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Abstract The importance of community participation in health care planning is well supported in the literature. Few authors provide a process for client-centred, client-driven health planning and development. This paper presents an example and a process for authentic and timely client-centred, client-driven, planning and development.The use of Open Space Technology (OST) as a method to engage the community to participate effectively in planning health services is described. An example of the use of OST to develop a neighborhood-based community health centre illustrates the potential of this technology in health planning. Effective health planning results when communities are facilitated to define their own needs, establish their own priorities, control their own solutions, and evaluate their own outcomes (Cooke et al, 1995). Open Space Technology (OST) is a method of facilitation and managing that supports the concept of client centred, client driven planning. Health and social services sectors, consumers, service providers, planners, and interested persons have the opportunity to provide leadership in the development of the plan. The concept of open space was first documented by Harrison Owen (1992) in the early 1980s while searching for better ways to organize meetings. In 1981, Owen was responsible for organizing an international symposium. The planning took more than a year using all of the traditional planning tools including committees, task forces, and speakers lists. While the conference was considered successful by traditional standards, it was apparent that the greatest energy, most interesting discussion, and creativity occurred during the coffee breaks. Owen set out to determine what the were the basic elements of human meeting and how these elements could replicate the energy found at coffee break to extend it to the entire meeting. He recalled from his African tribal village experience the key elements of community practice: the circle that breathes, the bulletin board, and the marketplace. These elements were developed into a framework which he called Open Space Technology. Several events were held in subsequent years, but since 1991, the methodology has spread world wide. Open Space Technology has been used primarily in medium- to large-size organizations including Fortune 500 companies, by communities for planning and conflict resolution, by school systems, by national organizations, and political parties. The popularity of OST is related to simplicity, low cost, adaptability to many settings and group sizes, and effectiveness for finding creative solutions to difficult problems (Henricks, 1995; Owen, 1994). User's have recognized its broad applicability and it is evolving rapidly to many new arenas, including management of a community agency (Owen, 1995). Open Space Technology can be used effectively when dealing with complex and potentially conflicting issues, when the answers are not known, and the participation of a number of people is necessary to deal with the questions (Owen, 1992). OST will not work when the answers are already known or when a person in power requires a particular outcome. The open space environment supports creativity, collaboration, and self-motivation. Using OST, groups are assembled to address a particular question, issue, or theme. The topic is usually quite broad, but not so broad as to not give direction. Whoever cares about the topic is invited to attend and as many people as needed to achieve the desired goals are encouraged to participate. Voluntary presence at the event is essential to success. Open space meetings have worked with groups as few as five and as many as 500 (Owen, 1992). There are several features to an open space event. Chairs are arranged in a circle to facilitate communication and there are no tables. The role of facilitator is to open the space and hold safe space open. There is no defined leader, which encourages anyone to come forward to take leadership and acknowledges the potential for leadership in every person. The agenda is created by the people in the room. Passion and responsibility are the two keys to the success of an open space meeting. Without passion, enthusiasm for an idea will soon wane and without responsibility, there is risk that the great ideas will never move forward. There are four principles and one law for conducting an open space meeting, which enable participants to stay focused on the event at hand and acknowledge that the wisdom to resolve the issue is present in the room (Owen, 1992). The four principles are: 1. Whoever comes is the right people
The Law of Mobility states that if persons find themselves in situations where they are neither learning anything or contributing anything, they are responsible for moving to another place, for example, to another group meeting. Owen (1992) introduces the concepts of bumblebees and butterflies. Bumblebees move from group to group, cross-pollinating ideas from many groups. Butterflies tend to stay in one place, may not attend any discussions, but usually end up talking to everyone present at the meeting over the course of the event and often contribute in a significant way to many discussions. The principles and laws enable people to participate in ways that are most meaningful to them. Having explained the process, the facilitator opens the meeting to let the group create the agenda, sign up for the topics of discussion that interest them and then, gets out of the way. The group self-manages the discussions and produces a report of the proceedings at the end of the meeting. It is difficult to imagine how such a process can work effectively, but it has never been known to fail (Owen, 1992). The following description of how OST was used to initiate planning of client-centerd programs for a new urban core Community Health Center illustrates how Open Space Technology can be used effectively to plan health care programs. Even more challenging is that this centre was being developed for and with marginalized populations. Hamilton Urban Core Community Health Centre The community of Hamilton, Ontario has a good system of health services that are characterized by collaboration. However, as in many communities, health planning and delivery is separate from social service planning and delivery. Further, the health system does not meet the tremendous health needs of homeless and underhoused people or the culturally diverse young families and seniors living in the downtown core (Wesley Urban Ministries, 1994). The idea for a community health center started in 1987 when a social service agency (Wesley Urban Ministries) sought assistance from the health sector to provide health services for the people living in the urban core. As a result, Wesley Urban Ministries submitted a proposal for funding for a Community Health Centre, with much assistance from the community and other service providers, particularly Public Health Nursing. Wesley received notification on February 14, 1995, that funding had been approved. Wesley Urban Ministries and its partner agencies are committed to building a community health center that is client-focused and client-driven. The partners recognized that the target population for the Hamilton Urban Core Community Health Centre (HUCCHC) had been frequently surveyed without experiencing any change in services and were sceptical of focus groups and other consultations. There was also concern that usual methods of community participation in planning would be dominated by a few vocal special interest groups. The Executive Director of Wesley Urban Ministries had much success with other diverse groups using Open Space Technology to facilitate similar meetings and believed the process would work well for an initial planning meeting for HUCCHC. It was decided to initiate planning using an open space meeting format. The community was invited to attend one or both days of a two day event in order to develop programs for the Hamilton Urban Core Community Health Centre (HUCCHC). Invitations were distributed by hand, via a mail out to stakeholders and community members who had participated in past processes, by word of mouth, through networking via staff and clients of shelters and health care programs, and through prominent advertisements in the newspaper. Participants could register in advance, with the first 100 registrants being guaranteed lunch, and many just arrived. More than 100 people participated over the two day event. There were many consumers present, although it was often difficult to tell who were consumers and who were service providers, because everyone was integrated in the large circle and equally engaged in subsequent discussions. Seniors, adults, men, women, and several cultural groups were represented. Only youth seemed under-represented at these meetings. The two day event was not considered to be a consultation from which proceedings would be taken away and developed by others. Instead, the participants generated the foundation for the future of th2e CHC, and will be responsible for moving the ideas forward either as members of a steering committee, the Board of Directors, or by remaining involved in an ongoing way by participati2ng in other capacities. Participants have a responsibility to hold steering committee members accountable for follow up from the two day open space event. The meetings commenced both days by gathering in the large auditorium. Chairs were assembled in concentric circles. Interestingly, many people sat in the back row of the circle to start, but were invited to join the circle as the meeting started and easily moved. People were welcomed, thanked for their attendance and introduced to the purpose of the meeting: They were present to develop the HUCCHC. They were informed that the collective wisdom gathered from the two days would be collated into a book of proceedings that will become the foundation of the center. The history of the project, as stated previously, was presented and the group was advised that, while there are unlimited possibilities for developing a CHC, there were some parameters to guide discussionn that the HUCCHC is a Community Health Center funded by the Ministry of Health. The four principles and one law of open space, as described above, were outlined for the group. Having established the rules, the participants were presented with the agenda for the day....a blank wall. There was no planning committee that met to decide an agenda. The people present created it. First-time participants in open space meetings are often anxious, wondering how this will happen. The anxiety was acknowledged and the process was described. After a brief explanation, persons who had issues or opportunities that they thought were important for the HUCCHC for which they had passion, and were willing to take leadership in discussions, were invited to come forward to the center of the circle, write the issue down in a few words, sign their name and announce the issue and their name to the group. The issue was posted on the blank wall and a post-it note attached indicating the time and location of the discussion. Once all of the issues were on the wall, the wall became the community bulletin board and the agenda. The group was reminded that persons who leave the day upset that their issues were not addressed, and the issues were not posted by them on the bulletin board, can only hold themselves responsible for the outstanding issues. Each discussion leader was asked to take a form to record a summary of the discussion and post the summaries on the wall at the completion of their discussion so that everyone could check in to see the progress and the ideas. Usually there is a pregnant pause at the point where the facilitator invites the group to start creating the agenda, but not so at these meetings. The facilitator had hardly finished speaking before many people were in the center of the circle writing their issues. The discussion and excitement in the room was so great that the issues could barely be heard being announced above the din. Twenty one issues were identified on the first day of the meetings and a further seven the following day, all within 20 minutes of starting the process. The breadth and scope of issues generated over the two days was overwhelming. Once the agenda was posted, the marketplace was opened and people were invited to sign up for the issues for which they had interest. Participants were advised that if nobody signed up for their issue, it did not mean that the issue was unimportant, but perhaps the time was not right. Individuals were invited to summarize the concerns they had individually and post them as part of the proceedings if they wished. Some similar topics were combined for discussion. From that point on, participants self-managed both days. The discussions were lively and reports from sessions were extensive and rich. The ideas generated in the two days would have taken years for a small committee to generate. As well, 21 people signed up to be on the Steering Committee, many of whom were consumers. The reports of the proceedings were typed and bound in a 40 page book and sent to all participants. The content has recommendations for specific services, but more importantly, guiding principles and values for the HUCCHC. Conclusions and Recommendations The experience of using OST for the development of the HUCCHC indicates that it may be an effective means to achieve client-centred programs and supports community empowerment. The process enables everyone to have an opportunity to have their voices heard. Strong lobby groups can not unduly influence the proceedings since every person has an opportunity to state their issues and have them discussed. The process and the people deal with the lobby groups and the facilitator stays out of the way. All ideas are recorded and no one set of ideas has any greater influence than another. By maintaining the integrity of the principles of open space, the special interests were heard, but so were all of the other issues that the group generated. The open space process enables effective community participation as defined in Cooke et al (1988, p. 2): "defining their own needs, setting their own priorities, controlling their own solutions, and evaluating their own progress." Communities will generally act and organize around specific issues (Labonte, 1994). The process of OST provides the vehicle that creates the time and space for the community mobilize around specific issues. This paper has provided the reader with a process and an example for client centred and client driven planning and development. It is recognized that Open Space Technology is a relatively new model that requires further testing. It has merit for supporting effective community participation in health care planning and community empowerment. Anecdotal experience using OST is sufficient to stimulate interest in trying it, but greater acceptance by many health care professionals and communities at large is likely only after OST is researched more fully. The outcomes of interest lend themselves well to qualitative research and the such study is encouraged to contribute to a greater understanding of the impact and applications of Open Space Technology. References Cooke, H. L., Goeppinger, J., Brunk, S., Price, L., Whitehead, T. L.
& Sauter, S. V. H. (1988). A reexamination of community participation
in health: Lessons from three community health projects. Family Community
Health, 11(2), 1-13.
List of Issues Generated in HUCCHC Open Space Meetings Day 1 1. User involvement
Day 2 22. Serving our youth in the best way.
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