A new way for system design: building a relational infrastructure

Mandy D. Owens, Sally Ngo, Sue Grinnell, Dana Pearlman, Betty Bekemeier and Sarah Cusworth

This blog post is based on the Evidence & Policy article, ‘Co-producing evidence-informed criminal legal re-entry policy with the community: an application of policy codesign‘, part of the Special Issue on Creativity and Co-production.

Health service researchers are plagued by the fear that policy and system-level improvement efforts will ignore or under-utilize research. Consequently, efforts at system improvement that come out of research centers tend to use “research-first” approaches that include protocols, trainings, and coaching sessions around evidence-based programs. But oftentimes the issue is not that a system is unaware of the research, it is uncertainty about how to get something going that fits the local context. This has as much or more to do with local values, personalities, and working relationships as it does with the specifics of a protocol.

Our study finds that engaging a community in a policy codesign process that prioritizes mutual learning, rather than a protocol, not only yielded a high-quality plan but built the relational infrastructure for local collaboration long after the external design facilitators left.

The county involved in this project was a thriving logging town at the turn of the 20th century. Since that boom, the area has struggled to reinvent itself and is challenged with high rates of poverty. The opioid epidemic hit the area hard, with a higher rate of opioid-deaths than the state average. A particularly knotty problem was the cycling of individuals with opioid addiction through the county jail. The county jail recognized this issue and had already tried to set up an in-facility screening and treatment program. Unfortunately, according to the jail program officer, the program was not successful in connecting clients to care after release. In other words, the county knew what best practices were, they just couldn’t get a working program off the ground.

The critical question was how to build working relationships across systems and maintain optimism in the face of significant infrastructure and resource challenges. The county public health department wanted to try a new approach. They reached out to university partners who implemented a system design method developed by Otto Scharmer called Theory U. In contrast to “top-down” methods of quality improvement in which system actors are given an evidence-based protocol and then coached through implementation, Theory U centers the learning and development process in the creative and emotional states of participants. The process moves partners through stages of discovery, knowledge integration, and prototyping with exercises aimed at promoting “open mind, open heart, open will.” Adopting this process rather than a top-down training approach requires a leap of faith that the developed plan will reflect accumulated knowledge about what does and does not work. At only one point was formal evidence brought into the design process. At the second session, the design group asked the university partner to compile the evidence available on the components of effective jail-based reentry for opioid use disorder. 

Fascinatingly, when we evaluated the process and asked design participants if they learned anything new during the project, not a single participant mentioned the results of the evidence review. Instead, participants mentioned learning from each other: what it was like to be a person struggling with opioid addiction navigating public systems, and what it was like working out of a jail-based system. Even more interestingly, the jail-based treatment and reentry plan precisely followed the steps recommended by evidence-based protocols. The final plan also included meaningful enhancements not found in these protocols, but came from the codesign process. This included hiring people in recovery from opioid use disorder to support clients transitioning from jail to the community. After design, implementation went quickly. The first position hired for the jail-based reentry program occurred just six months from the start of the design planning, and the local design team has subsequently largely stayed intact, weathering bumps in workforce transitions to keep the program still going one year later. While important questions about this process remains, the project taught us that focusing on mutual learning, trust-building, and creative processes builds the relational infrastructure needed for long-term, meaningful system transformation. 


Mandy D. Owens, Assistant Professor, Addictions, Drug & Alcohol Institute (mandyo@uw.edu)
Sally Ngo, Program Operations Specialist, CoLab for Community and Behavioral Health Policy
Sue Grinnell, Director, Population Health Innovation Lab
Dana Pearlman, Social Change Facilitator
Betty Bekemeier, Director, Northwest Center for Public Health Practice
Sarah Cusworth, Director, CoLab for Community and Behavioral Health Policy


You can read the original research in Evidence & Policy:

Owens, M.D. Ngo, S. Grinnell, S. Pearlman, D. Bekemeier, B. and Walker, S.C. (2022). Co-producing evidence-informed criminal legal re-entry policy with the community: an application of policy codesign. Evidence & Policy, DOI: 10.1332/174426421X16445109542161. OPEN ACCESS


If you enjoyed this blog post, you may also be interested to read:

He Ture Kia Tika/Let the Law Be Right: informing evidence-based policy through kaupapa Māori and co-production of lived experience OPEN ACCESS

Creative processes in co-designing a co-design hub: towards system change in health and social services in collaboration with structurally vulnerable populations OPEN ACCESS

Creative and collaborative reflective thinking to support policy deliberation and decision making OPEN ACCESS


Disclaimer: The views and opinions expressed on this blog site are solely those of the original blog post authors and other contributors. These views and opinions do not necessarily represent those of the Policy Press and/or any/all contributors to this site.

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