Introduction: Increased interest in collaborative and inclusive approaches to healthcare improvement makes revisiting Elinor Ostrom’s ‘design principles’ for enabling collective management of common pool resources (CPR) in polycentric systems a timely endeavour.

Theory and method: Ostrom proposed a generalisable set of eight core design principles for the efficacy of groups. To consider the utility of Ostrom’s principles for the planning, delivery, and evaluation of future health(care) improvement we retrospectively apply them to a recent co-design project.

Results: Three distinct aspects of co-design were identified through consideration of the principles. These related to: (1) understanding and mapping the system (2) upholding democratic values and (3) regulating participation. Within these aspects four of Ostrom’s eight principles were inherently observed. Consideration of the remaining four principles could have enhanced the systemic impact of the co-design process.

Discussion: Reconceptualising co-design through the lens of CPR offers new insights into the successful system-wide application of such approaches for the purpose of health(care) improvement.

Conclusion: The eight design principles – and the relationships between them – form a heuristic that can support the planning, delivery, and evaluation of future healthcare improvement projects adopting co-design. They may help to address questions of how to scale up and embed such approaches as self-sustaining in wider systems.