Evaluation and Program Planning 33 (2010) 11–13

Locating the system in a system of care

Pennie G. Foster-Fishman *, Erin Droege

Department of Psychology, Michigan State University, 125 D Psychology Building, East Lansing, MI 48824, USA

A R T I C L E I N F O

Article history:

Received 1 April 2009

Received in revised form 28 April 2009

Accepted 28 April 2009

Keywords:

System of care

Systems change

Systems theory

A B S T R A C T

While systems of care are recognized as a systems-level intervention, a gap remains between systems

theory and practice that challenges the effectiveness of future system of care efforts. This article explores

the extent to which the expanded system of care definition proposed by Hodges et al. [Hodges, S. Ferreira,

K., Israel, N., & Mazza, J. (this issue). Systems of care, featherless bipeds, and the measure of all things.

Evaluation and Program Planning] addresses this gap and suggests ideas for strengthening its systemic

focus. Specifically, recommendations address considerations for assigning and adapting appropriate

boundaries around intervention efforts and leveraging critical system characteristics and interactions to

promote systems change. Implications for system of care practice and theory are discussed.

� 2009 Elsevier Ltd. All rights reserved.

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Communities that develop a system of care for children withsevere emotional disorders embark on a transformative process ofchange for their local community. System of care developmentoften involves shifting the roles of providers and consumers,building connections across an array of fragmented services,expanding the continuum of services offered, and creating moreflexible funding pools by merging categorical funding streams intoblended or braided financing (Stroul & Blau, 2008). Significantchanges throughout the service delivery system are necessary for asystem of care to become fully implemented and effective within acommunity (Hodges, Friedman, & Hernandez, 2008).

Although much progress has been made at understanding howto more effectively implement a system of care (e.g., Hodges et al.,2008), less attention has been paid to understanding the characterand dynamics of systems and their implications for these efforts.Hodges et al. (this issue) call attention to this gap in the literatureby pursuing an important task: the creation of an expandeddefinition of systems of care that more adequately captures theirsystemic nature. The purpose of this article is to examine theextent to which the Hodges et al. definition incorporates a systemiclens and to identify what, if any, changes could be made to thisdefinition to strengthen its systemic focus. Through this analysis,we hope to increase practitioners’ and researchers’ attention to andunderstanding of system-level properties and behaviors; suchinsights can potentially increase the effectiveness of future systemof care efforts.

* Corresponding author. Tel.: +1 517 353 5015; fax: +1 517 432 2945.

E-mail addresses: fosterfi@msu.edu (P.G. Foster-Fishman), droegeer@msu.edu

(E. Droege).

0149-7189/$ – see front matter � 2009 Elsevier Ltd. All rights reserved.

doi:10.1016/j.evalprogplan.2009.04.001

1. The importance of systems thinking in systems of care

If system of care efforts target ‘‘systems’’ as the unit of change,researchers and practitioners need to adopt frameworks (anddefinitions) that adequately attend to the characteristics anddynamics of systems. Systems are defined as a collection ofinterdependent parts that, through their interactions, function asa whole (Ackoff & Rovin, 2003; Maani & Cavana, 2000). Systemschange, therefore, refers to the process of altering the status quo byshifting the form and function of a targeted system (Foster-Fishman,Nowell, & Yang, 2007). To aid this process, systems theorists havedeveloped a variety of systems thinking tools to guide theassessment of system characteristics, the interrelationships acrosssystem parts, and the patterns within systems that support andsustain current conditions (e.g., Trochim, Cabrera, Milstein, Galla-gher, & Leischow, 2006). Systems theorists would argue that it is onlythrough such understanding that change agents and researchers areable to identify how to effectively leverage transformative andsustained change within a targeted system (e.g., Senge, 1990).

Overall, the above suggests two criteria one can use to assessthe ‘‘system-ness’’ of Hodges, et al.’s definition: (1) does thedefinition help one to clarify what and who to include in thesystem targeted by the system of care effort—in other wordsestablish the system boundary? and (2) does the definition help todetermine the system parts and interactions that are critical to thetargeted problem and the desired solution—the creation of asystem of care? We explore each of these questions below in ouranalysis of the Hodges et al. definition.

1.1. Establishing the system boundary

The act of establishing the system’s boundary is considered oneof the most critical and potentially transformative steps in a

P.G. Foster-Fishman, E. Droege / Evaluation and Program Planning 33 (2010) 11–1312

systems change effort like a system of care (e.g., Midgley, 2000).Boundary clarification includes both clarifying the targetedproblem and determining who and what is contained within thesystem given the selected issue. For example, a narrow problemdefinition within a system of care effort may focus entirely onimproving the way mental health services are currently providedto children and families and thus may draw its boundaries aroundprograms and organizations currently involved in treatmentservices (e.g., community mental health organizations andproviders, schools, courts, child protection agencies). In contrast,a broader definition could also include a focus on prevention, thusexpanding the system of care boundaries to include agencies andprograms related to prevention and natural community supports(e.g., after school programs for youth, faith-based organizations,pre-school programs). These two examples also illustrate how theprocess of defining the target problem determines the range ofpossible solutions, who will be involved in carrying them out, andwhat resources could possibly be brought to bear on the problem.

Because system boundaries are arbitrary constructions, depen-dent entirely on who is chosen to assign them, it is critical toengage a diverse set of stakeholders in these decision-makingprocesses to ensure that the final boundary selections and problemstatements are informed by diverse perspectives and worldviews.Given that many system of care efforts involve system buildingactivities, in that they bring together organizations and groupswho have traditionally been disconnected from each other andthen work to build a cohesive vision and coordinated servicesystem, the processes of problem identification and boundarydelineation are particularly relevant. In fact, the very act ofdetermining system boundaries requires discussion and reflectiveprocesses that can produce insights and lead to what Meadows(2008) considers the most transformative lever for change within asystem—paradigmatic shifts in understanding the targeted pro-blem (Fear, Rosaen, Bawden, & Foster-Fishman, 2006).

1.2. Analysis of the revised definition as it relates to system boundaries

Hodges et al.’s (this issue) new system of care definitionprovides vague and indirect reference to both problem definitionand system of care boundaries. One could infer from theirdefinition that the targeted problem is insufficient ‘‘access to and

availability of necessary services and supports across administrative

and funding jurisdictions’’ (Hodges et al., this issue) for children andyouth with serious emotional disturbances and their families thatare ‘‘grounded in system of care values and principles.’’ Given that acore system of care principle is the local identification of thepopulation and problem to target (Hodges et al., 2008), it isunderstandable that the new definition avoids more prescription.In terms of establishing the system boundaries, given this problemstatement, Hodges et al.’s definition mentions the structures,processes, and relationships located within the system of carenetwork across administrative and funding jurisdictions but leavesthe task of selecting specific boundaries up to the reader. On onehand, this is perhaps a wise choice, since the boundaries will andneed to be highly dependent on the local context and the problemthat is selected. On the other hand, without providing practitionersand researchers with guidance on boundary selection, it is possiblethat communities will resort to using existing networks andtraditional service providers, potentially excluding critical stake-holders in the system of care, such as neighborhood organizations,smaller non-profits, and natural support systems. In fact, com-munities often do not engage in a conscious analysis of theboundaries for their targeted problem, and instead approach thisprocess as though it is predetermined (due to granting agencymandates regarding who must be included) or an opportunisticmoment to bring key resources or stakeholders to the table.

Neither of these situations promote the critical reflection needed toeffectively determine the boundaries of a system of care.

1.3. Recommendations related to system boundaries

Overall, we recommend that Hodges and colleagues modifytheir definition to more fully incorporate the importance ofdefining – though not prescribing – the system of care’sboundaries. There are several issues they should consider whenaddressing this revision:

� Systems change efforts are more successful when they promotecompatible problem solving actions at multiple layers of asystem (Cohen & Lavach, 1995). Therefore, the system of caresystem boundaries should cut across a wide array of ecologicallayers, settings, organizations, and populations in order toinclude a diverse range of stakeholders, system parts, andresources in solution development (Foster-Fishman et al., 2007).� Boundaries should be drawn wide enough to include an adequate

range of system parts and players so the effort can be sustainedand effective, yet narrow enough so the effort remains feasible(Foster-Fishman & Behrens, 2007). In our own work with onesystem of care, the system boundary for the first phase of theeffort was drawn more narrowly, only including the major publicagencies in the county. This initial boundary was created due tothe long history of distrust across these public agencies and theneed to first strengthen those inter-organizational relationshipsbefore expanding the system of care network.� System boundaries are dynamic and need to adapt to changes in

the environment. Boundaries set at the onset of a system of careeffort will likely need to be redrawn as the problem situationchanges due to the successes and challenges of the initiative.

1.4. Understanding and leveraging critical system parts, patterns and

interdependencies

The values, principles, and activities embedded within a systemof care are often incompatible with current practices in acommunity. As a result, communities must work to shift localconditions so they become more aligned with and supportive of asystem of care model. The dilemma is, however, determining whatto shift in order to foster the changes needed to create a supportiveand sustaining environment within a community. Because systemsof care are system-level interventions, it is useful to use a systemiclens to identify and understand critical system characteristics.Foster-Fishman et al. (2007) identified five key categories ofsystems parts and interactions that guide system-level behaviorand seem relevant to the system of care field. Researchers andpractitioners can use this framework to understand current systemoperations and identify where and how the current system isincompatible with and supportive of the desired changes:

� System Norms: Refers to the underlying attitudes, values, andbeliefs that direct current behavior, practices, policies andprograms across different stakeholders and organizations� System Resources: Includes three categories of resources: (1)

Human Resources, including the knowledge, skills and capacitiesof all system stakeholders, particularly as they relate to thedesired change; (2) Social Resources, including the relationshipsand connections that exist within current systems acrossdifferent organizations and stakeholders and (3) Economic

Resources & Opportunities, including how funds and opportu-nities are currently distributed and whose needs are attended toand ignored in these allocations.� System Regulations: Includes the policies, practices and proce-

dures that regulate the behavior of system members and the

P.G. Foster-Fishman, E. Droege / Evaluation and Program Planning 33 (2010) 11–13 13

extent to which these are supportive of or incompatible with theplanned change.� System Power Operations: Includes how decisions are made

within the system, where decision-making authority resides, andhow the system of care challenges existing power and decision-making structures.� System Interdependencies: Includes how the above system parts

reinforce and interact with each other and how current feedbackmechanisms support or impede project goals.

1.5. Analysis of the revised definition as it relates to system parts and

interactions

Definitions or frameworks are considered adequate system-level conceptualizations when they provide sufficient informationfor researchers and practitioners to identify and understandsystem characteristics and behaviors. Hodges and colleague’s newdefinition (this issue) incorporates several key system partsincluding:

� System of Care Relational Resources: A system of care is an‘‘adaptive network of structures, processes, and relationships.’’� System of Care Norms: A system of care is ‘‘grounded in system of

care values and principles.’’� System of Care Economic & Opportunity Resources: A system of

care promotes ‘‘access to and availability of necessary services and

supports.’’

They also recognized system interdependencies when they notedthat a system of care is an ‘‘adaptive network.’’ This is particularlyimportant since all systems, including systems of care, are affectedby interactions between system parts that come in the form of twomain types of feedback loops: reinforcing and balancing (Senge,1990). As the names imply, reinforcing feedback loops increase acertain type of outcome or behavior where balancing loops serve tobring these escalations back down to create a state of equilibriumin the system. Understanding system interactions and how asystem responds to such feedback is critical, given that a systemcan sometimes take time to produce outcomes and can causepeople to make incorrect conclusions about the success or failureof an effort (Meadows, 2008).

Interestingly, the definition does not appear to include areference to system power operations even though a core tenet ofthe system of care model is the inclusion of family and youth voice.It is possible that this core element was embedded in the referenceto system of care values and principles.

1.6. Recommendations related to system parts and interactions

While the new system of care definition includes most of thekey system components, it does not provide enough informationabout any one system characteristic to guide the system buildingwork of practitioners or researchers. This is particularly concern-ing, given that Hodges and colleagues aimed, in part, to promotefidelity to the system of care concept by creating a new, moreencompassing definition and promoting public dialogue aroundthis definition. As they noted themselves ‘‘clarity around the

concept of system of care facilitates our understanding of the purpose

and goals of such system reform as well as our evaluation of its

impact.’’ (this issue). While their definition takes an important stepin this direction, there are still some areas where more clarity couldbe provided. Specifically:

� Hodges and colleagues may want to consider identifying some ofthe system characteristics that are most critical to the desiredsystem reform and embed these within the revised definition.

For example, some recent evaluations on system of care effortssuggest that successful communities share several key char-acteristics including the creation of shared accountability andprocesses for delegating authority (Hodges, 2009). Such detailscould easily be incorporated into the revised definition.

2. Conclusion

The revised system of care definition suggested by Hodges andher colleagues takes an important step in advancing the system-level focus in system of care efforts. By including concepts andcharacteristics that reside mostly at the system level of analysis,their definition forces practitioners and researchers to recognizethat systems of care target the reform of communities and servicedelivery systems, not simply the addition of new programs orpolicies. By incorporating even more system-level details, such asrecognizing the need to define system boundaries and providingdescriptions of key system parts and interactions, this definitioncould further advance both the fidelity and the success of thesesystem reforms.

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Pennie G. Foster-Fishman, PhD, is a professor in the Department of Psychology and aSenior Outreach Fellow in University Outreach and Engagement at Michigan StateUniversity. Dr. Foster-Fishman has focused her research, evaluation, and consultationwork on understanding and improving systems change efforts. She has investigatedhuman service delivery reform, multiple stakeholder collaboration, inter-organiza-tional coordination, comprehensive community initiatives, coalition development,community organizing, and resident empowerment as vehicles for systems change.She has also worked with federal and state agencies, public sector and not-for-profitorganizations, and community and state-wide coalitions to improve their organiza-tional capacity and the efficacy of their efforts.

Erin Droege, MA, is a doctoral student in ecological community psychology atMichigan State University. Her interests center on the promotion and sustainabilityof systems change, structural oppression and power, and citizen participation withincommunity-based research and action. She has applied her interests to a variety ofareas, including comprehensive community initiatives, system of care efforts, andcommunity coalitions.