Monday, May 26, 2008

Community Engagement. Later is better.

By Anton Hart

My most memorable NIMBY experience occurred a few years ago. The fury of it all makes it seem like yesterday. I went to a meeting organized by members of my community who were aggrieved by the imminent arrival of a methadone clinic. The crowd literally spilled out onto the sidewalk of a local bar made available for the proceedings. Several doctors – clinic affiliates – were there, ostensibly to engage the community. After the chair and a local lawyer laid out the “facts,” the games began. For the next two hours or so not a rational thought surfaced, not a constructive word was spoken. The local representative on city counsel tried but was generally shouted down. The crowd went home in a highly excited mood to prepare their tar and feathers to ride the principals and politician out of town and so protect their neighbourhood. The raging battle spilled out into the kitchens, living rooms and local eateries. Even the local church found its voice a few days later when the Reverend Canon Christopher King, Senior Pastor of Little Trinity Church, wrote that “the church looks to Jesus as the one who shows us how to bring healing and transformation to hurting people and into communities. . . . He never compromised their safety by his healing, transforming work with social outcasts.” And so, the pastor reasoned, no clinic should come to his church’s back yard. Or, in this case, across the street.

On the other hand, the doctors at the meeting accused the crowd of not caring and putting their hard-earned home equity and personal welfare ahead of the dire needs of patients – who were also members of the community. The local blogger described it this way: “Tabarnouche! One would think, reading some of this, that the Gaping Gates of Hell were open and inhaling local residents in droves.”

Clearly, community engagement was not working.

This is not a new story. It is repeated often where we find the public fearful and frustrated when it has collectively determined that a cause, event or thing will destroy them. In this case, the clinic’s patients were presumed to be social outcasts who would threaten the neighbourhood and members of a church congregation. The mantra is, “build it anywhere – but not in my community.”

Let me report that this situation has since resolved itself to a dull roar, and postulate that it could now benefit from continued community engagement. These notes are a reflection of what subsequently happened and the application of some recent learnings. See what you think.

In the first place, neither the clinic nor the local politicians nor the government of the day engaged the community to ask them if and how and when they would like a methadone clinic in their community. They knew what the answer would be. Street smarts told them to stay under the radar. But the politicians also understood the need for the clinic in this community and even supported its owners in their search for a suitable building. Not fully succeeding in this limited goal they left the operators of the clinic, more or less, to their own devices. This, says journalist Malcolm Gladwell, is a process where the doing comes before engagement. And, I add, it is a demonstration that “doing” is more important to social change than any awareness campaign or pre-implementation community engagement. It is a demonstration that if you are in a position of power you can effectively begin the process of change. By doing. Consultation and awareness do not in themselves constitute change and, in fact, they accomplish nothing, says Gladwell. If anything, awareness (or community engagement) is the final stage of social change. That’s where it can have impact. Engagement is then designed specific to the goals set out. It is educational. But the doing will already have been done.

And so, in this community, the clinic went ahead. It weathered some unpleasant treatment from members of the community, a little extra attention from the media and from some vigilant cops keeping an eye on things. Today, the operators are keeping the place clean, enforcing rules to ensure a quiet operation and are going about their business without fanfare. As this was unfolding the Minister of Health (Ontario) commissioned a task force to take a close look at Methadone Maintenance Treatment across the whole province – prompted only in part by matters in his own riding. In response, the residents and business association – my neighbours – prepared and presented a thoughtful brief to the task force. Residents were given an opportunity to speak, and they gave heartfelt commentary. In the local blogger’s words, “Community residents presented their concerns in a dignified and reasonable way.” The advice was cogent, and the residents were heard. Some of the subsequent recommendations from the task force reflected the residents’ submission. In response, the provincial government set in place a province-wide program to improve communications, training, counselling, community engagement and other related services, and the city is working with the clinic to better integrate its operation with the neighbourhood. I know for a fact that the Minister made an unscheduled stop at the clinic – without fanfare.

The engagement shouldn’t stop here. It needs to be ongoing, and the mechanisms are available. Some members of the community stay in touch with the clinic owners, and the owners know where to find them. Some obvious exterior improvements have been slow to come about, hampered by city bureaucracy and some lethargy from the clinic’s operators. It’s a concern near the top of a neighbourhood’s list. Both the clinic and the city need to get on with it. (The same could be said for other businesses on the block.) The cops report little or no related crime and include the clinic in their rounds. In the meantime, new condominiums, new restaurants and new stores are all coming to the neighbourhood – unfazed by the operation of a methadone clinic with a stormy past. Real estate values are up. A few nay-sayers still want to be heard, but the neighbourhood’s silent optimists are drowning them out.

David Bornstein, who has studied social change and written about it, says that people who want to change the world are obsessively driven to succeed; they are, therefore, good listeners; they build good teams; they pay close attention to their environment; they stay focused on long-term goals but continually adapt to changing environments; and they are always looking for new opportunities to grow and innovate. By adopting this attitude, the local parliamentarian, the local councillor and the renewed rate payers’ group can improve this community, serve the sick and maybe even bring the church onside – or invite the Salvation Army to start a counselling service. The task force was strong on the need for counselling and community support. That presents an opportunity for continued community engagement.

In the end, I went back to the local blogger for a comment, and found that he had just posted a report that “research shows supportive housing has no effect on property values or crime rates. And, as in earlier studies, it showed initial community opposition disappeared once the homes opened.” Now’s the time, I add, for community engagement to ramp it up. Later is better.

Some of these thoughts come from the book, How to Change the World, by David Bornstein (Oxford University Press, 2004). They also reflect my notes taken during a debate between journalist Malcolm Gladwell and philosopher Mark Kingwell on the merits of awareness and engagement in the process of social change (May 13, 2008 on the campus of the University of Toronto).

Anton Hart is publisher of a range of healthcare publications from Longwoods Publishing Corporation, a member of a number of boards engaged in social change and the Chair of Ontario’s Methadone Maintenance Practices Task Force, which tabled its final report in March 2007. Contact:

Taking Community Engagement Seriously: How to Find Good Ideas and Make Them Stick

By Neil Seeman

IN THE LAST TWO YEARS, “community engagement” was mentioned more than 5,400 times in international newspapers and government and corporate press releases. Compare that to 1998-2000 when “community engagement” came up 111 times. What’s behind the new fashion in community engagement (a.k.a. “stakeholder engagement”), and does it work?

Community engagement (in my view) means developing and enhancing public participation in change: the more vigorously you engage stakeholders, the more you will understand their legitimate issues, misconceptions and potential resistance to change. Your solution will not only therefore be more effective, you will enjoy better “buy-in” for implementing new initiatives.

“Community engagement” is a concept that William E. Connolly, the Johns Hopkins political theorist, might consider an “essentially contested concept” : wide agreement exists on the virtues of the notion, but argument arises about what it means or what it aims to achieve. In some organizational contexts, extensive community engagement can reflect a culture of risk aversion (a.k.a. “buck-passing”) to the community; or political posturing (“hearing out the stakeholders,” with no follow-through). The exercise of consulting the community can be meaningless. Lacking intelligent oversight, the final result of expensive and time-consuming public engagement sessions is often a long list of complaints, unanswered questions, and unfulfilled wishes. The ensuing report makes it seem that everything (and, therefore, nothing) is a “priority”.

But sometimes – and let’s not kid ourselves, this is rarely done well – community engagement can bring about real, lasting innovation (though this “suitcase” word , too, needs definition). Why do some experiences in community engagement achieve greatness result while others remain an exercise in futility?

Before embarking on the engagement exercise, many fail to ask fundamental questions: Do community members offer better insights than those who have studied the issue; or are the “experts” themselves bound by conflicts (e.g., wanting research funds to evaluate new, untested programs rather than being keen on implementing proven solutions)? In some situations – e.g., improving access for the community – stakeholders offer profound insight and are in the ideal position to design solutions. When the solution needs to be adopted by the community to be effective (e.g., the use of walking trails or bike lanes to support increased physical activity), community engagement is critical. In other situations, community “stakeholders” come to the table with their stakes dug in. The concern may not be the bias itself, but leaving it undeclared.

To help illustrate the appropriate role for stakeholders, my IBM colleague, John Soloninka, has identified the following taxonomy of problems, and their related engagement goals :

Problem | Goal of Engagement

Complex problem needing expert solution
Engage stakeholders for input on what the problem is and possible solution elements, but do not ask them for the entire solution

Complex problem that only those on the front line know how to solve
Engage front line in designing the solution

Problem for which there is wide variation in opinion, and no “objectively” right solution (i.e., one based on values)
Engage in societal values definition

Problem for which there is poor general understanding of the facts among the general public, and many special interests legitimately or illegitimately driving misperception
Engage for education, and how to manage perceptions (this may be misinterpreted as paternalistic, and communications must therefore be managed delicately)

Once the right scope for community engagement is defined, there are two errors in logic that can trip up the initiative. These errors badly disrupt the progress of innovation.

First, it is a fallacy that all new ideas are of equal merit; secondly, more voices do not necessarily lead to better ideas. Ideas have to be sifted and weighed, and that takes serious effort.

The trouble with innovation in health care (or in any other sector) is that it’s not tangible; it cannot be measured easily – and its success cannot be easily predicted. When thinking about innovation, people often make an “attribution error,” welcoming an idea that is familiar because it fits well with traditional values of the culture or the organization. True novelty at first feels “foreign” and, therefore, is frequently rejected.

Gary Hamel of the London Business School finds this problem widespread among corporate executives today, and has compared the current state of business innovation unfavourably to the early 20th century era of Fredrick Winslow Taylor, who pioneered new ways of managing business, or to later 20th century examples such as the Toyota Production System or total quality management. In my view, this attribution error is exaggerated in healthcare, an expert-driven industry where there is a high degree of deference to yesterday’s opinion as the best model for tomorrow’s.

It is for these reasons that community engagement gatherings sometimes keep re-inviting the very same people who came to the previous session, usually the most outspoken and best mobilized groups, and measure the supposed success of the enterprise by the number, rather than the quality, of ideas generated.

Just as corporations generally tap into the creative potential of a very small proportion of their talent pool, health care leaders run the risk of enlisting only a small segment of their stakeholders when they try to generate innovative ideas. Insufficient resources are invested in marketing and recruitment efforts to get the right people to the table. More intelligence needs to be harvested to identify and quantify the good ideas – the ideas that have real promise of improving quality of life or another outcome of interest.

The problems of group idea-generation have been well-documented in the organizational context. Amy Edmondson of the Harvard Business School finds that corporate teaming exercises – often designed in good faith to be representative of a diversity of skill-sets and knowledge, typically break down in three ways. First, depending on who else is there, people may be too afraid to share information. Second, some people may be na├»ve about others’ self-interests, eliciting argument rather than generating ideas. Third, some people, all too aware of competing interests, withhold information. These problems can be overcome by an effective moderator and by group exercises such as role play where, for instance, the group is divided into fact-providers and Devil’s Advocates, and then roles are exchanged.

A greater challenge – especially in a tight funding environment – is inviting the right people (rather than just more people) to the sessions, and then synthesizing the best ideas.

Social networking tools online are instructive here. IBM, which launched its open “Innovation Jam” process in 2006 , posted White Papers and internal strategy documents online, inviting public comment using blogs. Customers, suppliers, and family members of employees provided input into IBM’s corporate strategy. Wired magazine has dubbed this approach “crowdsourcing.” The message here is to take risks and invite “competitors” and customers to the table; in the health care context, this might mean involving representatives from neighbouring hospitals, regions, private industry, and from government.

Once the ideas are generated, how are the best ones selected? Remember that idea generation and mobilization – the focus of any communication engagement – is just the first stage. In Crafting Organizational Innovation Processes, Kevin Desouza and colleagues dub the second stage “advocacy and screening”. They observe that corporations have more success when this process is transparent and standardized. The third stage is experimentation; this stage assesses the sustainability of ideas for a particular organization at a particular time. The fourth stage is commercialization or market testing – in a public health care context, this might mean “client feedback” – to analyze the costs and benefits of rolling out the innovation. Finally, the last stage is diffusion and implementation: gaining company-wide buy-in. In health care, this last stage means championing the idea internally and externally.

All this is to say that successful community engagement is more than just a cocktail party bringing together the usual suspects. It requires significant effort to find the right people – i.e., targeted message campaigns to historically unrepresented voices. It requires transparent analytics – such as statistical forecasting tools and correlation analyses to assess the anticipated impact of new ideas on outcomes of interest to corporate strategy. It then requires piloting; returning to the community to gain feedback on the ideas selected; and, finally, pursuing a corporate strategy in order to “own” the idea publicly.

Innovation is like a glow-worm, easier to see from far away, long after someone else has thought of it. If it weren’t hard, it wouldn’t be worth it.

Neil Seeman, JD, MPH is a Managing Consultant and Researcher at IBM Healthcare and IBM Global Business Services in Toronto. He is a writer and adjunct professor of health services management at Ryerson University. His research focuses on governance and social networking tools in healthcare. He is currently writing a book about obesity and community. He may be reached at: