CREATING A HEALTHY HILLTOP
Peggy Holman, Allan Paulson and Laure Nichols
Background
Franciscan Health System (FHS) is a
system of hospitals, primary care clinics, and long term care facilities with operations
in the South Puget Sound area of Washington State. It
is part of the national health system, Catholic Health Initiatives. In 1996, the governing board of FHS recognized the
need to more effectively achieve its Vision of “being a healing influence in the
communities we serve and improving health status”.
They authorized the formation of Community Health Councils in discrete geographic
areas served by the Health System to act as catalysts for long-term, systemic change and
to build capacity for improved health. Each
Council brings together individuals with extensive community experience and professional
expertise in such areas as public health, medicine, education, public and private sectors,
religious, public safety, and community activism.
After completing a preliminary
community health assessment using data from sources including the Health Department,
schools, cities and United Way, members of the St. Joseph Community Health Council in
Tacoma decided to pursue a process of direct assessment with residents of the Hilltop
area. The Hilltop community has a wide range of ethnicities, including African-Americans,
Hispanics and many Asian immigrants for whom English is not an easy language. The area is often characterized as poor and crime
ridden. St. Joseph Medical Center has been
located in the Hilltop area of Tacoma for over 100 years, yet has had little direct
interaction designed to improve the health of the neighborhood's residents.
Appreciative Inquiry was chosen as the
means to do direct assessment. It was
recommended by a Council member who had participated in an organization-wide inquiry at
Group Health Cooperative of Puget Sound. Her
positive description of the impact of that project got the Council’s attention.
What We Did
Creating a Healthier Hilltop spanned
seven months of planning and action. It began
with the kernel of an idea -- that those in the community were best equipped to set the
priorities for a healthy community. While the
final project activity took place on a set day, the impact of the effort continues to
ripple through community.
What follows is the story of what we
did.
Early December, 1996
A call to this consultant came from a
colleague at work, who also happened to be the Chair of the St. Joseph Community Health
Council. He was looking for someone who knew
something about Appreciative Inquiry to participate in this volunteer project.
When we gathered later that month,
there were four consultants who received such a call to work with the Community Health
Council to accomplish our task. We began by
looking at desired outcomes. The discussions
reflected the diversity of perspectives among the Council.
Some were focused on the people in the community.
Others were focused on creating more synergy among the service providers that
served the community. What we ultimately
concluded was that these goals were quite compatible and that we could accomplish both
with our design. The goals the Council set
were:
1.
To develop relationships and improve
connections between a broad variety of constituencies around the values and agenda of
being a healing influence in the communities where we serve;
2.
To enhance individual and organizational
visibility and capacities by training a significant group of stakeholders in appreciative
inquiry;
3.
To learn how the health care organizations
might more effectively collaborate, align and support existing organizations' healthy
community initiatives; and
4.
To create a pattern of communication that can
be replicated.
What were the dimensions of this work? About 85 people were invited to training in
Appreciative Inquiry with the expectation that they would conduct two interviews each. Nearly 70 people from 60 agencies actually
participated as "Listeners" in doing over 100 interviews with
"Talkers."
January, 1997
With some feel for the goals of the
effort, we began to put a process in place to make it happen. One of our challenges, with
four consultants with their own views of how best to do this, was to learn to separate our
needs to be experts from our conversations with the Community Health Council we were there
to serve! During the early sessions and
formation of the project, the agendas of the Council members and the agendas of the
consultants made for a messy mix. With a lot
of deep listening to each other, a design emerged that we all felt good about:
· We would invite all of the social service providers serving the
Hilltop community to a morning of Listener Training.
· Each Listener would conduct at least 2 interviews over the next
six weeks.
· A Listener gathering would be held to review what they heard.
· Finally, we would invite all of the Talkers and the Listeners to
participate in a one- day conference to review the interviews, formulate possibility
statements and discuss next steps.
January - February
The work began with an invitation to
potential Listeners. The letter was mailed on
February 21 to 100 health and social service providers from the Hilltop area. Meanwhile, The Council grappled with the
appreciative interview questions -- with much angst over how best to word them. They also struggled with one other challenge: how
would we identify the Talkers?
The challenge of identifying Talkers
requires some perspective: most members of the Council, while reflecting some racial
diversity, were college educated and lived outside the Hilltop area. Given the cultural divide between service
providers and the low-income, ethnically diverse residents, how could they link Listeners
and Talkers?
The challenge was resolved when,
ironically, a group called the Hilltop Action Coalition approached the Council about
sponsoring publication of a Block Handbook. The
Coalition has been recognized nationally for organizing block groups and provided the
perfect access point into the community. They
were quickly engaged and supplied Talkers for the initiative.
Interview questions were also
finalized during this time:
1.
Tell me a little bit about what it is like to
live in this area.
2.
Tell me about the best experience you've had
living in this community.
What
happened?
What did you
do?
What were
your thoughts and feelings?
What made it
a good experience?
What made it
possible?
3.
What are the best things about the Hilltop
that you think the community should build on to make this a better place to live?
4.
What is your picture of the Hilltop community
you want to live in?
5.
What are three things you and others need to
do to make this neighborhood a healthier place to live?
These questions started by: grounding
the Talker, then focused on the best of what is, shifting focus to what might be which
allowed the Talker to dream about what was possible and finally, how they might act to
create the future they wanted.
April 1 - Listener Training
We had three and one-half hours to
help Listeners understand what an appreciative interview was and to cover the logistics of
doing interviews.
It was a day full of anticipation. The members of the Council were there to express
their excitement and support for this collaboration among service providers. The consultants were all primed to equip the
Listeners with the information and the spirit of the project.
We started by giving them an overview. We then covered the very basics of Appreciative
Inquiry. Most of the time was used to
practice interviewing each other. We then
discussed their interview experience, enabling them to assimilate the concepts of
Appreciative Inquiry through their own discussion. We
ended the session by covering the logistics of contacting Talkers and collecting
interviews. And we sent them off to listen.
The morning did its job. The Listeners left excited by their role and the
potential value for the community.
April 25 - Interim Review
The desire for this meeting grew out
of the Community Health Council's need to know what people were saying before there
was a large gathering of Talkers and Listeners. Ironically,
once they had done some interviewing, their need for this interim review disappeared. Nonetheless, the date had been set, so an optional
gathering of about 25 Listeners came together for a half-day to check-in on the experience
to date.
The structure of the session was very
simple. We had copies of interviews at each
table. People took some time to read them and
discuss their impressions of what people said. We
then identified common themes among the interviews for use during the Talker-Listener
conference in June.
People came with stories to tell. The
positive voices and experiences the Talkers described stunned professionals who had served
this community for years and had never really ventured into it. This neighborhood was characterized by the media
as one of the west coast's most poverty-ridden, dangerous places. Yet, it was full of people who cared about the
same things that the professionals did -- a nice place to live, a good place to raise
their kids, a community that drew strength from its diversity.
One challenge crept into our process
design about this time. The County Public
Health Department had volunteered their Office of Community Assessment to analyze the
interviews. These highly skilled
epidemiologists were trained to look at data for its problem-solving opportunities. The clash between our now tight-knit band of
appreciatively focused consultants and these newly-arrived community assessment experts
provided a background drama through the remainder of the project.
June 7 - Talker-Listener Conference
By this time the goal of the
initiative had been much simplified:
To build and sustain a healthier Hilltop community.
When the 50 Talkers and Listeners
gathered on a Saturday morning, the anticipation in the room was palpable. These were the people who had been most profoundly
affected by the stories they had heard or told. They
came together to discuss how they could make a difference.
We began the day using the themes that
had come from the April 25 session coupled with the analysis done by the County Health
Department. The themes and the participant's
experiences became the basis to develop possibility statements to describe the Hilltop
Community they really wanted to live in. Among
the possibilities:
1.
In this community -- every child grows up in
a nurturing home with neighbors and community members valuing and supporting the nurturing
home.
2.
A model of cultural ethnic engagement where
our streets are more like day camps than armed camps and neighborhood mentors emerge.
3.
The Hilltop is a peaceful, respectful and
connected community that shares, cares and involves everyone.
4.
The community thrives because of diversity.
We invited the participants into a
circle and used Open Space Technology to focus the dreams expressed through the
possibility statements into activities to create what they said they wanted. We asked them to declare any idea to discuss that
they personally felt would move them towards the possibilities they had identified. Because there was no sponsoring agency who would
follow up on recommendations, we made it clear that "If it's to be, it's up to
me." This refrain was heard frequently
through the day as people gathered to discuss project ideas and schedule time to pursue
them following the conference.
Among the projects that emerged:
1.
Develop a Police Athletic League for sports
activities targeting Hilltop youth;
2.
Create a quarterly Hilltop news bulletin
delivered to residences and businesses describing opportunities for linking people to
community activities and resources; and
3.
Enhance resources available through the
Hilltop Family Support Center to bring isolated residents of the Hilltop together.
As part of the physical layout, we had
posted a mural sized sheet of butcher paper with the title "Picture of a Healthy
Hilltop Community." Throughout the day
people added to the drawing. By the end of
the session, an inspiring mural had been created that gave form to the possibilities
stated by these committed people.
We consultants had an interesting
learning from this day. The interview summary document compiled by the County Health
Department contained some less than appreciative observations, including references to
crime and poor police relations. These observations did not in any way shift the focus
from creating a healthy Hilltop community. Participants
successfully made the leap from problem-solving into the realm of possibilities.
The final role of the St. Joseph's
Community Health Council was to send out a summary of what took place to all participants
and key community leaders.
Outcomes: What's Happened Since
Six months after the June conference,
we interviewed a number of members of the Community Health Council and the Council staff
person from the Franciscan Health System. Among
the Council members we interviewed were two CEO's of social service organizations based in
the Hilltop area. We asked each what outcomes they had expected. Three desires were
consistently identified:
1.)
To listen to the people of the Hilltop talk
about what they see as the community’s assets and what constitutes a healthy
community.
2.)
To find collaborative ways that the Health
System could help advance the community’s health agenda.
3.)
To create a more positive reputation for the
Franciscan Health System. As one Council
member put it, “ We want to meet the community where they are, and be a catalyst to
help the community help themselves.”
All of those we interviewed reported
that their expectations have been met, along with surprises about what they heard from the
community. Several specific initiatives are moving forward, and the Community Council has
a new sense of energy and purpose, as well as an influx of new members from the community. At the same time, some Council members pointed to
opportunities to extend the learnings of the inquiry through the community by more
provocative sharing of the data.
There have been several tangible
initiatives growing out of groups that first convened during the Open Space. One group
focused broadly on communication and identified needs for better exchange of information
between both the residents and the service agencies in the Hilltop. As a result of that
session, a large group of social service providers and funders met to focus on the
objective of building an electronic information network that would facilitate information
referral and provide easy access to health information and education. Another initiative attempts to further identify
and showcase the community’s assets through developing a “100 year
project.” The project will identify both
buildings and institutions that have existed in the community for 100 years, supporting
both the pride and desire for multi-culturalism that was expressed in the appreciative
inquiry interviews.
It is less clear what happened to a
number of other ideas that surfaced in the Open Space sessions. As one person pointed out,
“We did not create another movement, but gave more focus to others’ on-going
efforts.” However, some Council members
believe it would be good to have more follow-up to see what else is happening, and perhaps
an occasional newsletter to highlight, encourage and recognize people’s efforts.
In late fall, the Council presented
its efforts to the System’s Board of Trustees. In making the presentation, the
Council Chair tried to convey his significant learnings from the process: discovering and
collaboratively supporting a community agenda is far different from the usual modus
operandi of the business world. “What we typically do,” he said’ “is
find a problem and solve it, making every effort to control the outcome with goals,
timetables, etc. You just can’t approach a community in this way.”
Most of those we talked with about
results spoke enthusiastically about the interview process itself. They described their
experience as "exciting," "enlightening," "wonderful." The
positive focus of the interviews helped both the listeners and the talkers recognize and
affirm the most positive aspects of the community, and this contributed to the feeling of
pride that emerged in the interviews.
All of the Council members felt that
the process helped them to understand the community better, and was successful in creating
a more positive perception of the Health System's role in the community. Too often, they
noted, a person’s only contact with a hospital is during an experience of illness,
pain and sadness. People don’t normally think of what positive influences a health
system can bring to the community’s well-being.
One specific change has been in the
membership of the Council. Through natural rotation, the Council has recruited seven new
members in the past few months. Every person asked to join the Council accepted the
invitation, and the new members as a group are more closely connected to the Hilltop
community. Their willingness to commit their time, in the face of a multitude of
opportunities and demands, is viewed as a significant endorsement of the Council’s
relevance and sensitivity to the Hilltop.
Another positive result has been the
establishment of stronger relationships between the Health System and several important
community organizations such as the County Public Health Department and the City of Tacoma
Police Department. The Health Department has been represented on the Council, and took on
responsibility for processing the interview data. In the course of the project, the
hospital and the health department learned much more about how each works and approaches
their role in the community. As a result, they opened a dialogue on new ways to work
together and be resources to each other’s efforts. As for the police, a wide spectrum
of views of community safety and the role of law enforcement in the Hilltop was expressed
in the interviews. Both the fact and the perception of safety were important components of
the picture of community health that emerged. Recently, a senior member of the Police
Department has joined the Council to support continued focus on the connection between
community health and safety.
Opportunities remain to share the
learnings from the inquiry with other community organizations. While most of the data
generated from the interviews and workshops was sent in written form to many social
agencies in the broader community,
there is still an opportunity to bring
together organizations in an interactive forum, asking them what they might want to do to
facilitate the community health agenda. Some Council members noted that the turn to action
after the Open Space, also seemed to end the generative aspects of the inquiry, and the
possibility of engaging and empowering others who had as yet not been involved. As both
the outgoing and new Council Chairpersons noted, there is a tension between the need to
problem solve and show results and the desire to generate greater levels of involvement
and initiative throughout the community. This
will provide the challenge as the Council continues its work.
What is Appreciative Inquiry?
Appreciative Inquiry is an exciting philosophy for change. The major assumption of Appreciative Inquiry is
that in every organization something works and change can be managed through the
identification of what works, and the analysis of how to do more of what works.
What problems are you having?
What is working around here?
These two questions underline the difference between
traditional Change Management theory and Appreciative Inquiry. The traditional approach to change is to look for
the problem, do a diagnosis, and find a solution. The
primary focus is on what is wrong or broken; since we look for problems, we find them. By paying attention to problems, we
emphasize and amplify them…
In the mid-seventies, David Cooperrider and his associates at
Case Western Reserve University, challenged this approach and introduced the term Appreciative
Inquiry. David's artist wife Nancy
brought the "appreciative eye" perspective to David's attention. The idea of the appreciative eye assumes that in
every piece of art there is beauty. Art is a
beautiful idea translated into a concrete form. Cooperrider
applied the notion to business: to the appreciative eye, organizations are expressions of
beauty and spirit…
Appreciative Inquiry suggests that we look for what works in an
organization. The tangible result of the
inquiry process is a series of statements that describe where the organization wants to
be, based on the high moments of where they have been.
Because the statements are grounded in real experience and history, people know how
to repeat their success.
From The Thin Book of Appreciative Inquiry, Sue Annis
Hammond
Peggy
Holman
Peggy can be reached at:
Allan
Paulson
You
can reach Allan at arpconsult@mindspring.com
or (206) 246-0931.
Prior
to serving in this capacity, Laure worked for ten years as Senior Vice President for
Franciscan Health System-West, overseeing managed care contracting, planning, marketing
and communications, real estate development and property management. Previously, she worked for United Health System in
New York and Kaiser Permanente in Northern California.
Laure received her B.A. from Smith College and her Masters in Public Health
and Hospital Administration from Yale University.
Laure can be reached at: LaureNichols@chiwest.com or 253-552-4116.
Excerpt from
Hammond, Sue Annis and Cathy Royal
(eds.), Lessons from the Field: Applying Appreciative Inquiry, Practical Press,
Inc.; Plano, TX, 1998.
For more information, contact Peggy Holman