If Cincinnati Children’s Hospital Medical Center had its way, far fewer children would come through its doors in need. The top-ranked pediatric hospital set out a comprehensive five-year strategic plan back in 2015 that included the formation of All Children Thrive, a network for sharing data and quality improvement methods among the United Way of Greater Cincinnati, the City of Cincinnati Health Department, Cradle Cincinnati, Cincinnati Public Schools, and other partners. The mission from the outset was to help make 66,000 children in the city of Cincinnati among the healthiest in the U.S.
Illustration by Fran Labuschagne
A key relationship CCHMC needed to strengthen was with Avondale, its home neighborhood. Despite literally being in the shadow of the hospital’s ever-expanding campus, Avondale has one of the nation’s highest infant mortality rates, a frustrating situation for everyone involved. “We knew we needed new approaches,” says Dawn Denno, senior director for community and population health at CCHMC.
The hospital contracted with Design Impact, a Madisonville-based firm focused on human-centered design, to research the underlying causes of poor health outcomes in Avondale and devise more holistic solutions that went beyond basic treatment improvements the hospital had already tried. The first challenge was to get neighborhood residents to honestly share their life stories with an institution that many had come to distrust over the years.
“What does ‘thriving children’ mean to actual community members?” says Ramsey Ford, Design Impact’s cofounder, of his team’s starting point. “If you are living in Avondale and thinking about improving your family’s health, what does that mean to you outside of the clinical hospital space? We worked with Children’s to engage parents as what we would call peer researchers. Not just doing interviews with community members, but saying, ‘Hey, would you become part of this process?’”
So Design Impact hired eight Avondale residents to interview their friends and neighbors, a process that yielded as many as 20 ideas for how CCHMC could help the community address a range of health-related issues. Six of the ideas were tested among Avondale residents, resulting in a CCHMC-funded pilot program called Justice Promoters to help families avoid evictions from their rental housing.
The conversations those peer researchers had revealed that housing insecurity—moving children from neighborhood to neighborhood and school to school—is one of the root causes of poor health outcomes in Avondale (and elsewhere). It’s the kind of insight that medical professionals at CCHMC likely wouldn’t have discovered on their own. “Design Impact’s process was invaluable to us for the empathy that it developed among all of the team members to what our families need and desire and what they think about Children’s,” says Denno.
Photograph courtesy Design Impact
Cofounders Ford and Kate Hanisian have been refining their vision for human-centered design since they got together as a couple more than a decade ago and tested their theories over four years in India. The Design Impact model starts with peer research and data gathering and leads to opportunities for communities to analyze the data and create their own ideas for solutions—which, in Avondale, are already producing tangible results.
Natasha Miles, a longtime neighborhood resident and mother of seven, is one of several Justice Promoters hired to go door to door offering insight on housing issues, particularly renters’ rights. She’s helped resolve several eviction problems, including her own.
“I enjoy helping people, and I think I make an impact in my community with the different things I do,” says Miles. “In the process of helping neighbors learn about their leases, my landlord ended up trying to evict me. So I was able to iterate what I knew from my training, and I’m still in my home.”
Kate Hanisian and Ramsey Ford always knew they wanted to build something together. “Before we started Design Impact, we talked about opening a pancake shop,” says Hanisian. “We were going to have an art van we’d drive around.”
They started first with their relationship—both graduated from Walnut Hills High School, though they didn’t date until years later, after college. Hanisian studied English and history at Ohio University and received a master’s degree in education from Xavier University, and Ford graduated from UC with an undergraduate degree in industrial design and a graduate degree focused on how design and community organizing overlap as processes. “The romantic story is mutual friends came back from Europe and wanted to show people their slides,” says Ford. “Yes, their slides.”
The jet-lagged friends went to bed early, and Hanisian gave Ford a ride home. Only they stopped at a now-demolished café and talked for hours. They decided to exchange letters (“There was a period of my life where I was anti-technology,” Hanisian says) and love bloomed. They married in 2007.
Photograph by Aaron M. Conway
Hanisian was working with the Ohio Justice and Policy Center at the time, and Ford was teaching at DAAP and consulting with Kaleidoscope Cincinnati, a design and development firm. Kaleidoscope wanted to bring him on in a larger capacity, and the CEO, Matt Kornau, asked Ford where he saw himself in five years. “Ramsey said, ‘Well, I’m actually really interested in this thing called social design,’” says Hanisian. “He loved the process of design but didn’t really love the by-product, which is often consumer goods. Social design was, How do you use this process for social change? My background was all about social change and social justice.”
Three presentations and a budget proposal later, Kornau approved their pitch and gave the pair $150,000 of seed funding to build out their social design idea. The stroke of good luck isn’t lost on either of them. “There’s a lot of privilege in entrepreneurship,” says Hanisian. “It’s important to say that we had social networks and opportunities put in front of us. We weren’t laden with student debt. We had all these other supports that allowed us to basically not earn money for a few years.”
Their initial idea was called “embedded design,” with an emphasis on embedding within a community to help residents solve problems in ways that primarily took into account their perspectives. Design is usually centered around solutions, but Ford and Hanisian find answers strewn everywhere on the path—the process—that arrives there. “We decided we’d commit to a year to two years of working with the same community on whatever problems they wanted us to work with,” says Ford. “We worked through a nonprofit organization to help us center in a community and build relationships.”
They chose India for a number of reasons: many English speakers, plenty of opportunities for upward trajectory for low-income residents, and a good physical and nonprofit infrastructure already in place. They joined the Organization for Development Action and Maintenance (ODAM) nonprofit in Tiruchuli, India.
Photograph by Aaron M. Conway
The pair’s original model focused on social enterprise based around products, helping ODAM with projects they wanted to get off the ground. Two primary ideas surfaced: fair-trade soap made from the glycerine by-product of ODAM’s biodiesel plant, and clean-burning charcoal briquettes made from charcoal powder generated from an invasive tree species in the region. Hanisian and Ford designed a fellowship program to help them. “We learned what it looks like to put designers in deep partnership with community members, through nonprofit agencies, and what the limits of that are,” says Ford.
In total, they were in India from September 2009 through mid-2013. Visa issues complicated their stay, as did a series of family health emergencies and the increasing difficulty of funding their fellowship program. “We were training a bunch of other people to do it, and the model needed to be reenvisioned,” Hanisian says. “It was one of those things where all of your shit starts to go wrong at the same time, and we were just like We need to step back.”
The pair returned to the U.S. and took on a series of teaching jobs and small projects, but the Design Impact approach wasn’t quite sustainable yet. “It slowly evolved and picked up,” says Hanisian. “We had to rethink the whole way we were talking about it, and it took us a year and a half to do that.”
A second project with India came through the Center for Creative Leadership, a national leadership development organization. Hanisian and Ford designed a training program for Indian business students and had a key realization. “You can do work and embed the idea of design in people in different ways,” says Ford. “Our first breakthroughs here were more like, instead of people hiring us to go do the work, we got hired to teach other people how to do the work.”
Both the United Way and the Greater Cincinnati Foundation hired them in early 2014 to do what Ford calls “equipping programs” with other local nonprofits. In three years, Design Impact’s core team grew from three to six to 12. They operated from 2013 to 2018 out of Kaleidoscope’s downtown office and were poised to expand when Kaleidoscope relocated out of the city limits. Design Impact moved to Madisonville in August 2018 into a building that houses “other like-minded nonprofits,” says Ford, including Starfire Council and Green Umbrella.
In the 1970s, Stanford University was one of the first U.S. institutes of higher education to experiment with what Jim Tappel, an associate professor at the University of Cincinnati, calls the “blending” of design and engineering. Combining skill sets from both disciplines forms the most basic foundation of human-centered and social design.
Tappel received his undergraduate degree in engineering from UC and went to Stanford for graduate school to research orthopedic biomechanics, when he was introduced to this blending concept firsthand. “In engineering school, the teachers generally give you a problem, you work on it, and there’s the answer,” says Tappel. “We couldn’t understand why our buddies who were architects stayed up all night working on a problem. It’s like, ‘What’s the deal?’ Then in graduate school I realized, when you’re designing a house, a room, a building, there’s not one answer—there are many answers. That was this fundamental difference between engineering and design. One has a concrete answer that can be proven and validated by different methods, but in architecture and the design field it’s, What’s the most correct design, or what’s the best design based on the criteria?”
“It’s important to remember that design is a process, and not just a product,” says Sara Aye, cofounder of Greater Good Studio in Chicago.
The end goal of introducing the respective toolkits of each field of study to the other and integrating them—having an engineer participate in the process of problem-solving the need, or perceived need, for a product—creates empathy. And that’s integral to human-centered design. “That pays dividends,” says Tappel. “If they have a direct connection to that user, they might go, ‘You know what, let’s spend more money and more time getting this right because it really matters.’ That’s the empathy part, having engineers be empathetic to the user.”
IDEO, an international design and consulting firm based in Palo Alto, California, was the
one of the first organizations to take human-centered design out of the halls of higher education and implement it in the real world. An example the company touts is the mouse IDEO designed for Steve Jobs’s Lisa computer, a component of which is still used in most mouse products today. Not coincidentally, founder David Kelley also founded Stanford University’s Hasso Plattner Institute of Design, which codified the blending that Tappel describes and is often referred to in shorthand as the “d.school.”
Tappel worked for IDEO from 1987 to 1990 and again from 1997 to 2003, practicing firsthand his “blending of fields” approach. He joined UC’s College of Engineering and Applied Sciences in 2009, where he’s helped introduce this integrated model of thinking. “How do you put these individuals together in a room, with different disciplines, and how do these people work? We need a lot of different people working together on these teams,” says Tappel. “At least within the college, we’re exposing the engineering students to Here’s the process you’re going to use to design and develop products.”
Other universities have followed suit with implementing human-centered design curriculum. In fact, the d.school has a whole section on its website devoted to sharing its principles and the necessary steps for those curious about starting a design program.
Sara Aye, cofounder of Greater Good Studio in Chicago—one of the national organizations that hews most closely to the human-centered design work Design Impact does—attended the Illinois Institute of Technology’s Institute of Design for graduate school. “I think I got into mechanical engineering because I wanted to be a designer and didn’t know what a designer was,” she says of her undergraduate years at Northwestern University. “When I got to take a class that was called Engineering Design, the light bulb went off for me: We had a client, the client had a user, and the user had a need.”
Greater Good Studio has joined Design Impact twice to participate in day-long learning sessions. By helping one another in this fairly niche field—one that doesn’t necessarily lead to a new app or a physical product—Aye says the field grows stronger and gains momentum, as do the organizations. “It’s important to remember that design is a process, and not just a product,” she says. “I think there’s a misconception that design is what it is at the end, and everything basically in the world has been designed and can therefore be redesigned. Whether that’s an institution, a process, a program, or a service, we can redesign things if they’re broken. And we should.”
Hanisian echoes that belief. “It’s a process by which we understand what is, and turn it into what it ought to be, particularly based on the perspective of those people with the most understanding of the problem or lived experience,” she says.
As human-centered design becomes more ubiquitous, the positions offered within firms get more diverse. Design Impact, for example, employs not only designers but folks like Hanisian with backgrounds in social justice, storytelling, and education. That diversity is key to addressing deep-rooted problems organizations like CCHMC find themselves grappling with.
According to the National Academy of Medicine, medical care determines only about 10 to 20 percent of an individual’s health status. The other 80 percent results from the conditions in which people are born, age, grow, work, and live. “Housing insecurity is such a huge issue for our community in terms of health and education, because of the mobility,” says CCHMC’s Denno. “That child keeps switching schools and loses time learning, so housing affects a lot of things.”
Avondale was the focus of a housing crisis spotlight in 2017, when a handful of Cincinnati City Council members—including mayoral candidate Yvette Simpson—moved to oppose zoning changes requested by CCHMC to accommodate a planned $205 million expansion. The motion failed, but the housing issues in Avondale remained relevant. “We’re trying to deeply understand these broken systems,” says Hanisian. “People hire us to work as process facilitators. We are not content experts, though we do know a lot about social change. We’re hired to ask, ‘What is the process by which we get from where we are now to where we want to be within the scope of this timeline, this budget, this problem? How do we get there?’”
Photograph courtesy Design Impact
Design Impact’s empowerment of the peer researchers in Avondale—including Natasha Miles, who later became a Justice Promoter—afforded direct access to the perspectives of families and community members. The researchers were paid what Ford calls a living wage to gather information within their community. They took photographs of the neighborhood against certain prompts set out by Design Impact and reported back, recruiting and interviewing other community members about what it means to thrive and what thriving looks like to them. “We facilitated residents thinking about the issues they run into with their rental housing,” says Ford. “They came up with their own design for having a conversation with neighbors about their leases.”
Miles worked four mornings a week during the research phase, balancing the care of her children, ranging in age from 3 to 25, and their schooling. She says motherhood was a huge motivating force for putting in the necessary groundwork in the neighborhood. “My mother always helped in the community, telling children to use the crosswalk or telling parents to take their children to the rec center or feed them,” says Miles. “She instilled that in me.”
The conversations turned up key housing factors such as poor building maintenance, bad landlord practices, and general lack of information about renters’ rights as contributing to health problems in Avondale. Design Impact hosted a meeting at the Xavier Innovation Lab for community members, CCHMC physicians, and local nonprofits to dig into the data, discuss possible solutions, and identify concepts to test among Avondale residents.
People call us because they have a big problem or a big idea and they’re not sure, like, How the hell do I actually do this in a way that’s creative and inclusive?
When the Justice Promoters program was rolled out in 2018, an information campaign called “Decoding the Lease” became popular immediately. Miles and other Promoters educate neighbors about their rights as renters, with an ultimate goal of reducing evictions and empowering Avondale residents to become advocates for and leaders in their community.
“I’ve met people who ended up leaving their apartments because they didn’t know their rights, after their landlord gave them a three-day notice,” says Miles. “I told them a three-day notice isn’t a legally binding eviction. You just need to know your lease rules.” According to the Hamilton County Clerk of Courts’ website, the court usually gives tenants seven days to vacate once an eviction order has been filed, though landlords may request a shorter time frame.
“When they were trying to evict me, I went to Legal Aid [Society of Greater Cincinnati],” says Miles. “They told me to put my rent money in escrow if I have a dispute, and to write a letter [saying that’s what I did]. If you have a legitimate complaint, you need to document it and document talking to someone at the leasing office or to a building owner, then give a 30-day notice to your landlord to fix the problems and put your rent money in escrow. You can’t just say, ‘Well, I’m not paying my rent this month.’ Even if you have 10 complaints in the past month, you still have to document it all legitimately in writing.”
The hope is to adapt this self-empowerment process to other aspects of daily life in Avondale beyond housing. “We design the work to get to a Justice Promoters prototype at the end of it, recognizing that Justice Promoters by itself is insufficient to change the actual problem,” says Ford. “But you need to have an anchor to build on.” Miles says she’d like to see a peer-to-peer sex education program evolve from her Justice Promoters work and from the All Children Thrive network more broadly, so fewer community teens become young parents, as she was.
Design Impact celebrated its 10-year anniversary in May 2019. The firm’s work on Justice Promoters received an honorable mention at Fast Company’s annual World Changing Ideas Awards, in the “Experimental” category. As it moves into its second decade, Design Impact tackles projects as large and deeply entrenched as pervasive, recurrent societal inequities (with United Way) and as niche and specific as helping two wings of the Montgomery County Job Center work more collaboratively to provide better outcomes for the residents it serves.
“What we focus on is the ‘how.’ That’s what we do,” says Hanisian. “People call us because they have a big problem or a big idea and they’re not sure, like, How the hell do I actually do this in a way that’s creative and inclusive?”
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