systems integration: pursuing the “holy grail” of … corbett.pdfabove the waterline are things...
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Institute for Research on Poverty
University of Wisconsin - Madison1
Systems Integration:Pursuing the “Holy Grail” of Public Policy
Toronto, Canada
October 2007
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Institute for Research on Poverty
University of Wisconsin - Madison2
Overview
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Discussion Topics
Background Information
– Why are we interested in this topic once again?
– What is happening around the United States?
Service Integration 101
– What do we expect?
– Why the current interest?
Challenges
– What challenges have been identified?
– How can these challenges be overcome?
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Institute for Research on Poverty
University of Wisconsin - Madison4
Background
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Framework for Research, Analysis, and Technical Assistance
Since 2002, we have been participating in an umbrella project involving several partners that encompasses:
– A legal analysis of what is possible under current federal law.
– An operational analysis focusing on sites pursuing service integration.
– A technical and methodological analysis of accountability and evaluation issues.
We have adopted an iterative process whereby research and analysis informs technical assistance and technical assistance informs research and analysis.
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Iterative Process Components
Welfare Peer Assistance Network (WELPAN)
Intensive on-site work in Midwest states
NGA Policy Academy on Cross-Systems Innovation
National ―lighthouse‖ site visits and meetings
Brainstorming meetings with policy analysts, evaluation researchers, and state and local practitioners
Other analysts and researchers at the local, state, national, and international levels
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What states are doing it?
Arizona
Michigan
Pennsylvania
Hawaii
Utah
Wisconsin
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What counties are doing it?
Oregon: Coos and Jackson Counties
New Jersey: Atlantic County
Georgia: Bibb County
California: San Mateo County
Ohio: Montgomery County
Colorado: Mesa and El Paso Counties
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What localities are doing it?
Hampton City, Virginia
Louisville, Kentucky
Seattle (White Center), Washington
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Key Observations
Overall belief that systems integration has the potential for improving outcomes for target populations.
Bottom-up, locally-driven strategies are germinating all over the country.
Innovation benefits from—and often requires—technical assistance and information about ―lessons learned‖ from other sites.
More evidence is needed to test the hypothesis that systems integration leads to improved participant outcomes.
Systems integration is easier said than done.
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It is easier said than done.
Service integration is:– not extensive. Even in ―successful projects,‖ none had fully
developed intended service linkages.
– an evolutionary process. It takes time to organize and implement, to attain legitimacy in the eyes of service providers, and to develop working relationships among participating agencies.
– facilitated and inhibited by numerous factors, but no single factor is instrumental in benefiting or impeding a majority of projects.
There is no one best services integration method for providing client services.
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Who said that?
From ―An Evaluation of Services Integration
Projects‖ completed for…
U.S. Department of Health, Education, and
Welfare, Social and Rehabilitation Services
in…
1972.
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Institute for Research on Poverty
University of Wisconsin - Madison13
Systems Integration 101
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What is systems integration?
No single definition.
Other labels include ―service integration‖ and ―cross-systems innovation.‖
Common goal: to simplify and streamline access to and coordination of a broad, often complex array of services in order to improve outcomes for a specific population (e.g., children and families, children aging out of foster care, ex-offenders).
Requires a shift in program management focus from delivering discrete services to a more holistic approach.
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“Typical” Service Delivery System Attributes
The system is too fragmented, leaving those clients with multiple issues vulnerable.
The goals of individual programs are too limited.
The services are often provided ―in an inefficient, duplicative, and bureaucratically confusing manner to those who have the need.‖
The services tend to be lacking in accountability and to be self-perpetuating regardless of effectiveness.
The service system is not sufficiently attentive to the long-term needs of clients.
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Selected Attributes of Interest
Families have:
– Access to a broad range of services and supports
– Ability to engage the system at different levels of
intensity
Families have access to individualized
service plans that:
– Accommodate multiple issues simultaneously
– Respond to changing circumstances
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Selected Attributes of Interest (continued)
The focus is on achieving overall goals for
individuals and families rather than those of a
particular program.
Public programs are viewed as one part of
an overall system designed to support
achievement of individual, family, and
community goals.
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Current interest is driven by opportunity…
Natural progression of reforms since the
1980s.
There has been a fundamental shift in how
policy challenges are framed at the state and
local level.
This shift is reflected in evolving program
purposes and emerging institutional cultures.
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Evolving Program Purposes
Income Support
Job Placement
Work Support
Family Support
Community Support
Prevention
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Emerging Institutional Cultures
Traditional Attributes Emerging Attributes
Focus on benefits Focus on behavior
Limited purpose Multiple goals
Autonomous agency Collaborative agency
Autonomous staff Teams/collaborative staff
Rule oriented Flexible
Limited target populations Broader target populations
Short-term focus Long-term focus
Process oriented Outcome oriented
Static operations Dynamic operations
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…but also by necessity.
Various populations have multi-faceted needs that
individual programs are not designed to address.
Concurrently, the ability to access flexible resources
has diminished.
The Deficit Reduction Act is requiring a re-
examination of current practices.
Effectiveness is more often being measured by
outcomes rather than inputs or outputs.
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Institute for Research on Poverty
University of Wisconsin - Madison22
Challenges
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A Few Minor Challenges!
1) Not starting in the ―right place.‖
2) Confusing the means with the end.
3) Not having a alternative framework for thinking about integration.
4) Failing to appreciate the institutional implications of proposed changes.
5) Thinking about service integration as an event and not a process.
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Not Starting in the Right Place
Focusing on implementation of tactics rather
than on:
– A specific population.
– A set of goals related to that population tied to
measurable outcomes.
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A Conceptual Framework for Service Integration
Policy
Administration
Practice
Improved
Outcomes for
Target Populations
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Confusing the Means with the End
―Importing a solution‖ by picking from a list of
tactics such as:
– Co-location
– Realigning governance structures
– Consolidating intake
– Consolidating job functions
– Blending or braiding funding
– Hiring a service liaison or ―broker‖
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Not Having a Framework for Thinking About Systems Integration
Institutional Similarity
Relationship Intensity
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Institutional Similarity Continuum
Routinized – benefits-issuing; rule-driven;
bureaucratic
Mixed – contained elements of both
routinized and non-routinized
Nonroutinized – people changing, discretion-
focused, professional models
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Institutional Similarity Matrix
FIRST
CULTURAL
TYPE
SECOND CULTURAL TYPE
Routinized Mixed Nonroutinized
Routinized A B C
Mixed B A B
Nonroutinized C B A
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Relationship Intensity Continuum
Communication
Level 1
Cooperation
Coordination
Level 2
Collaboration
Convergence
Level 3
Consolidation
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Relationship Intensity Matrix
INSTITUTIONAL
SIMILARITY
―A‖
RELATIONSHIP INTENSITY
Level 1 Level 2 Level 3
1st/2nd Communication Collaboration Consolidation
Routinized/
Routinized1 2 3
Mixed/Mixed 1 2 3
Nonroutinized/
Nonroutinized1 2 3
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Institutional Similarity-Relationship Intensity Matrix
SIMILARITY
INDEX
CULTURAL TYPESRELATIONSHIP INTENSITY
1 2 3
First Second Communication Collaboration Consolidation
A
Routinized
Mixed
Nonroutinized
Routinized
Mixed
Nonroutinized
A1 A2 A3
BRoutinized
Nonroutinized
Mixed
MixedB1 B2 B3
C Routinized Nonroutinized C1 C2 C3
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Failing to Appreciate Institutional Implications
Concentrating efforts on modifications to
practice protocols, administrative systems
and policies.
Neglecting differences in leadership style,
organizational culture, and institutional
systems.
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Visualizing the Implementation Challenge
Think of an iceberg.
Above the waterline are things we can easily see:
practice, administration, policy.
However, there are other important factors below the
waterline: leadership, organizational systems, and
organizational culture.
Below the waterline factors are often overlooked
when designing and carrying out these innovations.
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A Conceptual
Framework for Systems
Integration
Empowering
Organizational
Culture
Effective
Organizational
Systems
Effective
Leadership
Administration
Improved
Outcomes
for Target
Population
Practice
Policy
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A Conceptual Framework
for Service Integration
Effective Leadership
Effective
Organizational
Systems
Empowering
Organizational
Culture
Necessary
political
support is aligned
Community/stake-
holder input is
truly valued &
used appropriately
Power is
effectively shared
Organizational
environment is
accurately
assessed
Strengths & weaknesses of
existing systems are accurately
assessed
Authorizing
environment is
accurately
assessedShared beliefs about the
importance of the “right work are frequently
discussedVision & desired
outcomes are clearly &
continuously articulated
Financial
management is
flexible &
accountable
Contracting system is efficient & incents desired performance
IT technical
environment
is conducive
to innovation
Human resource
management is
responsive &
flexible
Training is
responsive,
relevant & on-
going
Staff & managers
display growing
skill &
competence
Program
planning &
accountability are
outcome-oriented
Performance
management
drives strategy
Organizational
learning
is valued
Policy
Administration
Practice
Services Provided in the
Community
Focus on Family as Client
Integrated
Case Management
Coordinated Intake
Integrated IT Systems
Cross-Program Planning
& Management
Blended/Braided Funding
Service Co-location
Realigned Governance
Structure
Improved Outcomes
for Target
Populations
Build on Natural Supports
Realigned Job Functions
Common Outcome
Measures
Continuous
improvement is
expectedAchievement
is
recognized
Creativity
is valued
& risk-taking is
supported
Staff feel
empowered,
engaged &
listened to
Staff understand
their leadership
role in producing
outcomes
Staff know
what is expected
of them
A set of beliefs/
principles guide
decision-making
Staff are committed to a
shared organizational
vision
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Thinking of Service Integration as an Event, Not a Way of Doing Business
Limiting flexibility within the implementation
process.
Failing to adjust to changing circumstances.
Employing a ―once and done‖ mind-set.
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Systems Integration Life Cycle
1) Assess Situation
2) Develop Vision
6) Manage to Outcomes
3) Do a Line-of-Sight
Exercise
5) Implement
the Plan
4) Develop a
Plan
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Institute for Research on Poverty
University of Wisconsin - Madison39
How can identified challenges be overcome?
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Central Questions
What is to be accomplished and for whom?
What tactics and strategies will lead you to the desired outcomes?
Is there a good fit between the tactics and strategies chosen ―above the water line‖ and the institutional milieu ―below the water line‖?
What strategy is needed to bring these two into correspondence?
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Four Critical Steps
1) Start with the ends rather than the means.
2) Replace tactical solutions with strategic thinking.
– Begin with the participant‘s perspective.
– Follow with the institutional perspective.
3) Determine feasibility (understand the systems you are blending together).
4) Assess and adjust as you go.
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Step 1: Focus on the ends rather than the means.
Start with the population of interest.
Determine what you want to accomplish for
this population.
Articulate a vision for change.
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Step 2: Do a “Line-of-Sight” Exercise!
Develop the story from the participant‘s
perspective
– What will the system look like?
– How will it be qualitatively different from what they
experience now?
Test your theory of change
– Will your proposed strategies lead to your desired
outcomes?
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Outcome-Sequence Chart
A linear, graphical depiction of the
relationship between events and activities in
a participant‘s experience with the integrated
system and defined benchmarks that need to
be reached in order to achieve the intended
outcomes.
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Questions for Consideration
For each event, interaction, and decision point, consider:
– Why are you pursuing this particular strategy?
– How will it contribute to the intended outcomes?
For the sequence of events:– What are the critical junctures?
– What needs to happen to move down the sequence?
– Are there gaps in your logic/line of sight?
What do you need to measure to make sure you are progressing? What are your benchmarks?
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“Before” Strategic Thinking
Economic
security of
families
increased
Child safety
and well-
being
improved.
Integrated
Service
Plan
Children do
better in
school
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Families
participate in
development
of plan
Families have
access to all
needed
services
Staff conducts
SSP meetings
with families
Families‘
needs
addressed
more quickly
Service
delivery
systems
improved
Economic
security of
families
increased
Child safety
and well-being
impacted.
Families
empowered to
take charge
Families call
one number
Families have
easier access
to agency
SSP model
developed
Children do
better in
schoolWorkers have access
to integrated data
reporting
Inputs/Activities Process Outputs Intermediate Outcomes End Outcomes
“After” Strategic Thinking
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Add the Institutional Perspective
Consider what changes are needed in
institutional practice, administration and
policy to support the transformation in the
participant‘s experience.
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Step 3: Consider whether the proposal is realistic; appreciate your institutional cultures!
Do you have the pieces in place—leadership,
empowered organizational culture, and
dynamic organizational systems—to support
taking these actions?
What changes do you need to make before
going forward?
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Step 4: Assess and adjust as you go!
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Benchmarks
Inputs/Activities—expected to lead to outcomes but
are not, in and of themselves, what we hope to
achieve.
Process Outputs—immediate benchmarks.
Intermediate Outcomes—typically measures of
participant behavior or circumstances.
End Outcomes—long-term consequences or
conditions in the target population that you desire.
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Thinking Critically About the Model: Process Benchmarks
Saturation
Misdirection
Drift
Leakage
Dosage
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Thinking Critically About the Model: Operational Benchmarks
Efficiency
Comprehensiveness
Individualized treatment
Family coverage
Family involvement
Satisfaction
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How do we know if systems integration really makes a difference?
The Conundrum
The more successful the effort to integrate
(and many agencies/communities are very
enthusiastic about their progress on this
front), the less successful the ability to apply
traditional evaluation strategies. As a result,
very little rigorous evaluation has occurred.
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Problematic Attributes of Systems Integration Models
Research designs are complicated by questions about:– Which populations are served or targeted?
– Which service technologies are ‗integrated‘?
– What are the program boundaries?
– What are appropriate time frames for client outcomes and for when integration is implemented?
– What are the agreed upon outcomes?
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Institute for Research on Poverty
University of Wisconsin - Madison56
Questions, Comments, Final Thoughts
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Contact Information
Jennifer Noyes
608-262-7990
Tom Corbett
608-262-6358