In mid-2014, Living Cities selected five cities to participate in a newly designed one-year planning process as participants in Round II of The Integration Initiative (TII). Albuquerque, New Orleans, San Antonio, San Francisco and Seattle/King County participated in the planning year, generating learning across different geographies and local conditions about how large scale change happens—especially when fueled by new ways for different sectors to work together, deploying private capital for public purposes, and harnessing public sector resources and influence for maximum impact. Now, those TII site partners are reflecting on their experiences and discussing what others can learn from their work.
Think of outcomes as mile-markers on the journey to achieving your broader, shared result.
I was able to reflect on this statement during my involvement in the planning year for The Integration Initiative. Much of the time I spent in planning focused on defining what outcomes we wanted to achieve for the Communities of Opportunity, a collaboration focused on reducing health disparities in Seattle/King County, which I help lead. An outcomes planning process can be stressful at times, but I found that the key is to not myopically focus on a set of outcomes, but instead to think of outcomes as mile-markers on the journey to achieving your broader, shared result.
This mindset had guided the work of the Communities of Opportunity, ensuring that Seattle/King County doesn’t end up “program rich and systems poor.”
Communities of Opportunity is an interesting mix of community development and health work—two fields that are beginning to collaborate more and more. We have chosen three communities in south King County, which have some of the worst health disparities in our region, and we are focusing in on a variety of health and community development outcomes, such as typical health outcomes like diabetes reduction or preventable hospitalizations, and mental health measures like “frequent mental distress” and “adverse childhood conditions.” In our partnership with The Seattle Foundation and county community development and housing staff, we’ve stretched our thinking to include housing and economic opportunity outcomes like unemployment and income above 200% of the poverty level.
But there can be hidden traps when our work zooms in too narrowly to one outcome. In my time working in our public health department, I’ve spent a lot of time with evaluators. (Typically, public health projects devote 5-10% of their budget on evaluation.) One thing we’ve learned over many years of this level of evaluation investment is that a narrow or myopic focus on outcomes, one that only looks at at the very last mile-marker before the desired result, can too easily misinform project design.
For example, say a project is trying to reduce a town’s obesity rate. If you want to reduce obesity, increasing exercise is a good thing to promote. Walking is a great form of exercise; so increasing the presence of sidewalks could be a chosen strategy for this anti-obesity campaign. Measuring this would obviously require an outcome of how many miles of sidewalks are in a town, and thus you would begin to track how many sidewalks are built from your project’s efforts. This process likely seems familiar to anyone involved in a strategic planning process or theory of change conversation.
But if this outcome is followed too closely with too short a time period, the work will zoom in on how to build the greatest number of feet of sidewalks within one year, and not how to increase exercise and lower obesity rates. The project would get busy assembling volunteers, digging paths and pouring concrete that may or may not lead to decreased obesity. In this case, the initiative followed their mile-makers too closely and ended up in a very different place than they had intended.
Alternatively, and more strategically, work could be done at the policy and systems level in the first year to explore why the town didn’t have many miles of sidewalks built in the first place. Are there zoning rules that didn’t require developers to install sidewalks when new houses were built? Do the current regional funding formulas disincentive sidewalks being built in this location? Or it could be that there are plenty of sidewalks in place, and the real problem is there aren’t useful destinations within walking distance or alternatively that people don’t feel safe exercising outside.
One way to be clear about our path along the many mile-markers is to use a tool like Results Based Accountability. RBA can offer protection from the tyranny of outcomes.
The RBA approach forces program designers to look at the underlying root cause of a particular problem by asking “why does the problem occur” and to keep asking why, so that underlying policy and systems that create this problem can be unearthed. Somewhere in that process of asking “why?”–as many as five times–lies a policy, or system, or environment change that should be the focus of our work rather than the most immediate antecedent to our chosen outcome.
For example, a multi-sector partnership looking at reducing diabetes could improve life for several people who have diabetes by improving their medical treatment. And while that is still an accomplishment to be celebrated, it’s not sufficient to catalyze the scale of change we’re looking to achieve through our work in The Integration Initiative, or in other collective impact efforts, nor will it prevent others from getting Type 2 diabetes in the first place (Type 2 diabetes is largely preventable through diet and exercise, in contrast to Type 1 which is partly inherited). However, a community development/health partnership that was able to shape a community by building affordable housing, safe sidewalks, parks, schools, and community centers along with grocery stores, farmers markets and community gardens – that effort would help prevent generations of people from becoming at risk for diabetes in the first place.
So, from a field like public health, that has historically “bought in” to letting outcomes guide interventions, a word of caution about hewing too close to your outcomes without the guidance of your long term, shared result as a north star.
A focus on outcomes has to be balanced with listening to the knowledge that community members and subject matter experts have about why a problem exists in the first place. Successful initiatives will adopt both a rigorous measurement approach and a willingness to undertake political strategies to make changes to underlying policies and systems that have given rise to the current problem state. RBA can be one useful tool in this work and there are certainly other ways to thoughtfully and strategically sequence our work. Other inspired and accelerated approaches could learn from similarly situated communities that have overcome obstacles in their paths. As we continue our work with The Integration Initiative, we are looking forward to the ongoing learning and sharing we will be doing with our partners and with you.