How might we design health systems to promote health and wellbeing and not just treat illness and disease and manage infirmary and chronic conditions? What if health systems were about health?
If we were to apply design thinking to health systems, what might be do?
In a previous post, I suggested that knowledge translation is too important to be trusted solely to health professionals, partly because they have largely failed to take up the charge. Taking a step back — a systems thinking perspective — one realizes that to design better knowledge translation, we need to design better health systems.
Julio Frenk, Dean of the School of Public Health at Harvard, believes this too. In a 2010 paper published in PLOS Medicine, Frenk comments on the state of health systems and examines how we might re-think them in light of global health challenges.
Health systems are the main instrumentality to close the knowledge–action gap. To realize this potential, it will be necessary to mobilize the power of evidence to promote change. Yet all too often reform efforts are not evaluated adequately. Each innovation in health systems constitutes a learning opportunity.
Frenk’s article is an invitation to engage in systems and design thinking about health. Both approaches invite pause to consider what the problem is in the first place. For design thinkers, problem scoping is the first step.
For systems thinkers this is akin to setting the boundaries around the problem.
Once we set the boundaries and find the appropriate problem, we then frame it appropriately for design. Problem definition is something often over-looked or under appreciated, but is the core of effective problem solving and design.
If I had an hour to solve a problem I’d spend 55 minutes thinking about the problem and 5 minutes thinking about solutions – Albert Einstein
Health systems are typically defined in light of professional services and policies aimed at making the sick well. They are essentially illness and disease (sick care) systems. This conceptualization, still dominant in the professional and policy discourse in many Western countries, places medicine at the centre of health services with the allied disciplines working alongside, but rarely ventures its gaze beyond the institutions of care or the conditions such institutions are designed to treat.
Frenk, writing in PLOS Medicine, suggests its time to expand our view of what makes a health system if we are to truly promote and sustain global health and see three key points as provoking such re-thinking:
First, health has been increasingly recognized as a key element of sustainable economic development , global security, effective governance, and human rights promotion . Second, due to the growing perceived importance of health, unprecedented—albeit still insufficient—sums of funds are flowing into this sector . Third, there is a burst of new initiatives coming forth to strengthen national health systems as the core of the global health system and a fundamental strategy to achieve the health-related Millennium Development Goals.
In order to realize the opportunities offered by the conjunction of these unique circumstances, it is essential to have a clear conception of national health systems that may guide further progress in global health.
Frenk offers some suggestions:
Part of the problem with the health systems debate is that too often it has adopted a reductionist perspective that ignores important aspects. Developing a more comprehensive view requires that we expand our thinking in four main directions.
First, we should think of the health system not only in terms of its component elements (like human resources, financing, hospitals, clinics, technologies, etc.) but most importantly in terms of their interrelations. Second, we should include not only the institutional or supply side of the health system, but also the population. In a dynamic view, the population is not an external beneficiary of the system; it is an essential part of it.
It’s important to note the mention of the role of the population and its dynamical impact on the system. As populations change dramatically in their composition and form of residency within countries, including a greater movement to urbanization, so too will the myriad factors that influence health systems. The people are the system and thus it will change as populations change. While Frenk lists this as one point of many, it is a radical departure for reductionists or those who see health systems as being about care, not people.
A third expansion of our understanding of systems refers to their goals. Typically, we have limited the discussion to the goal of improving health. This is, indeed, the defining goal of a health system. However, we must look not only at the level of health, but also at its distribution, which gives equity a central place in assessing a health system. In addition, we must also include other goals that are intrinsically valued beyond the improvement of health. One of those goals is to enhance the responsiveness of the health system to the legitimate expectations of the population for care that respects the dignity of persons and promotes their satisfaction. The other goal is fair financing, so that the burden of supporting the system is distributed in an equitable manner and families are protected from the financial consequences of disease.
Frenk’s third challenge is to affirm the very point of health systems at all.
While not explicitly speaking of systems thinking or design thinking, there is much that both fields have in common with Frenk’s argument. Design thinkers might ask: What have we hired our health system to do?
Frenk argues that our health systems must go well beyond just making gains in measured health outcomes towards dignity, respect and social justice.
Finally, we should expand our view with respect to the functions that a health system must perform. Most global initiatives have been concerned mainly with one of those functions, namely, the direct provision of services, whether they are medical or public health services. This is, of course, an essential function, but for it to happen at all, health systems must perform other enabling functions, such as stewardship, financing, and resource generation, including what is probably the most complex of all challenges, the health workforce.
Frenk did not identify specific solutions, but did pose some key questions for health systems design.
If we were to take this challenge up as designers and systems thinkers, what might we do? Here are some suggestions for inquiry:
- Consider new definitions of health like the one posed in the British Medical Journal that emphasizes looking at the social and environmental influences on health beyond just the absence of physical symptoms. Further inclusion of a psychology of human flourishing might add to this definition.
- Map out a new system visually with people at the centre, not professionals or institutions. What does that look like? Tools like a Gigamap might provide the kind of multi-media, multi-sensory visual way to conceive of the interrelationships that make up health system. System dynamic models can help this out as well.
- Engage people across this system to validate this map and co-create possible future models that could serve to shape discussion at multiple levels and mobilize civil society to support healthy environments.
- Create small scale, safe-fail / fail-forward, prototypes of small-scale innovations that can be tested, developmentally designed, and rapidly re-developed as needed to start shifting the system as a whole.
Designing health requires designing health systems. Applying new thinking and envisioning a system that is dynamic, comprised of people and just institutions is a start.
Photo: Bartolomeo Eustachi: Peripheral Nervous System, c. 1722 shared by brain_blogger used under Creative Commons Licence
If a health scare manifested itself in the world and there were no journalists to cover the story, what would the impact on the public be?
That is a question that lingered with me throughout the start of the 2013 Ontario Public Health Convention (TOPHC) which began with a morning dedicated to improving public health communication. Opening up the conference was a series of linked keynote presentations from a risk communications researcher (Julie Leask); a former newspaper editor, journalism professor and social media advocate (Wayne MacPhail), and one of Canada’s leading health specialist reporters (Helen Branswell).
The Academic’s Perspective
Keynote speaker Julie Leask (pictured above) and her colleague Dr. Claire Hooker (a good friend of mine) have been looking at the ways journalists engage in risk communication with the public on matters of public health from immunization to SARS to understanding the health priorities of professionals. In 2010 they published a paper looking at how the media covers health topics and argued that the health professions need to be aware of how stories are made, communicated and to be an active partner with reporters if they are to have positive impact in moments of health scares.
“It’s too late when the crisis comes up” – Julie Leask speaking on the need for public health to get engaged with the public using social media
In a previous post I wrote about how journalism is the fourth estate of medicine and public health. Journalists are the storytellers that the public listen to and are charged with looking at a problem from many perspectives to develop that coherent narrative that speaks to their audience. These are qualities that most scientists and public health professionals don’t bring to their jobs, nor are they always expected to or even should. As such, journalists play an important role for this very reason.
Nonetheless, the health sector has an uneasy relationship with journalism. Health professionals – particularly researchers — poorly understand the world of journalists and sometimes view the profession with suspicion. Julie Leask and her colleagues have found this to be the case, but argue that it is no reason to shy away from engaging the public using the tools that are comfortable to journalists. She spoke to the invaluable role of specialist health journalists in acting not only as producers of high quality health content in the news, but also guardians against low quality content making into press. In speaking to her research, she pointed out that specialist health journalists help educate their peers and editors on health issues, which are often complex and require more than a passing understanding of context to communicate well, as key gatekeepers for quality in the health landscape.
The Editor’s Perspective
To this end, Wayne MacPhail, a former editor of the Hamilton Spectator, argued that public health has a near ethical imperative (my choice of term) to be in the social media space to not only promote good health, but counter and challenge myths and misinformation. This isn’t some naive pronouncement that we’ll eliminate the snake oil sales or quackery that proliferates in the public sphere and media, but rather a simple observation that we have no chance of making impact if we are not even engaged in the space at all.
Like Leask, MacPhail says that it’s too late to engage the public when a health crisis comes up and that public health needs to be in the conversation stream before that happens.
The Reporter’s Perspective
Helen Branswell, a reporter from The Canadian Press, rounded out the panel and spoke frankly about the dwindling resources and rapidly changing landscape in journalism. She was on the front lines of reporting the 2003 SARS outbreak and showed a picture taken during that time of an empty newsroom and remarked how that the scene is the same now only for different reasons (limited budgets due to decreased ad revenue and the related shift to digital information on the web being two such reasons, among others).
Branswell paints a bleak picture of the present and future in many areas of health journalism. Stories are increasingly being covered by general reporters who may treat the story the same as they would a traffic incident, political story, or crime; journalists who are unlikely to know the context and details that are critical to communicating the nuances present in health matters. Interns are replacing some full time or veteran reporters in the newsroom and there are only a handful of specialists in practice.
Pressures from time, budget and competing interests in the newsroom are all contributing to an environment where quality health reporting is threatened.
I asked the panel what they thought public health should do to ensure that the healthy stories are reported well and there was little answers. Helen Branswell said, truthfully and somewhat cheekily: “buy newspapers”. She reminded us that we should be paying for the quality content and supporting good journalism in practice if we want it to survive, which is hard to argue against.
But that alone will not do all the work needed to preserve good journalism. I spoke to another conference attendee, a formally trained journalist who is now working with a research firm, about the ways in which journalists have helped other organizations craft their messages and engaging the public citing the Calgary Police Service’s social media team as an example. This pointed to ways in which journalists can make a difference in matters of public health and social services.
Yet, what about investigative journalism? What about the potential conflicts that come from being paid to report on issues that might be critical of the organization who does the paying (e.g., Ministries of Health, Departments of Public Health, Universities and colleges etc..)? This model doesn’t solve that, but it is at least another option.
Yet, the examples from public health taking this challenge of working with journalists up are few. Many still believe that social media is another means of broadcasting, which misses the mark. Others still view social media, journalism, engaging with the public through the media, with suspicion on the grounds that much of the work out there is not evidence based.
But what evidence did we have when SARS hit us 10 years ago? We had lots of epidemiological data on infectious disease, but that was only part of the story. Many of the leading health scientists were adapting their models, creating new ones and only after the disease left did we really have a full sense of what happened. We learned as we went.
This is what social media is all about, too. The lessons from major health events — disasters, outbreaks, and pandemics — parallel social media. It is innovation space at its clearest and thus there is an imperative to view it as innovation space with the tools and lenses that best support movement within complex adaptive system. From a communications standpoint, social media and the tools of modern journalism (and the style of communication they employ) are one thing to consider. Developmental design and evaluation are also among these tools combined with systems thinking.
Linear thinking and action will not work in a complex system and as this panel pointed out, there is much reason to be concerned if we are not prepared to communicate and support those that communicate well in such times when — not if — they come back.
Ten years after SARS how better off are we? And if we are better, how are we communicating that to the public?
Normative behaviour is what we expect from others operating in the world around us. It is what defines the world “normal”. It’s based on a complex array of history, social conventions, mores, values, context and timing, but it is the reason we know weird or odd from something else. Weird, is by definition, something that is not normal.
What I Learned From Denim
Many years ago I saw a TV special looking at the world of fashion and was struck by the process of designing denim jeans for men. The audience was told that jeans are often designed based on the prototype of the ‘average’ man and then worked out from there. What struck me was that they also said the ‘average’ man has a size that matches about 1 in every 7500 men. So the average — the normal — is not average at all. Indeed, he is particularly rare. Male models who represent this size do very well in their profession.
While there is a norm of social behaviour, there are actually very few people who are wholly ‘normal’ in their actions, nor are there obvious cases where normal is indeed, then norm in social systems. Why? Because social systems are complex by their very nature. They bring together diverse, overlapping, dynamic elements together operating at different scales simultaneously. This is complexity.
Just as individuals we bring our familial history, education, gender, sex, age, faith (if it exists), height, race (which might be highly mixed), experience, physical abilities, fashion choice, body type, vocal acuity, energy level and on to every single interaction we have. Every one of those factors — of this limited group — bring with it a set of unique attributes that individually and socially have differing weight and ‘normality’ depending on the circumstance. To imagine that there is a place where all of these line up with everyone else is utterly absurd if not statistically impossible.
Yet, we cling to the idea that normal exists and might even be something to aspire to. We push a conformity on to our expectations of each other and our research that is unreasonable and often harmful.
It’s not unexepcted. From our earliest days in the society we belong there is pressure to conform. Norms are what hold societies together. They are what creates culture. But where the confusion comes in is with the treatment of norms as truly common things that is universally positive (if attainable).
It is the often mis-attributed following quote to many that still stands out as true:
There is nothing so uncommon as common sense
In complexity science, norms are not disregarded, but are only minimally useful in helping understand patterns of activity. There are path dependencies, which guide certain activities and point to the importance of knowing where things start to help trace the manner in which they project outward. There are things called minimum specifications, often referred to as ‘simple rules’, that can help us create certain conditions within boundaries to shape behaviour. Yet, no matter how we shape these, the normative condition is not and will not be normal in any sense like your favourite pair of jeans.
What Relationship Break-Ups Can Teach Us About Complexity
Psychology and Psychotherapy, when operating at its best, helps people to understanding their true selves independent of, although interdependent with, the world around them. It falls short when it pushes people to conform to social norms apart from their true self. This is a shame.
Ask anyone who has endured a particularly heartfelt breakup of a relationship about normal and you’ll see the pain caused when we ascribe normative behaviour to complex systems. Sensemaking in a breakup is hard to do because of the massive cultural and social baggage we attach to them. Marriages, engagements, boy/girlfriend partnerships, affairs, flings, and flirts all bring socially normative expectations (and taboos) with them. And yet, if you think to any of those relations you’ve had I suspect that you’ll find that at its core there was relatively little ‘normal’ actually going on. Each relationship has its own cadence, pattern and normalness to it.
The best relationships have their own way of creating patterns that are unique to themselves, which is why we can’t replace or hope to replace one with another. They are irreplaceable for the very reason they are special. Not necessarily better or worse — but perhaps more congruent, happy, loving and so on — but different. The things that turn one person on are not the same as some one else and this is what makes relationships hard, but also exciting. This is what a complex adaptive system is like in real life.
Unless there was some obvious punctuated event like an affair or assault or major crime, most relationships don’t end because of a single thing. There might not even be a clear sense of what the “thing” that caused the breakup was. Sometimes people drift apart, sometimes the spark disappears, other times individuals forget who they are, while in some cases people discover themselves to be altogether new. Even still, sometimes this all happens at the same time, over time, in ways that neither couple can see until they are too far apart to connect. A complex system.
Treat this like a linear system and you may find potentially catastrophic consequences and hence the drama that TV and film introduce in their break-up scenes. For a funnier, but no less important take on this, see the video below from Dave Snowden.
This happens with lovers, spouses and friends all the time. A look to popular psychology or media will suggest that there are ways to handle this and no doubt efforts will be made to show how ‘healthy’ people transition and what they do to do so. These ‘healthy’ people will represent the ‘norm’. They’ll take time out for themselves, they’ll ‘get back up on the horse’, they’ll do the Eat, Pray, Love journey.. All of these might work, but they are based on an assumption that whomever is recommending these strategies knows the complexity of the individual’s case to whom they are referring.
Some therapists do, many do not. If you’re in for two or three sessions it will undoubtedly fall to the latter.
This is parallel to what we do in our efforts to inspire systems change. We look to the norms of our society, our discipline, our sector, our community and so on and we hire people for the equivalent of one to three to five sessions to tell us what to expect and do. What we get is Dr. Phil, which sounds great, allows us to boil enormous complications into a one hour soundbite or self-help book, and feel good because we are doing something that matches society’s expectation and we end up with what Russell Ackoff suggests as doing the wrong things righter.
Minding Our Norms
We expect to go into these encounters being the 1 in 7500 male model for jeans, when we are our own model for our our denim.
Work in complexity means breaking up with normative expectations and becoming mindful of what our own unique ones are as well as what the minimum specifications are that link us to that common thread of humanity — society, discipline, family, community, whatever. This is not easy. Mindfulness is very hard, but remarkably simple.
The more mindful we are of the rules and norms we live by or try to live up to, the better we can understand where they fit and where they collide against our own specific condition and setting and better craft strategies and design opportunities for real, genuine social innovation and not a caricature.
We need to be the model for our own jeans. When we do that, the fit will be both bespoke and very fashionable.
A brilliant and comprehensive new book has been launched that brings together the best scholars working in the area of systems thinking and complexity and applying it to health.
The book description can be found here along with a link to the abstract for a chapter I co-authored with Andrea Yip looking at the overlap between design thinking and systems science and complexity. This chapter takes a design lens on previous work developing the CoNEKTR model for engagement in complexity and health.
It’s a big book, but well worth a look if you’re wrestling with complexity and systems thinking in health and social innovation.
Higher education is asking itself some big questions and making substantive changes to the way it sees itself and produces value for society. Education is increasingly being rationalized, which calls into question the metrics that are being used to judge how resources should be allocated. In a previous post, I looked at the jobs metric. Now, it’s time to look at the knowledge metric.
Just the facts
Education writer and teacher Will Richardson‘s TED Book Why School is a provocative read for those connected to teaching or just interested in schooling. While it focuses largely on grade school, the issues are the same for universities and colleges particularly as the primary and secondary students of today are tomorrow’s graduate and professional learners. Richardson questions the role of the school as institution in its current form suggesting that if the status quo — one characterized an information delivery warehouse — is maintained there is little need for schools to exist at all. Yet, if the education within schools is focused on asking better questions and learning when to apply knowledge, not just what knowledge to apply, there is hope.
The current trend in school reform is towards Common Core Standards, which emphasizes specific forms of knowledge, ‘facts’ and asks that students be able to recall such content when required. Under this model, the role of the teacher is one of content manager and facilitator rather than guide or mentor and students are prepped for the tests of their knowledge (memory) rather than be asked to demonstrate its application to anything outside of the test. It is this model that many proponents of online education embrace, because the Internet is a fabulous content delivery system and education can be literally programmed and delivered to students directly without the ‘noise’ that teachers introduce to the signal. Under this model, educational content can be delivered cheaply and widely to support uniform intended effects among learners.
Richardson argues for reforming schools to something closer to the alternative model that was advanced by educational reformer and philosopher John Dewey. Richardson writes:
“In this version of reform, schools and classrooms are seen as nodes in a much larger learning network that expands far beyond local walls. Students are encouraged to connect with others, and to collaborate and create with them on a global scale. It’s not “do your own work,” so much as “do work with others, and make it work that matters.” To paraphrase Tony Wagner, assessments focus less on what students know, and more on what they can do with what they know. And, as Dewey espoused, school is “real life,” not simply a place to take courses, earn grades, amass credits, and compete against others for recognition. There lies the tension.
This second path is simply not as easy to quantify as the first. Developing creativity, persistence, and the skills for patient problem solving, B.S.-detecting, and collaborating may now be more important than knowing the key dates and battles of the Civil War (after all, those answers are just a few taps on our phones away), but they’re all much more difficult to assign a score to. I’m not saying that a foundation of content knowledge isn’t still important. To communicate, function, and reason in the world, students need effective reading and writing skills, as well as a solid foundation in math, science, history, and more. But I’m convinced we must revise the overreaching coursework requirements we place on students — requirements created at a time of scarcity, by the way. And we desperately need to revisit the thinking we’ve developed around assessment that, as Harvard researcher Justin Reich says, “optimizes the measurable at the risk of neglecting the immeasurable.””
Facts vs Problems
The knowledge metric is flawed because it assumes that content solves problems. It also presumes that the curriculum teaches the right knowledge for the right problems and that those problems can be known in advance. Let’s look at these.
One need only look to cigarette smoking as an example of how knowledge alone doesn’t always solve or prevent problems. One would be hard pressed to find anyone over the age of five who doesn’t know that sticking a lit tube of anything in their mouth and sucking on it isn’t at least somewhat unhealthy (and most know it is very unhealthy). An individual’s knowledge of smoking’s effects on physical health may not be complete, but it is often sufficient to inform the decision to quit or not start the unhealthy habit. And yet, citizens in highly educated countries like the United States, Canada and the U.K. smoke more than 1000 cigarettes per year per capita (and over 2700 per capita in places like Russia). These are not countries lacking in information on tobacco and health.
Using students’ ability to recall content makes the presumption that what is contained in a curriculum is what they need to know when they leave their program of study (at least as a start). While it may be somewhat true for students in the humanities and languages, it becomes highly problematic for those in dynamic fields or emergent areas of practice, which is becoming more normal than rare. There is no doubt that a corpus of key concepts, skills and ‘facts’ is useful, but the manner in which this knowledge can and may be applied is changing dramatically. For example, social media has upended communications in ways that very few health professionals are trained for. Journalists are particularly aware of the role that Twitter and related tools have had on their profession.
It also presumes that the content itself is relatively static. Certainly, curriculum renewal is something that most learning institutions engage in, but the primacy of content itself as the driver of education also assumes that the foundation for that knowledge is solid and can be applied today in the manner it was applied yesterday. In dynamic conditions, that isn’t often true. Further, the relevance of knowledge is framed by the problems to which that knowledge is applied. Genetic information, for example, can be incredibly useful when framed against tests that have high confidence, predictability and value to people, yet without such a context it is largely useless to those non-scientists who have it.
Areas of social innovation — which are expanding dramatically in number and scope — illustrate the problem of changing context well. This is a field characterized by problems, problem solving and novelty (which is what innovation is all about). Standard approaches don’t apply easily or at all when we are faced with high levels of novelty. Thinking and re-thinking the problem frame, knowing what to find, where to find it, and the skills to integrate relevant knowledge together is something that is not captured in the knowledge metric. Yet, it is those skills that will lead innovation. Knowledge translation professionals know this and so do knowledge brokers.
Are we designing our educational programming to advance on the kind of design issues of problem framing, finding and solving that our world is facing? Or are we simply taking content that can be obtained through books, the Internet and other materials, repackaging it and creating expensive warehouses of information that take learners out of the world and out of context in the process?
I don’t suggest that universities and continuing education programs stop delivering content, but if knowledge is the metric by which they are judging their success then it behooves educational administrators and funders to justify why they can do it better than other tools. What made sense when content was a rare commodity makes little today when it is overflowing in abundance for little or no cost. Universities and post-graduate training programs have an opportunity to re-imagine education and have the tools to do it in a way that makes learning more powerful and relevant for the 21st century should they choose to change their metrics of success.
How might we take the enormous talent trust that exists among university faculty (and their students) who co-locate (physically, virtually or in some combination) in a school and develop the skills to not only address problems of today, but prepare everyone for possible challenges in the future?
How might we integrate what we know, identify the knowledge we need, and create systems to take advantage of the talent and creativity of individuals to make universities, colleges, and post-professional training venues for innovation and inspiration rather than just content delivery vehicles?
What kind of metrics do we need to evaluate this kind of education should we choose to develop it?
These are questions whose answers might yield more learning than those focused on what knowledge students have when they graduate.
Image source: Shutterstock.
Earlier this week I has the pleasure of attending talks from Bryan Boyer from the Helsinki Design Lab and learning about the remarkable work they are doing in applying design to government and community life in Finland. While the focus of the audience for the talks was on their application of design thinking, I found myself drawn to the issue of evaluation and the discussion around that when it came up.
One of the points raised was that design teams are often working with constraints that emphasize the designed product, rather than its extended outcome, making evaluation a challenge to adequately resource. Evaluation is not a term that frequents discussion on design, but as the moderator of one talk suggested, maybe it should.
I can’t agree more.
Design and Evaluation: A Natural Partnership
It has puzzled me to no end that we have these emergent fields of practice aimed at social good – social finance and social impact investing, social innovation, social benefit (PDF)– that have little built into their culture to assess what kind of influence they are having beyond the basics. Yet, social innovation is rarely about simple basics, it’s influence is likely far larger, for better or worse.
What is the impact being invested in? What is the new thing being created of value? and what is the benefit and for whom? What else happened because we intervened?
Evaluation is often the last thing to go into a program budget (along with knowledge translation and exchange activities) and the first thing to get cut (along with the aforementioned KTE work) when things go wrong or budgets get tightened. Regrettably, our desire to act supersedes our desire to understand the implication of those actions. It is based on a fundamental idea that we know what we are doing and can predict its outcomes.
Yet, with social innovation, we are often doing things for the first time, or combining known elements into an unknown corpus, or repurposing existing knowledge/skills/tools into new settings and situations. This is the innovation part. Novelty is pervasive and with that comes opportunities for learning as well as the potential for us to good as well as harm.
An Ethical Imperative?
There are reasons beyond product quality and accountability that one should take evaluation and strategic design for social innovation seriously.
Design thinking involves embracing failure (e.g, fail often to succeed sooner is the mantra espoused by product design firm IDEO) as a means of testing ideas and prototyping possible outcomes to generate an ideal fit. This is ideal for ideas and products that can be isolated from their environment safely to measure the variables associated with outcomes, if considered. This works well with benign issues, but can get more problematic when such interventions are aimed at the social sphere.
Unlike technological failures in the lab, innovations involving people do have costs. Clinical intervention trials go through a series of phases — preclinical through five stages to post-testing — to test their impact, gradually and cautiously scaling up with detailed data collection and analysis accompanying each step and its still not perfect. Medical reporter Julia Belluz and I recently discussed this issue with students at the University of Toronto as part of a workshop on evidence and noted that as complexity increases with the subject matter, the ability to rely on controlled studies decreases.
Complexity is typically the space where much of social innovation inhabits.
As the social realm — our communities, organizations and even global enterprises — is our lab, our interventions impact people ‘out of the gate’ and because this occurs in an inherently a complex environment, I argue that the imperative to evaluate and share what is known about what we produce is critical if we are to innovate safely as well as effectively. Alas, we are far from that in social innovation.
Barriers and Opportunities for Evaluation-powered Social Innovation
There are a series of issues that permeate through the social innovation sector in its current form that require addressing if we are to better understand our impact.
- Becoming more than “the ideas people”: I heard this phrased used at Bryan Boyer’s talk hosted by the Social Innovation Generation group at MaRS. The moderator for the talk commented on how she had wished she’d taken more interest in statistics in university because they would have helped in assessing some of the impact fo the work done in social innovation. There is a strong push for ideas in social innovation, but perhaps we should also include those that know how to make sense and evaluate those ideas in our stable of talent and required skillsets for design teams.
- Guiding Theories & Methods: Having good ideas is one thing, implementing them is another. But tying them both together is the role of theory and models. Theories are hypotheses about the way things happen based on evidence, experience, and imagination. Strategic designers and social innovators rarely refer to theory in their presentations or work. I have little doubt that there are some theories being used by these designers, but they are implicit, not explicit, thus remaining unevaluable and untestable or challenged by others. Some, like Frances Westley, have made theories guiding her work explicit, but this is a rarity. Social theory, behaviour change models and theories of discovery beyond just use of Rogers’ Diffusion of Innovation theory must be introduced to our work if we are to make better judgements about social innovation programs and assess their impact. Indeed, we need the kind of scholarship that applies theory and builds it as part of the culture of social innovation.
- Problem scope and methodological challenges with it. Scoping social innovation is immensely wide and complicated task requiring methods and tools that go beyond simple regression models or observational techniques. Evaluators working social innovation require a high-level understanding of diverse methods and I would argue cannot be comfortable in only one tradition of methods unless they are part of a diverse team of evaluation professionals, something that is costly and resource intensive. Those working in social innovation need to live the very credo of constant innovation in methods, tools and mindsets if they are to be effective at managing the changing conditions in social innovation and strategic design. This is not a field for the methodologically disinterested.
- Low attendance to rigor and documentation. When social innovators and strategic designers do assess impact, too often there is a low attention to methodological rigor. Ethnographies are presented with little attention to sampling and selection or data combination, statistics are used sparingly, and connections to theory or historical precedent are absent. Of course, there are exceptions, but this is hardly the rule. Building a culture of innovation within the field relies on the ability to take quality information from one context and apply it to another critically and if that information is absent, incomplete or of poor quality the possibility for effective communication between projects and settings diminishes.
- Knowledge translation in social innovation. There are few fora to share what we know in the kind of depth that is necessary to advance deep understanding of social innovation, regularly. There are a lot of one-off events, but few regular conferences or societies where social innovation is discussed and shared systematically. Design conferences tend towards the ‘sage on the stage’ model that favours high profile speakers and agencies, while academic conferences favour research that is less applied or action-oriented. Couple that with the problem of client-consultant work that is common in social innovation areas and we get knowledge that is protected, privileged or often there is little incentive to add a KT component to the budget.
- Poor cataloguing of research. To the last point, we have no formalized methods of determining the state-of-the-art in social innovation as research and practice is not catalogued. Groups like the Helsinki Design Lab and Social Innovation Generation with their vigorous attention to dissemination are the exception, not the rule. Complicating matters is the interdisciplinary nature of social innovation. Where does one search for social innovation knowledge? What are the keywords? Innovation is not a good one (too general), yet neither is the more specialized disciplinary terms like economics, psychology, geography, engineering, finance, enterprise, or health. Without a shared nomenclature and networks to develop such a project the knowledge that is made public is often left to the realm of unknown unknowns.
Moving forward, the challenge for social innovation is to find ways to make what it does more accessible to those beyond its current field of practice. Evaluation is one way to do this, but in pursuing such a course, the field needs to create space for evaluation to take place. Interestingly, FSG and the Center for Evaluation Innovation in the U.S. recently delivered a webinar on evaluating social innovation with the principle focus being on developmental evaluation, something I’ve written about at length.
Developmental evaluation is one approach, but as noted in the webinar : an organization needs to be a learning organization for this approach to work.
The question that I am left with is: is social innovation serious about social impact? If it is, how will it know it achieved it without evaluation?
And to echo my previous post: if we believe learning is essential to strategic design we must ask: How serious are we about learning?
Tough questions, but the answers might illuminate the way forward to understanding social impact in social innovation.
* Photo credit from Deviant Art innovation_by_genlau.jpg used under Creative Commons Licence.
In complex systems there is a lot to pay attention to. Mindfulness and contemplative inquiry built into the organization can be a way to deal with complexity and help detect the weak signals that will make it thrive and be resilient in the face of challenges.
Most human-centred social ventures spend much of their time in the domain of complexity. What makes these complex is not the human part, but the social. As we interact with our myriad beliefs, attitudes, bases of knowledge, and perceptions we lay the foundation for complexity and the emergent properties than come from it. It’s why we are interesting as a species and why social organizing is such a challenge, particularly when we encourage free-flowing ideas and self-determination. Because of this complexity, we get exposed to a lot of information that gets poorly filtered or synthesized or missed altogether. Yet, it is in this flotsam and jetsam of information that keys to future problems and potential ‘solutions’ to present issues might lie. This is the power of weak signals. But how to we pay attention to these? And what does it matter?
The Strength of Weak Signals
A human social organization, which could mean a firm, a network, or a community — any collection of people that is organized by itself or other means — most likely generates complexity, sometimes often and sometimes occasionally. If we consider the Cynefin Framework, the domain of complexity is where emergent, novel practice is the dominant means of acting. In order to practice effectively within this space, one probes the environment, engages in sensemaking based on that information, and then responds appropriately. Viewed from another perspective, this could easily be used to describe mindfulness practice.
Mindfulness is both a psychological state and activity and a psychospiritual practice. I am using this in the psychological sense, even if one could apply the psychospiritual lens at the same time if they wished. Bishop and colleagues (2004) proposed a two-component definition of mindfulness:
The ﬁrst component involves the self-regulation of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present moment. The second component involves adopting a particular orientation toward one’s experiences in the present moment, an orientation that is characterized by curiosity, openness, and acceptance (p.232)
Weak signals are activities that when observed across conditions reveal patterns that provide beneficial (useful) coherence that has meaningful potential impact on events of significance, yet yield little useful information when observed in discrete events. In other words, these are little things that get spotted in different settings, contexts and times that when linked together produce a pattern that could have meaningful consequences in different futures. By themselves, such signals are relatively benign, but together they reveal something potentially larger.
One reason weak signals get missed is the premature labelling of information as ‘good’ and the constrained definition of what is ‘useful’ based on the current context. Mindfulness practice allows you to transcend the values and judgements imposed on data or information presented in front of you to see it more objectively.
Mindfulness involves quieting the mind and focusing on the present moment, not the past or the possible implications for the future, just the here and now. It is not ahistorical, however. Our past experience, knowledge and wisdom all come to bear on the mindful experience, yet they do not guide that experience.
Experience provides a frame of reference to consider new information, not judge it or apply value to it. It is what allows you to see patterns and derive meaning and sense from what is out there.
Building Mindful Organizations
A review of the research and scholarship on mindfulness finds a nearly exclusive focus on the individual. While there is much literature on the means of using mindfulness and contemplative inquiry as means of being active in the world, this is done largely through mechanisms of individuals coming together as groups, rather than the organizations they form as the focus of analysis.
There is an exception. Social psychologists Weick and Sutcliffe (2007, summarized here and here – PDF) wrote about resiliency in the face of uncertainty using a mindfulness lens to understand how organizations make better sense of what they do and experience in their operations. In their manuscript, Organizing for High Reliability: Processes of Collective Mindfulness (PDF), they lay down a theory for the mindful organization and how it increases the reliability of sensemaking processes when applied to complex informational environments.
They describe the conditions that precipitate mindfulness in organizations this way (p.38):
A state of mindfulness appears to be created by at least ﬁve processes that we have induced from accounts of effective practice in HROs (High Reliability Organizations) and from accident investigations:
1. Preoccupation with failure
2. Reluctance to simplify interpretations
3. Sensitivity to operations
4. Commitment to resilience
5. Underspeciﬁcation of structures
It is notable that the aim here is not to reduce complexity (or impose simplicity), nor is it to focus on ‘positivity’, rather it is focused on events that help contribute to moving in particular direction. In that regard, this is not neutral, but it is not active either. It enables organizations to see patterns, focus on structures and information that encourages resilience to change, and contemplates what that information means (sensemaking) in context. Doing so provides useful information for decision making and taking action, but doesn’t frame information in those terms a priori.
Seeing Beyond Events
At issue is the development of consciousness of what is going on within your organization moment-to-moment, rather than punctuated by events. Events are the emergent properties of underlying patterns of activity. When we spend time attending to events without understanding the conditions that led to those events, we are doing the equivalent of changing the dressing on a wound in the absence of preventing or understanding its cause.
A mindful organization, like the image of the Buddha above, can emphasize the eye, but not at the expense of the rest of the picture. It is attuned to both simultaneously, noting events (e.g., like the square highlighted eye above), but that it is only through the underlying pattern beneath it that the highlighted context makes sense (the rest of the pictured squares). Yet, the only way the organization can learn that the yellow square is different or to ascertain its meaningful significance is through a sense of the whole, not just the part and that is social.
The Curious Organization
Mindfulness and its wider-focused counterpart Contemplative Inquiry both have a root in attending to the present moment, but also in curiosity about the things that is brought to the mind’s attention. It’s not just about seeing, but inquiring. What makes it distinct is that it does not impose judgement on what is perceived not seeking to change it while in that state of mindful awareness. This judgement and imposition of value on to what is going on is where organizations can get trapped.
In complex systems, the meaning of information may change rapidly and is likely uncertainty. The wisdom of experience, shared among others contemplating the same information without judgement, allows for a sensemaking process to unfold that does not impose limitations, yet also keeps a focus on what is going on moment-to-moment. Gathering this data, moment-to-moment, is what developmental evaluation with its emphasis on real-time data collection seeks to do and can serve as a valuable tool for organizing data to allow for a mindful contemplative inquiry into it that will illuminate weak signals.
Creating an organizational culture where open sharing, questioning, experimentation, and attention to the adjacent possibles that come from the data and experiences from operations is the foundation for a mindful organization. This means slowing down, valuing non-doing instead of the constant push to action, cultivating contemplative inquiry and reflection, while also being clear about the directions that matter. Thus, strategy in this case is not divorced from mindfulness, rather it gently frames a directionality of effort. In doing so, it creates possibilities for innovation, attention to quality, and a mechanism for building resiliency within organizations and those working with them and within them.
In creating these mindful systems we move closer to making sense of complexity and better prepare ourselves for social innovation.
If to think and be aware of those thoughts (to think about thinking) is a defining feature of what it means to be human, why is it such a challenge to think about types of thinking? An answer to that question might help explain why design thinking is so difficult to translate into action and scholarship and why it continues to be the recipient of intense criticism and boosterism.
The other day a colleague reminded me of an essay on the demise of design thinking that I commented on in an earlier post . The post by William Storage adds further to the growing list of critiques of design thinking and ends this way:
In short, Design Thinking is hopelessly contaminated. There’s too much sleaze in the field. Let’s bury it and get back to basics like good design. Everyone already knows that solution-focus is as essential as problem-focus. Stop arguing the point. If good design doesn’t convince the world that design should be fully integrated into business and society, another over-caffeinated Design Thinking book isn’t likely to do so either.
Storage is right to argue that another book will not convince people of the merits of design or design thinking (which is different), but I can’t imagine it is just because of its merits. There appears to be something that troubles people with picking up metacognitive concepts.
Thinking about (Design) Thinking
Metacogntion is thinking about thinking and concepts like design thinking and systems thinking are, at their most basic, about the thought processes involved in contemplating systems or design. What commentators like Storage and Bruce Nussbaum are railing against is how this more sophisticated concept of design thinking (design metacognition if you will) has over time become synonymous at best, but a wholesale replacement at worst with a set of tools and creativity exercises.
Here we see the gap between the methods and their methodology.
Systems thinking, having had a few decades jump on design thinking seems to be faring better in that its common use is treated more as a metacognitive exercise than just a method, but only slightly. Why does adding thinking to something make it so difficult to communicate?
There is a reductionist push towards making thinking — design thinking, systems thinking, critical thinking, visual thinking — into a discussion of methods and tools. The concern, not unfounded, is that concepts like design thinking is pitched as a set of very simple techniques to provoke innovation while being stripped of its genuine innovation potential and reflective capacity, ironically removing the “thinking” part of the approach. These tools are manifest expressions of thinking and facilitators of it, but they are not thinking on its own.
The business and evidence of thinking
Maybe this is our fault for not putting thinking into the development of these concepts from the start. For example, the field of design suffers greatly from a lack of scholarship and theory around its methods and approaches. Designers are a practical bunch and seek to create and build things over theorizing and submitting their own processes to research. There are notable exceptions to this of course, but overall it is safe to say given design’s pervasiveness in our world that we know relatively little about it.
Systems thinking (as it applies to human systems) is in a different position, almost an opposite position. Whereas design thinking has come from a long history of practice with little formal research supporting it, systems thinking has emerged largely from academia and has far less empirical support for its applications to social affairs.
Another issue is economic. The drive for innovation-led market advantages in many fields is pushing anything to support such activity — something design thinking can do — into high demand. Markets abhor vacuums so they get filled and early markets favour the swift and bold, not necessarily quality. As my doctoral advisor once told me when I was hesitating on publishing my research: “people remember the first, not necessarily the best“.
Thus, we have entire business enterprises founded on teaching people design thinking without much depth in their process or intellectual foundations to support their work. They are out there in spades and contributing to the reasoned distrust, frustration and dislike of design thinking by many who could be its biggest advocates. Whether that’s hopeless or not remains to be seen.
So what is to be done? One option, that taken by Bruce Nussbaum, is to consider design thinking a failed experiment and seek alternative terms and concepts that capture the essence of what it does to improve innovative thinking, but in a manner that is less distorted. The challenge here is that, even if a new term does supplant design thinking, what is to prevent that concept from being co-opted and distorted as well with the same innovation-related market drivers in place?
Some argue that by formalizing design thinking into accredited programs, designations, certificates or degrees can assure quality just as we’ve started to see creep into the field of evaluation,. This presumes that have an empirically supported or widely agreed definition of what design thinking is and what are its core competencies. It also presumes we have the faculty with these skills and in positions to train people using methods tested to produce specific outcomes. Neither of these is true at present. This is the equivalent of suggesting that artists must have art degrees. Some artists do, but many do not and there is little to distinguish the difference in quality of the work between them.
A third option, the more complicated one and the most flexible, is to consciously build a community of practice around design thinking aimed at improving the scholarship, research and communications about design thinking to enable the wider world to learn about it, debate it, and apply it. This is already starting to form through such venues as the Design Thinking LinkedIn group and the Design Thinking Network. To that end, we could see a tremendous opportunity for professional organizations such as DMI and AIGA to contribute to this by opening themselves up to the wider community in the focus of their events and training options. By increasing commitment from those doing design and design thinking to education and contemplative inquiry into their craft we are naturally developing a field of practice that forms an attractor basin for better thinking and action.
Some further suggests to this point:
- Follow what psychology did after the American Psychological Association President George Miller suggested they “give away psychology” to the world. Psychology was once an elitist, opaque field of therapy and science and now is widely taught, incorporated into nearly every human-centred discipline, and is founded on a strong scientific and practice base. Democratize design thinking.
- Enlist creative professionals from fields like environmental studies, public health, social work, and education into the design thinking fold beyond traditional design disciplines. Get those living the spirit of Herb Simon who are out there trying to actively change current conditions into preferred ones — the social innovators, the public servants, the entrepreneurs of every stripe — to contribute their stories and insights on design thinking and get those into the public sphere for debate and dialogue.
- Fund and support more research programs beyond examples of my own modestly-supported Design Foundations project , which has sought to study design thinking by interviewing those experts that do it and the literature on its practice across disciplines. And rather than proclaim design thinking’s success and power, prove it and document it.
- Evaluate the programs that teach it, the processes used and determine what works, under what context, and document what happened along the way so we can learn more and be better at advocating for the power of design than simply proclaiming its worth.
Let’s contemplate more, study more, and reflect more about design thinking and maybe we’ll become better design thinkers.
What are your thoughts? Comment below.
Does it scale? That question is central to the discussion of social innovation, yet the answer to it might lead us to questions about why it is so important to us in the first place and answers that could surprise us.
“Does it scale?” or “how to we take [idea, product, service] to scale?” are commonly heard questions in social innovation circles; so much so that they are left unquestioned. The thinking behind these questions is that if something works well at one level (or scale) then taking it another scale larger and achieving a wider reach must be better. Who wouldn’t want to see the benefits of something that serves the needs of one population, community or user extended outward and upward?
This is a laudable utilitarian goal, but it is a deceptively problematic one when we look a little closer at what scaling something actually means in practice.
Jamer Hunt, the Director of the MFA program in Transdisciplinary Design at the New School in New York, speaking at last year’s DMI Fall Conference (which is available to view for DMI members), looked at the issue of design scaling through the lens of complexity and pointed to some of the problems with ‘scaling design’ in varied contexts. One of the examples he suggested is that of an ant compared with a human being taking a shower. For humans, the shower’s droplets of water are fine bodies of liquid that perform a particular task of facilitating cleaning, but for an ant those same droplets are enormous orbs of potential death. Water doesn’t scale the same for a human and an ant even though it is the same substance at both levels and the shower is identical in its structure.
In physics this is called scalar variance. What works ideally for humans is terrible for ants even though we are speaking of the same substance, same planet, same context. Water (most notably, a shower of it) doesn’t scale well in this case.
Yet, there is this insatiable desire among those working in social innovation to “scale things up” and “bring our innovations to scale” (even if we have little concept of how that would look or — as I will discuss — what that really means). The adherence to scaling as an ideology in social innovation (and applied social science in general) is bordering on “four legs good, two legs better” territory.
The Cult of Efficiency
International affairs scholar Janice Gross Stein attributes some of this fascination with scaling to a cult of efficiency, a political ideology that assumes that we can always rationalize human services optimally. What she found is that efficiency is used falsely as a stand-in for accountability, particularly in fields like education. Far from being against striving for optimal use of scarce resources, Stein nonetheless concludes that efficiency in human systems doesn’t always scale (my phrase, not hers) and that bigger and faster is often not better. Anyone who has taken a lecture with hundreds of others knows the difference of scale in learning between that and a seminar of five to ten people.
Taking Jamer Hunt’s argument: Bigger is just bigger…and whether its better or not is dependent on whether you’re an ant, a human and need to come into contact with water.
Designing for Systems and Scale: The Powers of 10
Designers and systems thinkers probably know the movie “The Powers of 10” by legendary designers Charles and Ray Eames. It’s a fascinating short film that looks at the universe moving out from a human being into the cosmos and inward towards what would now be quarks and everything in between. It is perhaps the best example of scaling ever produced. Beyond its educational and entertainment value, the Powers of 10 provide an illustrative example of where striving for scaling social innovations could be foolish and where it could have potential.
When traveling through the universe it is easy to see scales that are self-similar, thus they share properties that make them optimally relatable. These forms are often fractal in nature (thus, they share the same properties at different scales like that of a snowflake). Imperfectly, certain scales in the Powers of 10 are close to self-similarity where one scale looks and shows behaviour similar to those adjacent to it. These are spaces where it may be possible to transport an innovation from one to the other to good effect. Others scales look radically different from one another, suggesting a mis-fit in the scalar variance.
This is an idea, not an empirical point as we have little research on scalar variance in social innovation. Scaling innovation makes greater sense when the social systems have similar structures and ‘shapes’ and less when they do not. It is why in organizational science, certain models of management and decision making transport well from setting to setting and others do not. It’s why we’ve seen quality improvement processes like Six Sigma achieve great success in certain industries and firms and spectacularly fail in others.
Rather than adhere to an ideology that imposes scaling as a goal, social innovators need to generate the kinds of intelligence about the systems they are operating in (or seeking to operate or expand into) before making plans for scaling a promising intervention or product. As funders and policymakers this means setting performance targets that are appropriate or, perhaps better yet, working developmentally with innovators to co-create the outcomes of interest and the measures and metrics used to determine scalability and appropriateness early in the design and implementation cycle.
Without best evidence (which is almost always lacking in social innovation by its very nature), setting performance targets related to scale a priori is foolish. For innovators themselves, equally foolish is not gathering the kind of information about the systems they are operating in to know if they are the human or the ant and whether a shower is on the way.