are worse off on 90% of access measures, blacks and asians 33%. The situation in Southeast region is particularly difficult due to a shortage of providers which is severe and becoming critical. 50% of physicians in Southeast cities are dissatisfied with their work environment and 75% of people hiring physicians report difficulty in filling positions. What is access? "The most urgent health problem this country faces" according to Gallup Polls. The most valued aspect of health care for the sick according to Price Waterhouse Coopers (see chart below.) Access is a set of specific objectives: good birth outcomes, prevention through vaccination, early diagnosis of treatable diseases, ameliorating effects of chronic diseases, and reducing morbidity and pain in a timely fashion. Access is targeting specific regional outcome differences attributable to access disparities. In Southeastern Massachussetts this especially concerns differences in successful pregnancies, heart disease, diabetes, substance abuse, violence, HIV, Asthma, and smoking. Access is moving people into more regular relationships with care providers by eliminating barriers based on cultural, ethnic, racial, gender, andlinguistic differences; affordability, mobility or fear, or derive from poor communication or health literacy. Access is a ‘moral stance’ and equal access a ‘Civil Right’.


This set of snapshots about the situation in access is not comprehensive, it is impressionistic. The purpose of it is to elicit the perspectives of the participants in our deliberation on access. We have not yet discussed promising solutions, policies, initiatives. One way of framing approaches is as addressing enabling factors, utilization, equitability, inequitability, effectiveness and efficiency of access. We will address these in a briefing to follow. 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 methods and software tools two of which are referred to as the CogniScope and CogniSystem. You will see them referenced in the methods section. The section concludes with bios on the facilitation team. It is not necessary to read this material in order to participate in the deliberation. You may be intrigued by taking a minute to glance at a photo-essay covering a local application of the process in New Bedford’s Creative Economy.

From Improving Access To Care In America: Individual and Contextual Indicators, Ronald M. Andersen, Pamela L. Davidson 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.


Example: Convening New Bedford’s Creative Economy Committee 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 Bedford Dept 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

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 agreement addressing the future of New Bedford’s Creative Economy.


Forty participants, in twelve hours, producing a roadmap of twelve key challenges, and consensus on the three directives – starting with five dozen issues in eight categories.

Learning that their most important, needs would be addressed‌

‌from their collective focus on the most highly leveraging directives.


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. Based on our experience we can estimate the cost reductions for multiple engagements. Thus there are economies of scale and scope for the process.


Building Capacity

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 technologies at the Economic Development Council’s Office.

The graduate class, above, representing local area businesses (below), focused on identification and analysis of stakeholders in New Bedford’s Creative Economy – building a database of key participants. The course mobilized interest in local economic development of business people across a wide range of professions, from age 24 to 55. • • • • • • • •


Business Systems Analyst Education (3) Engineering(2) Financial Analyst Information Technology Insurance / Risk Management Manufacturing (2) Sales

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

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 Phase I and the What and How portion of Phase II. Further work and follow up will depend on interest in the community. We may also repeat this first phase with other groups of stakeholders.


Action Plan Architecture The process platform employed for our Deliberation on Access builds 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 disciplined deliberation on substantive challenges in the initiative. Alternative solutions are cultivated. The 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.

Stakeholder’s Issues & Them es

Forum Intent

Critical Problem s Collective Challenges Action Options Consensus Scenarios

Track I

Collaborative Leadership

Track II

A ction Plan A rchitecture Copyright Š 1999 - All Rights Reserved


Model Model Schedule Task Name Stakeholder Identification

1 4/25 2 5/2 3 4/18

May June 4 5/16 5 5/23 6 5/30 7 6/6 8 6/13 9 6/20 10 6/27 11 1 2 5/9 7/4

Ju 13 7/11

Literature Content Analysis Stakeholder Interviews Draft W hite Paper V.1 Review V.1 Design the Conversation Produce W hite Paper V.2 Simulations Pharm W orkshop W orkshoSafety p DELPHI Study Workshop Report

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


Methodology The CogniScope™ Approach to Collaborative Action Planning 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.


Com plex Situa tion




Alternative Alternative Alternative Alternative

S uperposition

C onsensus S cenario

C ollab orative A ction P la n

C riteria (1)




(3) LT D .

A. B. C. D.




C H O IC E S cenarios

O ptions

C opyright © 1991 - All Rights Reserved

Interactive M anagem ent C onsultants


The Definition Stage begins with an illustration of the systemic complexity of the situation determined from the preparation phase and the collaborative definition of challenges in an initiative to address it. Statements of these challenges are elicited from the participants. This is depicted 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 experience, what are the major challenges to improving Renal Safety?” Employing the CogniScope™ 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 the diagram above on the left side under the title of Definition.

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

O bvious T arget

Level II

Level III

Level IV

D eep D river

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

The influence pattern produced through conversation focusing on the influences among the challenges 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 with 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. 23

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 relationships among observations, 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, it simply tracks the consensus during the deliberation and propagates the emerging logic throughout the system of challenges. 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.

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

L ess Influential C hallenge

Level II

Level III

Level IV

Level V

O ption

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


Identifying those options (or actions) that, according to the majority of stakeholders engaged in 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 considered, this is precisely where such a collaborative decision-making forum ought to be when faced with the 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 organizational design issues. The products of deliberation at each stage is illustrated below.

Steps in each Stage of Inquiry (a) C om plex Situation

(f) D evelop Shared L anguage

(b) Fram e and Focus on a T riggering Q uestion




V ote & R ank T ype A

T ype B

(c) A rticulate O bservations

Structure A bductively

(d) C larify M eaning

(i) Interpret L earning

(e) C luster Inductively

(j) E valuate C ross-Im pact

T ype C


C lass


L abel

Copyright © 1999 - A ll Rights R eserved

Interactive M anagem ent C onsultants

The 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. 25

Erroneous Priorities vs Findings of High Leverage This graphic, taken from the workshop on New Bedford’s Creative Economy, illustrates the “Law of Erroneous Priorities.” In collaborative planning and decision making a common approach to consensus voting is the 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 that cultivates consensus on influence, into a “map” of leverage, managers and leaders gain confidence in their decision-making efficacy. The process makes the rationale for the prioritysetting transparent to stakeholders, and establishes ownership in the consensus plan by the participants.


The Practitioners and the Practice Our community engagement programs are led by a design management team which the Community Foundation of South Eastern Massachusetts extends as a capacity building and enhancement resource for boundary-spanning initiatives. The service is being extended as a pilot program called the South Coast Community Collaborative Design Studio (South Coast Design). The design management team roles consist of: * Managing Director: Dr. Thomas Flanagan * Technical Director: Mr. Kevin Dye The design methodology that we will use has a remarkable history. It traces its origins to work within the Academy of Contemporary Problems run by Battelle Memorial Institute four decades ago known as Interactive Management. The core of the method is computer-supported deliberation. The techniques employed have a strong evidence base in behavioral research for avoiding dysfunctions typical of group work. The overall system paces large groups through idea generation, inductive thinking, abductive hypothesizing, and creative scenario building. During the course of the work the process records and assembles individual statements, dialogue, and collective decisions creating a graphic display of the results.. The quality of input, scheduling control, and the consistency in the formation of consensus are assured by best in class practices drawn from hundreds of design experiences across many domains. The approach, formally called Structured Dialogic Design Process is a registered Service Mark of the st Institute for 21 Century Agoras. Its practice is certified through that organization. The CogniScope 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. Those wishing to gain a view of the method and its evolution might choose to visit the Institute for 21st Century Agoras – a 501c(3) organization set up to promote the practice internationally. You may also read one of two recent books Harnessing Collective Wisdom and T he Talking Point.


About our Design & Facilitation Team Thomas Flanagan is a design manager with a broad and diverse background in organic, self-assembling structures. His formal training includes degrees in Marine Science, Agricultural Science, Neuroscience, and the Management of Technology. Tom has worked at leading research institutions such as the Cold Spring Harbor Laboratory in New York, the Marine Biological Laboratory in Massachusetts, and the Borroughs Wellcome Company in Research Triangle Park in North Carolina. He has published and spoken on technical topics to diverse audiences nationally and internationally. Tom's interests in working with boundary-spanning technical teams led him into a program on the Management of Technology at MIT, where he and Mr. Dye shared interests. Tom returned to the life science arena co-founding a start up company and recruiting Mr. Dye. Several years later, when the start up had succeeded in recruiting a seasoned 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 technologybased 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 Administration, the US Department of Agriculture, and corporate clients in the life science and environmental technology fields. Both Tom and Kevin continue to work 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 with groups to help groups construct lists and forge some agreement on what they feel is important. Our empirical research has shown that when groups are guided to a collective decision, they are almost universally wrong when they first set their priorities. We call this the ”erroneous priorities effect.”. The reason that we are able to make this statement is because we have tested group preferences when they vote for priorities in an unstructured list, and then also when they have had the opportunity to build a structure from that list. Our breakthrough is that we provide a means for folks to connect the dots and capture new insights about what is really most important. Some are familiar with this as a systems view. Very few folks are currently even attempting to construct systems views with live audiences, and of those who are trying this far fewer can actually do this well. Our sweet spot is in guiding a discussion so that groups are prepared to co-create a systems view, and then allowing them to consider that view BEFORE they set priorities. We save time, resources, and group confidence by helping groups set their priorities with authentic systems thinking. We are unique in this way."


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. This spans roles in Fortune 20 Corporations in aerospace & building systems and launch of two Decision Support 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 Safety Foundation, 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 research for the Massachusetts Office of Dispute Resolution, Kevin became the Senior Research Fellow for the Future Worlds Center in Cyprus and the Director of Research for the Insitute for 21st Century Agoras. There he advances technology for bi-communal peace-building. Kevin provides South Coast Design a unique combination of 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 “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.


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, business, and industrial arenas, both in the United States and internationally. Christakis has served on the faculties of Yale University, the University of Athens (Greece), the University of Virginia as Professor of Systems Management, and George Mason University as founder and director of the Center for Interactive Management. A co-founder of the Club of Rome, the field of Eikistics, and the Academy of Contemporary Problems for Battelle Memorial Institute he was responsible for early research and development of the methodology and technology employed in Interactive Management and the later commercialization of the method and software called the CogniScope™. Christakis holds an undergraduate degree in Physics from Princeton University and a Ph.D. in Theoretical Physics from Yale University. It was his work in Field Theory that gave him insight into creating a mathematical system to support deliberation. He draws on this background along with a deep understanding of human behavior and democracy in ongoing development of a systemic approach to “focused and open dialogue” in the resolution of complex societal issues. A keynote speaker at several international symposia, he is also the co-author of two books on Technology Assessment. 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.




A Deliberation on Health Care Access