Overview of The ABLe Framework for Change

System of Care (SOC) is a popular approach for improving outcomes for youth with severe emotional disorders and their families by expanding the availability of and access to individualized, culturally competent, and family-driven services and supports (Hodges et al. 2007). There is a growing recognition that the creation of a SOC requires more than the improvement and expansion of community programs. Instead, in order for a SOC to become fully implemented and effective, communities must also focus on transforming the local service system (Foster-Fishman and Watson 2010): shifting the beliefs and roles of providers and consumers; altering the relational network between service organizations; creating feedback and learning mechanisms; expanding the continuum of services; and creating flexible funding pools (Hodges et al. 2007; Stroul and Blau 2008). While these shifts are critical, there is a growing body of evidence to suggest that most SOC communities struggle to effectively create this systems change (e.g., Bruns et al. 2005; Cook and Kilmer 2010).

The SOC field is not alone in this challenge. There is growing body of evidence to suggest that efforts aiming to transform communities and service delivery systems often fail to achieve what they promised (e.g., Best et al. 2003; Foster-Fishman and Long 2009; Kubisch et al. 2010; Tseng and Seidman 2007). Several explanations have been offered to explain this disconnect. First, while many initiatives claim they target systems change, they often primarily focus on implementing new or expanded programs and thus inadvertently limit their achievements to individual-level outcomes or first-order shifts (Foster-Fishman et al. 2007). While SOC efforts have fared better on this dimension, in that they explicitly target system-level goals such as service coordination and shifts in service delivery philosophy (Foster-Fishman and Droege 2010), SOC communities often face numerous barriers when pursuing these systems-level changes (Cook and Kilmer 2010) and thus experience diminished system-level outcomes. Second, even when initiatives actually target systems for change, communities often do not know how to effectively apply systemic thinking to their community problems or how to implement systems change (Hodges et al. 2007; Trochim et al. 2006). This capacity gap often results in communities targeting symptomatic problems instead of root causes and ignoring systemic issues as they design change strategies (Meadows 2008). Third, there is a growing body of evidence to suggest that effective change efforts require significant attention to process considerations (Tseng et al. 2002) such as implementation (e.g., Durlak and DuPre 2008; Fixsen et al. 2005; Klein and Knight 2005; Wandersman et al. 2008) yet most initiatives dedicate limited resources to these practices. As a result, it is not uncommon for communities to adopt important changes without actually shifting daily practices or behavior because implementation dynamics were ignored (Smith and Mogro-Wilson 2008).

To address these challenges, we have developed what we call the ‘Above and Below the Line’ (ABLe) Change Framework. The Above the Line component emphasizes the content of the change by embedding systems change concepts into the initiative’s theory of change (TOC). Meanwhile, the Below the Line work targets the implementation processes needed to ensure that change pursuits actually achieve what they were designed to accomplish. Four processes are emphasized: readiness, capacity, diffusion, and sustainability. To promote the effective integration of the Above and Below the Line components and the incorporation of a systemic lens throughout the duration of the project, three change strategies are employed: strategic action learning teams, small wins, and simple rules. Overall, the ABLe Change Framework was specifically designed to provide researchers and practitioners with the conceptual and strategic tools they need to effectively design and implement community change projects that aim to promote systems change. The purpose of this paper is to present the ABLe Change Framework and demonstrate its application through a case study that illustrates our success in using this approach to promote systems change within one SOC effort in Michigan.

Case Study Overview

The ABLe Change Framework will be illustrated using a case study of a SOC effort in Saginaw County, Michigan. Saginaw County has a population of 201,000 and includes urban, rurally isolated, and suburban areas. The majority of the population is Caucasian (72%); predominant minority groups include African Americans (18.5%) and Hispanics (7.4%) with the highest concentration of minorities found in the main urban city. Children and youth living in Saginaw face unprecedented levels of disadvantage; Saginaw is beset by high rates of unemployment, poverty, community violence and other social ills. For example, Saginaw has a violent crime rate 4.55 times the national average (State Police-Criminal Justice Information Center 2009), making it one of the most dangerous cities in the country (CQ Press 2008). Prevalence of SED in Saginaw among children and youth ages 0–18 is estimated to be 12% with many of these youth experiencing abuse and neglect or violent crime; less than 1/3 of these children have received mental health services.

While many local organizational leaders were highly effective and committed to improving services, they faced many challenges. The service delivery system was fragmented and suffering from severe resource cuts. Inter-organizational relationships were strained, and service coordination and collaboration efforts were either uncommon or unsuccessful. Youth and family members faced many barriers accessing needed services and were rarely engaged as system partners. As a result of these and other problems, youth with SED often found themselves suspended from school or within the juvenile justice or child welfare system. It was within this context that local leaders sought, and received, state funding to build a local system of care infrastructure. We were invited to partner on this effort upon the receipt of this grant in March, 2007. Given that prior efforts to transform the local service delivery system had failed—and many local leaders and service providers were skeptical about the feasibility of this SOC effort —we knew we needed an approach that would work to integrate needed content (specifically systemic change) while supporting effective implementation of this change. In other words, the ABLe Change Framework provided the specific tools and approach needed within this context.

During the following 3 years we pursued strategies and processes suggested by our ABLe Change Framework, working with our partners to understand their community through a systemic lens, to infuse systems thinking into their SOC theory of change, and to build a climate for system transformation by addressing system readiness, capacity, diffusion, and sustainability. These efforts were enhanced through the development of a systemic action research process, the use of simple rules to align system efforts, and a focus on small wins to increase momentum for change. Much was accomplished as a result of this SOC effort including enhanced service access, improvements in service coordination and collaboration, and strengthened inter-organizational trust. In Year 4, as a testament to the progress made to date, this community was one of nine selected to receive a federal system of care grant through SAMSHA.

Below we describe the details of the ABLe Change Framework and illustrate its application using our experience in Saginaw. Multiple forms of data collection were used to develop this case study during our 3 year partnership including: review of Saginaw system documents, including meeting minutes, budgets, grant applications, public relations materials and internal agency evaluation reports; observations of 69 action learning meetings across five action teams; multiple informal meetings with agency leadership; 41 interviews with key system stakeholders including leaders, agency supervisors and front-line staff, private organization leaders, and family members; survey data collected from 24 leaders, managers and front line staff; and focus groups with youth engaged in SOC services.

The Above and Below the Line (ABLe) Change Framework

The ABLe Change framework draws upon concepts and change strategies from a diversity of literatures including systems thinking (Foster-Fishman et al. 2007; Meadows 2008), organizational change (Pettigrew et al. 2001), implementation theory (Durlak and Dupre 2008), and comprehensive community change (Kubisch et al. 2010). It was created to inform the design of community change projects, guide the effective implementation and pursuit of these changes, and inform infrastructure development to oversee implementation efforts. We describe below each of the core components of this model (see Fig. 1).

Fig. 1
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The ABLe change framework

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Above the Line Work: Building a Systemic Lens for the Content Work

The Above the Line component emphasizes the content of the change by targeting the initiative’s theory of change (TOC). While many change efforts develop frameworks to guide their work, and in fact such an approach is considered best practice in many fields (Kubisch et al. 2010), most of these efforts exclusively focus on outcomes at the individual or programmatic levels. The ABLe Change Framework extends this focus by intentionally embedding systems concepts into the TOC. To embed a systemic lens into the content of the work, two activities are pursued: (1) understanding the community problem through a systems analysis; and (2) integrating system characteristics into the TOC. Both of these activities incorporate strategies adapted from soft systems (Checkland and Scholes 1990) and systems dynamic (Senge 2006) theories.

Understanding the Community Problem

Some systems thinkers argue that the act of defining a problem is potentially the most transformative step in a change effort (e.g., Midgley 2000). Problem definition includes clarifying the targeted problem by understanding its root causes and determining who and what constitutes the “system.” Engaging diverse stakeholders in this exploration is an essential part of systems change; through such engagement targeted problems become clarified and potentially renamed as stakeholders learn from each others’ perspectives (Checkland and Scholes 1990). Importantly, drawing boundaries around who to include/exclude in this analysis connotes value to stakeholder roles and determines which perspectives dominate and which ones are silenced (Midgley 2000). The ABLe Change Framework is explicit in its inclusion of stakeholders representing diverse vertical (staff, middle managers, leaders) and horizontal (public and private organizations, neighborhood organizations) system layers, and those affected by targeted problems (e.g., youth and families in SOC efforts). During this problem definition stage, specific attention is given to understanding stakeholders’ perspectives on why current problems exist (CADCA 2009). By examining these responses, important patterns and root causes are revealed. Many methods are available for this problem definition phase including standard qualitative techniques (interviewing, focus groups) and large group dialogic processes (Holman et al. 2007).

Integrating System Characteristics into the Theory of Change

Because many initiatives fail when they overlook system attributes (Best et al. 2003; Foster-Fishman et al. 2007), the ABLe Change Framework embeds system characteristics into the project’s TOC. This could include working with an existing TOC, or co-constructing a new TOC with community partners. In either case, community partners articulate their ideal state: given the identified problem, what do they want for their community. Using this ideal as their background, and building off of the knowledge gained during the problem definition phase, partners then identify current system attributes that have generated and sustained the targeted problem. The Able Change Framework explores the potential role of six system characteristics adapted from Coffman (2007) and Foster-Fishman et al. (2007): (1) System Components—the range, character, quality, and location of existing programs and supports; (2) System Connections—the relationships and connections that exist across different system actors; (3) System Power Dynamics—how decisions are made within the system and who participates; (4) System Regulations—policies, practices and procedures that regulate system behavior; (5) System Norms—underlying attitudes, values, and beliefs that direct current behavior and practices; (6) System Interdependencies—current feedback mechanisms and how the above system parts reinforce and interact with each other. After understanding current operations, researchers and practitioners identify where and how the current system is incompatible with and supportive of the desired changes and identify potential levers for shifting system components. These leverage points are then incorporated into the TOC. Table 1 includes a set of questions researchers and practitioners could use to identify key leverage points to incorporate into their TOC.

Table 1 Critical assessment questions for embedding systems change into above the line work
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Saginaw’s Initial Above the Line Planning Phase

To launch the SOC project and the initial development of its customized ABLe Framework, the authors met with numerous stakeholders including public sector leaders, management staff, direct service providers, and youth with SED and family members. The purpose of these conversations was to understand perceptions of the strengths and challenges of the current service delivery system, key problems encountered in the system, attitudes towards the proposed SOC, and suggestions for moving forward. These conversations were analyzed and potential Above the Line components were identified. For example, stories about coordination challenges across multiple agencies highlighted the importance of targeting system connections in Above the Line Work. Using these findings and a summary of the SOC literature provided by the authors, the above stakeholders collaboratively developed a TOC targeting the following systems-level changes: (1) easier access to services; (2) more coordinated services; (3) an expanded continuum of quality, community-based care; (4) increased inter-organizational trust and collaboration; (5) more inclusion of child and family voice; and (6) shared outcomes and accountability. Stakeholders from each partner agency also worked together to develop initial actions targeting each of the goals.

Below the Line Work: Creating a Continual Climate for Implementation

Below the Line work targets the implementation processes needed to ensure that change pursuits achieve what they were designed to accomplish. We argue that effective systems change projects like SOC efforts must simultaneously pursue Above and Below the line work and that attention to these two dimensions must be balanced, as much as possible. Prior research has well demonstrated that if inadequate attention is given to Below the Line components, change efforts will be reduced in their effectiveness and even potentially fail (e.g., Campbell and Alexander 2005; Smith and Mogro-Wilson 2008). For example, approximately 50% of organizational innovations fail due to inadequate implementation (Klein and Knight 2005); ineffective implementation has also been attributed to significant reductions in effect sizes in community programs (sometimes up to 12 times smaller!) (Durlak and DuPre 2008).

The ABLe Change Framework draws upon existing implementation and change theory frameworks (Durlak and Dupre 2008; Fixsen et al. 2005; Klein and Knight 2005; Wandersman et al. 2008) to identify the targets of its Below the Line work. Four conditions prior researchers have linked to effective implementation are emphasized: readiness, capacity, diffusion, and sustainability. The critical role these four factors play in effective implementation processes has been well documented by other researchers and thus they are not fully reviewed here (See instead Holt, Armenakis et al. 2007; Durlak and DuPre 2008; Rogers 2003; and Scheirer 2005). For the purposes of this paper, we refer you to Table 2 where we have provided brief descriptions and highlight the core components of each Below the Line factor. Because Below the Line work must be responsive to the content in the Above the Line TOC and contextual demands, the character and importance of any of the Below the Line components will shift in relationship to the context and demands of the targeted changes.

Table 2 Below the line components
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While prior researchers have tended to view the four Below the Line components as sequential steps in the process of change (e.g., Yin 1978), the ABLe Change Framework views them as continuous, dynamic and interdependent processes that should receive ongoing attention throughout the change process (Crossan et al. 2005). For example, both readiness and capacity for change are typically addressed at the beginning of a project (Foster-Fishman et al. 2006). However, in systems change efforts, new discoveries about the targeted system continually emerge as the system responds to prior actions and stakeholders gain deeper understandings about system operations (Patton 2011). Effective initiatives respond to these new insights by continually adapting their change strategies (Foster-Fishman and Long 2009). If Below the Line factors such as readiness and capacity are not considered prior to each new action, subsequent change efforts will likely encounter resistance (Cunningham et al. (2002).

Below the Line Elements must also penetrate multiple levels and contexts within the targeted system because complex initiatives require compatible changes across various system actors (individuals, units, organizations; Cohen and Lavach 1995). For example, educational reform efforts have found that changes in state level educational policies only lead to significant changes in the classroom when superintendents, principals, and teachers have the readiness and capacity needed to implement the new policies (King-Sears 2001). This suggests that an important and ongoing step in Below the Line work is to identify and engage critical system actors across multiple contexts and layers in ongoing efforts to assess and develop readiness, capacity, diffusion, and sustainability. These efforts must recognize that system actors change over time as individuals enter and leave the system and additional settings become engaged.

Finally, it is important to highlight the interdependencies that exist among the four Below the Line components. For example, sustainability is more likely to emerge when system actors are ready to support the change, particularly when they recognize the benefits that will emerge (Scheirer 2005). Diffusion processes are strengthened when targeted system actors have strong relational capacities and thus the ties needed to foster communication about the change (Dearing 2008). Readiness perceptions are enhanced when contingent capacities, particularly those related to the efficacy to implement targeted changes, are developed. Overall, this suggests that the Below the Line components, working in concert with each other, are necessary to build an overall climate supportive of the transformative system change implied by Above the Line work.

Identifying Below the Line Elements Within Saginaw

The stakeholder conversations described above were also used to identify the initial set of Below the Line elements in Saginaw. Specifically, potential implementation gaps, barriers, and strengths related to readiness, capacity, diffusion, and sustainability were identified. For example, comments about the willingness of agency leaders to partner on this SOC due to their desires to improve outcomes for youth and more efficiently use dwindling resources suggested their readiness to support this change. Meanwhile, comments about staff’s inexperience with promoting family voice suggested capacity needs in this area. Actions related to promoting or building upon these Below the Line components were then identified and integrated into the action plan. As the SOC moved forward, stakeholders at all levels continued to identify, address, and monitor Below the Line components across their efforts.

Key Methods for Promoting Integration Across Above and Below the Line Efforts

Providing simultaneous attention to both the content of the work and the processes needed to foster its success can be challenging. For example, in a SOC effort, as the content of the work unfolds, the demands to roll out services and meet funder expectations such as numbers of clients served can easily overwhelm local systems and significantly diminish the resources available for attention to critical process considerations, such as dissemination of newly adopted policies. In response to these challenges, the ABLe Change Framework incorporates three strategies designed to foster simultaneous attention to Above and Below the Line work, leverage compatible change efforts across different system layers and stakeholders, and ensure a sustained focus on systems change: Systemic Action Learning Teams, Simple Rules, and Small Wins.

Systemic Action Learning as a Method for Balancing the Content-Process Elements

To stimulate simultaneous focus on Above and Below the Line elements, systemic action learning is the primary method within the ABLe Change Framework. Action research is a popular method for engaging ordinary people in iterative problem-solving cycles to address local issues (Stringer 2007) such as community health promotion (Minkler 2000), education and curriculum changes (Sagor 2000), and local government improvements (Bell 2008). Action research’s explicit focus on action—specifically action to resolve a presenting problem—made it an ideal method for the ABLe Change Framework since systems change requires ongoing identification and resolution of systemic issues. Within the action research process, stakeholders are engaged in ongoing cycles of inquiry in which they analyze contextual conditions, design and take actions, assess the efficacy of these actions, and reanalyze existing conditions (Foster-Fishman and Watson 2010). These steps ensure that efforts are tailored to the unique characteristics of the targeted system and are flexible enough to adapt to shifts in context. Action research cycles continue until the presenting problem is solved or, more commonly, until a new problem develops or is identified.

Systemic action research builds upon these action learning concepts and applies them to complex social contexts such as service delivery systems. Specifically, systemic action research involves the creation of “parallel and interacting” action research teams across multiple layers and parts of a targeted system (Burns 2007; e.g., separate teams for organizational leaders, direct providers, and family members). While each team is given the freedom to creatively pursue their own unique direction of inquiry and action, patterns and experiences across teams are identified and shared in order to promote understanding of underlying system operations and identification of levers for change. Over time the teams’ activities are integrated into a cohesive effort to transform the system (Burns 2007). This process amplifies traditional action research by enabling stakeholders to gain a more comprehensive understanding of the system and to develop the capacity to problem solve within more complex contexts. In addition, by giving stakeholders the freedom to self-organize around emerging local issues, the systemic action research process allows change efforts to adapt to the dynamic conditions within complex systems (Zimmerman et al. 1998). This method also promotes the inclusion and valuing of diverse stakeholders and thus expands the constructed understanding of the targeted problem and system (Foster-Fishman and Watson 2010). Importantly, systemic action learning teams can easily respond to dynamic community conditions; teams can be added or shifted as new issues arise, new stakeholders are identified, or as system understandings change.

Small Wins as the Engines of Change

In order for efforts like a SOC to truly transform the targeted system, second-order changes that shift the status quo are necessary (Foster-Fishman et al. 2007). Yet, such radical changes can also generate strong resistance and system “push back” (Senge 2006), potentially stalling and even terminating an initiative. While the ABLe Change Framework works towards transformative change, it also draws upon Weick’s (1984) notion that small wins (first-order changes) are important first steps in significant change pursuits. By targeting smaller, more manageable problems, stakeholders become emboldened to pursue more significant changes (Foster-Fishman et al. 2006) and are far less likely to feel helpless facing insurmountable issues (Weick 1984). Small wins can also promote well functioning action learning teams because they provide quick feedback on the effectiveness of strategies, offer immediate insights into system reactions, and generate member commitment to the effort (Boydell and Volpe 2004).

Within the ABLe Change Framework, small wins are identified for targeted Above and Below the Line Components. To ensure that more transformative pursuits are not forgotten, longer term efforts are also identified. Within systemic action research teams, stakeholders work together to determine the scale of change required for each proposed action; all proposed changes are incorporated into action plans and identified as either a small win or larger change. To ensure the realization of small wins, responsible system actors for each action are identified and contacted between meetings to assess progress and identify and resolve barriers; these actors provide updates at subsequent systemic action research team meetings.

Engaging Systemic Action Research Teams and Generating Small Wins in Saginaw

Designing the Teams

Multiple organizational forms are available when designing systemic action learning teams; ultimately the structure should fit the context and the purpose of the systems change project. The ABLe Change Framework considers three factors when designing systemic action learning teams: (1) System boundaries—which determine the critical stakeholders and settings to include; (2) Initial Above the Line Framework—which highlights which system characteristics to target for change; and (3) Initial Below the Line Conditions—which highlight the conditions needed for an effective climate for implementation.

Within the Saginaw SOC project, initial system boundaries were drawn by the funder: efforts should prioritize local public sector organizations including community mental health, child welfare, juvenile justice, and public education systems. Given the emphasis on promoting youth and parent voice in the initial Above the Line Framework, it also seemed essential to include these constituent groups within the systemic action teams. Initial Below the Line conditions suggested, however, that because youth and families had few prior experiences participating in decision-making groups, it would be important to provide them with opportunities to build their capacity to do so. In addition, a history of inter-organizational conflict had created a relatively distrusting space between organizational leaders and among providers from different agencies. Thus, the systemic action teams needed to create a safe space where issues could be explored and honest dialogue could occur. Interview data suggested that initially mixing consumers with providers and leaders with their staff would likely inhibit such discussion. Considering these initial conditions and goals within the community, we decided to create teams that could promote cross-agency trust and coordination between stakeholders operating within the same horizontal layer of the system (e.g., leaders talking to leaders).

Four systemic action learning teams were developed to promote parallel and intersecting cycles of inquiry: (1) a Leadership Team (LT, N = 14) consisting of the top leadership in key public sector organizations (community mental health, schools, courts, and department of human services); (2) an Implementation Team (IT, N = 30) including key middle managers, supervisors, and front-line staff (i.e., social workers, probation officers, therapists, and child protective services staff) from the relevant units within each of the key public sector organizations; (3) a Family Advisory Board (FAB, N = 11) involving family members of children who were receiving services from at least two public sector services; and (4) a Youth Advisory Board (YAB, N = 10) including youth, ages 14–17, who were actively involved in at least two of the public sector services. Around year 3, as these teams considered how to create an infrastructure that could sustain these processes and facilitate even greater cross-team coordination and learning, a fifth systemic action research team was added. Called the Executive Committee (N = 8), it includes the two co-chairs from each of the above action teams. All of these groups continue to meet throughout the year (some groups meet monthly, others bi-monthly or quarterly) and support (e.g., stipends, transportation, childcare) is offered for members of the Family and Youth Advisory Boards. The authors convened and facilitated each of these groups for the first 3 years; a local staff person now serves in this role while the authors support the overall process.

Learning Teams in Action

Each group has engaged in several cycles of inquiry designed to promote Above and Below the Line conditions while facilitating understandings and addressing issues relevant to each group’s position in the system. Team meetings were organized and facilitated in a manner that encouraged an emphasis on problem identification, action, and learning; the content of these learning cycles facilitated movement towards targeted Above and Below the Line conditions and responded to emergent issues. Sometimes a cycle of inquiry emerged in response to inquiries from other groups; other times they were created in response to an issue that was discovered during a team conversation; other times they were initiated around the TOC elements with the goal of better understanding the current context relative to the goal.

All meeting agendas were organized around targeted Above and Below the Line Components. During each meeting participants described current experiences relative to the targeted goal (e.g., for the access to care goal, they discussed their recent experiences trying to get clients access into the community mental health center), gave updates on actions relative to the targeted goal, highlighted challenges and successes they experienced, and identified additional actions to take. When issues emerged, the facilitators initiated a cycle of inquiry, prompting members to first more fully examine the problem; sometimes this required gathering additional information before the next meeting. Once the needed data was available and discussed, the group redefined the problem, identified potential action to take, and volunteers were recruited to pursue this action; this action was then logged onto the shared action plan and updates were requested at subsequent meetings. Actions that could be carried out within 6 months were prioritized in order to generate a series of small wins that would increase buy-in, generate momentum, improve inter-organizational relationships, and promote readiness (Foster-Fishman et al. 2006; Weick 1984). Below is an illustration of these cycles and their outcomes.

Leadership Team

The primary purpose of the leadership team (LT) was to provide overall leadership to the SOC effort, identify and address policy and procedure issues, promote collaboration across member organizations, and generate resources for the effort. As mentioned above, one of the first tasks of the LT was to develop a theory of change (TOC) for the effort. After these initial planning meetings, the LT began to further explore the root causes of the problems targeted in the TOC. For example, the team explored the reasons for poor service coordination and identified agencies’ policies around information sharing as a significant problem; there were no processes in the county that encouraged, or in some situations even allowed, providers from different agencies to exchange important information about their shared cases. This served as a major barrier to providing integrated care to youth and their families. In response, the leaders discussed several solutions and agreed to adopt a county wide, multi-agency shared consent form. Using information and examples gathered from other communities and feedback from organizational lawyers, compliance officers, Implementation Team (IT) members, and Family Advisory Board (FAB) members, LT members drafted a shared consent form. Additional feedback was sought from the FAB on the form’s wording and how to properly explain the form to families. Within 8 months after the SOC effort was launched, the shared consent form was officially adopted by partner agencies.

Once implementation of the form was initiated, multiple barriers to using the form were identified by members of the IT Team and the FAB. This feedback was shared with the LT members; addressing implementation barriers then became the topic guiding the next LT action research cycle. Overall, these cycles illustrate how the LT has used the systemic action learning process to target both Above (shared consent form policy) and Below the Line (implementation of the consent form) issues, how the process promotes problem solving around emergent issues, and how the different systemic action teams provided diverse perspectives on a problem and its resolution. On a practice note, we found it useful to, whenever possible, provide information about identified barriers or issues to relevant leaders during one-on-one private sessions before the group meetings to provide them with an opportunity to explore resolutions and present the “wins” during the group sessions. This allowed for a more efficient action learning process and contributed to the group’s positive momentum.

Implementation Team

The Implementation Team (IT) was primarily designed to learn about service delivery challenges and promote coordination across partner organizations. Individuals within the LT nominated direct care supervisors or providers (e.g., school social workers) to participate in this group and efforts were taken to ensure that IT members represented the different units within each organization. One parent advocate employed by community mental health also joined this team. Just as in the LT, the IT initially took time to better understand the problems facing their community by exploring some of the reasons why the SOC elements were currently not in place. During this process, one overarching barrier to effective access and care coordination emerged: providers’ lack of understanding of each other’s organizations. This issue became the problem targeted in the first IT cycle of inquiry. IT members identified and implemented several action steps for increasing awareness, including: sharing information about programs and services, eligibility requirements, service capacity, and access and referral processes with each other during IT meetings; developing a reference chart illustrating the continuum of available services in the county; and holding cross-agency trainings and information workshops. Overall, these processes helped providers develop their knowledge of the system (a Below the Line element) including their awareness of gaps in services in the county. To ensure this awareness continued to expand, new IT members were invited to share information upon joining the group and were given a copy of the services chart.

To encourage vigilant attention to Above and Below Line Elements, and to ensure that the work was addressing current issues and problems, time was allocated during each IT meeting for members to share recent experiences that either highlighted successes or challenges related to each core TOC element (e.g., service coordination, access to care). Because many of these case stories highlighted challenges with service coordination, this topic became the focus of many of the IT’s subsequent action research cycles. As much as possible, the IT group worked to resolve these issues themselves; however, when ineffective policies and procedures were identified, the LT was informed. Sometimes smaller action teams were developed if significant issues were identified that needed more time for exploration than monthly meetings allowed, illustrating the self-organizing nature of the action learning process.

Family Advisory Board

The primary purpose of the Family Advisory Board (FAB) was to provide ongoing customer feedback on the service delivery system and implemented changes, and to infuse family voice into the SOC process. The first few meetings of the FAB were organized to provide family members with the opportunity to share their experiences with raising a child with SED and accessing and receiving services. This process promoted group cohesion and trust and helped families see commonalities in their experiences. Through this process one issue emerged as a shared need across FAB members: the lack of available social supports for family members in the county. This issue became the focus for their first cycle of inquiry. Over the next few meetings, the board generated ideas to address this gap, gathered information from other communities, and eventually decided to develop a network of peer-to-peer parent support groups. A trained parent advocate working for CMH took on the task of organizing the effort and worked collaboratively with the FAB to design the form and function of these groups. The IT was updated on this effort and strategized ways to inform eligible family members within their systems about ways to join the support groups. To date, 13 peer support groups have been held.

The FAB has also pursued several action learning cycles related to the TOC goal of increasing the inclusion of youth and family voice, primarily in the context of service planning. Family members shared their experiences of participating in service planning and identified several key systemic barriers to their genuine inclusion in this process, as well as practical suggestions for how service providers could more effectively engage them in this process. For example, one suggestion was to set aside 5 min at the beginning of every service planning meeting involving parents to highlight positive things about the youth before discussing any issues or concerns. These recommendations were turned into a two page “Words of Wisdom” document that was edited by the FAB and later distributed to all providers in the system.

Youth Advisory Board

The Youth Advisory Board (YAB) shared the same purpose as the FAB. Initial meetings were primarily organized to give youth an opportunity to share their stories and develop trust with each other. One common theme emerged across these initial meetings: youths’ frustration with their interactions with providers across the system. This issue became the first action research cycle topic. As part of their investigation of this issue, the group identified discrepancies in how youth and service providers perceive each other (e.g., youth see themselves as capable while providers see them as helpless), and the consequences of these different mindsets on service provision. The youth collectively themed their responses and edited a “Words of Wisdom” document to be distributed across the system.

Executive Committee

To ensure sustainability of the effort, and cross-team learning and synergy, an Executive Committee (EC) was formed that includes the two co-chairs from each of the four groups. This committee provided a setting where co-chairs could: learn about the systemic action learning activities of other groups; discover common problems and expand problem definitions; and reflect upon successes and lessons learned. Relevant information was then incorporated into the action learning processes of the four systemic action learning teams and captured on the shared action agenda. To encourage shared learning and understanding, each group could identify problems or issues they would like other groups to analyze and address, and send these requests with their co-chair to share at the next EC meeting. In addition to sharing information, the EC also developed into a unique setting for multi-stakeholder problem solving. Members of the group capitalized on their different perspectives to collectively develop solutions to issues raised in the different teams. Overall, this multi-layered action learning process not only helped to reveal deep structures and patterns within the system but it also enhanced the effectiveness of the systems change pursuits by encouraging synergistic actions at multiple systemic levels (Cohen and Lavach 1995).

Promoting Cross-Team Learning

While the systemic action research teams could direct their own action learning processes, procedures were put into place to promote cross-team learning across these efforts; such synergy was necessary to gain system-wide understanding and to identify key leverage points (Meadows 2008). Teams could suggest action learning topics for each other, direct questions to other groups to gather information or test out action ideas, or request feedback on the effectiveness of actions taken. In addition, actions from all groups were tracked onto a shared action agenda that was periodically reviewed by the teams and used for identifying shared patterns and the next round of objectives to target. The SOC facilitators initially assumed primary responsibility for connecting team efforts and building cross-team learning; the EC was designed, in part, to assume this role.

The efforts to improve Community Mental Health’s (CMH) access and intake processes can serve as an example of this cross-team synergy. Issues regarding the access process at CMH were first identified by members of the IT and the FAB; among other issues, the access process required five separate steps over the course of several days. These issues were presented to the LT with follow-up private meetings with key CMH leaders. Immediate steps were taken to shift the access process by eliminating two of the interviews. Despite this progress, members of the IT and FAB quickly reported that a 3-step intake process was still too cumbersome. Upon sharing this feedback with the LT, CMH took more action and eliminated another step in the process. The response to this second change was quite positive, and many stakeholders commented that this “win” had increased their confidence in the SOC effort. As this example illustrates, iterative action learning processes and cross-systemic action learning team feedback and responsiveness is critical to the success of the systemic action learning process.

Simple Rules to Embed Core Content and Process Components

Simple rules are based on the idea that coherent system behavior can emerge from the interactions of independently acting individuals when these individuals follow a shared set of simple rules or, in social psychology terms, simple schemata (Bonabeau and Meyer 2001; Olson and Eoyang 2001). This phenomenon can be seen in many types of systems, for example a flock of birds uses the following simple rules: (1) match your speed to others in flock; (2) avoid running into others; (3) fly toward the center (Olson and Eoyang 2001). In applied contexts, simple rules can be intentionally developed and explicitly used to shape and guide system behavior (Olson and Eoyang 2001). Here a change agent’s task is twofold: (1) help system stakeholders identify and reflect upon the current rules guiding their behavior; and (2) assist stakeholders in developing new rules that can shift system patterns to better align with their goals (Olson and Eoyang 2001).

In the ABLe Change Framework, systemic action learning teams identify patterns of behavior that highlight barriers to the Above and Below the Line work. For example, the tendency of stakeholders to keep new information to themselves instead of strategically sharing it with others may serve as a barrier to the Below the Line process of diffusion. Once these behavior patterns are identified, they are reframed as simple rules. To ensure that both Above and Below the Line content are considered, simple rules are developed for each of these areas. These simple rules are then incorporated into subsequent problem analysis, action, and reflection sessions in all of the action learning groups and team members are encouraged to continue to use these rules outside of the action research teams to promote widespread adoption.

Infusing Simple Rules into the Action Learning Process

In our SOC effort, we first looked at the patterns of behavior (e.g., existing simple rules) across our systemic action learning teams that highlighted barriers to the Above and Below the Line work. Using these insights, we worked with our community partners to develop a new set of simple rules that responded to the emerging needs of the system as it strived to implement its SOC. The current four rules include:

  1. 1.

    Put the pieces together work to discover how the system’s form or function must be shifted to address the presenting issue, paying particular attention to connections across organizations, units, and stakeholders.

  2. 2.

    Spread the word once solutions to systemic problems are discovered, diffuse the knowledge or practice to others throughout the system.

  3. 3.

    Keep the fire alive take steps to ensure that changes are supported with the appropriate resources, capacities, and attention.

  4. 4.

    Challenge the status quo push the system toward 2nd order change.

We have used these simple rules to guide our facilitation of the four systemic action groups and their action learning cycles. For example, in each meeting we looked for opportunities where stakeholders (provides, youth, leaders, family members) could (or needed to) use the four simple rules to guide their change efforts; we then posed questions to help group members identify ways to apply the rules. An example of the application of these rules occurred in a recent IT meeting. In previous meetings the group had discussed a reoccurring issue regarding the difficulty in transferring students’ credits between alternative schools and the public school system; we posed questions during the problem identification stage to help the group apply rule #1 to this issue (e.g., What gets in the way of the effective transfer of credit?). In response to these discussions, one stakeholder from a local alternative high school followed rule #1 and personally investigated why the problem was occurring. At a subsequent IT meeting, she described the underlying cause of the issue: inconsistent course names (Biology A vs. Biology 101) across institutions impeded credit transfer. During the action phase, the stakeholder noted that she made a copy of the entire public school class listing so she could align courses within her alternative school. We helped to facilitate rule #2 by asking “Who else in the system needs to have access to this class list? How can they get this information?”. The group identified other stakeholders and plans were made for the list to be distributed.

Outcomes in Saginaw

Tracking of actions and outcomes is an important component of the ABLe Change Framework because it helps multiple systemic action teams acknowledge and coordinate their diverse efforts and fosters momentum and commitment as participants pay witness to the numerous wins. In this SOC effort, we tracked all action suggestions and recorded them, along with the date and lead organization, in the meeting minutes; we also tracked all outcomes related to initiated actions and recorded these in the meeting minutes as well. To foster follow-through and effective pursuit of suggested actions, we would contact lead organizations in-between systemic action meetings to gather implementation information and brainstorm solutions to barriers. To further coordinate efforts across systemic action learning teams, and to identify potential next steps, the initiated and completed actions from each action team were merged together into a shared action agenda; activities were merged around the core elements of the TOC in order to review the progress made within each core element.

The systemic action learning teams have been extremely productive in regards to identifying problems and selecting and initiating relevant actions. Within the first 6 months of the SOC effort, 81 action items were identified and initiated within the four systemic action learning groups. Examples include simplifying CMH’s intake processes (as described above), distributing up-to-date directories of all employees in the public sector agencies, providing training to providers about how to effectively engage in school planning meetings, jointly applying for grant funding, and co-locating a staff member from CMH in the courts. While all six elements within the TOC were targeted in these efforts, improving coordination between agencies and access to services received the highest concentration of actions. Compared to the other TOC elements, increased service coordination and access were considered priority areas by all four systemic action learning teams and were thus given significant attention in most meetings. In addition, CMH both initiated and completed more actions than any other agency, most likely because they assumed the role of lead agency in the effort.

In addition to tracking the system’s actions over time, we also surveyed members of the LT and IT with an open-ended questionnaire that examined perceived benefits of the SOC effort to date, and suggestions for improvement and next steps. A qualitative analysis of these responses revealed that participants experienced significant benefits through the SOC effort. The majority of benefits appeared related to the primary focus of the teams’ works to date: increased service coordination and access. For example, some key benefits cited by members of the LT and IT included: (1) increased collaboration and service coordination across agencies, including better relationships, communication, and putting a “face with the names at the end of the telephone”; (2) greater understanding of each others’ agency, including their policies, limitations, available services, responsibilities, and strengths; (3) increased feelings of trust and self-efficacy, including a belief that the group is “in this together” and “moving in the right direction;” and (4) increased ability to understand issues from multiple perspectives, as well as how each agency is viewed by the rest of the system. In contrast, there were very few comments within this survey regarding improved partnerships with youth and families, or an expanded continuum of services in the county. These issues have now become priority areas for next year’s efforts.

Perhaps one of the most significant examples of this effort’s accomplishments to date includes the recent awarding of a 9 million dollar Federal System of Care grant through SAMHSA; Saginaw was one of only nine communities selected during this funding cycle. While multiple factors supported this success—not the least of which was the tremendous leadership provided by the public sector organizations, particularly CMH, in this application—the infrastructure developed and early wins achieved through the SOC effort were important contributing factors.

Conclusion

The ABle Change Framework provides an approach to transformative change that incorporates a simultaneous focus on the content of the work (Above the Line) and the processes needed (Below the Line) to support successful implementation. By making the content focused on systems changes, the ABLe framework heightens the likelihood that systems-level outcomes will emerge (Tseng et al. 2002). The use of parallel systemic action research teams capitalizes on stakeholders’ unique perspectives while promoting synergy across diverse actions in order to leverage targeted systems change (Burns 2007). The strategy of parallel action research processes is also a highly flexible model that can adapt itself to local needs by initiating new inquiry processes where and when they are needed. Perhaps most importantly, the systemic action research approach fosters the construction of learning groups that are meaningful to the local issue and context. For example, in the SOC effort described in this paper, the development of a systemic action learning team that only included direct care providers and supervisors increased the likelihood that actual implementation issues were considered and reduced the emergence of the common pitfall found in many inter-organizational efforts—the disconnect between new leadership policies and actual provider practices (Smith and Mogro-Wilson 2008).

The ABLe Change Framework’s emphasis on small wins certainly energized the stakeholders within Saginaw and leveraged important shifts in system functioning. These wins are particularly important to highlight given the initial conditions present within this community: inter-organizational trust, service coordination, and access to care were all problematic. However, shifts in system functioning appeared to target inter-organizational relationships and service access more than the role of family voice. This may be an unintended consequence of the structure of the systemic action learning teams within this community. By organizing teams around horizontal versus vertical slices of the system, stakeholders were better positioned to promote inter-organizational inquiries than professional-consumer actions. Certainly, initial stakeholder conversations suggested that low levels of inter-organizational trust were significant barriers to systemic change and attention to these relationships was a critical first step in this effort. In fact, prior research has suggested that systems may first need to take steps to improve inter-organizational relationships before moving on to include families in those relationships (Hodges et al. 2003). The recent construction of the Executive Committee may provide a more effective venue for promoting family voice.

Finally, it is important to consider how communities can effectively staff and support the ABLe Change Framework. Given our experience facilitating this process for the past 3 years, it seems critical for communities to develop and hire “policy entrepreneurs” to convene these efforts. Policy entrepreneurs are individuals who possess the skills and relationships needed to effectively develop and disseminate policy innovations. Because the systems change process is necessarily a political one (Frost and Egri 1991), with competition for scarce resources and priorities heightened at the time of change, the presence of individuals capable of successfully navigating these political waters is critical. According to Mintrom (1997), policy entrepreneurs have social perceptiveness (i.e., ability to listen, to understand needs and motivations), social connectedness (i.e., strong, diverse social network that includes connections to key players), and the ability to creatively problem solve and frame solutions in a manner that resonates with diverse interest groups. Policy entrepreneurs have been found to play a critical role in promoting systems change, particularly the adoption of new and innovative policies, at the local (Schneider and Teske 1992), state (Oliver and Paul-Shaheen 1997) and federal (Heclo 1978) levels.

There is great potential for the ABLe Change Framework to guide systems change initiatives across a diverse array of community contexts. Future research should continue to develop and enhance elements of the framework by documenting how to adopt it within unique settings and contexts. Application of the framework could also be enhanced with empirical investigations of the model components and outcomes achieved; the definitions provided in Table 2 offer construct operationalizations while the concepts included in Table 1 highlight the systems change elements to examine. In addition, the TOC could be used to identify and quantify small wins within an effort, and systems dynamics modeling could be used to explore the dynamic processes and outcomes of systemic learning teams.

In conclusion, the ABLe Change framework facilitates a change process that can promote three important outcomes for change efforts like a SOC initiative. First, the creation of systemic action learning teams can result in a flexible infrastructure to support the work. Second, the framework promotes proactive and responsive action by fostering continuous learning via ongoing exploration of issues related to Above and Below the line issues. The final key outcome of the ABLe Change framework is the development of targeted systems changes. While these changes may start small through the strategy of enacting small wins, over time efforts can lead to more comprehensive and deep structural changes.