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As part of the Center for Rehabilitation Outcomes Research (CROR) Rehabilitation Research and Training Center on Home and Community-based Services (RRTC on HCBS), investigators explored not only what’s challenging about delivering person-centered HCBS, but also what’s working. To understand why this approach matters and how it shaped the work, we spoke with CROR scientist Jacqueline Kish, PhD, OTR/L, who incorporated appreciative inquiry into her study of high-performing HCBS organizations.
Q: To start off, what exactly is appreciative inquiry?
Kish: It’s an approach that started as an organizational development strategy in business during the 1980s. It was introduced as a new paradigm that offers an alternative to traditional strategic planning.
Instead of strategic planning that identifies the problem first and then the solution, appreciative inquiry is more along the lines of identifying what is already working, what inspires us, what helps us be our best, and how do we make more of that. It’s this strength-based approach, but it doesn’t assume that problem to solution is linear. It’s more about the process of continual improvement.
Q: How is that different from the way organizations usually think about improvement?
Kish: If your line of questioning is: What are all the problems? Why can’t you do your job the way you want to?, then everyone talks about all the terrible things that are happening at their jobs. And then you ask, Well, what’s going well? and you can’t think of anything. You’ve just spent 15 or 20 minutes talking about everything that’s terrible.
Appreciative inquiry just flips the script. It’s like, what is going well in the system? What’s going well within your organization? And how are individuals enabling that?
Q: How did you apply appreciative inquiry for the project to identify characteristics of organizations doing exceptionally well at providing person-centered HCBS?
Kish: We know that HCBS is rife with challenges. We know what the barriers are… but we don’t know a lot about what’s going well.
So, we asked high-performing organizations basically: What’s going well for you? And surely, they identified all the same problems that we know exist: workforce issues, pay issues, complicated hierarchies within states and limited support for outcome measures. But instead of stopping there, they readily spoke about all the things that were going well. They talked about the structures they put in place, sometimes in response to challenges, and sometimes preemptively.
That is exactly what appreciative inquiry is designed to uncover.
Q: Is appreciative inquiry mainly a method for gathering information, or does it also affect the people being interviewed?
Kish: We used it as an approach to gathering information, but the steps towards organizational change are known as the “4D Cycle” of appreciative inquiry: ‘discover,’ ‘dream,’ ‘design,’ ‘deliver.’
In our project, we basically focused on ‘discover’ and ‘dream.’ We asked: What is the best of the organization? What is the best of HCBS? And then we asked people to envision what could be. Most HCBS providers don’t get invited into that kind of aspirational thinking.
Q: That idea of ‘creating desired futures,’ how does that matter for HCBS research and policy?
Kish: If all we do is identify the problems, then our research just hands those problems off to somebody else, often someone who’s not embedded in HCBS, to solve them.
Whereas appreciative inquiry begins to engage folks in the process of re-imagining HCBS. That’s what I think is really interesting, and what we should be striving toward with policy change.
Q: You mentioned participatory research earlier. Is appreciative inquiry the same thing?
Kish: No. They’re not the same, but appreciative inquiry can be participatory because it brings people through those multiple cycles of ‘discover,’ ‘dream,’ design,’ ‘deliver.’
That said, we didn’t go through all those steps in this project. We envisioned our project as exploratory, so we applied appreciative inquiry to help identify important components of positive practices in HCBS.