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Key Components of Systems ChangeA Discussion Paper For A Colloquium on NOT FOR DISTRIBUTION Prepared By: Michael J. Kendrick PhD December 2004
© December 2004 Lex Frieden Publications Staff: Sharon Finney, Marisa Demaya, and Darrell Jones This paper was developed under Grant No. 18-P-91554/6-01 from the U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS). The contents do not necessarily represent the official position of CMS and no endorsement should be inferred. This paper is a draft for discussion purposes at the January 11-13, 2004 colloquium, “Unlocking the Code of Effective Systems Change,” and may not be reproduced or quoted in its present form. We gratefully acknowledge the gift of time and insights shared by Real Choice Systems Change grantees, New Hampshire Department of Health and Human Services, Arkansas Division of Aging and Adult Services, Connecticut Association of Centers for Independent Living, Connecticut Department of Social Services, Long Term Care Authority of Tulsa, New York State Department of Health and Broome County New York CASA, and Center for Excellence in Disabilities at West Virginia University; and their numerous associates. ILRU is a program of The Institute for Rehabilitation and Research
(TIRR), a nationally recognized, freestanding rehabilitation facility
for persons with physical disabilities. TIRR is a part of TIRR Systems,
which is a not-for-profit corporation dedicated to providing a continuum
of services to individuals with disabilities. TABLE OF CONTENTS INTRODUCTION Many people have explored the question of what constitutes systems change in the context of programs that claim to support citizens who experience a disability or chronic illness. Independent Living Research Utilization (ILRU) has also looked at this question and resolved to explore it from the point of view of systems changes that produce outcomes that are beneficial to the service user. ILRU refers to this dialogue as unlocking the code of effective systems change. The dialogue has two components. The first aspect asks the question, “What are the specific core ingredients that produce systems changes?” This question places the change process in the forefront. The second aspect asks, “What are the specific features of systems that are people friendly?” and “How are these features built into systems?” This second question relates more to the character of the resultant system than to the process of creating it. Both aspects are important components of the fundamental question, “What are the key ingredients involved in creating system changes that are beneficial to the service user?” ILRU has elected to address this challenging question through a Colloquium to be followed by expanded efforts if the Colloquium proves to be productive. The first step was to select some areas of the country where ILRU believed that people had met with success in achieving a measure of systems change that was beneficial to service users and, as well, to draw upon their sense of what had been most critical in bringing about these positive outcomes. They sought to catch people doing the right thing, and then ask them to reflect on their experiences to glean any lessons they may contain for systems change. ILRU staff and partners identified six localities in the country where their technical assistance work with federal Real Choice Systems Change grants recipients led them to conclude that some significant systems change had taken place that had proved beneficial to service users. These localities were not selected because they were believed to be the only such localities where systems change had occurred; rather, they provided a suitable beginning for exploring the question of unlocking the code of effective systems change. The chosen localities are quite diverse in terms of the grants they are working on including the scale, scope and character of the service systems in place; the people and their needs that are the focus of change; the kinds of participants involved in the change process; the changes being pursued; and the history and duration of the change process. The states that participated are Arkansas, Connecticut, New Hampshire, New York, Oklahoma and West Virginia. ILRU engaged a consultant whose task was not to document six examples of systems changes or provide a social history of how they had come about. Instead, the objective was to draw upon the people who had been involved in these systems changes to gain their perspective on what it had taken to bring about the positive changes that have benefited the people being served. The focus was on the more abstract, but relevant question of whether there were change factors that appeared repeatedly in the testimony of those interviewed and, if so, whether these common factors were considered to be central to their achievement of a measure of people-friendly systems change. This paper identifies what these commonly occurring, and possibly universal, systems change factors are. Its purpose is to serve as the starting point of a much more extensive two and one half day colloquium or think tank in which many of the same people interviewed, in conjunction with others interested in the question, will attempt to deepen our understanding of what works and why. The proposed colloquium will proceed to the further question: “What are the kinds of investments that can be made in systems improvement that offer the most hope of producing systems changes that benefit service users?” The ability to identify core elements of beneficial systems change and to note the presence or absence of such elements in specific systems may well set the stage for progress as well as help avoid systems change strategies that are less helpful or likely to be ineffective. Challenges In Describing Systems Change The term “systems change” may be difficult to define precisely since human service and community systems are not normally a single unified system, but rather a composite of many systems and sub-systems that find themselves interconnected to one degree or another. For instance, families and other informal caregivers are often the principal backbone of any care system providing supports to individuals, yet many families remain remote and disengaged from the formal service systems that rely on their presence. The relationship between the two systems may be so weak that to speak of them as a singular system would be quite misleading. It is perhaps easier to capture the character of formal systems and structures since their very formality lends itself to greater definitional clarity. Even this clarity may be misleading given the powerful roles that individuals and informal relationships within formal systems have in the functioning of formal systems. The most notable component in this regard would be the values, attitudes and relationships of the individuals who have roles within the formal systems. In some instances, the conduct of officials in systems may even be in contradiction to the stated goal of the systems. One example is when officials offer services that are little more than custodial maintenance when they were meant to be empowering to recipients. Notwithstanding the problem of getting a precise definition of specific system change, we can still largely name and describe various systems changes that have been deliberately fostered. For instance, we can speak of systems that have gradually de-institutionalized, become more community-based, individualized, more granting of individual control and direction, and better integrated with other systems. These kinds of summary and shorthand definitions may not be precise enough for every purpose, but they do give people enough of a shared sense of the type and boundaries of the intended systems changes so they can converse and organize on the basis of these. Overall Versus Partial Systems Changes Given that formal systems may be quite sizable in scale and scope, it is useful to describe whether the system change is that of the system as a whole or simply one component of a larger system. The systems changes being attempted may be significant and relevant in either instance, but the aspects of the overall system being changed may vary from minor components to major components, or from small sub-systems to ever more comprehensive degrees of alteration in overall systems. For instance, to facilitate more productive transitions between acute inpatient care and community living, we may conceivably leave the overall hospital system largely intact, but make considerable changes in the specific hospital sub-systems related to discharge planning as well as the coordination, planning and financing practices of the community agencies involved in community-based services. It may not be any more difficult to make a large systems change than a small change if the timing is right and the parties involved are well positioned. Similarly, we must not assume that small component or sub-system changes are easier to make due to their scale, since these systems components may have proportionately well entrenched defenders and interest groups that hold them in place. Additionally most people interested in large scale systems change may simply not be in a position to effect large scale changes but they may have leverage to effect changes in smaller systems components. Systems Changes Containing Intended And Unintended Aspects Many people may have the perspective that social service systems are a kind of apparatus that responds to rational external engineering much in the way that a machine would. Others may have a sense that systems are composed of both rational and non-rational elements and that the application of intention and logic must compete with non-rational factors like vested interests, attitudes, habits and expedience. Others may assume that talented agents of change can invariably foresee and guide all aspects of change. Under this approach the character of the resulting changes is largely predictable and will follow the pathways prescribed by intentions. Others may tend to see more complexity and nuance in the change process and believe that elements of uncertainty preclude our ability to both steer and predict how change will unfold. Those who presume a manageable systems change universe may be caught by surprise when intended changes unfold in unforeseen ways. This does not, however, mean that all aspects of change are unforeseeable or that change cannot be steered, to some degree, with logic and rationality. It may mean that changes to complex systems involve many factors that have a measure of uncertainty and risk. In other words, change might have to be attempted in the face of a very real chance of failure. The complex nature of systems change may affect whether systems are fixable, even in the narrow mechanistic sense, if other conditions are not present that provide the political climate to permit the change. This political climate includes the underlying will and values to overcome resistance to the change. Many systems might be technically fixable but be unfortunately lodged at a time and place in history in which the moral, cultural and political basis of change are absent, weakened or otherwise underdeveloped, thereby rendering solely technical changes ineffective. People and communities may simply be unready to endorse, at a given moment, changes that are feasible technically, but which collide with the prevailing view of what is proper and needed. If these dominant community views were to change it is conceivable that system changes could be successful. Thus it is extremely important to stress community and constituency education strategies. The Prospect Of People-Centered System Changes Undoubtedly, there are many people who long for systems that are humane, functional and responsive to the needs of oppressed and sometimes mistreated people. This appetite for change often arises from a recognition that there can be a conflict between the conditions of life that people are forced to contend with and their actual needs and potential. The more idealistic people may presume that such systems ought to change simply because it is the right thing to do. Unfortunately, systems do not exist solely to benefit the people dependent upon them; rather, they also have to contend with the needs, pressures and vested interests of all sorts of parties other than those of the intended or officially named “beneficiaries” of the system, i.e. the users of services. Changes centered on individuals will usually have to compete with the needs and priorities of other parties, many who are likely to be more entrenched, powerful and difficult to persuade about the merits of systems change. This does not mean that systems do not, or could not, exist that uphold the people they support in an honorable and beneficial way; it simply underscores the difficulties in creating or protecting aspects of systems that are particularly people-friendly if these aspects collide with the priorities and preferences of others. It is also logical that people-friendly outcomes will have systems requirements that differ in kind from system requirements where the outcomes are less people-centered. Some people may believe that creating people-centered outcomes automatically follows from setting or declaring that one has people-centered goals, directions or vocabulary. There are also people who do not fully see how much systems changes may cost the proponent of change or the community that has to live through them. Yet most realistic people would grant that achieving beneficial change normally requires meeting and addressing many demanding challenges. These challenges are only partially foreseeable at the outset or while underway. This makes it useful to frame and pursue the question of what is required for a system to become or stay people centered to appreciate these demands and to respond effectively. All of these concerns arise from the question of what theory and assumptions about people-centered systems change are valid, and what others are misleading or incorrect. What follows in this paper are some of the key factors repeatedly identified by practitioners in the change process as being significant for them. Those interviewed are not directly quoted here, but the factors presented touch on essentially the same substance that they have struggled with in diverse locations as they have worked to bring about systems changes that benefit the people that must use the system’s services. Suggested Key Ingredients Of Systems Change The Mandate for Change: Obtaining Enough Agreement On What Systems Changes Are Needed So That Action Is Possible The presence of sufficient agreement and clarity as to why specific system changes would help people does not arise in a vacuum. It is usually preceded by extensive opportunities for people to name their issues, discuss them extensively and eventually settle on the remedies that seem to offer the most hope for progress. This process can take a great deal of time, but it may be the only way that diverse constituencies can get to a point where they are willing to pursue or at least tolerate system changes that may disrupt their status quo and security. No one suggests that systems change requires anything approaching unanimity, but most agree that there needs to be sufficient consensus in favor of the changes among key constituencies to enable action to be taken. Gaining such a mandate is clearly easier where there already has been a lot of work done to raise consciousness and issues, dissect and evaluate the arguments and proposals, and engage large numbers in some kind of thinking, discussion and deliberative process. Rome was not built in a day and neither is a mandate for change. Many people identify the role of specific crises that are astutely exploited for systems change purposes. However, it is doubtful that these crises are permanently resolved in person-centered directions in the absence of some form of underlying widespread agreement with the direction of the changes. This is because change normally requires “buy-in”, which is another way of saying the change largely has to have the assent of those affected. Changes that are introduced too far ahead of where there is understanding and informed support for their adoption risk rejection. We are all well aware of the fate of leaders and ideas that are much too ahead of their time. A lack of fundamental agreement as to what the issues are and what would resolve these issues leaves a given constituency so divided that its leaders cannot obtain a mandate that might resolve issues that are at an impasse. Readiness for change, in both the cultural and political sense, does not occur until enough people in enough constituencies achieve consensus to prevail over the dissenters. Obviously, many changes that were initially heatedly contested eventually become accepted, but this process takes both time and serious educational and persuasive effort. A Way Forward: A Feasible Plan Or Proposal For Action On Systems Change Is Present People do not rally behind change unless they see hope for a feasible way forward. Consequently, the presence of sufficient agreement, clarity and competence as to how specific components of the system could be changed for the better will greatly increase the likelihood that these systems changes will occur. Leaders who can generate these kinds of action proposals are more prone to make headway than those who cannot deal with the challenge of fashioning action proposals and building consensus for proposed changes. These types of proposed changes are normally concerned with either entirely new approaches or incremental steps to build upon what has already been implemented. However, plans for change must be persuasive and attractive to a number of key constituencies. However difficult, there is often ample reason to pursue change because without change the present system remains at status quo and many might agree that the present system needs improvement. Nonetheless, an action proposal will still be needed to show how the change might be achieved Among the systems change grantees the initiating plan or proposal was usually not packaged as a comprehensive systems change proposal. In the case of one state the proposal was simply a modest attempt to see if a small number of municipalities would be interested in taking a leadership role in becoming more responsive to and supportive of their citizens with disabilities. In another state the proposal was simply to bring people together for a conference. In another locality, the idea was to strengthen an advisory group to enrich its role relative to the system. These initiatives eventually facilitated a measure of systems change even though they originally did not explicitly claim to create widespread systems change. The creation of engagement, movement and endorsement of change does not happen by leaving matters as they are. On the contrary, encouraging things to happen requires that key leaders take initiative to create opportunities that might possibly lead events forward. In many instances, a great deal more has happened than was foreseen by the initiators and subsequent actions moved in directions that had not been predicted. In the instance of several small communities in separate states, there were attempts to attend to the question of physical access to the full community that stimulated a lot of activity that reached well beyond this initial concern to the role and importance of people with disabilities within community life. Action proposals, often quite straightforward on the surface, seem to serve as a catalyst for change in that they stimulate progress, lift hopes and expectations, provide direction, and serve as a basis for convening people, raising consciousness, finding common ground, and making key issues legitimate. In some ways the phrase make your breaks seems apt in that leaders try to find some way to move matters forward that is not already part of the ongoing way of doing business. This requires the creation of something where nothing had existed before. This conjuring up of plausible ways forward is usually unsanctioned behavior that acquires sanction via the process of how the proposal is received and implemented. The presence of experienced, realistic and skillful bureaucratic, technical and advocacy leaders who have a history of cooperating on matters of progress or vision, seems to be significant in effecting systems change. Leadership appears to be central to the capacity to mobilize and influence people. Leadership, of course, can be collective in nature, and may readily cross over institutional lines and silos when specific leaders find common purpose with other leaders that are outside their particular domain. A term that may capture this configuration better would be that of a “leadership alliance”, most often informal in expression, but an alliance nonetheless. Leadership alliances are often formed through loose networks where people share ties such as values, ideology and beliefs, common interests, personal relationships and relationship networks. While these commonalities may not rise to the level of institutional formalities, they can be quite influential in both what gets done and how it is done. Such informal networks of leaders often are based on relationships that have been forged in the past and for which there is some measure of trust built up. This minimizes how much energy in new situations must go into the need to size up each other. Relationships, particularly among key players and leaders, were often mentioned by grantees as being critical in ensuring that events moved forward. It is not always the case that only leaders with historical ties to each other and the human services sector occupy key roles; newcomers are often able to establish themselves and essentially be welcomed into these informal alliances. These leaders come from various sectors, not just government as some might presume. They can include families, consumers, advocates, community providers, neighbors and employers, academics, technical consultants and progressive professionals. What may make governmental figures seem more prominent is not necessarily the decisiveness of their specific leadership contribution so much as the centrality of government to systems change. Nonetheless, having the right kind of governmental leadership remains a clear advantage. While both leaders and the acquired social capital of established
relationships has to be present in order to foster systems changes,
it would be wrong to suggest that the mere presence of these is
sufficient. In almost all cases, people spoke about leaders as being
decisive. The importance of this quality of leadership is better
appreciated if the reverse reality of poor quality leadership is
considered. No one spoke about the advantages of having inept and
weak leadership. Everyone understood this lack of effective leadership
to be a liability. A key set of leadership skills can be grouped under the term “strategic leadership disciplines”. Leaders must be part of evolving strategy, skillful with tactics such as astute positioning and partnering, adept at preparation and planning, able to exercise caution and discretion, careful to avoid conflicts of interest and have other political skills that are associated with getting things done in an acceptable way in the public domain. While it may be automatic for many people to highlight vision as a desirable asset of leaders, it is evident that vision without the practical operational skills is insufficient. There are advantages that come from being able to count on key people who are able to handle the range of challenges involved by being both visionary and competent. Such personal credibility is not to be underestimated. As one civil servant said about a long-term bureaucratic leader, “He is very politically astute and yet he never stops dreaming up new ideas!” Faithful Alignment And Partnering With Consumers, Families And Community Many people spoke of the necessity that leaders and systems both be value based or values led. Most often, this seemed to refer to the quality within leaders of being able to see and value the worth of consumers and families and to act in accord with their true needs and potential. Hence, the description of them, and the system they wanted to shape, as being people-centered or some such similar term. This seems logical when one thinks about it, as it would be difficult to imagine people-centered systems changes resulting if the leaders were unconvinced of the merits of having the system benefiting those who use its services. Another dimension of this right kind of leadership is having leaders who uphold the interests of individuals and families in the face of competing pressures from vested interests. Faithfulness to the people served implies a kind of standard by which leaders are judged, much as moral leaders in many domains are judged by their faithfulness to values and to the people who have placed their trust in them. On another level, we expect that leaders will act to ensure the well being of the people entrusted to their care and they would therefore be considered negligent and disappointing if the care/services actually offered was inferior. This implied social contract explains why so many leaders are adamant about placing priority on systems changes that are people friendly. Their values integrity is on the line. Another key aspect of this tacit alignment or partnering between leaders and service users is the extent to which the partnering is ethical and honorable, i.e. whether there exists a “right relationship”. This was most often measured by the extent to which the leaders acted to ensure that people’s involvement was meaningful and consequential, as compared to merely symbolic, tactical or pro forma. This active desire to hear and attend authentically to the voice of consumers, families and communities undoubtedly makes it more probable that the type of system that the leaders want to fashion is more consistent with what the partnered people themselves think is desirable. The active ingredient is not that participation by consumers occurred, but rather that the voice of consumers is respected and unmistakably used to inform policy decisions and directions. There seems to be an additional advantage coming from a strong alignment of leaders and consumers in that the solutions generated by way of the alignment produces better outcomes than would have occurred otherwise. This fusing of the best that each can offer, through various processes of getting to know the thinking and perspectives of the other, probably creates the environment that eliminates weaker answers in favor of more viable options. It also produces mutual understanding and confidence that undoubtedly makes for good partnering. Perceived Governmental Endorsement Of Systems Change It is more likely that people from varying constituencies will have faith in the system change prospects that increases the buy-in when there is a perceived official (governmental) endorsement of, or at least non-antagonism toward beneficial change for consumers. An interesting example of this was described in one state where the seeming endorsement by the Centers for Medicare and Medicaid Services of self-direction in services had the effect of making it much easier for those people who favored this direction to proceed with this kind of change in both state government and in the provider sector. Had this perceived federal endorsement of self-direction not been in place, these practices would likely have been considered more questionable. The Olmstead decision, in spite of its remaining ambiguities, seems to be another example where the perception is that authority is aligned with a particular outcome thereby creating momentum in that direction. The effect of Olmstead has been major work at the State level to bring social service systems into compliance. In effect, Olmstead makes it easier for advocates, civil servants, and others who agree with this decision to bring about system changes in which there is a greater emphasis on choice and social inclusion. In the case of several municipal governments, in two different
New England states, the fact that key municipal officials were supportive
of people with disabilities allowed for the flowering of a variety
of initiatives supporting the full inclusion of people with disabilities
in those locations. Clearly, the fact that people with disabilities
were in favor with the municipal government acted to encourage additional
people to come forward and invest themselves in system changes.
In another instance, a state long term care agency was so convincing
in the seriousness and systematic quality with which it sought consumer
input that it persuaded even doubting consumers to have faith in
the state’s system change agenda and take an active role. A Sense Of Personal And Collective “Agency”, Particularly In Leaders Within the social sciences the term agency refers to the belief that people have the capacity to act meaningfully on matters of importance to themselves. Put another way, people have the conviction that they are not powerless and that their actions will make a difference. This is very similar to the term self-efficacy, commonly used in the new psychology movement, which refers to the belief in the ability of oneself to shape one’s life. Were this sense of free agency to be lacking, particularly in leaders, people would despair of being able to make a difference. This leads to self-defeat that may, in turn, lead people to remain silent, accept the status quo or give up altogether. These negative psychological states do not encourage people to invest in the type of activities and committed struggle that lead to systems change; whereas a sense of free agency readies them for independent action, at least within the limits of what is possible at a given moment The capacity of existing leaders to be constructively opportunistic is evident in many of the locations; local leaders repeatedly seek or see opportunities in the events of the day that might be used to advantage for their change agenda. Many pursue these perceived openings with the hope that they might prove fruitful. People who lack a sense of their own capacities to act, in all probability, will not be quite so opportunistic and proactive. Those who make change happen demonstrate a confidence that they can use or build upon the advantages of the moment to keep hope alive. When they are successful they generate various small victories, i.e. low hanging fruit, that helps build momentum and provides tangible signs that the struggle for change is worth it. Leaders and followers alike may settle for a measure of incremental
and additive change if that is all that is achievable at a given
moment in the process of larger change. While many would prefer
more far reaching and immediate systems changes, the successes that
are achieved in small steps may be the only ones that can be negotiated
for the moment. Consequently, being able to make the most of the
change opportunities of the moment does not mean forsaking ones
larger vision, but it may help leaders and activists see value in
small victories as building blocks. Having The Right People “At The Table” Many mentioned that changes would not have been achievable if key players had been left out of the process. This obviously requires change agents to both identify who these parties are and know what will bring them to and keep them at the table. This insight relies on the underlying premises that change can be negotiated across many groups and that leaving people out of that negotiation process can be costly. In the case of one state, a very significant and inclusive conference was developed that brought an impressive range of stakeholders together to gradually build a shared vision and to make it more likely that agreements could eventually emerge from such dialogue. That state’s spokespersons think this event was a key high water mark in terms of recent developments in that state. This belief in the efficacy of engaging key people may be realistic in terms of generating the necessary support that eventually leads to a workable mandate. It may also be valuable in formulating substantive answers to system changes that are more credible and persuasive. The engagement of key people allows for a negotiation of change process that lets people test and modify positions so that the questions of many people are answered rather than those of just a few. In separate New England states, two small towns were able to marshal an impressive range of initiatives affecting people with disabilities. Subsequent efforts built upon each other to bring in new supporters and stakeholders to the collective network and generate considerable additional good will and momentum in the process. In these instances, there were actually many tables rather than a single table, but the principle of having the right people at the right table flourished and expanded. It is naïve to think that systems changes are always based entirely on voluntary and negotiated plans that are absent of coercion. Majorities have imposed their will on minorities throughout recent and ancient history. However, even minorities have the ability to make change processes more costly, so there might still be long-term sense in negotiating a cordial agreement with unwilling partners rather than imposing a remedy. Achieving the same ends with reasonably amicable relationships rather than troubled ones, might well be an investment in the future. An Inclination Towards More Altruistic Rather Than Selfish Agendas It did not seem to be true that any locality made meaningful systems changes that benefited service users by focusing on narrow and selfish vested interests. In fact, people find it much easier to concentrate on the needs and interests of service users when they let go of their narrow interests in consideration of the greater good that is possible to achieve. Put in other terms, the ethic that is more transformative is not self before others, but rather that of others before self. Though it may go against the reflexes and instincts of the cynic, money does not make the world go round. There are many other motives that are both community building and pro-social that can stir and inspire people. An interesting example of this is the extent to which a small New England town opened itself up to the needs of people with disabilities almost entirely in the absence of any financial incentives rather than because of them. People and municipal government agencies, willingly and repeatedly, gave up their time to help things along largely because they identified so strongly with the inherent merit of the undertaking rather than due to any personal gain they might hope for. In another state, a key consultative process involving consumers in shaping system change was actually quite difficult, demanding and exhausting in terms of the commitment that both staff and participants had to make to ensure that a great volume of work got done and done well. Often this involved extensive preparations, travel and disruption of people’s schedules, long meetings and so on. Nonetheless, the people involved took on these inconveniences and burdens without hesitation, over a period of years, largely because they truly believed that the exercise would do good things for their state. Naturally, if an emphasis on a higher good is lacking, then the obvious fall back position is going to be narrower and potentially more selfish interests. For this reason, whatever aspect of human nature is fostered and encouraged by leaders will create a legacy towards one pole or the other. Leaders clearly have the ability to influence people, and that ability can either bring out the good in people or reinforce tendencies that undermine the pursuit of more altruistic goals. It may matter a great deal to the eventual outcome what direction the inner compass of leaders and their alliances points towards. Utilization Of Various Means Of Convening People To Build And Share Vision, Values and Priorities Intentional consensus, frame alignment and vision building are processes that also serve to assist with relationship and agreement building and help to solidify what might have been disparate elements into functional alliances. Erving Goffman originally coined the term “frame alignment” which describes the process within collective behavior whereby how people view the world adjusts to take into account the frames or outlooks of others. It also helps produce shared frames and shared vision. Once this is in place, it enables people to act collectively to unite people’s efforts, energies and purposes. This unity is a very helpful foundation for effecting system changes, particularly when the alliance is broad and inclusive of many of the key parties. The formats to achieve this unity are many. They include trainings, meetings, social occasions, conferences, special project work, or any other format that serves to convene people and immerse them in dialogue and resolution of the key issues of the day. Another necessary element is that people are challenged and enlightened by exposure to promising directions and practices. A small working group of state bureaucrats in New England were very clear that their regular meetings, despite their personal location in different government agencies, were extremely useful for coordinating their work, forming their thinking and keeping their vision clear. In another state, a similar group of bureaucrats with differing but interlinked responsibilities in different state government agencies was equally adamant that their work was greatly enhanced by meeting regularly. They saw themselves as part of a bigger picture in spite of their formal personal roles. In one small town initiative to support people with disabilities a key format was an advisory group that met regularly with the town manager. However, they also saw the need for various people to attend important vision-related training events. Similarly, the state that had carefully developed a special multi-constituency conference has been holding other vision and consensus building events at the same location for years, such that the name of this venue has almost become synonymous with efforts at change making. In a county initiative in another state, the key county officials often developed crucial policy and priorities in the context of meetings that were actually concerned with much more routine matters. The major ingredient was that the officials participated in discussions on key issues. The rest flowed from this starting point. Interest In And Respect For The Truth Of What Might Be Best For People It may seem strange to link systems change to a willingness to be guided by truth as it relates to the well being of people who must rely on services and systems for meeting many of their daily needs. However, it is unlikely that people who lack a genuine interest in advancing practice and improving outcomes in people’s lives would even attempt systems change, given the difficulties involved. So, people genuinely interested in advancements and progress will always be alert to any developments or prospects that might make a difference for service users because these could conceivably support people better. At the same time, just because something is new or heralded as better, it still might not be all that convincing to people and leaders who may first want to see evidence that the claims are justified. Thus, the key linkage is between an ideal and a commitment to introduce useful system or practice advances, but only if they are authentically better. Naturally, a concern for authentic progress may cut across any number of constituencies, as many people may have a stake in the question. It is not hard to discern an interest in, indeed a passion for, bettering lives in all of the locations that we visited. This idealism was evident in the curiosity of many of the people and leaders in what was happening more broadly in their fields, where there might be practices that ought to be imitated, and what others think about the issues. On the other hand, the vast majority of the leaders are seasoned and sophisticated people who have an appropriate respect for the need for evidence, facts and good rationales. In other words, they had a respect for truth and a willingness to be guided by it. The Challenge Of Determining Higher Order Versus Lower Order Factors The suggested key ingredients of systems change identified in this discussion paper are not presented in a linear relationship from the most important to the least. This is deliberate, as it is assumed that the factors here are merely the starting point of a longer discussion on what might be key elements of the specific systems change processes that have benefit for service users. This caution does not, however, eliminate the further problem of trying to order the ingredients in beneficial change into some order of importance. Obviously, not all elements are necessarily equal to each other and trying to determine why this might be is a perplexing and demanding task. Nonetheless, this latter task is not even possible until the ingredients themselves are specified and agreed upon. This paper is offered as a shared resource for the participants in an anticipated colloquium and its purpose is to begin a discussion that may well challenge the suggestions offered in this paper as to what leads to beneficial systems change. Thus the reader needs to consider not only the merits of what is offered here, but also what has been inadvertently overlooked or distorted in the construction of this discussion paper. It would be a sign of success with the dialogue that all or part of this initial paper is discarded in favor of one that better captures the thinking of the participants at the Colloquium. Badcock, C.R., The Problem Of Altruism, Basil Blackwell, 1986
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The Technical Assistance Partnership is sponsored by the Centers for Medicare and Medicaid Services to provide technical assistance to Real Choice Systems Change Grantees. The complete ILRU Web site was developed with support from grants from the Department of Education. However, its contents and the opinions expressed do not necessarily represent the policy of the Department of Education, and no endorsement by the Department should be assumed. ILRU is a program of TIRR (The Institute for Rehabilitation and Research), a nationally recognized medical rehabilitation facility for persons with disabilities.
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