In Philadelphia in 2004, they decided to tackle the things that were wrong in their services. They did a giant exercise in information gathering, something they called a ‘fearless inventory’ after the AA fourth step. You can see the detail here:
They uncovered that some unhealthy stuff was going on. Organisations were not talking to each other. They existed like islands connected by drawbridges that ‘were permanently up’.
Focus groups uncovered “an underlying tone of paternalism, disrespect and, at times, outright contempt.”