- Email: [email protected]
Locating the system in a system of care
Evaluation and Program Planning 33 (2010) 11–13
Contents lists available at ScienceDirect
Evaluation and Program Planning journal homepage: www.elsevier.com/locate/evalprogplan
Locating the system in a system of care Pennie G. Foster-Fishman *, Erin Droege Department of Psychology, Michigan State University, 125 D Psychology Building, East Lansing, MI 48824, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 April 2009 Received in revised form 28 April 2009 Accepted 28 April 2009
While systems of care are recognized as a systems-level intervention, a gap remains between systems theory and practice that challenges the effectiveness of future system of care efforts. This article explores the extent to which the expanded system of care definition proposed by Hodges et al. [Hodges, S. Ferreira, K., Israel, N., & Mazza, J. (this issue). Systems of care, featherless bipeds, and the measure of all things. Evaluation and Program Planning] addresses this gap and suggests ideas for strengthening its systemic focus. Specifically, recommendations address considerations for assigning and adapting appropriate boundaries around intervention efforts and leveraging critical system characteristics and interactions to promote systems change. Implications for system of care practice and theory are discussed. ß 2009 Elsevier Ltd. All rights reserved.
Keywords: System of care Systems change Systems theory
Communities that develop a system of care for children with severe emotional disorders embark on a transformative process of change for their local community. System of care development often involves shifting the roles of providers and consumers, building connections across an array of fragmented services, expanding the continuum of services offered, and creating more flexible funding pools by merging categorical funding streams into blended or braided financing (Stroul & Blau, 2008). Significant changes throughout the service delivery system are necessary for a system of care to become fully implemented and effective within a community (Hodges, Friedman, & Hernandez, 2008). Although much progress has been made at understanding how to more effectively implement a system of care (e.g., Hodges et al., 2008), less attention has been paid to understanding the character and dynamics of systems and their implications for these efforts. Hodges et al. (this issue) call attention to this gap in the literature by pursuing an important task: the creation of an expanded definition of systems of care that more adequately captures their systemic nature. The purpose of this article is to examine the extent to which the Hodges et al. definition incorporates a systemic lens and to identify what, if any, changes could be made to this definition to strengthen its systemic focus. Through this analysis, we hope to increase practitioners’ and researchers’ attention to and understanding of system-level properties and behaviors; such insights can potentially increase the effectiveness of future system of care efforts.
1. The importance of systems thinking in systems of care If system of care efforts target ‘‘systems’’ as the unit of change, researchers and practitioners need to adopt frameworks (and definitions) that adequately attend to the characteristics and dynamics of systems. Systems are defined as a collection of interdependent parts that, through their interactions, function as a whole (Ackoff & Rovin, 2003; Maani & Cavana, 2000). Systems change, therefore, refers to the process of altering the status quo by shifting the form and function of a targeted system (Foster-Fishman, Nowell, & Yang, 2007). To aid this process, systems theorists have developed a variety of systems thinking tools to guide the assessment of system characteristics, the interrelationships across system parts, and the patterns within systems that support and sustain current conditions (e.g., Trochim, Cabrera, Milstein, Gallagher, & Leischow, 2006). Systems theorists would argue that it is only through such understanding that change agents and researchers are able to identify how to effectively leverage transformative and sustained change within a targeted system (e.g., Senge, 1990). Overall, the above suggests two criteria one can use to assess the ‘‘system-ness’’ of Hodges, et al.’s definition: (1) does the definition help one to clarify what and who to include in the system targeted by the system of care effort—in other words establish the system boundary? and (2) does the definition help to determine the system parts and interactions that are critical to the targeted problem and the desired solution—the creation of a system of care? We explore each of these questions below in our analysis of the Hodges et al. definition. 1.1. Establishing the system boundary
* Corresponding author. Tel.: +1 517 353 5015; fax: +1 517 432 2945. E-mail addresses: fosterfi@msu.edu (P.G. Foster-Fishman), [email protected] (E. Droege). 0149-7189/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.evalprogplan.2009.04.001
The act of establishing the system’s boundary is considered one of the most critical and potentially transformative steps in a
12
P.G. Foster-Fishman, E. Droege / Evaluation and Program Planning 33 (2010) 11–13
systems change effort like a system of care (e.g., Midgley, 2000). Boundary clarification includes both clarifying the targeted problem and determining who and what is contained within the system given the selected issue. For example, a narrow problem definition within a system of care effort may focus entirely on improving the way mental health services are currently provided to children and families and thus may draw its boundaries around programs and organizations currently involved in treatment services (e.g., community mental health organizations and providers, schools, courts, child protection agencies). In contrast, a broader definition could also include a focus on prevention, thus expanding the system of care boundaries to include agencies and programs related to prevention and natural community supports (e.g., after school programs for youth, faith-based organizations, pre-school programs). These two examples also illustrate how the process of defining the target problem determines the range of possible solutions, who will be involved in carrying them out, and what resources could possibly be brought to bear on the problem. Because system boundaries are arbitrary constructions, dependent entirely on who is chosen to assign them, it is critical to engage a diverse set of stakeholders in these decision-making processes to ensure that the final boundary selections and problem statements are informed by diverse perspectives and worldviews. Given that many system of care efforts involve system building activities, in that they bring together organizations and groups who have traditionally been disconnected from each other and then work to build a cohesive vision and coordinated service system, the processes of problem identification and boundary delineation are particularly relevant. In fact, the very act of determining system boundaries requires discussion and reflective processes that can produce insights and lead to what Meadows (2008) considers the most transformative lever for change within a system—paradigmatic shifts in understanding the targeted problem (Fear, Rosaen, Bawden, & Foster-Fishman, 2006).
Neither of these situations promote the critical reflection needed to effectively determine the boundaries of a system of care. 1.3. Recommendations related to system boundaries Overall, we recommend that Hodges and colleagues modify their definition to more fully incorporate the importance of defining – though not prescribing – the system of care’s boundaries. There are several issues they should consider when addressing this revision: Systems change efforts are more successful when they promote compatible problem solving actions at multiple layers of a system (Cohen & Lavach, 1995). Therefore, the system of care system boundaries should cut across a wide array of ecological layers, settings, organizations, and populations in order to include a diverse range of stakeholders, system parts, and resources in solution development (Foster-Fishman et al., 2007). Boundaries should be drawn wide enough to include an adequate range of system parts and players so the effort can be sustained and effective, yet narrow enough so the effort remains feasible (Foster-Fishman & Behrens, 2007). In our own work with one system of care, the system boundary for the first phase of the effort was drawn more narrowly, only including the major public agencies in the county. This initial boundary was created due to the long history of distrust across these public agencies and the need to first strengthen those inter-organizational relationships before expanding the system of care network. System boundaries are dynamic and need to adapt to changes in the environment. Boundaries set at the onset of a system of care effort will likely need to be redrawn as the problem situation changes due to the successes and challenges of the initiative. 1.4. Understanding and leveraging critical system parts, patterns and interdependencies
1.2. Analysis of the revised definition as it relates to system boundaries Hodges et al.’s (this issue) new system of care definition provides vague and indirect reference to both problem definition and system of care boundaries. One could infer from their definition that the targeted problem is insufficient ‘‘access to and availability of necessary services and supports across administrative and funding jurisdictions’’ (Hodges et al., this issue) for children and youth with serious emotional disturbances and their families that are ‘‘grounded in system of care values and principles.’’ Given that a core system of care principle is the local identification of the population and problem to target (Hodges et al., 2008), it is understandable that the new definition avoids more prescription. In terms of establishing the system boundaries, given this problem statement, Hodges et al.’s definition mentions the structures, processes, and relationships located within the system of care network across administrative and funding jurisdictions but leaves the task of selecting specific boundaries up to the reader. On one hand, this is perhaps a wise choice, since the boundaries will and need to be highly dependent on the local context and the problem that is selected. On the other hand, without providing practitioners and researchers with guidance on boundary selection, it is possible that communities will resort to using existing networks and traditional service providers, potentially excluding critical stakeholders in the system of care, such as neighborhood organizations, smaller non-profits, and natural support systems. In fact, communities often do not engage in a conscious analysis of the boundaries for their targeted problem, and instead approach this process as though it is predetermined (due to granting agency mandates regarding who must be included) or an opportunistic moment to bring key resources or stakeholders to the table.
The values, principles, and activities embedded within a system of care are often incompatible with current practices in a community. As a result, communities must work to shift local conditions so they become more aligned with and supportive of a system of care model. The dilemma is, however, determining what to shift in order to foster the changes needed to create a supportive and sustaining environment within a community. Because systems of care are system-level interventions, it is useful to use a systemic lens to identify and understand critical system characteristics. Foster-Fishman et al. (2007) identified five key categories of systems parts and interactions that guide system-level behavior and seem relevant to the system of care field. Researchers and practitioners can use this framework to understand current system operations and identify where and how the current system is incompatible with and supportive of the desired changes: System Norms: Refers to the underlying attitudes, values, and beliefs that direct current behavior, practices, policies and programs across different stakeholders and organizations System Resources: Includes three categories of resources: (1) Human Resources, including the knowledge, skills and capacities of all system stakeholders, particularly as they relate to the desired change; (2) Social Resources, including the relationships and connections that exist within current systems across different organizations and stakeholders and (3) Economic Resources & Opportunities, including how funds and opportunities are currently distributed and whose needs are attended to and ignored in these allocations. System Regulations: Includes the policies, practices and procedures that regulate the behavior of system members and the
P.G. Foster-Fishman, E. Droege / Evaluation and Program Planning 33 (2010) 11–13
extent to which these are supportive of or incompatible with the planned change. System Power Operations: Includes how decisions are made within the system, where decision-making authority resides, and how the system of care challenges existing power and decisionmaking structures. System Interdependencies: Includes how the above system parts reinforce and interact with each other and how current feedback mechanisms support or impede project goals. 1.5. Analysis of the revised definition as it relates to system parts and interactions Definitions or frameworks are considered adequate systemlevel conceptualizations when they provide sufficient information for researchers and practitioners to identify and understand system characteristics and behaviors. Hodges and colleague’s new definition (this issue) incorporates several key system parts including: System of Care Relational Resources: A system of care is an ‘‘adaptive network of structures, processes, and relationships.’’ System of Care Norms: A system of care is ‘‘grounded in system of care values and principles.’’ System of Care Economic & Opportunity Resources: A system of care promotes ‘‘access to and availability of necessary services and supports.’’ They also recognized system interdependencies when they noted that a system of care is an ‘‘adaptive network.’’ This is particularly important since all systems, including systems of care, are affected by interactions between system parts that come in the form of two main types of feedback loops: reinforcing and balancing (Senge, 1990). As the names imply, reinforcing feedback loops increase a certain type of outcome or behavior where balancing loops serve to bring these escalations back down to create a state of equilibrium in the system. Understanding system interactions and how a system responds to such feedback is critical, given that a system can sometimes take time to produce outcomes and can cause people to make incorrect conclusions about the success or failure of an effort (Meadows, 2008). Interestingly, the definition does not appear to include a reference to system power operations even though a core tenet of the system of care model is the inclusion of family and youth voice. It is possible that this core element was embedded in the reference to system of care values and principles. 1.6. Recommendations related to system parts and interactions While the new system of care definition includes most of the key system components, it does not provide enough information about any one system characteristic to guide the system building work of practitioners or researchers. This is particularly concerning, given that Hodges and colleagues aimed, in part, to promote fidelity to the system of care concept by creating a new, more encompassing definition and promoting public dialogue around this definition. As they noted themselves ‘‘clarity around the concept of system of care facilitates our understanding of the purpose and goals of such system reform as well as our evaluation of its impact.’’ (this issue). While their definition takes an important step in this direction, there are still some areas where more clarity could be provided. Specifically: Hodges and colleagues may want to consider identifying some of the system characteristics that are most critical to the desired system reform and embed these within the revised definition.
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For example, some recent evaluations on system of care efforts suggest that successful communities share several key characteristics including the creation of shared accountability and processes for delegating authority (Hodges, 2009). Such details could easily be incorporated into the revised definition. 2. Conclusion The revised system of care definition suggested by Hodges and her colleagues takes an important step in advancing the systemlevel focus in system of care efforts. By including concepts and characteristics that reside mostly at the system level of analysis, their definition forces practitioners and researchers to recognize that systems of care target the reform of communities and service delivery systems, not simply the addition of new programs or policies. By incorporating even more system-level details, such as recognizing the need to define system boundaries and providing descriptions of key system parts and interactions, this definition could further advance both the fidelity and the success of these system reforms. References Ackoff, R. L., & Rovin, S. (2003). Redesigning society. Stanford, CA: Stanford Business Books. Cohen, R., & Lavach, C. (1995). Strengthening partnerships between families and service providers. In P. Adams & K. E. Nelson (Eds.), Reinventing human services: Community and family centered practice (pp. 109–125). New York: Aldine DeGruyter. Hodges, S. (2009). Framing systems change: Factors supporting system development. Presentation at the 22nd Annual Research Conference of the Research and Training Center for Children’s Mental Health, Tampa, FL, 2 March, 2009. Hodges, S. Ferreira, K., Israel, N., & Mazza, J. (this issue). Systems of care, featherless bipeds, and the measure of all things. Evaluation and Program Planning. Hodges, S., Friedman, R. M., & Hernandez, M. (2008). Integrating the components into an effective system of care: A framework for putting the pieces together. In B. A. Stroul & G. Blau (Eds.), The system of care handbook: Transforming mental health services for children, youth, and families (pp. 71–94). Baltimore, MD: Brookes Publishing. Fear, R., Rosaen, C., Bawden, R., & Foster-Fishman, P. (2006). Coming to critical engagement: An autoethnographic exploration of engaged faculty lives. Lanham, MD: University Press of America. Foster-Fishman, P. G., & Behrens, T. R. (2007). Systems change reborn: Rethinking our theories, methods, and efforts in human services reform and community-based change. American Journal of Community Psychology, 39(3/4), 191–196. Foster-Fishman, P. G., Nowell, B., & Yang, H. (2007). Putting the system back into systems change: A framework for understanding and changing organizational and community systems. American Journal of Community Psychology, 39(3/4), 197–216. Maani, K. E., & Cavana, R. Y. (2000). Systems thinking and modeling: Understanding change and complexity. Auckland, New Zealand: Pearson Education New Zealand Limited. Meadows, D. H. (2008). Thinking in systems. White River Junction, Vermont: Chelsea Green Publishing. Midgley, G. (2000). Systemic intervention: Philosophy, methodology and practice. New York: Kluwer. Senge, P. M. (1990). The fifth discipline. New York: Doubleday Currency. Stroul, B. A., & Blau, G. M. (2008). The system of care handbook: Transforming mental health services for children, youth and families. Baltimore, MD: Brookes Publishing. Trochim, W. M., Cabrera, D. A., Milstein, B., Gallagher, R. S., & Leischow, S. J. (2006). Practical challenges in systems thinking and modeling in public health. American Journal of Public Health, 96(5), 538–546. Pennie G. Foster-Fishman, PhD, is a professor in the Department of Psychology and a Senior Outreach Fellow in University Outreach and Engagement at Michigan State University. Dr. Foster-Fishman has focused her research, evaluation, and consultation work on understanding and improving systems change efforts. She has investigated human service delivery reform, multiple stakeholder collaboration, inter-organizational coordination, comprehensive community initiatives, coalition development, community organizing, and resident empowerment as vehicles for systems change. She has also worked with federal and state agencies, public sector and not-for-profit organizations, and community and state-wide coalitions to improve their organizational capacity and the efficacy of their efforts. Erin Droege, MA, is a doctoral student in ecological community psychology at Michigan State University. Her interests center on the promotion and sustainability of systems change, structural oppression and power, and citizen participation within community-based research and action. She has applied her interests to a variety of areas, including comprehensive community initiatives, system of care efforts, and community coalitions.
Contents lists available at ScienceDirect
Evaluation and Program Planning journal homepage: www.elsevier.com/locate/evalprogplan
Locating the system in a system of care Pennie G. Foster-Fishman *, Erin Droege Department of Psychology, Michigan State University, 125 D Psychology Building, East Lansing, MI 48824, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 April 2009 Received in revised form 28 April 2009 Accepted 28 April 2009
While systems of care are recognized as a systems-level intervention, a gap remains between systems theory and practice that challenges the effectiveness of future system of care efforts. This article explores the extent to which the expanded system of care definition proposed by Hodges et al. [Hodges, S. Ferreira, K., Israel, N., & Mazza, J. (this issue). Systems of care, featherless bipeds, and the measure of all things. Evaluation and Program Planning] addresses this gap and suggests ideas for strengthening its systemic focus. Specifically, recommendations address considerations for assigning and adapting appropriate boundaries around intervention efforts and leveraging critical system characteristics and interactions to promote systems change. Implications for system of care practice and theory are discussed. ß 2009 Elsevier Ltd. All rights reserved.
Keywords: System of care Systems change Systems theory
Communities that develop a system of care for children with severe emotional disorders embark on a transformative process of change for their local community. System of care development often involves shifting the roles of providers and consumers, building connections across an array of fragmented services, expanding the continuum of services offered, and creating more flexible funding pools by merging categorical funding streams into blended or braided financing (Stroul & Blau, 2008). Significant changes throughout the service delivery system are necessary for a system of care to become fully implemented and effective within a community (Hodges, Friedman, & Hernandez, 2008). Although much progress has been made at understanding how to more effectively implement a system of care (e.g., Hodges et al., 2008), less attention has been paid to understanding the character and dynamics of systems and their implications for these efforts. Hodges et al. (this issue) call attention to this gap in the literature by pursuing an important task: the creation of an expanded definition of systems of care that more adequately captures their systemic nature. The purpose of this article is to examine the extent to which the Hodges et al. definition incorporates a systemic lens and to identify what, if any, changes could be made to this definition to strengthen its systemic focus. Through this analysis, we hope to increase practitioners’ and researchers’ attention to and understanding of system-level properties and behaviors; such insights can potentially increase the effectiveness of future system of care efforts.
1. The importance of systems thinking in systems of care If system of care efforts target ‘‘systems’’ as the unit of change, researchers and practitioners need to adopt frameworks (and definitions) that adequately attend to the characteristics and dynamics of systems. Systems are defined as a collection of interdependent parts that, through their interactions, function as a whole (Ackoff & Rovin, 2003; Maani & Cavana, 2000). Systems change, therefore, refers to the process of altering the status quo by shifting the form and function of a targeted system (Foster-Fishman, Nowell, & Yang, 2007). To aid this process, systems theorists have developed a variety of systems thinking tools to guide the assessment of system characteristics, the interrelationships across system parts, and the patterns within systems that support and sustain current conditions (e.g., Trochim, Cabrera, Milstein, Gallagher, & Leischow, 2006). Systems theorists would argue that it is only through such understanding that change agents and researchers are able to identify how to effectively leverage transformative and sustained change within a targeted system (e.g., Senge, 1990). Overall, the above suggests two criteria one can use to assess the ‘‘system-ness’’ of Hodges, et al.’s definition: (1) does the definition help one to clarify what and who to include in the system targeted by the system of care effort—in other words establish the system boundary? and (2) does the definition help to determine the system parts and interactions that are critical to the targeted problem and the desired solution—the creation of a system of care? We explore each of these questions below in our analysis of the Hodges et al. definition. 1.1. Establishing the system boundary
* Corresponding author. Tel.: +1 517 353 5015; fax: +1 517 432 2945. E-mail addresses: fosterfi@msu.edu (P.G. Foster-Fishman), [email protected] (E. Droege). 0149-7189/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.evalprogplan.2009.04.001
The act of establishing the system’s boundary is considered one of the most critical and potentially transformative steps in a
12
P.G. Foster-Fishman, E. Droege / Evaluation and Program Planning 33 (2010) 11–13
systems change effort like a system of care (e.g., Midgley, 2000). Boundary clarification includes both clarifying the targeted problem and determining who and what is contained within the system given the selected issue. For example, a narrow problem definition within a system of care effort may focus entirely on improving the way mental health services are currently provided to children and families and thus may draw its boundaries around programs and organizations currently involved in treatment services (e.g., community mental health organizations and providers, schools, courts, child protection agencies). In contrast, a broader definition could also include a focus on prevention, thus expanding the system of care boundaries to include agencies and programs related to prevention and natural community supports (e.g., after school programs for youth, faith-based organizations, pre-school programs). These two examples also illustrate how the process of defining the target problem determines the range of possible solutions, who will be involved in carrying them out, and what resources could possibly be brought to bear on the problem. Because system boundaries are arbitrary constructions, dependent entirely on who is chosen to assign them, it is critical to engage a diverse set of stakeholders in these decision-making processes to ensure that the final boundary selections and problem statements are informed by diverse perspectives and worldviews. Given that many system of care efforts involve system building activities, in that they bring together organizations and groups who have traditionally been disconnected from each other and then work to build a cohesive vision and coordinated service system, the processes of problem identification and boundary delineation are particularly relevant. In fact, the very act of determining system boundaries requires discussion and reflective processes that can produce insights and lead to what Meadows (2008) considers the most transformative lever for change within a system—paradigmatic shifts in understanding the targeted problem (Fear, Rosaen, Bawden, & Foster-Fishman, 2006).
Neither of these situations promote the critical reflection needed to effectively determine the boundaries of a system of care. 1.3. Recommendations related to system boundaries Overall, we recommend that Hodges and colleagues modify their definition to more fully incorporate the importance of defining – though not prescribing – the system of care’s boundaries. There are several issues they should consider when addressing this revision: Systems change efforts are more successful when they promote compatible problem solving actions at multiple layers of a system (Cohen & Lavach, 1995). Therefore, the system of care system boundaries should cut across a wide array of ecological layers, settings, organizations, and populations in order to include a diverse range of stakeholders, system parts, and resources in solution development (Foster-Fishman et al., 2007). Boundaries should be drawn wide enough to include an adequate range of system parts and players so the effort can be sustained and effective, yet narrow enough so the effort remains feasible (Foster-Fishman & Behrens, 2007). In our own work with one system of care, the system boundary for the first phase of the effort was drawn more narrowly, only including the major public agencies in the county. This initial boundary was created due to the long history of distrust across these public agencies and the need to first strengthen those inter-organizational relationships before expanding the system of care network. System boundaries are dynamic and need to adapt to changes in the environment. Boundaries set at the onset of a system of care effort will likely need to be redrawn as the problem situation changes due to the successes and challenges of the initiative. 1.4. Understanding and leveraging critical system parts, patterns and interdependencies
1.2. Analysis of the revised definition as it relates to system boundaries Hodges et al.’s (this issue) new system of care definition provides vague and indirect reference to both problem definition and system of care boundaries. One could infer from their definition that the targeted problem is insufficient ‘‘access to and availability of necessary services and supports across administrative and funding jurisdictions’’ (Hodges et al., this issue) for children and youth with serious emotional disturbances and their families that are ‘‘grounded in system of care values and principles.’’ Given that a core system of care principle is the local identification of the population and problem to target (Hodges et al., 2008), it is understandable that the new definition avoids more prescription. In terms of establishing the system boundaries, given this problem statement, Hodges et al.’s definition mentions the structures, processes, and relationships located within the system of care network across administrative and funding jurisdictions but leaves the task of selecting specific boundaries up to the reader. On one hand, this is perhaps a wise choice, since the boundaries will and need to be highly dependent on the local context and the problem that is selected. On the other hand, without providing practitioners and researchers with guidance on boundary selection, it is possible that communities will resort to using existing networks and traditional service providers, potentially excluding critical stakeholders in the system of care, such as neighborhood organizations, smaller non-profits, and natural support systems. In fact, communities often do not engage in a conscious analysis of the boundaries for their targeted problem, and instead approach this process as though it is predetermined (due to granting agency mandates regarding who must be included) or an opportunistic moment to bring key resources or stakeholders to the table.
The values, principles, and activities embedded within a system of care are often incompatible with current practices in a community. As a result, communities must work to shift local conditions so they become more aligned with and supportive of a system of care model. The dilemma is, however, determining what to shift in order to foster the changes needed to create a supportive and sustaining environment within a community. Because systems of care are system-level interventions, it is useful to use a systemic lens to identify and understand critical system characteristics. Foster-Fishman et al. (2007) identified five key categories of systems parts and interactions that guide system-level behavior and seem relevant to the system of care field. Researchers and practitioners can use this framework to understand current system operations and identify where and how the current system is incompatible with and supportive of the desired changes: System Norms: Refers to the underlying attitudes, values, and beliefs that direct current behavior, practices, policies and programs across different stakeholders and organizations System Resources: Includes three categories of resources: (1) Human Resources, including the knowledge, skills and capacities of all system stakeholders, particularly as they relate to the desired change; (2) Social Resources, including the relationships and connections that exist within current systems across different organizations and stakeholders and (3) Economic Resources & Opportunities, including how funds and opportunities are currently distributed and whose needs are attended to and ignored in these allocations. System Regulations: Includes the policies, practices and procedures that regulate the behavior of system members and the
P.G. Foster-Fishman, E. Droege / Evaluation and Program Planning 33 (2010) 11–13
extent to which these are supportive of or incompatible with the planned change. System Power Operations: Includes how decisions are made within the system, where decision-making authority resides, and how the system of care challenges existing power and decisionmaking structures. System Interdependencies: Includes how the above system parts reinforce and interact with each other and how current feedback mechanisms support or impede project goals. 1.5. Analysis of the revised definition as it relates to system parts and interactions Definitions or frameworks are considered adequate systemlevel conceptualizations when they provide sufficient information for researchers and practitioners to identify and understand system characteristics and behaviors. Hodges and colleague’s new definition (this issue) incorporates several key system parts including: System of Care Relational Resources: A system of care is an ‘‘adaptive network of structures, processes, and relationships.’’ System of Care Norms: A system of care is ‘‘grounded in system of care values and principles.’’ System of Care Economic & Opportunity Resources: A system of care promotes ‘‘access to and availability of necessary services and supports.’’ They also recognized system interdependencies when they noted that a system of care is an ‘‘adaptive network.’’ This is particularly important since all systems, including systems of care, are affected by interactions between system parts that come in the form of two main types of feedback loops: reinforcing and balancing (Senge, 1990). As the names imply, reinforcing feedback loops increase a certain type of outcome or behavior where balancing loops serve to bring these escalations back down to create a state of equilibrium in the system. Understanding system interactions and how a system responds to such feedback is critical, given that a system can sometimes take time to produce outcomes and can cause people to make incorrect conclusions about the success or failure of an effort (Meadows, 2008). Interestingly, the definition does not appear to include a reference to system power operations even though a core tenet of the system of care model is the inclusion of family and youth voice. It is possible that this core element was embedded in the reference to system of care values and principles. 1.6. Recommendations related to system parts and interactions While the new system of care definition includes most of the key system components, it does not provide enough information about any one system characteristic to guide the system building work of practitioners or researchers. This is particularly concerning, given that Hodges and colleagues aimed, in part, to promote fidelity to the system of care concept by creating a new, more encompassing definition and promoting public dialogue around this definition. As they noted themselves ‘‘clarity around the concept of system of care facilitates our understanding of the purpose and goals of such system reform as well as our evaluation of its impact.’’ (this issue). While their definition takes an important step in this direction, there are still some areas where more clarity could be provided. Specifically: Hodges and colleagues may want to consider identifying some of the system characteristics that are most critical to the desired system reform and embed these within the revised definition.
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For example, some recent evaluations on system of care efforts suggest that successful communities share several key characteristics including the creation of shared accountability and processes for delegating authority (Hodges, 2009). Such details could easily be incorporated into the revised definition. 2. Conclusion The revised system of care definition suggested by Hodges and her colleagues takes an important step in advancing the systemlevel focus in system of care efforts. By including concepts and characteristics that reside mostly at the system level of analysis, their definition forces practitioners and researchers to recognize that systems of care target the reform of communities and service delivery systems, not simply the addition of new programs or policies. By incorporating even more system-level details, such as recognizing the need to define system boundaries and providing descriptions of key system parts and interactions, this definition could further advance both the fidelity and the success of these system reforms. References Ackoff, R. L., & Rovin, S. (2003). Redesigning society. Stanford, CA: Stanford Business Books. Cohen, R., & Lavach, C. (1995). Strengthening partnerships between families and service providers. In P. Adams & K. E. Nelson (Eds.), Reinventing human services: Community and family centered practice (pp. 109–125). New York: Aldine DeGruyter. Hodges, S. (2009). Framing systems change: Factors supporting system development. Presentation at the 22nd Annual Research Conference of the Research and Training Center for Children’s Mental Health, Tampa, FL, 2 March, 2009. Hodges, S. Ferreira, K., Israel, N., & Mazza, J. (this issue). Systems of care, featherless bipeds, and the measure of all things. Evaluation and Program Planning. Hodges, S., Friedman, R. M., & Hernandez, M. (2008). Integrating the components into an effective system of care: A framework for putting the pieces together. In B. A. Stroul & G. Blau (Eds.), The system of care handbook: Transforming mental health services for children, youth, and families (pp. 71–94). Baltimore, MD: Brookes Publishing. Fear, R., Rosaen, C., Bawden, R., & Foster-Fishman, P. (2006). Coming to critical engagement: An autoethnographic exploration of engaged faculty lives. Lanham, MD: University Press of America. Foster-Fishman, P. G., & Behrens, T. R. (2007). Systems change reborn: Rethinking our theories, methods, and efforts in human services reform and community-based change. American Journal of Community Psychology, 39(3/4), 191–196. Foster-Fishman, P. G., Nowell, B., & Yang, H. (2007). Putting the system back into systems change: A framework for understanding and changing organizational and community systems. American Journal of Community Psychology, 39(3/4), 197–216. Maani, K. E., & Cavana, R. Y. (2000). Systems thinking and modeling: Understanding change and complexity. Auckland, New Zealand: Pearson Education New Zealand Limited. Meadows, D. H. (2008). Thinking in systems. White River Junction, Vermont: Chelsea Green Publishing. Midgley, G. (2000). Systemic intervention: Philosophy, methodology and practice. New York: Kluwer. Senge, P. M. (1990). The fifth discipline. New York: Doubleday Currency. Stroul, B. A., & Blau, G. M. (2008). The system of care handbook: Transforming mental health services for children, youth and families. Baltimore, MD: Brookes Publishing. Trochim, W. M., Cabrera, D. A., Milstein, B., Gallagher, R. S., & Leischow, S. J. (2006). Practical challenges in systems thinking and modeling in public health. American Journal of Public Health, 96(5), 538–546. Pennie G. Foster-Fishman, PhD, is a professor in the Department of Psychology and a Senior Outreach Fellow in University Outreach and Engagement at Michigan State University. Dr. Foster-Fishman has focused her research, evaluation, and consultation work on understanding and improving systems change efforts. She has investigated human service delivery reform, multiple stakeholder collaboration, inter-organizational coordination, comprehensive community initiatives, coalition development, community organizing, and resident empowerment as vehicles for systems change. She has also worked with federal and state agencies, public sector and not-for-profit organizations, and community and state-wide coalitions to improve their organizational capacity and the efficacy of their efforts. Erin Droege, MA, is a doctoral student in ecological community psychology at Michigan State University. Her interests center on the promotion and sustainability of systems change, structural oppression and power, and citizen participation within community-based research and action. She has applied her interests to a variety of areas, including comprehensive community initiatives, system of care efforts, and community coalitions.