The Stew BLOG

Negotiating Clear Boundaries Strengthens Agreement on a Shared Theory of System Change

Bobby Milstein, Director, System Strategy and Kalila Jackson-Spieker | 11/06/2018

Over the past few weeks, the ReThink Health team has been blogging about the critical role sound strategy plays in transforming regional health and well-being. In the last blog, Tami Gouveia wrote that a sound strategy is made up of two components, each important to achieving a shared vision for the region: (1) a credible theory of system change, which demonstrates how the myriad forces in a region interact to create health or disease and then explains how these forces will submit to or resist change over time if a particular set of actions takes place; and (2) a portfolio of interventions, which describes how leaders will achieve the change they seek through a selection of policies, programs, and investments. .

Creating an effective theory of change and portfolio of interventions will require you to have a frank discussion about system boundaries. The simplest definition of a system boundary is that it encompasses everything a system needs to function. For example, in a closed system such as a wristwatch, the system boundary is the body of the watch itself because everything necessary to the system’s functioning—the gears, springs, batteries, hands, etc.—is contained inside it.

In an open system, such as an entire region, setting boundaries that delineate what is most relevant to achieving your region’s shared vision may seem more complicated. However, articulating clear boundaries—for example, by defining the geographic scope, or the span of time you are considering, among others—is a critical step in any collaborative process of strategy design because all participants bring their own preferences and goals. That is particularly true when attempting to transform a complex health system precisely because the task appears to be so broad and unwieldy. In those circumstances, it is imperative to negotiate boundaries that are as clear as possible.

Human systems—such as cities, institutions, and social networks—are all open systems. When we ask, for example, what is necessary for a city to exist and prosper, the answer might include any combination of physical infrastructure, political management, or the relationships of its inhabitants. We all might have a general sense of what is needed for a city to function, but the exact details will vary from one person to another, depending on their particular interests.

Thus far in this blog series on strategy development, the posts have discussed the challenges regional leaders face in designing a strategy that is best able to transform health and well-being in a region. Defining boundaries is one of the most daunting challenges your regional partnership must tackle, especially because transformation on this scale requires that stakeholders collaborate to design a system that enables them to work together very differently. Without establishing clear boundaries for such an undertaking, it can seem like you are trying to focus on everything—and likely not truly focusing on anything. By clearly defining boundaries of a system, you make it much easier to make choices; in fact, the path forward may become more obvious.

Sound Strategy Requires Tough Decisions

The act of boundary setting helps uncover what is most important relative to a given vision or problem at hand. In a world of limited resources, all decisions about investments and interventions stem from judgments about boundaries that emphasize certain priorities and not others. When diverse stakeholders take time to agree on where to set shared boundaries and why, they are less likely to argue or to divert time and energy away from the goal—even when pursuing their own activities.

To enact a sound strategy, leaders need to make hard decisions. They need to delineate not only the overall system of interest, but also the specific sectors or elements that will be the focus of their actions—sometimes it may be useful to break the entire transformation process into smaller efforts that can each be better bounded.

Because establishing system boundaries is inherently subjective, it is important to make it an intentional step when developing a comprehensive strategy. Skipping this important step can lead to ill-defined assumptions when deciding which programs and policies to include in a portfolio that will achieve your vision. For example, oftentimes those leading the work may have reached consensus only on a high-level strategy and not on crucial details for implementing it. It may go without saying that hospitals and clinics are part of a health system, but what about fitness centers? School cafeterias? Private homes? Prisons? Depending on where a group chooses to set its boundaries, any of these spaces could be treated as vitally important or essentially extraneous to the system challenges the group seeks to address.

Typically, a theory of system change involves many aspects, each of which has boundaries that might need to be negotiated. Consider this example of what happens when regional leaders seek to develop a shared understanding about how to improve health and well-being in their community. As one element of their portfolio, the group has set a widely shared goal to reduce overall disease burden and costs by reducing metabolic disorders (i.e., health concerns, such as obesity and diabetes, that arise when metabolic processes fail).

To pursue this goal, a hospital representative recommends that their portfolio of interventions should include developing new primary care clinics at all hospitals where clinicians will teach patients self-care strategies to manage their illnesses. Then, a member of the nursing association who is also a school nurse suggests, instead, that elementary schools incorporate a health segment into their curriculums to teach children healthy habits, such as the importance of diet and exercise, and reduce rates of metabolic disorders over time. The contrasting perspectives brought by the hospital and nursing association representatives are natural and to be expected; they are based on the knowledge and values that accompany each person’s role and their assumptions about what is most important to do.

Neither person thinks the other’s plan is going to be as effective as their own, even though both draw on proven interventions for reducing the burden and cost of metabolic disorders. In this case, the hospital administrator perceives a health system that is centered narrowly around the interactions between a clinic and its clients, whereas the school nurse sees it as extending much further in time and space, specifically into childhood and educational spaces, where many health habits are first formed. Both of the these views are legitimate and either is possible, but reconciling them will require the group to make judgments based on their values, goals, time preferences, and other interests. The act of eliciting different theories and then setting shared boundaries will help the group consider the alternatives and make higher-leverage decisions about their portfolio of interventions and how best to achieve their shared vision.

Boundaries Founded in Values and Knowledge

System boundaries act as lenses through which we see and understand the world. We create them based on both facts and values, or what we each think is important. As such, our boundaries can change as values shift or new facts come to light.

This creates a special set of challenges for effective collaboration: people may agree that some kind of change is needed, but their ideas for how to get there can vary—sometimes dramatically. At ReThink Health, we’ve identified at least five distinct categories of boundaries that emerge again and again as sticking points when developing a shared theory of system change:

  • Time Horizon(s): The time period over which the intended and unintended effects of your partnership’s interventions will play out. Many interventions have different effects in the short, medium, and long term; therefore, a group could reach dramatically different decisions on a preferred strategy depending on which time horizons they consider, (e.g., 1-3 years, 10-20 years, or 2 generations)
  • Geography: The physical areas that your group’s interventions cover (e.g., a neighborhood, county or multiple counties, health care service area, etc.)
  • Partners: Individuals or groups who can dedicate resources, influence, or provide implementation support to advance your theory of system change
  • Beneficiaries and Bearers of Burdens: The individuals and groups who ought to benefit most from your group’s investments, as well as those who may bear the burdens. Your partnership may distinguish between those who benefit directly (e.g., program recipients) vs. indirectly (e.g., those who will experience positive externalities). Even if the benefits seem compelling, never forget to consider where the burdens fall and how they might be alleviated.
  • Intervention Areas: The programs, practices, and policies that need to be changed or implemented to advance a theory of system change. A wider or narrower set of intervention domains may come to the foreground, depending on where one sets their boundaries.

In the story above, about the hospital administrator and the nurse, both the time horizon and the beneficiaries seem to be sticking points. The hospital administrator may think the beneficiaries ought to be adult patients who are sick enough to go to the hospital, while the school nurse instinctively prioritizes children. Each is also focused on a different time horizon. The hospital administrator seems concerned with immediate needs, whereas the school nurse takes the longer view, considering children who will mature over decades.

While these may seem like intractable differences, leaders can often agree when they better understand each other’s boundaries and the reasoning behind them. In addition, discussing the assumptions that underlie different perspectives allows stakeholders from different sectors to identify commonalities and reach compromises that will also serve as a foundation for future conversations.

Two Perspectives: Two Different Solutions

Let’s revisit our illustrative example one last time to see the implications of that group’s discussion about system boundaries. As they talk, the hospital administrator identifies her key value: that we should act to alleviate suffering and costs as quickly as possible. She points to key facts:

  • Current patients suffer the most from chronic metabolic illnesses
  • The timeline to see benefits from improved self-care is a few months to a few years
  • Children (generally) do not develop chronic metabolic illnesses

For the school nurse, however, prevention is the most sustainable way to reduce suffering and costs. The key facts in her view are different:

  • Preventing and mitigating chronic disease starts with healthy behaviors
  • The timeline to see benefits from healthy behaviors is a few months to several decades
  • Adults often have years of bad habits they need to overcome to develop healthy behaviors.
  • The most difficult and costly time to intervene is after an adult is sick enough to show up at the hospital or a clinic.
  • Even if we are able to help adults with current disease, we will continue to face a growing problem with each new generation unless we instill healthier habits earlier in life.

These discussions have uncovered the values and knowledge base that inform each stakeholder’s understanding of their system boundaries. The debate rests on a tension between whether the theory of system change ought to focus on sustainability or immediacy and that has specific implications for the portfolio of interventions the group pursues. Compromise in this case could take several forms. If the team has funding for only a few years, it could focus on self-care clinics and use the money saved as a result of improved disease management to invest in longer term programs focused on creating a culture shift for the next generation. Or perhaps they could devise a theory of system change using a boundary that falls in between adults and children, where interventions would focus on young adults at high risk for metabolic disorders who are still young enough to reverse the damage and develop better long-term habits. Neither of these is the “right” answer; both require tradeoffs, and those should be part of the group’s deliberations about which judgments to make.

Regardless of what they decide, by understanding each other’s boundaries, they can consider tradeoffs and negotiate a shared theory of system change. This is the value of articulating clear system boundaries: deliberately setting boundaries facilitates decision-making for multisector groups, which by definition reflect a multitude of perspectives. These may be difficult discussions, but avoiding discord won’t ever get you very far in this work.

What do you see as the benefits of creating system boundaries? Share your ideas and experiences in the comments below or send them to [email protected].