Applying Elinor Ostrom’s Design Principles to Guide Co-Design in Health(care) Improvement: A Case Study with Citizens Returning to the Community from Jail in Los Angeles County

Planning phase:

• assessed the system and which service providers contributed to it before delineating boundaries for the project

• definition of the identities of service users and providers and the boundaries of the group were outlined (e.g. to focus on the county jail population – rather than state prisons – on the basis that this was likely to have greater impact and utility given the relatively poorer coordination and resources available for re-entry from jails)

• through process of refinement decided on specific inclusion criteria to help ensure participants could speak from experiences grounded in a similar set of available services, e.g., a focus on a specific geographic area—the South LA area, individuals released from jail within the past year, comfortable speaking English, and having had a mental health, substance abuse, and/or chronic or serious physical health condition during or after incarceration

• intentionally recruited a diversity of returning citizen participants proportionally reflective of the socio-demographics of the re-entry population for South LA in terms of race/ethnicity and sex. Although the overall final sample of returning citizen participants achieved the desired diversity on these characteristics, women were relatively underrepresented early in the project—particularly for the film of participants’ experiences, a key tool used during later project events. The sample also tended to skew older, likely a result of self-selection of individuals more inclined to engage in the co-design process

• purposively selected service providers to include (1) key countywide agencies involved in health and re-entry services in LA, (2) community coalitions providing support and advocacy for returning citizens and re-entry services and, (3) community-based organisations that provide various health and re-entry services to returning citizens in South LA

• realised a meaningful distinction existed between (1) county agencies who administered key funding and core programs for returning citizens and (2) community-based organisations who provided many of the direct health and re-entry services to clients, and consequently formed two service provider focus groups—one for each set of agencies.

Planning phase:

• ensuring all participants received equal in-kind benefits (food at events) and financial reward (participation payments at events) despite its value being more significant for some (e.g., returning citizens) than it was for others (e.g., service providers)

Planning and delivery phases:

• identified that the U.S. healthcare system has struggled to meaningfully engage service users in service improvement, and this was also the case for local re-entry services. Therefore, participating in this project was identified as being rewarding for local service providers as it afforded them the opportunity to engage directly with returning citizens

Delivery phase:

• took care to equalise status and power differences through the structure and facilitation of co-design events (e.g., use of names without titles, alternating opportunities for discussion)

• provided transportation for returning citizens to attend events and solicited donation of conference space for the co-design workgroups from service agencies—viewed as equitable benefits and costs given the differential resources between the groups

• regularly sought feedback and evaluated practice and in so doing found that returning citizens found the opportunity to share their experiences and the authenticity of the collaboration with the project team and service providers to be rewarding.

Evaluation phase:

• a key concern of CO-SHARE participants voiced early in the study (particularly by service providers), as well as during the closure event, was the degree to which the project would focus on impact and promoting change in health and re-entry services. That is, they wanted their participation to lead to change. This was also evident in the comments of one returning citizen who commented after the final workshop “Everyone’s concern was: what are they going to do with this information and what is going to be the impact?”

Planning and delivery phases:

• considered collective-choice arrangements as inherent to the ‘doing’ of co-design itself; consensus building was a deliberate feature of the staged co-design approach

• the main aim was for service users and providers to identify the main needs and priorities relating to health and re-entry services which were then discussed by both groups presented at the joint returning citizen/service provider event.

Delivery phase:

• at the stakeholder event the project team attempted to establish a relaxed environment with an atmosphere of trust and respect. As part of this clear ground rules were set to honour the privilege of hearing each other’s stories and to clarify that no one was required or expected to share personal experiences they did not wish to reveal in a group setting. This was not a collective decision but one the project team considered good practice in co-design facilitation

• the project team decided – without consultation – to forgo the service provider feedback event, which resulted in scheduling of a later debrief call for providers (see Figure 1)

• decisions about who was to be interviewed for the trigger film were made solely by the project team and based on a decision to represent diversity of re-entry journeys and comfort articulating experiences. This selection was subsequently criticised by returning citizens for under-representing women and not representing women of colour.

Evaluation:

• in reviewing the notes from the joint event, the project team observed that some service providers appeared more reticent to participate in the event discussions. They speculated that this may have been the result of service providers not having an opportunity to share perspectives before meeting with the returning citizens. This could have been avoided if decision-making had been a more collective endeavour

• feedback suggested the study could have benefited from less time between events and greater frequency and length of events, particularly in the latter codesign phase to devise strategies. The frequency and duration of events were decided by the study team rather than collectively.

Planning and delivery phases:

• monitoring was primarily the task of the group facilitators with consideration given to who was best placed to facilitate the co-design process

Delivery phase:

• monitoring was primarily about ensuring the comfort of returning citizens in order to facilitate and support their engagement in the co-design process (rather than to protect against free-riding or active exploitation of resources), e.g., throughout the joint event the study team monitored and attempted to address any relative unease among returning citizens with speaking in a group workshop setting or engaging with service professionals on an equal basis outside the usual client-provider relationship.

Planning, delivery and evaluation phases:

• no evidence of sanctions being collectively agreed upon. However, the project team did have a form of sanction ‘waiting in the wings’ as the consent form for participation was deliberately written so as not to imply continued involvement was assured. This sanction was neither collectively agreed nor explicitly stated but acted as a safeguard for the project team against continued involvement of those deemed either not to be contributing or to be contributing in what was deemed to be a problematic way. What was deemed problematic was at the discretion of the project team rather than the group more broadly.

no evidence beyond sense that this was an inherent task for the facilitator(s) during the co-design process

the context of the work – a time-limited feasibility study supported by a grant from an external funding foundation – focused the project on facilitating meaningful collaboration with a marginalized service user group in co-design with multiple service providers—a challenging task in itself; but not development of governance mechanisms for self-organization of either the group within the project or the wider community-wide system for health and re-entry.

Planning and delivery phases:

• participants were part of both formal hierarchical systems and informal peer-to-peer networks and pooled their resources through the co-design process to coordinate activities that might lead to beneficial impacts

• there was acknowledgement that most efforts to coordinate services are largely designed from the perspective of providers and system-level decision-makers so attempts were made to work with the relevant service providers in a co-design process to demonstrate the benefits of an alternative way of working. The co-design process also facilitated returning citizens of different backgrounds to develop a common group identity that prepared them to productively voice, share, and pool their experiential resources with service providers in the project’s joint activities. However, limited consideration of how this pilot could have been conducted to prepare and support those involved to sustain the co-design of services or how this way of working could be embedded in the current system.