Meadow’s Leverages Points with Ostrom’s Governance Principles & Rippel Foundation Model’s Levers

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The whole point of Meadow’s list, Rippel’s list and Ostrom’s list is for activists to USE them. So what do they look like together and what designs and action can we take NOW based upon this collected wisdom applied to the health and wellbeing of our communities?


1. The power to transcend paradigms.

This is the wellspring of innovation. Some of us must be very curious about the way we think, where our values and assumptions come from, the consequences of our current world views. Some need to seriously explore the possibilities that arise from fundamental shifts in thinking and in practices.

2. The mindset out of which the system arises.

Ostrom’s # 1 Clearly defined boundaries

Pathways to advantage

Healthier behaviors

Preventive and Chronic Illness

Reducing Crime

Reducing Environmental Hazards

Reducing Hospitalizations through Post-discharge Care

Each of the above levers in the Rippel model will require that we think of the healthcare system very differently. It must become porous. We will need to look way up stream. We will need to empower patients and families to play new roles. Investments as well as savings from decreases in per capita health expenditures will need to be routed into education and civic projects. It is not only health care than must think very differently but so must educators and elected officials if we are going to work together to improve the wellbeing and health of our communities.

3. The goals of the system.

Adherence Support for  Routine Care

Care for Chronic Mental Illness

4. The power to add, change, evolve, or self-organize system structure.

Ostrom’s #2 Local Rule

Ostrom’s #3 Collective-choice arrangements

Ostrom’s #7 Minimal recognition of rights to organize

Ostrom’s #8 Nested enterprises

5. The rules of the system.

Pay providers for performance (out of captured savings)

6. The Structure of Information Flows

Ostrom’s #4 Monitoring

Ostrom’s #6 Confilict-resolution mechanisms

Adherence Support for Routine Care

Coordinated Health Care

The businesses that employ healthcare service providers are siloed and often competing against one another without a shared interest in the patient or the community. The needed structures for information flow must become much more patient and community centered and more collaborative around individual patients and in support of whole community (population) health.

7. The Gain around Positive Feedback Loops

Adherence Support for Routine Care

Establish Innovation Fund

Expand use of Hospice Care

8. The Strength of Negative Feedback Loops

Ostrom’s #5 Graduated sanctions

9. The Lengths of Delays.

Create Medical Home

Improve Hospital Efficiency

10. The Structure of Material Stocks and Flows

Capture Savings

Insurance Coverage Expanded

11. The sizes of Buffers and other Stabilizing Stocks.

Recruit Primary Care Providers in Private Practice

Recruit Primary Care Providers in Safety Net Practices

Redesign Primary Care Practices

12. Constraints, Parameters, and Numbers.

Prevent Hospital Acquired Infections