Download Living Dialogue on Health and Care

The Valeo Initiative
Creating an Epidemic of
Health
LIVING DIALOGUE ON HEALTH
AND CARE
PILOT STUDY REPORT
June 2002
6 Hawthorne Lane
Corte Madera, CA 92925
Phone: 415 927-4305
Email: [email protected]
BACKGROUND AND PURPOSE
If the American people had a chance to speak from their hearts about their visions of a better
health and care system, what would they say they really wanted? If people were asked to
describe the best aspects of health and care, what would they say they want to keep as we move
into a new and changing future?
In 1999, a group of people and organizations gathered around these and similar questions to plan
a process that would lead to improved health, transformation of roles, and redistribution of power
and resources. They wanted the plan to be so compelling that it would serve as a covenant with
one another and with the people they hoped would join them.
The group incorporated and became the Valeo Initiative — after the Latin valeo, which means “to
be able, to have the power (to); to be well, fit and healthy.” The essence of Valeo is optimal health
and well-being. Central to this vision, was the notion of the individual as the driver of change
Stimulating an Epidemic of Health through Dialogue
Members of the Valeo Initiative were particularly intrigued by the work of Jonas
Salk MD who proposed that the most powerful way to improve health would be to create an
epidemic of health. Health would be contagious, spreading from person to person in an everincreasing and self-reinforcing cascade. In the same manner as a disease-based epidemic,
healthy activities and knowledge that are nascent in the environment would suddenly “tip” into an
epidemic (Munnecke, 2000). At the tipping point, small changes can have a dramatic effect. As
Salk said, “only a few are needed to visualize and to initiate a process that would become selforganizing, self-propelling, and self-propagating, as is characteristic of evolutionary processes.”
(Munnecke & Wood Ion, 1995)
What if there were a health virus that could spread globally with the speed and virulence of an email virus? Rather than infecting people, a health virus made its recipients healthier? And, like an
email virus that spreads to everyone in the computer’s address book, a health virus spread this
health to one’s circle of acquaintances.
There is no central reservoir of health that is depleted when someone gets healthier. The
opposite is true: those avoiding or curing themselves of tuberculosis or alcoholism improve
everyone else’s health. Rather than pricing and allocating health as a derivative of care
transactions in a marketplace, the epidemic of health would trigger a positive feedback loop in
which everyone, acting in accordance to their own self-interest, could become healthier by
bringing about a more responsive systematic interplay of all the determinants. In so doing, they
would directly or indirectly improve everyone else’s health (Munnecke, 2000.)
An epidemic of health involves transformations – fundamental, long-term changes in the thinking
and behavior of individuals, based on their enlightened self-interest. The role of the organization
or enterprise is to facilitate these transformations, but the ultimate responsibility for the success of
the transformation lies with the individual.
Jonas Salk wanted people to discover those things they do that make them healthy, and share
those things with as many people as possible. He would ask often ask his patients three powerful
questions. What keeps your healthy? What do you want to teach your grand children? What
would keep the world healthy for those grandchildren?
Building upon Salk’s notion that powerful questions can stimulate the personal transformations
necessary for creating an epidemic of health, members of the Valeo Initiative decided to
undertake a national effort to engage the American people in a dialogue aimed at revealing their
core values and assumptions about health and care. If the American people had a chance to
speak from their hearts about their visions of a better health and care system, what would they
say they really wanted? If people were asked to describe the best aspects of health and care,
what would they say they want to keep as we move into a new and changing future? By
participating in these dialogues people would come to understand their role in their own health
more clearly and would become actively engaged in healthcare decisions involving themselves,
their family members and their communities.
Every one of us has in common the fact that we are or will be patients and care givers, involved in
healing and being healed; we all have aspirations for and visions of optimal health. Discovering
common ground, connecting around a shared and mutually beneficial purpose, and lifting the
inquiry to a level that recognizes our profound interdependence are each essential ingredients for
creating an epidemic of health. By creating a process that enabled people to voice their own
dreams, explore the meaning of optimal health and share valuable stories, Valeo members hoped
to inspire people to reclaim their share of power and participation in the healthcare system.
THE LIVING DIALOGUE ON HEALTH AND CARE
A work group of Valeo members designed the Living Dialogue on Health and Care as a vehicle
for inspiring people to think constructively about health and care -- paving the way for a new era
of health care consumers who regard health as more than medical care; whose behaviors reflect
their desire to keep themselves and their families as healthy as possible; and who are better
prepared to make increasingly difficult decisions about health care quality and financing. The
dialogues would both inspire participants and provide information that could lead to necessary
changes in the health care system.
The Living Dialogue would:
 Help people discover and articulate their own values about health and care
 Inspire people to think and act creatively about ways their can improve their own health
and care
 Uncover the many types of important decisions that people are already making
 Utilize this understanding of public values and creative spirit to:
o Identify opportunities to improve care and lower costs based on people's
experiences of what is already working
o Promote the types of patient-caregiver relationships that are most satisfying
o Construct new consumer health education programs based on individual and
community values
o Search for ways to improve the availability and quality of care for the uninsured,
the underinsured and other vulnerable populations.
The Living Dialogue would be designed around the principles of Appreciative Inquiry (AI,) a
strategy for purposeful change that identifies the best of “what is” to pursue dreams and
possibilities of “what could be.” AI is a cooperative search for the strengths, passions and lifegiving forces that are found within every system—those factors that hold the potential for inspired,
positive change.
Appreciative Inquiry As the Methodology for Dialogue
Recognizing the limitations of traditional approaches to organizational and systems change, two
PhD candidates at Case Western Reserve University, David Cooperrider and Suresh Srivasta,
developed Appreciative Inquiry in the early 1980s. Unlike the traditional approaches, which focus
on what is wrong and seek solutions to fix problems (French, 1969; Watkins & Mohr, 2001,)
Appreciative Inquiry begins with valuing and develops a vision and plan for the future that builds
on the best of the past and present.
According to Levinson (1972) most organizational analysis is directed toward “discover (ing) and
resolve (ing) problems. Research has primarily explored experience(s), which appear stressful to
people and that disrupts or disorganizes people” (p. 37). Typical questions in data gathering or
“problem solving” would include: “What problems do you see in your group, including problems
between people that are interfering with getting the job done the way you would like to see it
done?” and “What problems do you see in the broader organization or system?”
Appreciative Inquiry involves identifying and enhancing the core factors that give life and
resilience to organizations and make people’s work meaningful. Its theory lies in social
constructivism and the interdisciplinary arena of image theory—specifically looking at the
relationship between positive guiding images of the future and positive action. For example, in
medicine there is the placebo effect and in education there is the Pygmalion effect.
In practice AI involves systematic discovery of what gives “life” to a system when it is most
effective and healthy in economic, ecological, and human terms. AI involves the art and practice
of asking questions, much like those of Jonas Salk, that strengthen a system’s capacity to
capture, anticipate, and heighten positive potential. It mobilizes inquiry through the creation of
“unconditional positive questions” often-involving hundreds or sometimes thousands of
people. People are asked to recall times they felt most alive, most vital, most energized and then
are questioned about those incidents.
AI assumes that every living system has rich, untapped reserves of the positive—community
achievements, innovations, strengths, alternatives, assets, emergent possibilities, hopes, visions,
opportunities, contextualized wisdom, knowledge, and meaningful stories of things like courage,
leadership, and action. Link this “positive change core” directly to any change agenda and
changes not thought possible are suddenly and more democratically realized.
The AI Process
AI is based on five underlying principles:
1) the principle of social constructionism which suggests that we have considerable
influence over the nature of the realities that we perceive and experience, and that to a
great extent we actually create our realities through collective symbolic and mental
processes (Fitzgerald, Murrell & Newman 2002 )
2) the principle of simultaneity which posits that in human systems inquiry and change
cannot be separated – they occur simultaneously (Cooperrider & Whitney)
3) the poetical principle acknowledges that human systems are open books, continually
being co-authored by the people within them and those who interact with it (Watkins &
Mohr 2001)
4) the anticipatory principle acknowledges that the most important resources we have for
social change is our collective imagination and our discourse about the future (Watkins &
Mohr 2001)
5) the principle of positivism indicates that momentum for change requires large amounts of
both positive affect and social bonding—things like hope, inspiration, and sheer joy in
creating with one another (Cooperrider & Whitney)
These principles come to life through the design of the basic AI process, which is typically
presented as a cycle of four phases known the “4-D Cycle” (Cooperrider, 1996, p. 8). The
phases are: (1) discovery of people’s experiences of their group, organization, or community
at its most vital and alive, and what made those experiences possible; (2) dreaming together
to envision a future in which those exceptional experiences form the basis for organizing; (3)
designing appreciative systems and structures to support the manifestation of the co-created
dreams; and (4) destiny or delivery, which involves implementation of those systems and
structures in an ever-expanding positive-feedback loop of appreciative learning.
The Think Tank
Prior to beginning the 4-D cycle, David Cooperrider, who was now serving as an advisor to Valeo,
recommended a fifth D—Definition—of what we hoped to achieve through the dialogue and of the
questions to be asked. Fetzer Institute in Kalamazoo, Michigan, agreed to host a Think Tank. 26
people attended the October 30-November 1, 2000 meeting. In addition to Valeo members, David
Cooperrider invited people who had had used Appreciative Inquiry in social change organizations.
These included representatives from Habit for Humanity International in Nepal, Imagine Chicago,
and the United Religions Initiative (URI) in San Francisco.
At the Think Tank, participants were introduced to the core concepts and practices of AI. They
also defined the direction, context, and intent of the national conversation along with its goals,
time frames, and ultimate steps. They began the process of developing powerful interview
questions; putting together a national strategy for interviewer training; and building the project
network (partners, roles, communications, and resources).
Members formed an ongoing working group to continue the planning process, develop Living
Dialogue materials, plan the data analysis and test the concepts. The work group was co-chaired
by Anthony Suchman, MD and Col. Mary Ann Morreale, FACHE. The Department of Defense
funded the development, printing, and mailing of the pilot materials. (The Department of
Veterans Affairs provided in-kind support from the inception of Valeo.) Kaiser Permanente also
agreed to provide funding for the pilot phase.
Living Dialogue Methodology
The Living Dialogue on Health and Care was designed as the discovery phase of the appreciative
inquiry process, with a slight sojourn into the dream phase. It was the intent of the Valeo Initiative
to move into the design and destiny phase of the process at a later date.
In the discovery phase, large numbers of members of the system are involved in a bottom-up
interview process to uncover the "life-giving forces" in the system. People are asked to recall
times they felt "most alive, most vital, most energized " and are then questioned about those
incidents. The discovery phase typically begins with paired appreciative interviews exploring
participants’ peak experiences of each topic and what made those experiences possible. The
interview questions and process are designed to elicit and revitalize the positive affect associated
with participants’ stories, which in turn nurtures intrinsic motivation. The highlights and most
“quotable quotes” from participants’ stories are then shared in small and large groups. This
essentially builds a live, collective database of organizational excellence that includes metaphor,
imagery, and affect in addition to concrete examples.
The key component of the Living Dialogue on Health and Care is a half-day workshop. The
workshops were designed to enable between 8 -30 participants to explore their values about
health and care, as well as identify opportunities they can take individually and collectively to
improve their health, the care they receive, and the health of their community.
Workshops consist of:
1. Paired interviews in which participants were asked to share stories about:
o what health means to them and when they felt healthiest and alive
o what good care means to them and where they received exceptional care
o what decisions they were already making about their own health and care
2. Small group work to identify key themes from the paired interviews followed by review by
the entire group
3. Small group work to imagine the future as it relates to:
o taking charge of your own health and care
o the elements of a truly healthy community
4. Small group work to identify action steps, followed by review by the entire group.
(See appendix for a sample workshop agenda.)
Analysis of the data would reveal patterns in the ways that people perceive health and care as
well as practices that already exist to help make people healthier, provide them with the care they
want, and enable them to make important health-related decisions. The results of the analysis
would be used at a later date to identify opportunities to improve care and lower costs based on
people’s experiences of what is already working; promote the types of patient-caregiver
relationships that are most satisfying; encourage the pursuit of healthy behaviors; and construct
new consumer health education programs based on individual and community values.
Piloting the Living Dialogue Workshops
Members of the Valeo Initiative wanted to create a process for involving thousands of people in
Living Dialogue on Health and Care workshops—including people of all ages, races, economic
status and regions of the country. They also wished to include both consumers and health care
professionals. Since this was such an ambitious project, the Board felt it was necessary to include
a pilot phase—testing concepts and materials in a wide variety of settings.
The Pilot Phase, which started in the Spring of 2001 and was completed in January 2002,
consisted of:
 Developing the materials for a four hour Living Dialogue Workshop, including a step-bystep Facilitator’s Guide, a participant’s workbook (Storytellers Workbook,) and take home
material (Starter Kit)
 Testing the Workshop in 11 varied settings.
 Analyzing data collected in all workshops
The objectives of the pilot phase were to test the:
 Use of the workshops with diverse populations
 Effectiveness of the questions
 Ease of facilitation
 Data collection instruments
 Usefulness of data mining as a means of analyzing the data
From April-June, the Living Dialogue Work Group, wrote, designed and printed all the Living
Dialogue materials. In June, the Valeo Initiative posted an invitation to its members to host a
Living Dialogue Workshop. Valeo would provide all materials, coaching on how to customize the
materials for a particular audience and analysis of the data collected. There was no funding
available to conduct the pilots. Members volunteered to serve as facilitators, to locate
appropriate facilities to hold the workshops, and to invite community participants. Members
invited participants based on their relationships in their own communities. Some Valeo members
facilitated the workshops themselves while others brought in skilled facilitators. All facilitators
were professionals with strong backgrounds in community facilitation; many were experienced in
the AI process.
Valeo members from 11 communities, ten in the U. S. and one in England, volunteered to host
pilot workshops. Between June 2001 and January 2002 approximately 230 people participated.
These participants included: all age groups—from teenagers to seniors, health care professionals
and health care consumers, and the chronically ill in addition to a generally well population.
Although the workshops were designed for four hours, two of the workshops were shortened to
three hours.
Living Dialogue Pilot Workshops
1.
Students in Health Administration
University of Mississippi
Jackson, MS
Facilitated by Chris Arthur, PhD & Bill Rudman, PhD
2.
Seniors & Girl Scouts
Sponsored by the Chamber of Commerce.
South Bend, IN
Facilitated by Tom Evons and Roger Fox
3.
Students, Faculty, and others
Inter-generational Health Program.
Case Western Reserve University
Cleveland, OH
Facilitated by Peter Whitehouse, MD, PhD
4.
Faculty, Dean, staff & others
Thomas Jefferson Medical School Primarily from the Department of Family Medicine,
Philadelphia, PA
Facilitated by Terri Maxwell and Emilie Passow
5.
Diverse group of community representatives, health providers & local officials
Sponsored by the Peckingham Settlement Community Organizations
Peckham. South London, UK
Facilitated by Kate Start
6.
Diverse group of community representatives, including spiritual leaders, healers, activists,
seniors, etc. from the Tampa Bay area, including Pinellas, Hillsborough and Sarasota
counties
Hosted by the University of South Florida Center for Positive Health
College of Public Health
Tampa, FL
Facilitated by Sharon Joy Kleitch and Judy Morris-Hardy
7.
Community Health Coalition members, including individuals with diabetes, community
service professionals and local youth
Co-sponsored by the South Central Diabetes Project
Douglas County, MO
Coordinated by Shirley Emerson, South Central Diabetes Project
Facilitated by Suzanne Alewine and Doris Boeckman, of Community-Asset Builders
8.
Latrobe Partners Advocating Total Health
Latrobe, PA
Sponsored by Latrobe Hospital,
Facilitated by Barbara Terry, Pennsylvania Institute for Healthy Communities
9.
Braddock Community Partnership
Allegheny Co, PA
Sponsored by UPMC Braddock Hospital
Facilitated by Barbara Terry, Pennsylvania Institute for Healthy Communities
10.
Maui Health Coalition, including hospital senior leaders, business people, RNs, a
chiropractor and psychologist.
Sponsored by the Maui Memorial Medical Center (MMMC), operated by Hawaii Health
Care Systems
Facilitated by Linda Morgan, consultant
11.
Senior citizens along with representatives from social service organizations,
health providers and schools
Sponsored by the St. Michaels’s Community Center
St. Michaels, MD
Facilitated by Laverne Webb, CEO of Encompass Consulting and Susan DeLean-Botkin,
nurse practitioner
Living Dialogue Workshop Structure
The Living Dialogue workshops were divided into several parts:
1)
Introduction to the Project and to the Appreciative Inquiry Process
2)
Paired Interviews and Debrief
3)
Theme Identification
4)
Provocative Propositions
5)
Action Steps
6)
Workshop Debrief
At the beginning of the workshop, all participants were given a Storyteller Workbook that
consisted of:
 Brief description of the Valeo Initiative and the Living Dialogue Project
 Purpose of the Workshop
 Living Dialogue Questions
 Guidelines for Conducting the Paired Interviews
 Interviewer Note Form, which served as the data collection instrument for the paired
interviews. The form had a separate space for jotting notes for each question (story.) It
also included a space for demographic information and information about insurance,
whether or not the participant has a regular doctor, who they go to when they are sick or
hurt, and whether or not they use home remedies. The Interviewer Note Form is
detachable and returned to the facilitator at the end of the workshop
 Workshop Evaluation Form. This form is detachable and returned to the facilitator at the
end of the workshop.
Facilitators were instructed to code the Interviewer Note Forms and Evaluation Forms prior to
returning them to Valeo to ensure that researchers could match the evaluation with the data.
Paired Interviews
Workshop participants divided themselves into pairs and took turns interviewing each other,
guided by instructions from the group facilitator. The interviews consisted of three general
questions:
1) What does health mean to you and when did you feel most healthy and alive?
2) Tell me a story about when you received wonderful care.
3) Tell me how you go about making important decisions concerning your health and care.
For each question the interviewer (who is also a participant) would ask for a brief statement and
then a story or experience illustrating that statement. Typically, each participant was given about
7.5 minutes to tell a story related to each question.
At the beginning of the paired interview process, participants were told to exchange Storyteller
workbooks. The interviewer would take his/her notes on the Interviewer Note Form contained in
the workbook belonging to the person he/she was interviewing. After the paired interviews,
participants would return the workbooks to the partners. The Interviewer Note Forms were given
to the workshop facilitator at the end of the workshop.
Theme Identification
After the paired interviews, participants formed small groups (6-8 people). Each participant
presented a summary of his/her partner’s responses to the first three questions in paired
interviews. One person in the group was designated as scribe and would record responses on a
large sheet of paper. Members of the group would review the responses, searching for common
themes. Each group was asked to identify and record 3-5 common themes for each of the three
questions.
After the paired interviews and small group work, the entire group reconvened to review the
paired interviews and small group work, sharing inspirational stories and identifying those themes
that seem to best reflect the experiences of the entire group.
Note—depending on the number of people in the group and the time available, facilitators would
eliminate breaking into small group and do all theme identification work with the full group.
Provocative Propositions
In an AI process, once the group completes work related to their present experiences about
health and care, the “discovery” phase, they move into the “dream” phase in which they imagine a
better future and craft bold, affirmative, possibility statements, “provocative propositions,” that
express their expansive dreams. Typically, work in the dream phase is not done in the same
workshop as that of the discovery phase. However, recognizing that it would be hard to bring
participants back to a second workshop, Valeo wanted to at least begin the dream phase in the
Living Dialogue workshops. Rather than ask participants to craft provocative proposition
statements, the workshops include provocative, future-oriented questions that are designed to
identify key elements of the dream.
Participants returned to their small groups to explore the following provocative questions:
1. Imagine a world where everyone could be in charge of their own health and care
a. what you would need?
b. what would you do differently ?
c. who would you go to for help?
2.
Imagine what would be different if we lived in a truly healthy community
Responses to the provocative questions are recorded by a scribe on a large sheet of paper.
During the debrief session, responses are shared with the entire group.
Data Analysis
Typically, the AI process does not include a rigorous data analysis component. During the
workshop facilitators and participants look for themes and patterns in their responses. After a
series of workshops, design consultants, facilitators and some participants review themes from all
workshops. These themes are used in the dream, design and destiny phases.
The Living Dialogue, however, had the dual purpose of serving as the initial stage of the AI
process and also serving as a data gathering process in which the information could be used by
other groups to influence decisions about the design and provision of health and care services
and benefits. This presented Valeo with some problems not typically encountered by AI
practitioners.
It is particularly challenging to perform rigorous analysis on information gathered from an AI
discovery process because of the storytelling nature of the interviews. Questions are meant as
guides and prompts for participants to tell relevant stories. Participants rarely answer a specific
question. The individual stories themselves are not vital to the design, but are used for inspiration
and to illustrate key points. What is vital to the AI process is the common themes found in the
stories.
It is also challenging to capture the stories. Most AI practitioners do not tape paired interviews,
fearing the taping process would constrain the responses. Interviews were done in pairs, where
participants take turns interviewing each other. Capturing the highlights of the stories is totally
dependent on the skills of each interviewer.
To assist with this data capture and analysis challenge, Valeo members enlisted William
Rudman, PhD, associate professor, Health Information Management, School of Health Related
Professions, University of Mississippi Medical Center. Dr. Rudman, who specializes in qualitative
research, volunteered to conduct the data analysis for the pilot workshops.
Because much of the data was essentially stories and the rest (the small group work) was
essentially focus group work, Dr. Rudman felt that he needed to use multiple methods of
analysis-- data mining, traditional hypothesis testing statistical analysis, and qualitative analytic
methods to interpret data.
Data mining techniques would be used with the paired interview data to provide valuable insights
into underlying patterns and relationships between beliefs, actions, and socio-demographic data.
These techniques enable the exploration and analysis of data using automatic or semi-automatic
machine learning algorithms that discover meaningful patterns and rules. The use of rulegenerated findings eliminates researcher bias as well as preconceived notions (hunches) that
might limit analysis and interpretation of data. Unlike traditional hypothesis testing methods of
analysis, data mining techniques are not based on development of null and alternative hypothesis
or on the distributional form of the data. A data mining approach to analyzing data employs a
bottom-up approach of “knowledge” discovery rather than a top-down approach of hypothesis
testing (Berry & Linoff, 1997) Using data mining as a “directed” method of data discovery will
enable the categorization of data into relational fields, such as, the relationship between having or
not having insurance and being proactive in approach to health and care.
Traditional hypothesis testing methods adds both rigor and support to the data mining analysis by
testing the statistical significance of observed associations. Qualitative analysis adds important
depth and understanding to patterns found in the data mining and the statistical analysis.
Qualitative analysis is also used on all small group data.
Demographic Data
In order to contextualize information from the paired interviews, socio-demographic data was
collected from each individual who participated in the workshop. Here eight specific questions
were asked: Do you have a regular doctor? Do you have insurance? If yes, what type of
insurance do you have? Do you use home remedies? What is your gender? What is your
ethnicity? What is your educational level? Socio-demographic data was then matched with
individual data from the paired interviews.
Findings from analysis of socio-demographic data suggest that those who participated in the
workshops were primarily white, highly educated, female, and used both traditional and home
care remedies when ill. Of those who responded to the questions concerning race or ethnicity
86.8 percent were white, 6.6 percent African American, 3.8 percent Asian, and 2.8 percent
Hispanic or multiracial. Of those responding to the gender, age and education questions, 72.6
percent were female and 27.4 percent male, 59.4 percent were under the age of 55, 68.8 percent
had a college education, 17.2 percent had some college, 14 percent had high school or less as
an educational level. Of those responding to questions concerning health care, 89.4 percent have
a regular doctor, 95.2 percent have some type of insurance (74 percent of which have some type
of private/HMO insurance), and 78.4 percent regularly use home remedies when ill.
The socio-demographic data enabled Dr. Rudman to conduct a series of web matrix analyses.
For example, Dr. Rudman was able to explore the influence of having insurance on a variety of
factors, ie: having a positive attitude toward health, having a strong spiritual belief, taking charge
of your health, going to your family and friends for advice and having hobbies. Figure 1 (see
below) represents a relational matrix that shows the strength of the relationship between having
insurance and each of the other factors.
FINDINGS FROM THE PILOT WORKSHOPS
While the data analysis techniques enabled Dr. Rudman to quantify some of the results, the data
is essentially qualitative. The Appreciative Inquiry process does not lend itself well to producing
quantifiable data. It is intended to produce data that is directional and can be helpful in the design
of improved systems. Also, since this was a pilot, there was limited data available. Of the 230
people who participated in the workshops, only 183 completed and turned in the data worksheets
(Interview Note Forms.) As a result of incomplete or missing data from the forms, final analysis of
the paired interviews was limited to 151 participants. All participant responses are included in the
small group work.
PAIRED INTERVIEWS
Participants’ views about health can be classified into four dimensions:
 Psychosocial
 Physical-behavioral
 Holistic
 Spiritual
Of these dimensions, psychosocial was overwhelmingly the most important, with selfempowerment the key theme. Three out of four responses in the psychosocial category involved
self-empowerment: feeling good, having vigor, and the absence of disease (85.4 percent); taking
charge of personal care through self education (81.9 percent); and feeling happy and having a
zest for life (70.2 percent.) Sharing experiences with family and friends (77.5 percent) was
another aspect of the psychosocial dimension that was particularly important to participants.
Physical-behavioral, holistic and spiritual dimensions were not as important to
participants. In the physical-behavior category, exercise (42.4 percent); ability to work (29.1
percent); dieting (24.5 percent); and actively involved in a hobby (13.9 percent) were the most
frequent responses. 25 percent of the respondents mentioned mind, body, soul integration
(holistic) and 15 percent indicated prayer (spiritual)
What Influences How People View Health (Dimensions of Health)



Younger people were more likely to emphasize the physical-behavioral dimension of
health—indicating exercise as extremely important. Those under the age of 55 were
approximately two and half times more likely to view exercise as an important
dimension of health care than those over the age of 55.
Non-whites were 5.5 times more likely than whites to emphasize the spiritual
dimension of health—citing God and prayer/spiritual well being as an important
dimension of health and care.
Younger people (those under the age of 55) were 5 times more likely to rely on and
see interaction with family and friends (psychosocial) as an important dimension of
health and care than those over the age of 55.
For most people, good care meant involving the patient in the care process and
personalizing treatment to meet their need.
Participants in this study did not discuss the qualifications of their doctors when it came to
defining good care. Good care was not about finding a good doctor and turning over care
decisions to him or her—people do not want to turn over decisions about their care to their
doctors regardless of their qualifications. Becoming part of the care process was important in
shaping perceptions of care and in defining the patient physician relationship.
The lack of connectivity between the physician and the patient seemed to be a result of the health
care professional not being able to effectively communicate personal caring and concern to the
individual, and not providing the individual the opportunity to become involved in the care
process. For many of the participants this meant that the physician did not personally care about
the treatment, “take a personal interest,” or respect the individual’s judgment in defining
appropriate care. Where the physician was able to personalize treatment and show care and
concern, the patient/physician relationship was integral in the care process. Perhaps the most
poignant response concerning the relationship between the physician and patient was: “I have
never had a HUMAN doctor.”
People want to be in charge of their own health and care
91.7 percent of study participants emphasized the importance of personal responsibility and
taking charge of their own health and care. For most, taking charge also involved having a
positive attitude about life (90.9 percent.)
Participants thought it was very important to educate themselves about their health, which the
majority (75 percent) accomplished through the Internet. They also said that selecting the right
physician was an integral part of making decisions (75 percent.) However, most (70 percent)
indicated that they did not necessarily trust their physicians to make decisions for them. They
were much more likely to rely on their own judgment (82.9 percent) or on advice from family or
close friends (59 percent)
Most participants didn’t emphasize their physical behavior when discussing being in charge of
their health and care. Some mentioned dieting (29.9 percent); exercise (22.6 percent) and
actively participating in a hobby (15.3 percent) as being important.
What Influences How Proactive One Is About One’s Own Health and Care



Having health insurance. Findings from the web matrix analysis show that those
individuals who have insurance are more likely to be proactive in their care and health. In
all dimensions examined the link between having insurance was stronger than for those
who did not have healthcare insurance. (See Figure 1.)
Generally, females were more likely than males to be more proactive in their care
and health. However, when it comes to exercise and spirituality, males are slightly more
proactive. (See Figure 2.)
Having a positive attitude toward life.
THEMES
In the small groups, participant responses were categorized into two overarching themes about
health and care: Security and Self-Worth. Both have two dimensions.
Security

Social dimensions of health and care centered on integrating family and friends into
activities. “It is hard to feel wholly healthy in isolation from the community and those

around you” “ … being active and doing things with family and friends” “…being
surrounded by people you love so you don’t feel alone” and, in making health care
decisions, “…. when making decisions I have family and friends available.” One
participant noted: “I still have the rubber monkey my brother gave me while in the
hospital as a child.”
Spiritual dimensions of health and wellness focused on the role of prayer “…prayer
is all important” “I can not stress enough the value and relevancy of faith and prayer”
and of a reliance on God in times of sickness and health “… being at one with God - I
can do all things through Christ who strengthens me,” and “enlisting God’s help is
powerful.”
Self- worth
 Control over one’s life. Study participants wanted to feel in control of their lives. “I
am the creator of my own world,” “you can deal with things better if you’re in control
and not someone else,” “think for yourself, don’t always listen to the doctor.”
 Respectful Treatment. Participants wanted health care professionals to respect
them and to involve them in care decisions. One individual noted that when she
became part of the decision, she not only felt better about the treatment plan but also
was able to better connect with her doctor and to feel more in control of her life and
care: “I argued with the doctor about my care … good outcome … made him seem
human.” Participants were most likely to indicate they had a positive experience
when health care professionals (physicians in particular) involved them in the
decision-making process and showed respect and concern for them.
Health care consumers’ desire to have control over their lives and to be treated with
respect were also key themes in the 1999 Leadership for a Healthy 21st Century Study by
Arthur Andersen, the Health Forum and DYG.
PROVOCATIVE PROPOSITIONS
In small groups participants were asked to imagine a better world—one in which they could be
more in control of their own health and care and where the communities in which they lived were
healthier. In responding to these questions, participants clearly demonstrated a desire to move
away from traditional medical care to world in which health and care are people-centered.
When asked what they needed to be more in charge of their own health and care,
participants’ responses could be categorized into two main themes: changes to the health
care system and changes in socio-environmental conditions.


Health care system changes included universal coverage, affordability of care for
all, the ability to make their own decisions, rather than having managed care decide,
increased access to information (eg. hospitals publishing data), and increased
incentives for staying healthy (eg. from insurance companies.)
Socio-environmental conditions that would need to be improved include: better
services –for young and elderly, more time with their families, less stressful lives,
safer communities, and class equality and elimination of racism. Participants also
wanted healthier foods in restaurants, better biking and hiking paths, better air and
water quality and the elimination of alcohol and tobacco.
When asked what they could do now, participants’ responses fell into two categories:
personal empowerment and preventive practices.

Personal empowerment included finding physicians with whom you have a rapport,
making health a priority and a daily practice, educating yourself, and keeping good
health records.

Preventive practices meant eating right, exercising regularly and having
recommended screening tests
When asked whom they would go to for help, participants’ responses reflected their desire
to gather information from the Internet, support groups, and friends and family, rather than
go to health care providers for answers.
Participants were also asked what would be different if they lived in a truly healthy
community. Their responses fell into five categories: environmental conditions, economic
conditions, social conditions, behavior and health care.





Environmental conditions. Many of the participants felt it was important to take a
long-range, sustainable view about communities. Clean air and water were
considered essential, as were more recreational facilities and open spaces, better
transportation systems, and more beauty in the environment.
Economic conditions. Many people mentioned better economic conditions,
including more and better jobs and a redistribution of wealth. They also want less
emphasis on wealth, suggesting less attachment to material possessions and less
advertising.
Social Conditions. A stronger connection among people was an important theme.
Participants wanted better communications with each other, more dialogue, more
quality time with their families and less time at work. They wanted increased
involvement in their communities—with more volunteerism, stronger neighborhoods,
and better social institutions. They also wanted more spiritual dimension in their lives
and less stress. People wanted a more equitable society, where underserved people
would be included in decision-making; and there would be less discrimination based
on race, class or age. They wanted their social institutions, like churches and
community centers, to take the lead in emphasizing prevention, wellness and
healthier lifestyles.
Behavior. Participants indicated that in a healthy community people would not abuse
substances and would be more tolerant of others and more respectful of differences.
Health care. Participants emphasized universal coverage and accessibility of care.
They wanted that care to be patient-centered—even mentioning the return of home
visits by physicians. They felt that health benefits needed to include medical, mental
health, and a wide range of alternative treatment modalities. Most believed that
prevention and wellness should be emphasized.
Summary of the Living Dialogue on Health and Care Pilot Phase
The purpose of the Living Dialogue pilot phase was to test the:
 Use of the workshops with diverse populations
 Effectiveness of the questions
 Ease of facilitation
 Data collection instruments
 Usefulness of data mining as a means of analyzing the data
Use with diverse populations. The Living Dialogue workshop was tested in all regions of the
country. The workshops included a variety of age groups, ranging from teenagers to senior
citizens. They also included consumers and health professionals. However, most of the
participants were white and most had health insurance. The Valeo Board made a conscious
decision not to test the workshops on vulnerable populations in the first round. They wanted to
make sure that there was minimal opportunity to cause harm to these populations.
The 11 pilot workshops demonstrated the potential of the Living Dialogue to inspire participants
and to highlight the values and assumptions that shape people’s views about good health and
care. The individual evaluation forms, along with the assessment of the facilitators indicated that
participants not only enjoyed the workshops but felt it was a valuable learning experience. None
of the participants saw the workshops as threatening or insensitive to their needs.
Effectiveness of the Questions. As noted earlier, in the Appreciative Inquiry process
participants are not expected to answer the questions, but rather use them as a springboard for
telling stories about what is important and useful to them. An important benefit of AI is that
participants are able to contextualize their responses through story telling. The stories that
people told about good health, good care and the type of decisions they were making revealed
that they were not compartmentalizing health and care—but rather taking an integrative
approach. They consistently mentioned the same things in all three questions. Consequently, it
was much easier to discern what was actually important. The same was true for taking charge of
your health and living in a healthy community.
We did note, however, that participants did not seem to understand the true intent of Question 3,
“tell me the story about how you made an important decision about what to do when you were
sick.” The question was intended to elicit responses about actual actions they took, what led to
those actions, and who helped them make the decisions. We will have to rework this question.
Ease of Facilitation. In addition to reviewing the facilitator evaluation sheets, Valeo staff
conducted a phone debrief with each facilitator. The responses were remarkably similar. All
reported that they enjoyed facilitating the workshop and that participants had an excellent
experience. They felt the materials were clear and easy to follow. They recommended the use of
two facilitators (which occurred in most cases.) All reported that it was difficult covering all the
material in the four-hour workshop. Some felt breaking the workshop into two days would be
helpful. Others acknowledged it would be difficult getting the same group together twice or for a
longer time frame. None of the facilitators suggested cutting out a particular section.
Data Collection Instrument. It was extremely challenging capturing key elements of the stories
from questions 1-3. Many of the interviewers were not skilled at note taking. Facilitators reported
that senior citizens had a particularly hard time taking notes during the interviews. Others did not
have very legible handwriting. Data was collected on individual sheets called the Interviewer
Note Form, which were bound inside the Storyteller’s Workbook. Participants were asked to
detach these forms and hand them to the facilitator. However, it was difficult to keep the
appropriate sheets from each participant together. Sheets were mixed and lost, causing us to
drop some responses from the study. In the future, we will probably have to tape responses and
to create individual booklets for the notes. There was no problem capturing the key elements
from the small group work. The scribes did a good job of capturing the points on large sheets of
paper. Facilitators often retyped them prior to submitting them to Valeo.
Usefulness of Data Mining. Data mining techniques used in this study definitely added a rich
dimension to the paired interview data. In most Appreciative Inquiry projects, the stories are used
for illustration only. By adding data mining techniques, researchers were able to explore the
relationship between key factors (see Figures 1&2.) Dr. Rudman created only a few relational
matrices for this study for demonstration purposes. In the future, it will be possible to explore
relationships between many factors.
IMPLICATIONS FOR ACTION
Shift from medically centered approaches to people-centered health and care.
Participants strongly emphasized personal empowerment. Clearly people will no longer accept
the traditional medical model of healthcare provider as the decision-maker. Although few used
the words “people-centered,” this seemed to be what they had in mind. The Living Dialogue holds
promise as a tool for developing people-centered approaches—providing unique insights about
people’s concept of health, wellness, and health care in meeting their health and illness needs.
The Living Dialogue holds particular promise for improving the health and care of vulnerable
populations with chronic illness. Understanding and appreciating the strengths and capacity of
persons with chronic illness offers an affirmative alternative to discovering and resolving problems
in treating these diseases. Along with the School of Nursing at the University of Mississippi
Medical Center, the Valeo Initiative is currently seeking funding to expand the Living Dialogue
project to assess the commonalities and differences among individuals who are well and those
with chronic illness and use this data to design interventions and educational strategies.
.
Emphasize prevention and education.
Most study participants indicated that prevention activities like exercise, dieting and getting
regular screenings, and educational activities, like researching doctors and obtaining information
about health issues, were the types of things they should do now to become healthier and
improve the care they receive.
Promote dialogue
Study participants recognized an important connection between improved communications and
improved health outcomes. Many emphasized the need for dialogue with their doctors, with their
families and with their neighbors. Certainly participants’ experience in the Living Dialogue
contributed to their emphasis on increased dialogue. Data gathered in the large work groups
suggested that participants not only enjoyed participating in the workshops, but found the
workshops provided a valuable learning experience. None of the participants saw the workshops
as threatening or insensitive to their needs. Consequently, we concluded that the pilots
demonstrated the potential of widespread use of the Living Dialogue as a strategy for improving
health.
.
REFERENCES
Arthur Andersen, DYG & Health Forum (1999) Leadership for a Healthy 21st Century: Creating
Value Through Relationships, Health Forum.
Berry, M. J. A., & Linoff, G. (1997). Data mining techniques: For marketing, sales, and customer
support. New York: John Wiley & Sons
Browne, B. (1998). In S. Hammond & C. Royal (Eds.), Lessons from the field: Applying
appreciative inquiry. Plano, TX: Practical Press.
Bushe, G. R. (1995). “Advances in Appreciative Inquiry as an Organization Development
Intervention,” Organization Development Journal, 13, 14-22.
Committee on Quality of Health Care in America, Institute of Medicine. (2001). Crossing the
quality chasm: A new health system for the 21st century. Washington DC: National Academy
Press.
Cooperrider, D.L. (1990). “Positive Image, and Positive Action: The affirmative basis of
organizing,” In S.Srivastva & D.L. Cooperrider (Eds.), Appreciative management and leadership
(pp.91-125). San Francisco: Jossey-Bass.
Cooperrider, D. L., & Srivastva, S. (1987). “Appreciative Inquiry in Organizational Life.” In R.
Woodman & W. Pasmore (Eds.), Research in Organizational Change and Development: Volume
1 (pp.129-169). Greenwich, CT: JAI Press.
French, W. L., & Bell, C. (1978). Organizational Development. Englewood Cliffs, NJ: Prentice
Hall.
Hammond, S. A. (1998) The Thin Book of Appreciative Inquiry (2nd ed.). Plano, TX:
Kolb, D. A. (1984) Experiential Learning, Englewood Cliffs, NJ: Prentice-Hall
Levinson, H. (1972). Organizational Diagnosis. Cambridge, MA: Harvard University Press.
Ludema, J. D., L Cooperrider, D. D., Barrett, F. J. (2000). “Appreciative Inquiry: the Power of the
Unconditional Positive Question,” Handbook of Action Research, Reason, P., Bradbury, H., Eds.
London, Great Britain (UK): Sage Publications Ltd.
Munnecke, Tom & Wood Ion, Heather, (1995) “Creating an Epidemic of Health with the Internet,”
U.S. Medicine Magazine.
Munnecke, Tom (2000) “Tipping an Epidemic of Health”, White Paper
Watkins, J. M., & Cooperrider, D. L. (2000). “Appreciative Inquiry: A Transformative Paradigm,”
Journal of the Organization Development Network, 32, 6-12.
Watkins, J. M., & Mohr, B. (2001). Appreciative inquiry: Change at the speed of imagination. San
Francisco: Jossey-Bass/Pfeiffer.
Watson Wyatt Worldwide (2002.) Health Care Costs 2002: Watson Wyatt Worldwide Survey
Results.
FIGURE 1
INFLUENCES OF HAVING INSURANCE
Red = Insurance
Green = Positive attitude toward health
Purple = Strong spiritual dimension
Blue = Taking Charge of One’s Health
Orange = Goes to Family and Friends for Advice
Yellow = Hobbies
The darker the line, the stronger the relationship.
FIGURE 2
INFLUENCES OF GENDER
Red = Gender
Green = Positive attitude toward health
Purple = Strong spiritual dimension
Blue = Taking Charge of One’s Health
Orange = Goes to Family and Friends for Advice
Yellow = Hobbies
The darker the line, the stronger the relationship.
Living Dialogue on Health and
Care Volunteers
Work Group
Anthony Suchman, MD Co-Chair
Mary Ann Moreale, FACHE, Co-Chair
Wynne Grossman, CEO
Work Group Members
Paul Andrews
Chris Arthur, PhD
Ida Blocker
Bliss Browne
Shannon Collins
David Cooperrider, PhD
Joyce Essien, MD, MBA
Robert Fuller
Susie Hull
Heather Wood Ion
Jean Irish
Jerry Kaiser
Sharon Joy Kleitch
Mark Levine, MD
Sally Mahé
Keith McCandless
Katharine Miller
Ann Nichols
Mac Odell
Alton Powell
Henri Roca, MD
Judy Rodgers
Barry Sugarman
Peter Whitehouse, MD, PhD
Penny Williamson
Living Dialogue on Health and Care
Research Team
Chris Arthur, PhD
Joyce Essien, MD, MBA
Bill Rudman, PhD
Bill Pierce
Wynne Grossman
Facilitators
Chris Arthur, PhD
Bill Rudman, PhD
Tom Evons
Roger Fox
Peter Whitehouse, MD, PhD
Terri Maxwell
Emilie Passow
Kate Start
Sharon Joy Kleitch
Judy Morris-Hardy
Suzanne Alewine
Doris Boeckman
Barbara Terry
Linda Morgan
Laverne Webb
Susan DeLean-Botkin
Appendix A:
Living Dialogue Sample Agenda
Purpose:
To inspire people to think and act constructively about health and care
Objectives:
Uncover stories about experiences of exceptional health and care.
Share positive examples of taking charge of one’s own health and care.
Identify opportunities to empower people and communities to pursue dreams of “what could be.”
Share themes with others to create a “public voice” about the possibilities for health and care.
8:00
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



Welcome
Introductions
Purpose of the Living Dialogue Project
Participant Introductions
Introduction to Appreciative Inquiry
Guides for conducting a Living Dialogues

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


Paired Conversations
Modeling Exercise
Pairs work through Question 1
Small Group Debrief
Large Group Debrief
Pairs Work through Questions 2-3
8:15
9:30
Break
9:45



Summarization of Stories & Identification of Themes
Small Group Debrief of Questions 2-3
Identification of Themes
Debrief to Large Group




Provocative Propositions
Small Groups identify elements for Provocative Propositions 1&2
Small Groups identify related action steps
Large Group Debrief
Large Group identifies Powerful Patterns.




Debrief:
Action Now
Next Steps for Group
Reminder about inclusion of stories in The Valeo Initiative’s materials
Individual evaluation forms to be completed and collected
10:45
11:30
noon
Adjourn
The Valeo Initiative
Board of Directors
Advisors
Chris Arthur, PhD, CHES
Ida Blocker, DMin
Carolyn Hightower
Heather Wood Ion
Peter Juhn, MD
Rita Moya
John Porretto
Ellen Severoni
Anthony Suchman, MD
Ray Werntz
Barbara Baetz-Greenwalt, MD
Jim Bentley, PhD
David Cooperrider, PhD
Joyce Essien, MD
Robert Kolodner, MD
Mary Ann Morreale, FACHE
Tom Munnecke
Bill Rudman, PhD
Penny Williamson, ScD