HEALTH: Neighbors, Neighborhoods and Common Pool Resources

Health and wellbeing are community resources as well as the products of neighbors and neighborhoods. Individual and collective health are products of interactions at a neighborhood level. Health and wellbeing may be viewed a kind of doubled common pool resource–a resource which grows from both collaborative and collective efforts and which  decreases when individuals take without giving back. This may be a stretch of Elinor Ostrom’s definition of a common pool resource but I think that it could be a useful stretch–if her insights into governance of common pool resources can help up improve our common wellbeing. Let’s explore this from her perspective. Common pool resources usually arise from nature, water, grass for grazing, forests, fisheries. The difference with health is that it is the users who are also the creators. Rather than veer away from Ostrom’s precepts it may amplify them since cooperation is needed in the creation as well as in the usage.

Health is more than the absence of illness. It is a different kind of thing. The absence of health may invite illness. But the absence of illness does not create health. Nor does the presence of illness necessarily prevent wellbeing. Our culture has invested heavily in diagnosing and treating illness and has under invested in supporting health and wellbeing. Our preoccupation with  death has diverted attention from finding ways to live well.

The expertise and infrastructure needed for restoring health from a state of ill health may require resources beyond a neighborhood’s capability. The design of the relationship between the members of neighborhoods and such non-local institutions is of interest to me. I take my cue from Elinor Ostrom (governance of the commons) as well as Michael McGinnis (polycentric governance).

Light weight, inexpensive governance (without the costly overhead required by corporations and governments) operate by eight rules inside these two interdependent frameworks:

  • A) The inexpensive and proximate governing power comes from local peer relationships: to create boundaries and rules, to enter into a network of peer-based communities sharing the same resources and obtaining freedom for local governance from more distant powers.
  • B) Inexpensive arrangements for managing the input and withdrawal from the common pool is also provided by local peer relationships: to monitor compliance, to impose sanctions and manage conflict


Innovation in Hospitals and Clinics

While improved care will decrease the fraction of the population needing emergency and hospital care it will never eliminate it. The decreased utilization and decreased funding available per capita puts pressure on hospitals. I think that the best innovation strategy for hospitals will be something like: “Sooner, Better, Cheaper”. Hospitals that can provide needed service sooner in your life or your schedule, with better cllinical and experiential outcome, at a significantly lower cost than competitors will flourish–at least in contrast to hospitals that are “Slower, Average, Expensive”. As systems accept risk for population outcomes at lower costs, higher quality and higher satisfaction–they will buy services that meet these requirements when they are unable to produce it themselves.

Innovation in a health system will be a concerted effort to create 1) the clinic of the future, now (P4Medicine) and 2) the hospital of the future, now (Sooner, Better, Cheaper).

The Army and Schools are on the Same Page

Psychological resilience is important for every one. There are emerging programs to teach resilience to soldiers, their families and to school children. Here is a news clip from London. Here is a NPR transcript. Here is an HBR podcast and transcript. Comprehensive Army Fitness may be the most advanced model available to transform current employee wellness programs into employee wellbeing programs which should have a much bigger pay off, not just in health but in productivity and worker retention.

Back to the Source of Inspiration

There is a lot going on in health care. I regularly feel the need to reorient myself. This morning I reflect back upon my own source of inspiration. In 2001 a group of patients in my community articulated what a redesigned health care system would have to accomplish from their perspective. They simplified the problem/solution considerably. The asked consistently for three things:

  1. Navigator-Coaches,
  2. Their own life long, sharable, personal health records and
  3. Access to tailored knowledge, education, and training to have more self-caring capability.

I will continue to help this emerge in my community, my organization, my state, my country, and beyond.

Triple Aim Socio-technical Infrastructure

Technical Infrastructure to support efficiencies in the current illness-based, visit-based system (status quo):
  • Certified EMRs
  • Community connections between EMRs (HIE)
  • Organizational portals for providers and families

Socio-technical support for the new (near term future) Triple Aim based health care system:

  • Begins in earnest ONLY when financial reimbursement aligned with the community members–Triple Aim
  • Data repository and analytics for early pattern detection of managing a network or system
  • Care coordination (case management and beyond) that engages the patients
  • Patient and family health engagement tools
  • Engagement of people at work and at school (health, flourishing, and illness prevention)
  • Broad based support whole community policy creation and action


Why Change?

I want the human experience of each person, patient, family member and provider to be respectful, connected and deeply meaningful. Only in such an environment can each person adopt the behaviors and practices that will lead to their highest wellbeing.

In this talk I suggest how can we support all the people in our communities making new choices and adopting new behaviors that support health and wellbeing.

Here is a condensed PDF of the slide deck :Consumer-Centric Models of Change

Innovation teams must:
Enjoy openness in uncertainty
Must develop skill in suspending judgement (knowing)
Must participate in group dialogue with all stakeholders in order to get beyond politeness, and beyond challenges and discussion in order to reach the previously unknowable wisdom of the whole and from there to discover our best future.

There is an essential order to planning and organizing community change:


For the sake of what are we taking action. Out of what history and what historical mind set? Out of what belief system? At what scale? In what place(s)? For whom? Is this the time for a change of mind and direction?

Meadow’s first three “existential” leverage points address this first stage. The conversational methods for this stage must include dialogue and participatory action learning.


Who has had a voice? What kind of a voice have they had? Who must have a voice? What kind of a voice must they have for the change to emerge? When will the conversation change?

Meadow’s 4, 5 & 6th “political” leverage points Address this next stage. The methods for this stage must include dialogue, participatory action learning, social organizing, and democratic political action.


What are the nonlinear dynamics of this complex social system we are intervening in? What are the feed back loops, the delays, the unexpected consequences. What are the surprises that matter?

System dynamics modeling is the only way to understand this. Will we invest in this method or will we suffer the consequences. When do we need to create and update the model in order to have the necessary tool for policy design? Who will get to see and use the model? Will it be transparent to the whole community? If not, why not?


What are the visible linear systems, the processes, the inventories, the investments, the adjustments? How do we manage, day-to-day, the system that has emerged from the more fundamental leverage points?

The conversations here are about process flow, hand offs, organizational structure for coordination and decision making. How will we operate within a hierarchy or command and control structure in a way that does not kill the engagement and creativity of the participants. How often will improvements be made? Who will be allowed to make improvements? Who will see the performance data?