Orlando, Florida:
A case study of community transformation

by Joe Flower

This article was published as part of The Healthcare Forum's study, "Emerging Best Practices in Partnerships to Improve Health," funded by The California Wellness Foundation.
International Copyright 1996 Joe Flower All Rights Reserved
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She was frustrated,
and she called a friend.
That's how it started.

Marilyn King was frustrated, and she called her friend Linda about it. That's how it started.

King was a longtime community volunteer, a former president of the Junior League, a trustee on the board of Orlando Regional Healthcare System, and chair of its community benefits committee. She had seen Orlando erupt from a sleepy live-oak-and-Spanish-moss Southern town into something entirely different. Between the growth of the Kennedy Spaceport just to the east, and Walt Disney World just to the southwest, Orlando had been, throughout the 1970s and 1980s, one of the fastest-growing metropolitan areas in America, exploding with retirees, high-tech, tourism, theme parks, and low-paying service-industry jobs. Greater Orlando, now home to over 800,000, was suffering all the maladies of `90s America, in its own special flavors.

Now it was 1993, and something was bugging King at a very deep level, something she could not quite name. She had just served on a pair of task forces dealing with children's issues and the juvenile justice system -- "and it was clear that it wasn't working," she would say later. "We were not getting the results that we deeply needed to have, even though we had all these good professional people working on it, smart people, giving their best. But you know what they say: insanity is doing the same thing over and over and expecting different results. We had to do something different. So I called Linda."

Linda Chapin listened carefully, busy as she was. She was chairman of Orange County, the county that contains Orlando but, like King, she was also a former president of the Junior League. The next morning she called Marilyn from her cell phone in the car: "Listen, I just got a cancellation. Why don't you come in. We'll get some sandwiches and talk."

They talked. "I see people making these enormous efforts," she told Linda, "projects for every category of people and difficulties under the sun. But you know what?

"The problems don't stick
to the categories.
It doesn't work that way."

The problems don't stick to the categories. It doesn't work that way. We've got to try something new that cuts across the lines and brings these efforts together."

Chapin's advice? Spread the conversation. Marilyn should talk to John Haile, the editor of the Orlando Sentinel.

She did. "I made an appointment. I was afraid he would think I was batty." But he didn't. In fact, Haile had already been meeting with four or five friends, big players in town, about the same kinds of frustrations.

So they began to meet, just a few friends: Chapin, King, Haile, Diana Morgan from Disney, and Bill Mateer, who was a lawyer for Orlando Regional and the Sentinel, a few others.

These conversations, and a long series of lunches and coffees and tete-a-tetes that King had with every "power player" in town that she could get to, lasted for over a year. "The groundwork that has to be laid, which seems a sort of soft issue, is absolutely critical," she now says of this time. "We could not have begun to make the systemic changes that we have without the buy-in of the people who ran those systems."

When they started, neither King nor any of those she spoke with were aware of any body of experience that could help them tackle these problems. But one day she picked up a healthcare journal that carried articles by Dr. Trevor Hancock and Dr. Len Duhl about the concept of a "Healthy City," which Duhl had been writing about since the 1970s, and Hancock had pioneered in Toronto in the 1980s. To her, the ideas resonated perfectly with what she and her friends were attempting to do in Orlando. When she had lunch with Sharon McLearn, an executive at Orlando Regional, she told her about the meetings, about the sense of frustration that they shared, about how stuck they felt -- and about the articles she had read.

"McLearn said,
"Let me tell you
about something."

McLearn said, "Let me tell you about something." Sharon had just finished a year of training in the The Healthcare Forum's Healthy Communities Fellowship, along with Dr. Ted Hamilton, who was medical director of Florida Hospital. She had met, as faculty in the Fellowship, a range of experts from the Forum and the National Civic League. "I sent her boxes of materials," says McLearn now. King already knew The Healthcare Forum, and Orlando Regional was involved in their Daniel Yankelovich "What Creates Health?" study.

McLearn and Hamilton joined the meetings, by now grown to about 20 people. "The original group went around in a lot of circles," she says. "There was a clear sense of commitment to creating a greater community among the group, but there was not much agreement on what it would look like or how to get there." King wanted to bring in a facilitator from The Healthcare Forum (THF) or the National Civic League (NCL). The feeling of this high-powered group, according to McLearn, was, "We should be able to do this ourselves. We're smart people. We know what the problems are, we just need to do something about them." King's point of view? "We know what we think the problems are."

Eventually King prevailed. The group agreed to try a facilitator, just to see if it would work -- and the hands went up around the room. One group after another agreed to pay for a facilitator session.

The two organizations that they knew offered somewhat different models for kick-starting a community process. The Healthcare Forum offered a town-hall-style one-day event, while the National Civic League offered long-term facilitation. Given the choice, the group took both -- a one-day event from The Healthcare Forum, with long-term facilitation provided by the NCL.

The facilitator was Gruffie Clough, who was both a senior asssociate at the Forum and a top facilitator with NCL -- and the help paid off. "When we had some facilitation, we were able to hone in on what we were trying to get out of this," says McLearn.

"The Orlando people
asked themselves
excellent questions."

Clough credits the group: "The key was that the Orlando people had really asked themselves excellent questions ahead of time." The group decided to call its effort the "Healthy Community Initiative of Greater Orlando." They set out to create a formal Coordinating Committee by pulling in more people that they knew, the kind of active, community-oriented people that they felt could make a difference and bring some resources to bear.

They ended up with two dozen people at the first meeting in May, 1994, including four more former presidents of the Junior League, one of them the mayor of Orlando, Glenda Hood. The group included McLearn, plus the heads of several city departments, the Central Florida Healthcare Coalition (an employers' group), the school system, a local congregation, a bank, and a homeless coalition. Clough says, "They went from handful of dreamers and visionaries to four handfuls of instigators whose job it was to plan the planning process."

This group had four tasks:

  1. to come up with a definition and a mission for the effort. After much debate, they created a working version of an overall goal -- that an Orlando that was a great place to raise kids would be a great place for everyone.
  2. to select stakeholders to take part in the far larger planning process
  3. to form committees of support and infrastructure, such as outreach, research, logisitics, and fundraising
  4. to plan the stakeholders' kickoff meeting. When they set the date for the first three-hour meeting of the stakeholders, they picked October, only five months in the future.

"It was very exciting work," says Clough now of those meetings every month from May to October, "and very productive, because of the very consistent work of the leadership, especially Sharon and Marilyn. It was thought-provoking, educational and maybe a little threatening. These two dozen people were undergoing some changes of their -- changes in attitude, learning systems thinking, changes in perceptions. They couldn't make the decisions in the old adversarial ways, taking votes, declaring winners and losers, or have the same outcome, with the same old stakeholders. These were powerful people. If these people didn't experience a change, we had no hope of changing the city later on. That's what I have experienced in this kind of work: if the leaders don't change, the community doesn't. These leaders had to model the behaviors that they wanted for the citizens model. If they showed up late, didn't listen well, and jumped to conclusions, that's what they would model. That was one reason this phase was so important, and one reason Orlando was so successful, along with Marilyn and Sharon and the backing of the hospitals. Marilyn did hours and hours of behind-the-scenes work, phone calls, listening to poeple. In other communities I have seen a lot people cut a lot of corners, a lot of "iffie" commitment. In Orlando, they committed to it and they didn't turn back. They just did this right from the very beginning."

After working with Clough to get a sense of where they wanted to go, and what kind of people would need to be involved, they set out to gather them. Haile, of the Sentinel, kept pushing them to go beyond "the usual suspects." "It became an article of belief that we must not build a committee of people that we knew," says Sidney Green, a Coordinating Committee member and herself a "usual suspect," as a former president of the Junior League. "That became a real challenge."

The first attempt showed Haile's point. "Everybody made lists," said McLearn. "They were almost all upper-middle-class, professional, white, 35 to 65 years old, and educated.

"There was this
'Aha!" moment."

There was this `Aha!' moment when we realized that we were traveling in pretty homogenous circles."

For a second pass, the committee divvied up the economic sectors and demographic groups that would have to be represented, such as tourism, the service industry, Hispanics, African-Americans, and older people. Each member of the task force picked a group, did some research, asked around, thought about it, and came up with some names -- over 600 in all, stuck up on the walls on Post-Its. They put them in a database, categorizing them by race, marital status, age, location, and so forth. The one group they had trouble getting involved with (and still do) was Hispanics. In a series of meetings, they pared the list. They couldn't seem to get below about 164 -- but that would be fine since, they assumed, at least half of the people would decline the invitation to so much work and trouble. Then they would do a second mailing to "fill in the holes." Eighty would be a nice number.

They were wrong. They sent out a mailing, a nicely-designed, well-written four-page brochure called "Destination: Imagination" that invited the reader to imagine a "safe, healthy, and rewarding" Orlando, and spelled out exactly what would be asked of the Stakeholders, from the dates of the meetings to the fact that the process might become difficult, and might require patience. The cover letter, which listed the names of the committee down one side, invited the receiver to attend. A response card had check-off boxes for accepting or declining the invitation, and for requesting help with child care, transportation, getting time off of work (the meetings would begin at four in the afternoon) or other problems.

The response stunned the committee.

Almost everyone
said yes.

Almost everyone said yes. There was no second mailing needed.

The Stakeholders' agenda was ambitious -- 11 meetings over eight months to create a vision, build teams, assess the environment, identify leverage points and key performance areas, and map out actions. They would need support. Orlando Regional lent the services of McLearn and her secretary, part-time, as staff for the effort. McLearn and the Coordinating Committee asked both organizations and individuals for help with everything from the fees of the consultants to meeting space, copying, mailings, and even food for the meetings.

The committee approached the Orlando Foundation for help, but it didn't work out, for the very reasons that the Healthy Community Initiative was so powerfully different from the usual efforts: it cut across categories, it had no clearly-defined outcome, it would not even know what it was planning to do until it had listened hard to everyone in town. "We could not fit into their boxes," says King.

The major players, such as the two hospital systems and several large employers gave the bulk of the support. Yet all this help was kept very much in the background. No one got their logo on anything. No one got touted as a sponsor. "It was important that we not look `fat,'" says Green. Organizations and individuals would be publicly acknowledged for their help, but with an egalitarian touch. No one got more credit for giving more. In the initiative's eventual vision publication, everyone from Orlando Regional and Disney to the bakery that donated a tray of doughnuts would be listed -- in alphabetical order. King had seen far too many "hospitals touting themselves as the leaders of Healthy Communities efforts. We went out of our way to de-emphasize the hospitals. This was about people, not about promoting institutions." This reflected King's deep values, her commitment to "doing the right thing." When Orlando Regional's CEO had asked her to take on the community benefits committee, she told him that she wasn't interested unless it "community benefits" could mean more than marketing, and more than meeting the letter of the not-for-profit tax laws.

It was more than
the right thing.
It was tactically smart.

But it was more than the right thing. It was tactically smart. "There's no one's name on it," says McLearn. "In fact, a lot of the big players in town are involved, but if it belongs to anyone, it won't be as successful. Everyone has some baggage. People will think that you're doing it for the credit, that you're controlling it."

A few organizations have offered help, then withdrawn it when they discovered that they could not put their logo on it -- but only a few.

When the Stakeholders finally met, they set right to their tasks, with the help of The Healthcare Forum's one-day event, with such outsiders as Dr. Trevor Hancock of Toronto, the NCL's Tyler Norris, healthcare futurist Leland Kaiser, pollster Daniel Yankelovich, and Kathryn Johnson of The Healthcare Forum. The first task was to discover a common vision, a ground on which to build everything that would come after. Dr. Hancock reminded them that they all carried a vision of a healthy community in their heads, and invited them to search it out and share it, draw it, talk about it. When they had worked out a rough draft of the collective vision, a vision committee took over the work.

Over several months, starting in February, 1995, the Stakeholders conducted 30 focus groups of Orlando residents, hearing the concerns and interests of such groups as West Orange residents, Housing Authority residents, immigrants, young adults, gays and lesbians, Christian religious leaders, and owners of small businesses. That work shaped and refined the vision. One suggestion for change came from many different groups: when the vision document talked about what could be accomplished, many people heard nothing about personal responsibility. So the committee added an explicit statement on the importance of personal responsibility.

In the end, the vision contained 14 statements, on everything from the economy to children, from the arts, neighborhoods, and education, to interaction and security.

"It actually helps that we don't have the answers," says King. "We went to one small, very poor community. We held two focus groups for parents, 10 people in one, 11 in the other. Among other things, we asked them, `What is the most important thing we could do to improve the lives of our children?' Now you and I could have made up a list a mile long, but 20 out of the 21 said something that would not have been on our list at all.

"They said,
'Teach us
to read.'"

They said, `Teach us to read.'

"When you listen to people, you build trust," says King. "If you have trust, you can disagree with people and still go forward. But you have to spend time building those relationships."

The Stakeholders met about every three weeks in donated space in a local art museum, from 4:00 or 5:00 to 8:30 or 9, and talked over a donated dinner. Each time, they did specific activities to examine their own community, identify high leverage areas, look for opportunities and threats, and explore their civic infrastructures.

"Eventually," says Clough, "we would ask, `Now that you know it from a more diverse perspective, where are we going to make the biggest difference?' People gained new information, and new insights. But one of the greatest outcomes of the process was the opportunity to build relationships.

"It was not easy at all. Many people, in fact most people, don't appreciate the value of process. They find it quite restrictive. Some people felt that they could identify the key areas at the very first meeting. Some people got frustrated.

"Some people quit coming.
Some people
were disruptive."

Some people spoke to me or Marilyn, some people quit coming. Some people were disruptive in the meeting. Some people said, `Tell me again why we have to do this?' And I would say, `Two reasons. One, if you look at all the research around human behavior, people do not change because of information, people change because of relationships. Two, if you don't understand it from all the perspectives, you won't be able to solve it.'"

The assessment phase went quickly, for a simple reason: they re-invented no wheels. McLearn had recently done a similar study for Orlando Regional. Combined with information brought to her by other members of the committee, it made for a comprehensive, numbers-filled, 100-page book of facts about Orange County's health and quality of life.

To this they added the National Civic League Index, which measures a community's capacity for productive civic change. According to this index, Orlando was strong in leadership and philanthropy, but weaker in inter-group relationships and in civic education.

If the assessment were to mean anything, the numbers could not just sit in those 100 pages. They had to become real to the Stakeholders. The presentations of these realities, in meetings through December 1994 and January 1995, were creative, different, and striking. One member of the research committee, assigned to transportation, took a video camera to an outlying district of the county, and recorded his efforts to take a bus to a specific address in Orlando. Another member of the research committee played the role of a single mother working for minimum wages, with so many dollars to go around, while other Stakeholders played the part of the landlord, the grocery store, the day care center, demanding payment. She managed to scrape by until suddenly her car broke down, and she was on the street.

One stakeholder,
a nurse with four kids,
was homeless herself.

One stakeholder, a nurse with four kids, was homeless herself, and talked about how it happened, and what it was like. A third research committee member had Stakeholders pass around and collect playing cards to represent sexual contacts or shared needles. Some of the cards were marked as HIV carriers, and the infection spread through the group. Sidney Green says these presentations "had a powerful impact on all of us stakeholders."

Faced with these realities, the Stakeholders set out to plan some actions. Several parameters arose from their discussion. They had not convened, they decided, to lobby Tallahassee or Washington. Instead, they would search for "key performance areas," points of maximum local leverage, areas where they could make a difference. That decision removed some problems from the table. Transportation, for instance, was indeed a problem, but most of the leverage and funds were controlled elsewhere.

Another principal: they would build "initiatives," not "projects." The difference: they saw "projects" as the way well-meaning efforts usually turned out, focused on a single problem, with a particular method, particular sources of funds, and a distinct bureaucracy. The Healthy Community Initiative, in contrast, had to serve as the connective tissue bringing such narrow projects together in broad initiatives attempting to leverage change in whole segments of local society.

In the end, the Stakeholders identified three "key performance areas:"

This last concern -- a stand, essentially, against racism, sexism, and intolerance of all kinds -- had a curious history. Almost every other concern showed up in substantial agreement across all different races, classes, and other groups, both in the focus groups and among the Stakeholders. "The differences were like people looking at the same mountain through different lenses," as Sidney Green puts it. But on this one issue, there was stark division. Whites tended to dismiss racism as a major problem, while African-Americans put it at the forefront. In Stakeholder discussions, some whites suggested that, in fact, the fight against racism was subsumed and honored in every conceivable initiative before them. But an African-American gave a different perspective: "That's why it's never dealt with, because it's never the main subject. It's always part of something else." In the end, the Stakeholders came to consider one of the Initiative's three main concerns.

For three more meetings, the Stakeholders broke into small groups to hammer out action plans. The challenge was to get concrete, without breaking apart into a series of discrete "projects." "There are a million projects out there," says McLearn. "We want to attack the underlying issues. And we don't want to end up being the ones who are responsible for the community. Our goal is to get everyone in the community to see themselves as responsible for the community's future."

The group as a whole created five "Action Steps:"

  1. Bring the various parties to the table to begin to create broad-based, community-wide, collaborative responses to significant community issues
    • Focus early efforts on priorities identified by HCI Stakeholders:
      1. Community connectedness
      2. Strengthening families and children
      3. Diversity
  2. Develop a full spectrum of training opportunities for community trustees:
    • Include programs on facilitation, conflict resolution/mediation and leadership skills
    • Design leadership development program for grass-roots leaders and untapped professionals
    • Work with schools to explore, develop and implement civic education curriculum
  3. Increase the number of community stakeholders committed to the Healthy Community movement:
    • Launch a series of project-oriented community building experiences
    • Develop communication vehicles to increase awareness of HCI goals, programs, and concepts
    • Nurture media "civic journalism" role
    • Promote HCI programs/opportunities
    • Consider Neighborhood Watch approach
  4. Facilitate the development of informational resources:
    • Ensure centralization and accessibility to the community
    • Integrate the latest technology
  5. Provide celebration, recognition and revitalization programs for community trustees

    That done, the Stakeholders published a booklet with their findings in the fall of 1995, held a celebration, and participated in a 3-hour video of the project prepared and aired by a local television station.

    Then they cleared the decks for action. They had decided to turn the Healthy Community Initiative into a permanent organization, with a board, an endowment, and a building, to set the stage for fulfilling these plans.

    "I didn't want to incorporate," says King. "I held off kicking and screaming. We don't see ourselves as another agency, another provider, another entity in town. We are a connector. We bring people together -- but we can't do that, in a substantive way, in a town this size, without full-time people. We have done the most comprehensive work for several years now on volunteer labor and part-time loaned people. You've got to have people who can give this their total focus" And you can't hire people, collect funds, and pay salaries unless you exist as a legal entity. So they incorporated as a 501c3 public benefit corporation, and began to gather a permanent board.

    Orlando Regional's "loan" of half of Sharon McLearn's time ended, and Sidney Green came on as full-time staff, a "Director" with, at first, just a secretary. They were given a building, but it needed repairs and permits. All told, the re-organization took up the first half of 1996.

    "Of course, you've each
    got to start by asking
    for a million dollars."

    Leland Kaiser, over lunch at the Orlando airport with Dr. Hamilton and Marilyn King, told them, "Of course, you've got to start by going to both of your institutions -- Florida Hospital and Orlando Regional -- and asking them to commit a million dollars." They did. And the institutions said yes. That kicked off a low-key, face-to-face campaign to get other institutions and employers in the are to kick into an endowment and a fund to pay the first year's operating expenses.

    In the meantime, the Initiative's plans for action were on hold. Yet even during this breather, action did not stop. The spirit that the Initiative had stirred up in the community, and the awareness that it unleashed, began to turn up in projects that had no direct organizational connection to the Initiative, but were influenced by individual Stakeholders. Two homeless programs stopped their turf competition and merged.

    A "Collaborative Model Board" -- an informal organization of public and private grant-giving agencies, chaired by King -- began meeting to discuss how they could co-ordinate their grants to better serve the community. It brought major funders together with the mayor, the county chairman, representatives of state agencies (such as Health and Human Services), Disney, major foundations, and the head of the school system. "We're not telling anyone where to put their money," says King, "but we are beginning to evolve a shared vision of the community among those who fund things here."

    The Citizens' Commission For Children dedicated $6 million to the "family support model." It declared that it would only fund organizations that were working collaboratively, since it is not effective to work with a child if you are not looking at the whole family -- and it offered its grantees whatever help they needed to learn to work collaboratively with other providers. A number of local businesses began to take a hard look at their policies, searching for ways that they could be more "family-friendly."

    The county had already started a major " Targeted Communities" initiative dedicated to bringing a new direction to suffering communities by re-building the infrastructure.

    County officials realized that it was futile
    to rebuild the physical infrastructure
    without dealing with the human element.

    County officials realized that it was futile to rebuild the physical infrastructure without dealing with the human element, the civic infrastructure -- and they invited the Healthy Community Initiative to work with them.

    The next phase is to take those action plans to the next stage, to set goals, develop timelines, set benchmarks, and create mechanisms to monitor their progress in each area.

    McLearn feels that some of the action planning may have to be re-done in more depth: "If you really want to attack these huge social problems, you can't create the action plan in three or four meetings with 20 people. You really have to re-convene a subset of the Stakeholders, and bring some more people into the process, people with a stake in the situation, people with special experience, expertise, or information, and take them through a miniature version of the process to get to a consensus on the actions. The rush to get to actions and action plans -- to `do something' -- causes people to end up at the same old things. We have enough momentum and cohesiveness now to take the time to do it fully."

    For all Orlando's rapid progress, it still takes a long eye, sometimes, to see how quickly things are moving. One businessman told her that it was "the most exhilarating, and most frustrating" thing he had ever done. "People like me want to have an outline, we want to delegate the tasks, and check them off."

    "It's not efficient in terms
    of time. It's about
    personal transformation."

    King admits that "it's not efficient in terms of time. It's about personal transformation. You have to change the whole way you get involved. Your value system has to permeate everything."

    "There are still a lot of people who don't understand what we're trying to do," says McLearn. "People are a lot more comfortable with a project that has an endpoint, objectives, and a timeline. To try to tell people that we're setting out on a journey with no guarantees is a lot harder. We have become very comfortable with ambiguity and uncertainty, very comfortable with not having answers. That's not how people typically do business.

    "Marilyn and I sat in a meeting with a business leader one day who came right out and said, `I really admire you folks, but I am quite concerned that you've taken on an impossible task. Look across society, morals are crumbling, things are falling apart. You're just going to get taught a very hard lesson.'"

    "Everybody says its an impossible job, it can't be done," says King. "We feel that we don't know how to do it, but it must be done."

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