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Organizational culture in children's mental health systems of care
h [electronic resource] /
by Jessica Mazza.
[Tampa, Fla] :
b University of South Florida,
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Thesis (M.S.P.H.)--University of South Florida, 2008.
Includes bibliographical references.
Text (Electronic thesis) in PDF format.
ABSTRACT: A cohesive organizational culture has been linked to positive outcomes in child-serving agencies, such as improved child-level outcomes and positive organizational climate (Glisson & Green, 2006; Glisson & Hemmelgarm, 1998; Glisson & James, 2002; Hemmelgarn, Glisson, & James, 2006). Although isolated studies of organizational culture have been conducted in individual agencies (child welfare and juvenile justice), no study has examined the organization culture of successful, holistic systems of care that involve the coordination of multiple agencies, such as child welfare, juvenile justice, mental health and education. Data collected from the three system-of-care sites selected for participation in Case Studies of System Implementation was analyzed for themes using the Atlas.ti qualitative software package. The analysis was conducted through the framework of Schein's model of organizational culture. For each site, examples of artifacts, values, and assumptions were identified. The artifacts at sites were closely related to the articulated values of the organizations. Findings also suggest that there are underlying components to the organizational culture of system of care, including system of care values and principles, collaboration, willingness to change, and leadership. Results also showed that local context affects organizational culture. Suggestions for future exploration into these hypotheses are provided.
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Advisor: Oliver Massey, Ph.D.
x Community and Family Health
t USF Electronic Theses and Dissertations.
Organizational Culture in Children's Mental Health Systems of Care by Jessica Mazza A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Public Health Department of Community and Family Health College of Public Health University of South Florida Major Professor: Oliver Massey, Ph.D. Carol Bryant, Ph.D. Mario Hernandez, Ph.D. Date of Approval: April 2, 2008 Keywords: qualitative, case study, ar tifacts, values, assumptions Copyright 2008 Jessica Mazza
Acknowledgments I would like to thank my thesis committ ee for all of their help and feedback during this process. A special thanks to Dr. Massey for his patience and guidance throughout my entire program. I would also like to acknowledge the hard work of the rest of the RTC Study 2 dream team (Shar on Hodges, Kathleen Ferreira, Sharon KuklaAcevedo, and Nathaniel Israel). Thank you to all of my friends and family for their encouragement and support.
i Table of Contents List of Tables iii List of Figures iv Abstract v Chapter One. Introduction. Severe Emotional Disturbance & Systems of Care 1 Research and Training Center Study 2: Ca se Studies of System Implementation 1 Organizational Culture 2 Study Aim 3 Chapter Two. Literature Review 4 Serious Emotional Disturbance 4 Systems of Care 4 Shared Values 6 Leadership 6 Collaboration 7 Organizational Culture 8 Organizational Culture in Child-Serving Agencies 13 Significance of Study & Research Objectives 16 Chapter Three. Methods 18 Secondary Analysis (Case Studies of System Implementation) 18 Site Selection Criteria 19 Selected Sites 20 Region III Behavioral Health Care, Nebraska 20 Santa Cruz County, California 21 Westchester Community Network, New York 22 Data Collected 23 Analysis 24 Chapter 4. Results 27 Factor Methodology 27 Region III Site Profile 29 Santa Cruz Site Profile 39 Westchester Site Profile 46
ii Chapter 5. Discussion 54 Scheins Model of Or ganizational Culture 54 Other Models 56 Cross-Site Themes 57 Emic/Etic Approach 61 Limitations 64 Suggestions for Future Research 64 Conclusion 65 References 66 Appendices 71 Appendix A: Semi-Structured System Implementation Interview Guide 72 Appendix B: Local Implementation Factors 73
iii List of Tables Table 1 Construct Matrix 25 Table 2 Roles of Factors 28 Table 3 Identified Values at Research Sites 29 Table 4 Region 3 Results 30 Table 5 Santa Cruz Results 40 Table 6 Westchester Results 46 Table 7 Cross-Site Results 63
iv List of Figures Figure 1. Organizational Cu lture Model (Schein, 1985) 9 Figure 2. Cultural Dynamics Model (Hatch, 1993) 11 Figure 3. Region 3 Services Map 30
v Organizational Culture in Childrens Mental Health Systems of Care Jessica Mazza ABSTRACT A cohesive organizational cu lture has been linked to positive outcomes in childserving agencies, such as improved child-level outcomes and positive organizational climate (Glisson & Green, 2006; Glisson & He mmelgarm, 1998; Glisson & James, 2002; Hemmelgarn, Glisson, & James, 2006). Alt hough isolated studies of organizational culture have been conducted in individual agencies (child we lfare and juvenile justice), no study has examined the organization culture of successful, holistic systems of care that involve the coordination of multiple agencies such as child welfare, juvenile justice, mental health and education. Data collected from the three system-of-care sites selected for participation in Case Studies of System Implementation was analyzed for themes using the Atlas.ti qualitative software package. The analysis was conducted through the framework of Scheins model of organizational culture. For each site, examples of artifacts, values, and assumptions were iden tified. The artifacts at sites were closely related to the articulated valu es of the organizations. Finding s also suggest that there are underlying components to the organizational cult ure of system of care, including system of care values and principl es, collaboration, willingness to change, and leadership. Results also showed that lo cal context affects organizati onal culture. Suggestions for future exploration into th ese hypotheses are provided.
1 Chapter 1 Introduction Severe Emotional Disturbance & Systems of Care Epidemiological studies have shown that approximately ten percent of children will be diagnosed with a severe emotiona l disturbance (SED) (Kutash, Duchnowski, & Friedman, 2005) A SED diagnosis is given to a child when there is a DSM-diagnosable disorder of a sufficient duration (typically one year) and that the disorder results in significant functional impairment of mu ltiple domains (Kutash, Duchnowski, & Friedman, 2005). A system of care is describe d as an organizational philosophy that is meant to create and provide an integrated, community-based servic e array to children with SED and their families (Stroul & Fr iedman, 1986, 1994). Systems of care involve the coordination of multiple child-serving agencies in the treatment of children with SED and their families. These agencies frequently include mental health, child welfare, juvenile justice, and education. Successf ul systems of care have been to found to improve the structure, organization, and availa bility of childrens services, less is known about the factors that guide su ccessful system development to establish effective system implementation. Research and Training Center Study 2: Case Studies in System Implementation The Research and Training Center for Childre ns Mental Health at the Louis de la Parte Florida Mental Health Institute o ffers empirical support to systems of care implementation in order to improve services for children with SED. As part of these
2 efforts, Case Studies in System Implementa tion: Holistic Approaches to Studying Community-based Systems of Care was designed to identify strategies that local communities undertake in implementing community-based systems of care. The study examined six systems of care which were sel ected through a national nomination process. The six sites selected were: Placer County, California; Region 3 Behavioral Health Services, Nebraska; the state of Hawaii; Sa nta Cruz, California; Westchester County, New York; and the Dawn Project, Indiana. These sites were selected due to their accomplishments in serving youth with SED and their families through the establishment and sustainability of their sy stems of care. They were also selected for the varying contexts of their systems in order to provide variability in case sa mpling. Data collection included key stakeholder interviews, observati ons, document reviews, and survey ratings of the local factors identified as critical to successful implementation. For the analysis in this project, three of the sites will be ex amined for organizatio nal culture: Region 3 Behavioral Health Services, Nebraska; Santa Cruz, Californi a; and Westchester County, New York. These sites were selected fo r their variability of local contexts. Organizational Culture In the process of qualitative data anal ysis, themes of or ganizational culture emerged as important factors in syst em implementation. Although many nuanced definitions of the construct exist, organizational culture can essentially be defined as the artifacts, values, and assumptions collectivel y held and utilized by a group of people in a specific organization. Edgar Schein proposed a model of organiza tional culture that divides culture into three levels: artifacts, values, a nd, basic assumptions (1985). Artifacts are the most visible elements of an organizations culture and can include
3 symbols, language, physical space, and dress. Va lues are those articulated statements that are shared by an organizations members. Assumptions are the basic underlying notions that drive all other elements of organizationa l culture. Positive organizational culture has been linked to successful serv ice delivery in child-serving agencies, such as juvenile justice and child welfare (Glisson & Green, 2006; Glisson & Hemmelgarm, 1998; Glisson & James, 2002; Hemmelgarn, Glisson, & James, 2006). Study Aim To date, organizational culture has not been examined in systems of care, where multiple child-serving agencies collaborate to provide coordinated service and support to children with SED and their families. This project will explore the qualitative data collected at each of the sites for themes of organizational culture. Scheins model (1985) will be used as the conceptual framework to examine the organizational culture of three systems of care that participated in Case Studies of Syst em Implementation.
4 Chapter 2 Literature Review Serious Emotional Disturbance A review of the prevalence research indi cates that approximately 20% of children have a mental disorder worthy of a DSM -IV diagnosis, and approximately 10% of children have SED (Kutash, Duchnowski, & Friedman, 2005). Friedman, Kutash, and Duchnowski have estimated the prevalence of children with a serious emotional disturbance ranges from 9% to 19% (1996). In various studies, resear chers have found that only one in every four children with SED have received professional mental health services during their most recent period of having a disorder, and only one half of children with SED have ever gotten mental health services (Costello, Mustillo, Keeler, & Angold, 2004). This is a staggering gap in the provision of services. The amount of functional impairment expe rienced by children with SED is quite severe. Research has suggested children a nd youth with serious emotional disturbance also suffer in other domains of functioni ng (Friedman, Kutash, & Duchnowski, 1996). Negative outcomes are often associated with SED, which can include the psychological, social, and educational domains (Friedman, Kutash, & Duchnowski, 1996). The extent to which SED affects a childs well-being, along with the impact to a family, can be severe. Many youth with se vere emotional disturbance have problems transitioning into adulthood, a nd these outcomes create a great social and financial strain
5 in the community. The gravity of the impairments which accompany SED can be successfully addressed by a system of care. Systems of Care A system of care is an adaptive netw ork of structures and processes, and relationships grounded in system of care values and principles that effectively provides children and yout h with serious emotional disturbance and their families with access to and av ailability of services and supports across administrative and funding bounda ries (Hodges, Ferreira, Israel, & Mazza, 2006b). The concept of a system of care is de scribed as an organizational philosophy that is meant to create and provide an in tegrated, community-based service array to children with serious emotional disturbance (SED) and their families (Stroul & Friedman, 1986, 1994). Systems of care emerged from the idea that children with SED and their families often have multiple needs from various service sectors (such as special education, juvenile justice, mental health, and child welfare) a nd that these children would be best served by a coordinated array of services to meet these multisystemic needs (Anderson, McIntyre, Rotto, & Robertso n, 2002). The concept of systems of care began to emerge in 1984 when the Child and Adolescent Service System Program, (CASSP) was created (Kutash, Duchnowski, & Friedman, 2005). This program had the explicit goal of helping various communities develop systems of care for children with SED and their families (Kutash, Duchnowski, & Friedman, 2005). The foundation for systems of care, as outlined by Stroul & Friedman in 1986, developed out of the early CASSP efforts. The role of a system of care is to improve the quality and effectiveness of care necessary to treat ch ildren with SED through a co mmunity-based approach.
6 Stroul and Friedman describe the services in a system of care as being organized into a coordinated network to meet the multiple and changing needs of children and adolescents with severe emotional disturbanc es and their families (1986). Although the system of care philosophy was operationa lized in 1986, little is known about how the various components of the system of care interact to create and sustain a properly functioning system (Hernandez & Hodges, 2003). Systems of care have positive outcomes on the structure, organization, and av ailability of services for children with SED and their families (Hoagwood, Burns, Kiser, Ringeisen, & Schoenwald, 2001). Systems of care were developed with the pur pose of meeting the mental health needs of children and youth with SED and their families (Lourie & Hernandez, 2003). The coordination of multiple agencies may cause c onflicts of organizational identity within the system of care, and is worth investigation. Further, there are certain values and princi ples of systems of care that may relate directly to the study of orga nizational culture. To gain a better understa nding of how these components might contribute to the orga nizational culture of specific systems, a brief description of each of these univers al traits of systems of care follows. Shared Values One of the most critical ideas of importa nce in a community-based system of care is that of shared values. Values should be shared by system stakeholders, and incorporate the values of a system of care as outlined by Stroul and Friedman (1994). These values include services centered around the child a nd the family, and the incorporation of the specific strengths of each child and the family in to interventions. Further, the values of the system should include community-based services, and the community should be
7 considered critical in the design and provisi on of services. Of further importance, the services provided by the system of care should be culturally competent (Anderson, McIntyre, Rotto, & Robertson, 2002). Shared values are frequently identified as an important aspect of an organiza tions culture (Schein, 1985, 1990, 2004). Leadership It is important to remember that le aders in a system of care generate shared values of the system (Anders on, McIntyre, Rotto, & Robertson, 2002). Leadership has consistently emerged as a critical factor in system of care implementation (Hodges, Ferreira, Isr ael, & Mazza, 2006b; Mazza, Ferreira, Hodges, Israel, & Pinto, 2006; Meyers, 1985; National Implementation Research Network, 2005). Relationships exist among these leaders across the system, from service agencies to families, to state and local governments (Anderson, McIntyre, Rotto, & Robertson, 2002). Although the factors which make a good leader may vary, strong leaders in a system of care should be focused on the values of the system and the connections which occur interand intra-agency. Leadership is strongly tied to the cu ltural mores of an orga nization (Schein, 2004). Collaboration Perhaps at the heart of a successful system of care is collaboration. It requires system stakeholders to share in th e responsibilities of a system of care and also to hold steadfast to a commitment to propel and improve the system (Anderson, McIntyre, Rotto, & Robertson, 2002). Systems of care require a collaborative process in both their deve lopment and sustainability (Chorpita & Donkervoet, 2005). Human collaborati on helps to guide the provision of
8 appropriate, community-based services. At the heart of system collaboration is the idea that if leaders and stakeholders of the system coordinate and focus their efforts, various agencies will be able to provide multi-systemic services to the children and families in need. Collaboration, however, is more complex in action than it is in simplified theory. There are some threats to colla boration which can prevent the system of care from providing an array of coordina ted services. Thes e include personal barriers (such as individual mindsets about how to provide services), systemic barriers (like governmental bureaucracies) and environm ental barriers (like the location of services) (A nderson, McIntyre, Rotto, & Robertson, 2002). Some strategies to meet these chal lenges might be cross-system meetings, the facilitation of both written a nd oral communication among system stakeholders, and the creation of an atmos phere that celebrates the success of a system (Anderson, McIntyre, Rotto, & R obertson, 2002). The ability to utilize some of these strategies may relate to the organizational culture of a system of care. Organizational Culture The term organizational culture lacks a universal definition. A literature review in 1995 yielded 15 different definitions of the construct (Hudelson, 2004). The term organizational culture has evolved differe ntly in various disciplines, including anthropology, sociology, business management and medicine (Glisson & James, 2002). It has been noted as a fad among researchers, who saw the term appear in the early 70s in the management literature (Hofstede, Neuijen, Ohayv, & Sanders, 1990).
9 Examining an organizations culture is not unlike the anthropological study of the culture of a foreign grou p of people. There are artifacts such as language, logos, narratives, products, and style of dress (Schei n, 1985, 2004). There are also values, such as those widely-held beliefs about what the organization does and stands for. There are also assumptions which guide the behavior and res ponses of the organization, almost intrinsically. The purpose of organizational culture, simila r to a human culture, is to guide the way that a collec tive group of people responds to internal and external problems. It wasnt until the 1980s that Edgar Schein conceptualized organizational culture and its components into a frequently cited model of this complex phenomenon (Schein, 1985). His definition of organizational culture, useful in this discussion, is as follows: the pattern of basic assumptions that a given group has invented, discovered, or developed in learning to cope with its problems of external adaptation and internal integration, and that have worked well enough to be considered valid, and, therefore, to be taught to new members as the correct way to perceive, think, and fe el in relation to these problems. (Schein, 1985, p.9) Schein incorporated the noti ons of artifacts, values, and assumptions in a simple model that demonstrated the layered nature of organi zational culture. Figure 1. Scheins Model (1985) Values Artifacts Assumptions
10 Artifacts lie on the surface, as the visible components of culture. This includes language, the physical environment, technol ogy, art, stories about the organization, publications, and rituals. Artif acts include all of the observa ble phenomena that is visible in an organization. These are most easily id entified, Schein expl ains, to the outside observer. Values which produce artifacts, are the next group in his hierarchical model. Articulated values are those shared by the or ganization and are norms and rules that guide behavior in the organization. These are harder to identify within an organization, but are commonly held by most members of an organi zation. Values are th e outgrowth of the assumptions of the organization, unspoken rules fo r behavior that are generally so intrinsic that they are not discussed or easil y visible in an organization without thorough investigation. They guide the behaviors and cognition of organizational members. This is the most difficult layer of cultu re to uncover (Schein, 1985, 2004). An example of the models application to a child-serving agency might look like this: the language family-driven care is an artifact of the value that families served by the agency should have control of their ow n service treatment. This value is an assumption of the organization that treatment is most effective when driven by the family. Scheins model has been criticized by other researchers who find the model too static to explain complex organizationa l phenomena (Diamond, 1991; Hatch, 1993). The complexities of an organization, it has been argue d, cannot apply to such a linear model. For example, Hatchs cultural dynamics m odel posits two fundamental changes to the model: symbols are presented as a new element, and relationships and processes between
11 the elements (artifacts, symbols, values, and assumptions) are emphasized. The model appears below: Figure 2. Cultural Dynamics Model (Hatch, 1993) Here, the intermediaries between the elem ents are the processes which truly guide the expression and manifestation of organiza tional culture (Hatch, 1993). The model is more process based than Scheins, and Hatch argues that it is the fluid processes that better explain the mechanisms of cultural expression. Manifestation is the process by which tacit assumptions are transformed into values that are easily recognizable. As ev idenced by the two-way arrows, manifestation is also solidified by the recognition of va lues, which maintain or can even alter assumptions. Hatch proposes that when the values and assumptions of an organization align through the process of manifestation, members expe rience a positive confirmation of their culture. This is an important part of the model, as like Schein, the cultural dynamics model finds assumptions to be at the heart of an organizati ons culture. In this model, however, it is emphasized that ther e is an important reinforcement of the assumptions by the manifestation process. Values Artifacts Symbols Realization Symbolization Interpretation Manifestation Assumptions
12 Realization is the transformation of values in to artifacts, which are the visible aspects of culture. This in itself is anothe r important process, as the artifacts of an organization are the most tangible aspects of organizational culture. Similar to the process of manifestation, real ization allows for the transformation of values into visible artifacts. The artifacts also help to reinfo rce the values, as they remind employees of the values held by an organiza tion (Hatch, 1993). As an example, a mission statement displayed on a wall can reinforce the values held by an organization. Symbolization in the cultural dynamics model is important, as it deals with the concept of symbols not addressed by Sche ins cultural model. Here, symbols are anything that represents a c onscious or an unconscious as sociation with some wider, usually more abstract, concept or meaning (Hatch, 1993, p. 669). Symbols can include logos, stories, slogans, images, architecture, rituals, and charts. Although these are indistinguishable for what can be consid ered artifacts, the culturally dynamics perspective distinguishes the ac tual things which are symbol s from the ways that these things are created and used by the organiza tion. Therefore, sym bolization links the object or artifact to meanings that it is asso ciated with. The artifact must be transformed into a symbol to have any meanings for th e cultural objects or events. Classifying something as a symbol highlights the idea that certain artifacts hold more symbolic potential than others. Sealing the cultural dynamics model is the process of interpretation The notion here is that symbols can be reinterpreted with new meanings into the basic assumptions held by members of an organization. This, Hatch argues, allows for an organization to take symbolized content into the dynam ics of an organizations culture (1993).
13 The particular usefulness of the cultural dynamics perspective is the attention that is given to the actual processes between the levels of culture (artifacts, values, and assumptions). The addition of symbols are on ly, fundamentally, an abstraction of those artifacts that are bei ng interpreted by members of an or ganization. The nuance here is that artifacts can be symbols at various tim es, but only when they are being used to interpret and create organizational culture. Otherwise, they can be simply defined as artifacts (Hatch, 1993). The attention to the pr ocesses between levels of culture provides a particularly relevant unders tanding of the study of orga nizational culture in complex systems. Organizational Culture in Child-Serving Agencies Although organizational culture has been used to study organizations in the private sector since the 1970s, non-profit and so cial service sectors are just beginning to utilize the concepts (Glisson & Hemmelgarm 1998; Glisson & James, 2002). As in private businesses, the culture of an agen cy is useful for determining why some businesses are more successful than others (Glisson & James, 2002). Organizational culture in social serv ice agencies are important, as it has been found to determine the behaviors of workers, which in turn can lead to organizational success (Ashkanasy, Wilderom, & Peterson, 2000). Several studies have recently been used to examine organizational culture in childrens mental health services, and results consistently demonstrate the importance of organizationa l culture in child serving organizations (Glisson & Green, 2006; Glisson & Hemm elgarm, 1998; Glisson & James, 2002; Hemmelgarn, Glisson, & James, 2006).
14 The definition and model of organizational culture used in these studies parallels the models previously presented in this paper. The authors cite the construct supplied by Rousseau (1998), which states th at organizational culture is layered. That is, norms and behaviors are the outside layer that is visible to workers and outside observers, and the inner layers is comprised of those assumptions and values th at are intrinsic to norms and behaviors. The model is further defined by Hofstede (1998) who posits that invisible values drive visible behavior within an organization. Th e researchers using the model use it to reinforce the belief that workers may not be aware that they are internalizing the assumptions and values that are driv ing behavior (Glisson & James, 2002). These researchers also differ from trad itional organizational culture research in that they support the idea of organizational context which is comprised of organizational culture and climate. Climate refers to wo rkers perception of the work environment on their performance levels (this includes depe rsonalization, role overload, and emotional exhaustion) (Glisson & Green, 2006). The researchers combin e this with organizational culture to create the o rganizational context construct. This is important to understand when examining the results of their resear ch studies. While they have shown a connection between organizational culture and success, it is not al ways separated from the effects of organizational climate. Their research focuses primarily on child welfare and juvenile justice. These agencies are stressful environments, as jobs in these sectors can ha ve high demand with little compensation (Glisson & Green, 2006). Further, these systems are often perceived to be ineffective and often have defens ive cultures, due to the many bureaucratic procedures like paperwork, litigation, and defense against public criticism (Glisson &
15 Green, 2006). These agencies also have low job satisfaction and high turn-over rates, which can contribute to negative climate and culture (Hemmelgarn, Glisson, & James, 2006). Conversely, positive organizational culture s are more prone to incorporating inventive approaches and i nnovative technologies (Hemme lgarn, Glisson, & James, 2006). Innovation is always a concern in child serving agencies, as st akeholders strive to produce more desirable outcomes with new services and programs. It has been found that organizational cultures that are flexible and comfortable with taking risks are more successful in adapting these new technologi es (Hemmelgarn, Glisson, & James, 2006). The successful adaptation of soft technologies , like new mental health treatments, is frequently determined by the organizational cu lture within which they are implemented. The authors cite evidence-based practices (EBPs) as an example of a soft technology. Evidence-based practices and their incorporation into childrens mental health systems are a current topic of concern in services research (Pint o, Israel, Hodges, Ferreira, & Mazza, 2006). As mental health communities focus on the incorporation of evidencebased practices into existing se rvice arrays, attention should be paid to th e cultures in which they are being adopted. Building on research of adaptation of EB Ps by child serving systems, Aarons and Sawitzky (2006) focused their efforts on examini ng the cultural factors that contributed to the adoption of EBPs. They examined c limate and cultural factors from 301 public mental health service providers serving youth and their families. They found that those agencies with more constructive cultures had more positive attitudes towards the incorporation of evidence-based practices into their service array. They identified
16 constructive cultures as those environments that place emphasis on support, interpersonal relationships, and performance. Constructive cultures are also more likely to support conflict resolution and creative approaches to se rvice delivery and treatment. In contrast, those agencies with less constructive cultures were less likely to foster EBPs introduced into practice. Other studies have confir med that human serving agencies with less constructive cultures can be closed off to new innovation (Glisson & James, 2002). In one study, Glisson and Green (2006) st udied the effects of culture and climate on access to mental health care for children invol ved in juvenile justice and child welfare agencies. Social factors that contribute to th e referral of children to mental health care can include expectations and at titudes of case managers that work within juvenile justice and child welfare. Glisson and Green hypothesi zed that these factors would contribute to referral of children to mental health care se rvices. Their sample included 588 children involved in child welfare and juvenile jus tice case management un its across 21 urban and rural communities in Tennessee. Results fr om the study showed that children being served by units with a constr uctive organizational culture were 11 times more likely to be referred to appropriate mental health services. Their finding s suggest that childserving systems should place effort into build ing and sustaining cons tructive cultures. Glisson, Dukes, and Green (2006) found that ch ildren being served by case management teams with more positive cultures were more likely to be referred to mental health agencies. This is relevant in that many ch ildren being served by su ch agencies have the need for mental health treatme nt (Hernandez & Hodges, 2003). Significance of Study & Research Objectives
17 The literature shows that a strong orga nizational culture has been linked to positive outcomes in child serving agencies, such as low staff turnover and increased performance by workers (Glisson & Gr een, 2006; Glisson & Hemmelgarm, 1998; Glisson & James, 2002; Hemmelgarn, Gliss on, & James, 2006). However, organizational culture in systems of care has not been form ally researched. Because systems of care require the interaction of multiple agencies, a thorough analysis of organizational culture in systems of care will provide insight into these multi-agency structures. Although isolated studies of organizational culture have been conducted in these individual agencies (e.g. ch ild welfare, juvenile justice), no study has examined the organizational culture of successful, holistic systems of care that involve multiple agencies such as child welfare, juvenile just ice, mental health and education. This study will offer a cross-site comparison of thr ee system of care sites researched in Case Studies of System Implementation. Evidence of the three levels of organizational culture identified in Scheins model will be systematically examined to identify similarities and differences across the systemof-care sites. Evidence of the alignment of each level of culture (e.g. translation of values into artifacts) will also be re searched. Results will serve to generate future hypotheses on the function of organizational culture in systems of care.
18 Chapter 3 Methods Secondary Analysis (Case Studies of System Implementation) The purpose of Case Studies of System Implementation is to identify strategies that local communities undertake in impleme nting community-based systems of care and provide greater understanding of how factors affecting syst em implementation contribute to the development of local systems of care for children with serious emotional disturbance (SED) and their families. This study assumes that the processes c ontributing to system development cannot be adequately understood in terms of linear progress toward a goal. Given the complexity of SOCs, the structures, processes, a nd relationships contributing to system implementation should be studied holistically in order to understand the relationships among factors that support system implementation. To accomplish this, the Case Studies of System Implementation study used a multiple-case embedded case study design (Yin, 1994) to investigate how communities operati onalize and implement strategies that contribute to the development of community-based SOCs for children with SED and their families. A case study design explores a bounded system over time through detailed and indepth data collection that makes use of multiple sources of information (Creswell, 2003; Stake, 1995; Yin, 1994). Case studies are pa rticularly useful when phenomena are investigated within their real-life context and when the boundaries between phenomena and context are not clearly evid ent (Yin, 1994). They can be usef ul in the investigation of
19 phenomena that are greatly influenced by the overall socio culturalgeographical context, and in studies that intend to provide informa tion about important processes as they evolve over time. The unit of analysis in a case study desi gn determines how the study relates to a broader body of knowledge. In this study, the un it of analysis is the community-based SOC at participating sites. Each site is the subject of a separate case study, and this study is covering multiple case sites. Specific stra tegies related to the system implementation factors serve as the embedded units of study within each individual site. Site Selection Criteria A national nomination process was conducted to identify established SOCs. This process included the solic itation of nominations thr ough the Children, Youth and Families Division of the National Association of State Mental Health Program Directors, Center Dissemination Partners, Center Adviso ry Board, Department of Child and Family Studies staff, and an 18-member panel of national experts on we ll-functioning SOCs. Detailed document review and te lephone interviews were used as the basis for final site selection. Site selection criteria included sites that have identified needs for a local population of children with SED; have a set of goals for this p opulation that were consistent with SOC values and principles ; are implementing strategies to achieve progress towards these goals; and have demonstr able outcomes related to achieving those goals. In addition, system stakeholders had to ha ve the ability to reflect on key transitions during system development. Selected Sites
20 The study sites were selected via a purposive sampling method. Sites were selected for variance in terms of populati on density, racial/ethnic composition, and the way in which their systems of care were developed and sustained. The variety of landscapes make the data rich for studying organizational culture in a multitude of contextual settings. Region III Behavioral Health Care, Nebraska. Region 3 Behavioral Health Services (one of six regions in the stat e) is a 22-county area, which covers a 15,000 square mile area in rural central/south Nebraska. Region 3 has a population of approximately 223, 143 people. The racial/ethnic composition is 98% white, 2.2% Hispanic/Latino, 0.3% Native American, a nd 0.2% Black/African-American. The median household income is $31,867; 12% of all fam ilies are below the poverty level; and 16% of children under age 18 are below the poverty level (U.S Census Bureau, 2000a). Region 3 began its system of care effo rts in 1989 when a new position in each region was created by the state legislature to focus on childrens mental health on a system level. In 1997, Region 3 received a 5-year SAMHSA/CMHS system of care grant which allowed for a strengthening of thei r service array (Hodges, Ferreira, Israel, & Mazza, 2007). The system of care is a co llaboration between the Behavioral Health System and the Department of Child Protec tion and Safety (a combination of Children Welfare and Juvenile Probation), as well as the Department of E ducation and the local family organization. Region 3 is currentl y serving as a statewide system of care model(Hodges, Ferreira, Israel, & Mazza, 2007). Region 3 Behavioral Health Services was selected for analysis of organizational culture because it is the only rural site samp led. For this site, there are 27 interview
21 transcripts available for coding, as well as not es from 5 observations that occurred during the data collection process (Fall 2005). Santa Cruz County, California. Santa Cruz County, California is comprised of 441 square miles and a population of approximately 255,602 people (U.S. Census Bureau, 2000b). The racial/ethnic composition is 75% white, 26.8% Hispanic/Latino (of any race), 3.4% Asian-American, 0.2% Native American, and 0.7% Black/African American. The median household income is $53,998 and 6.7% of all families are below the poverty level (U.S. Census Bureau, 2000b). Approximately 27.8% speak a language other than English inside the home (U.S. Census Bureau, 2000b). In 1989, the Santa Cruz County system of care began, when the county received a grant through AB377 (the Childrens Mental Health Services Act). This grant provided funding to expand to additional count ies the Ventura County System of Care pilot project. Development was further supported by a 5-year SAMHSA/CMHS system of care grant which the county received in 1994 (Hodges, Ferreira, Israel, & Mazza, 2006a) Santa Cruz has been described as a b ifurcated county (Rosenblatt, Giffin, Mills, & Friedman, 1998). There are notable demographic differences between the north and south sections of Santa Cruz County, wh ich can make service delivery challenging. The south portion of the county is described as having a largely migrant and low income population (Rosenblatt, Giffin, Mills, & Fr iedman, 1998). A higher Latino population in South County creates a critical need for bili ngual staff, although a shortage of bilingual staff is a challenge throughout the county (Hodges, Ferreira, Isr ael, & Mazza, 2006a). Santa Cruz County was select ed for analysis of organizational culture because of its notable demographic differences. For this site, there are 35 interview transcripts
22 available for coding, as well as notes from 7 observations that o ccurred during the data collection process (Fall 2006). Westchester Community Network, New York. Westchester County, New York is 1,295 square miles and is the county located north of New York City. Westchester County is an urban population of approxi mately 920,000 people (U.S. Census Bureau, 2000c). The Westchester County Community Network has community networks in ten communities around the county, including Eastchester, Lakeland, Mount Vernon, New Rochelle, Peekskill, Port Chester, White s Plains, and Yonkers. The racial/ethnic composition is quite diverse in the differe nt communities located within the county. Overall, Westchester County is approximate ly 15.6% Hispanic/Latino, but some of the communities lie far from this number (Portchester is approximately 50% Hispanic/Latino, while East chester is only about 5%). There is a burgeoning Hispanic/Latino population in many of the communities serv ed by Westchester County (Hodges, Ferreira, Israel, & Mazza, 2006a). Westchester Community Network has its early roots in the first community network meeting, held in Mount Vernon in 1978. In 1989, the county received a small New York State grant to deve lop a coordinated system of care for children with SED and their families. System of care work continued to grow in Westchester County through the nineties. In 1999, Westchester County received a 5-year SA MHSA/CMHS system of care grant in order build upon their work with SED youth and their families (Hodges, Ferreira, Israel, & Mazza, 2007c). The Westchester Community Network was se lected for analysis of organizational culture because of its urban population and gras sroots development. For this site, there
23 are 38 interview transcripts available for codi ng, as well as notes from 7 observations that occurred during the data co llection process (Summer 2007). Data Collected The investigation used a multiple-case embedded case study design to investigate how communities operationalize and implemen t strategies that contribute to the development of community-based systems of care for children with SED and their families. Case study data was collected using semi-structured interviews with administrators, managers, direct service staff and families; direct observation; document review; and a review of aggregate outcome data. A brief description of these methods follows. Documents were used to provide organi zational-level data related to system implementation as well as system-of-care deve lopment in a historical context. Documents included materials related to goals and in tent of the system, legislative history, regulations or guidelines, budget justifications, monitoring re ports, annual reports, and reports of accomplishments. Factor brainstorming and rating were conduc ted in order to identify local factors believed to be critical to system-of-care implementation. Local system implementation factors and definitions were identified by st akeholders at each site using a Factor Brainstorming Exercise with key system leader s prior to on-site data collection. A Factor Rating Exercise was then used to validate the locally identified system implementation factors by a broader group of system stakeholders. The survey was a rating of the identified factors on a five-point scale with regard to both their importance and effectiveness in local efforts to develop systems of care.
24 Semi-structured interviews were conducted in person and by telephone for the purpose of understanding personal perceptions and beliefs about the process of systemof-care implementation and the role of the identified implementation factors in local system development and their relationship with one another. Interviews lasted 1 hour and were held at a time and place that was conveni ent for the interviewees, and sites assisted in identifying the key people to be included in the interview process. All interviews have been professionally transcribed. Observation of service delivery structur es and processes were conducted for the purpose of observing aspects of system impl ementation in action. Direct observations were coordinated with naturally occurring agency and community meetings. Each researcher attending meetings or observati ons took field notes on the processes and actions. Analysis All narrative data collected were analyzed for themes using the Atlas.ti qualitative software package (Scientific Software Deve lopment, 1997). The analysis was conducted using the framework of Scheins model orga nizational culture. Interview transcripts served as the primary data source, with suppl ementation of other data (locally-identified implementation factors, documents, and obs ervation data) for triangulation. For each site, examples of artifacts, values, and assumptions were identified. Evidence of the alignment of the three levels of culture we re examined. The following table outlines the operational construct of each of those levels.
25 Table 1. Construct Matrix Artifacts Visible struct ures and processes Examples: Language, narratives, logos, artwork, physical structure, publications Values Shared, articulated beliefs that stakeholders deem critical to system functioning or service delivery Assumptions Tacit rules th at guide behavior and decision-making Atlas.ti allows for analysis that can be done in an iterative process, and facilitated the development of emergent codes as the analyses were conducted. The analysis involved independent review a nd coding of the data by the in vestigator, as well as the identification of themes that were common acro ss sites. The Atlas.ti software allows for multiple levels of analysis that can be conduc ted in an iterative fashion and allows the coding of data into identified categories, a nd the ability to add comments that are linked to specific passages, codes, or families of codes. The initial coding schemes were guided by the constructs of Scheins organizatio nal culture model (ar tifacts, values, and assumptions). Additionally, the use of Atlas.ti facilitated the development of additional codes as the analyses are conducted. Themes and patterns emerging from the data were identified. Any emergent themes were rea pplied to the data set for further analysis, utilizing a systematic comparison method for en suring that new data is accurately coded (Strauss & Corbin, 1998). The researcher will give attention to the rigor and quality of data analysis. For the purpose of establishing construct validity, the triangulation of data will be used to build explanations through convergent evidence. An additional member of the RTC Study 2 research team trained in qu alitative data analysis offered a spot-check
26 of classification of the data, and any adjustme nt of coding schemes we re made to insure the validity of the data.
27 Chapter 4 Results Because of the research questions an d data collection methods used in Research and Training Center Study 2: Ca se Studies of Implementation the results of this study on organizational culture are presented through the lens of the implementation factors identified at each site. For the purpose of presenting the results, the implementation factors that were related to the values of th e system were identifie d as the organizational culture values for each site. Factor Methodology For Case Studies of System Implementation, locally derived system implementation factors were generated by key stakeholders at each participating community through a factor brainstorming pro cess that was conducted prior to onsite data collection. The brainstorming process was used to both identify and define critical factors in local system implementation. The research team worked closely with key system leaders via conference calls a nd reviewed documents to iden tify the factors considered critical in developing the system of care. Ke y stakeholders then provided definitions for these locally identified factors. A ratings exercise was subsequently used to validate the locally identified system implementation factors by a broader group of sy stem stakeholders. Interview participants were asked to complete a mail-in questionnair e in which they: 1) validated each factor and its definition, 2) noted the importance of each factor in the establishment and/or sustainability of the system, 3) rated each factor in terms of ease/difficulty of
28 implementation, and 4) rated each factor in terms of effectiveness of the system in implementing the factor. Therefore, each de finition was agreed upon by a larger group of respondents. For all sites, there was strong agreement for all definitions. Using the factor definitions, the rese arch team first grouped the system implementation factors into categories accord ing to their primary role in system functioning. The factors can be clustered into four categories as shown in Table 2. These clusters are a result of an early framework that was developed to analyze results of the case studies (see Hodges, Ferreir a, Israel, & Mazza, 2006). Table 2. Roles of Factors (Hodges, Ferreira, Israel, & Mazza, 2006b) 4 Roles of Factors Definition 1. Facilitating System Values Those factors that are related to the intrinsic philosophy that is fundamental to the system of care. 2. Facilitating System Goals Those factors that are broad-level goals that direct the SOC and brin g it under the control of a single plan. 3. Facilitating System Information Those factors that are related to the availability of feedback to system stakeholders 4. Facilitating System Structures Those factors that are related to specified roles, responsibilities, and authorities that define organizational boundaries and enable an organization to perform its functions. For the purposes of this analysis, factors that facilitate system values served as identified values in the analysis. The table below summarizes the values id entified at each site. For a full list of factors and definitions, please see Appendix B. Each value-based factors at each site was reviewed for corresponding artifacts and assu mptions. A profile of the organizational culture at each site is presented.
29 Table 3. Identified Values at Research Sites Region 3 Behavioral Health Services Site Profile Thats our culture. Because of our ruralness, we dont have everything, so we have to depend upon others to help each other. In times of struggle, nobody even thinks a second time to go help a neighbor out, or going across the state to help somebody. We cant have everything we have so limited resources, we pull our resources together. Thats how come it looks good. Family Member, Region 3 Behavioral Health Services Research Site Identified Values Region 3 Behavioral Health Services Collaboration Family and Youth Participation Leadership Responsiveness to Change Shared Vision Santa Cruz County Cultural Competence Interagency Collaboration System of Care Values Willingness to Change Westchester Community Network Community Organization Model Courage to Change Leadership Shared Values and Goals
30 The image above is a logo found on Region 3s publications. It outlines the 22 county region of Nebraska th at is covered by their servic es. The background in this picture reflects the landscape in which se rvices are provided. Region 3 covers 15,000 square miles in the south central part of the state, with a popula tion of approximately 223,143 people (U.S. Census Bureau, 2000a). Th is designates the region as a rural population, which is reflected in this logo. Suggested artifacts, values, and assumpti ons of the organizat ional culture in Region 3s system of care summarized in Table 4. For each value, the implementation factor related to that value will be discussed, followed by the artifacts and assumptions related to each implementation factor. Table 4. Region 3 Results Artifacts Values Assumptions Co-location; paycheck Collaboration Required for success in rural environment. Three-legged stool Family & Youth Partnerships Critical to system success. The Chili Story. Leadership Required for the shared vision; everyone is a leader. All stakeholders able to articulate a shared vision. Shared Vision SOC principles benefit children and families. Adapting the EICC from the ICCU Responsiveness to Change There is no other way to function. Figure 3. Region 3 Services Map.
31 Strikingly, the rural culture of the area is very much reflected in the organizational culture of the system of care. The values identified in the factors created by Region 3 were: Collaboration, Family & Youth Partic ipation, Leadership, Shared Vision, and Responsiveness to Change The consequences of providing services in a rural environment are reflected in many of the values of Region 3, specifically in the articulated value of collaboration. Collaboration in Region 3 is evidenced by an established level of trust, and stakeholders have developed networks across all service sectors, engage in collective problem solving, and share resources across system partners. Data indicate that stakeholders share a genuine commitment to collaboration and what it means. Stakeholders within Region 3 stressed the uni queness of the rural/fr ontier landscape, and stated that there is a frontier attitude in which providers mu st work together and support each other in order to be successful. Therefor e, the rural landscape serves as an impetus for system partners to sustain collaboration. Collaboration was identified by key stakeh olders as a factor critical to system implementation. The definition created by stakeholders describes the nature of Collaboration in Region 3: Collaboration is described as a process that involves relationships and partnerships with families, providers, child/family service entities and other leaders. It is characterized by a commitment to shared vision, and mission and support by all participants to system of care objectives. Collaborators have mutual respect for one anothers roles and responsibilities. They leverage, sh are and maximize resources and also share responsibility and accountab ility. Collaboration involves a commitment to learning and provi ding educational opportunities for system partners.
32 The strongest evidence of collaboration in Region 3 is found in their physical structure. In Region 3, sta ff from various agency partne rs are co-located. As one supervisor stated while discussing the coor dination of services among various agency partners, We are all housed toge ther, were all on the same floor. And I think that helps the rapport. I think its impor tant to house them together. That way you can just develop those relationships better. Th is quote reflects the notion that co-location as an artifact is not only evidence of collaboration, but a perceived facilita tor as well. Several stakeholders discussed collabor ation of agency partners as being so effective that the only notable difference between employees was the signature on their paycheck. This common theme reflects the depth to which collaboration in Region 3 has been established. You wouldnt know the di fference between the staff except who signs their paycheck, stated one administrator. This was similarly echoed in statements such as The only main difference [between worker s] is the paycheck, and what we wanted it to look like that was so integrated that no one would know who worked for who, that the only difference was their paycheck. This common phrase and use of the language reflects the value that the colla boration of agency partners is clearly evident in Region 3. The collaboration of agency partners is so successful, they are not distinguished as separate agency partners, but as a cohesive group. One stakeholder described collaborati on as a mindset of participants and facilitators. This reflects the tacit assump tion that guides stakehol ders to collaborate. Further assumptions found in the data indicate that there is also the belief that most partners understand the impor tance of collaboration in a rural environment with few resources, both financial and in services. The assumption that is that the rural landscape
33 serves as an impetus for system partners to value collaboration and to ensure its sustained success. Region 3 has indeed created stru ctural changes that have strengthened collaboration, like the co-locati on of staff from various agen cy partners. The assumption is that the system must continua lly strive for collaboration, sin ce it is required in this rural region with scarce resources. The definition of Collaboration provided by system stakeholders describes it as a process that involves relationships and partnerships with families, providers, child/family serving entities and other leaders One of the most striking values in Region 3 is that of empowerment of familie s and youth within the system. More than facilitating family/youth voice in the clinical process, data indicate that family and youth are viewed as critical to sy stem functioning. This is evid enced by the active involvement of family members that serve on boards at a ll levels of the systems, a strongly active family organization (Families CARE) and a youth-run advocacy organization (YES) that is involved both locally and on state and natio nal-boards. Families CARE has been an equal partner in the syst em from the beginning. Family and Youth Participation was iden tified as a critical factor to system implementation. This was the definition creat ed by key stakeholders describes Family and Youth Participation in Region 3: Family and Youth Participation is described as an important process through which the roles families and youth are integrated within the system. In these roles, family and youth participants ar e involved in all critical aspects of the system including service delivery, planning, implementation, and evaluation. Families and youth are values as participants in the system and their involvement allows other stakeholders to understand the importa nce of family voice, choice, and leadership in the organization. Fa mily and youth participation is facilitated by a strong family organi zation. The expressed goal of family and youth participation is fam ily driven/youth guided care.
34 Four stakeholders mentioned the three-legged stool in semi-structured interviews. According to a program administ rator, stakeholders understand the legs of this stool to be, The family, Health a nd Human Services, and Region III (Health and Human Services is a system partner). Interv iew data further indicated that for Region 3 stakeholders maintaining this balance is important, specifically as it concerns the family. This stool is not going to stay up right if one of the legs goes, voiced one respondent. One system administrator echoed this sentiment: And the three legged stool will not be level if you have someone with a lot more knowledge than the others have. Data indicates that the concept of the three-legged stool and the understa nding that one of the legs is the family organizat ion demonstrates how deeply embedded the value of family and youth participation is in Region 3. The assumptions underlying the value of family and youth participation in the system was reflected in both interviews and factor ratings data. Most system stakeholders truly believed that family and youth are crucial to the systems functioning at multiple levels, from the clinical service level. Implementation of services depends on the family, responded one stakeholder in th e factor ratings exercise. This was echoed in another sentiment by another respondent, Nothing happens without the family. On an even broader level, the assump tion of the benefits of family and youth participation in the system goes beyond the provis ion of clinical servic es. There is the idea that commitment to voice and choice for fam ily is critical to system success. This data implies that stakeholders in Region 3 have a shared belief in the importance of family and youth participation at a system level. Evidence at all three levels of Scheins
35 model (artifact, value, assump tion) suggests that this value is well embedded in the organizations culture. Evident in a discussion of family a nd youth participation is the leadership provided by family and youth within the system As discussed in the review of the literature, leaders in a system of care help to cultivate the values of the system (Anderson et al., 2002). Relationships exist among these leaders across the system partners (Anderson et al, 2002). This is important, as lead ership is invariably linked to the cultural values of an organization (Schein, 2004). In Region 3, data indicate that ther e are exemplary leaders across all system partners and they are described as passi onate, strong, and possessing a shared vision. Leadership in Region 3 was described as: A process that supports a strong and shared vision among empowered stakeholders including agencies, families and providers. Leadership is based on a strong commitment to the values, goals, and mission of the system of care and a belief in the systems ability to achieve result s. Leadership facilitates the sharing of authority and responsib ility, and it fosters a vision for the future and understanding of how to get there. Leadership is characterized by all system st akeholders accepting and having power to carry out th eir responsibilities. In Region 3, the narrative/myth called The Chili Story illustrated how the system leaders came together in the stat e capitol and came up with the idea of implementing a system of care in Region 3. As one system leader stated, We came up with this (chuckles) great idea over the 50 cent cup of chili at the state capitol. This story extended to other stakeholders in the system, who use it to c ite the leaders coming together to form their system. Although this story is often cited, not all system members know much about it. One partner in the fa mily organization stated, I dont think Ive
36 ever heard the full chili story. I heard refe rence to it once. What is evident from interview data is that The Chili Story is a narrative that allows stakeholders to link the beginning of the system to the leaders in a familiar way. It also reflects the value of collaboration and shared vision within the system. Some of the assumptions around leadersh ip are found in other values of the system, which is consistent with Scheins id ea that leadership within an organization is critical to enforcing shared values in that specific culture (Schein, 2004). For example, in Region 3, leaders were identified as the mai n champion to bring others to the shared vision, and play an invaluable role by h elping all stakeholders understand the shared vision. This is also evident in the local defi nition of leadership, in that it is described as a process the supports a strong and shared vision among empowered stakeholders. Another assumption of leadership within the system, identified in their definition, is that it is characterized by all system stakeholders accepting and having the power to carry out their responsib ilities. This assumption translat es to all system stakeholders feeling capable of holding positions of leadership or make leadership decisions. Data indicated that processes of ensuring that all workers have an opportunity to sit on the leadership board for a period of 3 months demons trates that this behavior is enforced by system processes and is part of Region 3s culture. Leaders were identified as playing an i nvaluable role by hel ping all stakeholders understand the shared vision of Region 3. Th is shared vision is synonymous with many of the original federal CASSP principles and have been fortified and supplemented over time to include an emphasis on cultural competence and family/youth-driven care. This trend is tantamount to the system of care move ment on the federal leve l. Region 3 started
37 its system of care efforts while recipient of a CASSP grant, so it is not surprising that these are retained in the vision of the system. Stakeholders described the shared vision of Region 3 as: A strong desire to achieve better outcomes for children and families that is based on a common belief that system of care principles will benefit children and their families. This shared vision also includes building upon modes of services delivery that are al igned with system of care values and principles including access to commun ity-based services throughout rural and frontier regions of the system, im plementation of promising practices and evidence-based care, and using the wraparound approach to deliver services and supports. Stakeholders describe a determined effort to communicate this vision. Overall stakeholders are ab le to articulate a shared vision, and they demonstrate their self-awareness of this valu e. We can all mouth the shared vision and know that its really what we all want to do. We want to create something that makes it better for children and families. Weve all got that shar ed vision. Evidence of this vision was not found in other agency documents or available da ta. However, system of care values and principles are present in more specific ways, including the emphasis on family-driven care within the Region. One assumption of valuing a shared visi on is embedded in the locally-generated definition itself. The defini tion describes a shared vision as being based on a common belief that system of care principles will be nefit children and their families. There is also the assumption that the shared vision is commonly und erstood by various levels of staff and stakeholders within the system of care. Responsiveness to Change was grounded in the values and beliefs of the system. A general feeling within Region 3 is that ch ange is an ongoing process, and they are never finished with building the system. Re sponsiveness to Change was identified as:
38 as innovation as well as the willingness to adjust planning and implementation based on the systems experiences. Innovation is reflected in the ability to combine models and try new approaches to service delivery and system design. The flex ibility to adjust planning and implementation is created by the availab ility of constant feedback and the willingness to take action on feedback given. Processes that support constant feedback include meetings at all levels and across all parts of the system and 360 feedback loops. This responsiveness includes being open to changes that provide funding opportunities. One salient example of an artifact in Region 3 for a responsiveness to change was a new effort to curtail the needs for costly, deep-end services. One program in the array of services provid ed by the Region is the Integrated Care Coordination Unit, a specialized intens ive wraparound program for wards of the state. Based on positive success and cost savings created by this program, system stakeholders realized that a similar ty pe program could implemented for those youth at-risk of becoming wards, a growing number of youth in Region 3. Stakeholders used funds to implement the Early Intensive Care Coordination program to prevent children from becomi ng state wards, and data showed this programs ability to divert out-of-hom e placements for those children and youth at risk of being removed from the home. This is one example of how the program used strategic planning to create and res pond to changing needs, in an effort to respond to what works and applying it to programs in order to serve a broader population. Responsiveness to Change was described by stakeholders as an understanding that this was the way they do business. This wa s reflected in such quotes as I just dont know how else you do things, said one stakehol der. That is so much a part of our lives, said another, We don t even think about that. A value like Responsiveness to
39 Change was identified as one of the str onger elements of Region 3s culture. One stakeholder noted, This is our culture, we are not satisfied unless we are asking What if? and then willing to change based on resu lts and data. So here, Responsiveness to Change closely fits with Scheins descri ption of an assumption, an unspoken rule for behavior that is deeply intrinsic (Schein, 2004). Santa Cruz County Site Profile Santa Cruz County, California is compri sed of 441 square miles and a population of approximately 255,603 people (U.S. Cens us Bureau, 2000b). The racial/ethnic composition is 75% white, 26.8% Hispanic/Latino (of any race), 3.4% Asian-American, 0.2 Native American, and 0.7% Black/African American. Approximately 27.8% speak a language other than English inside the home (U.S. Census Bureau, 2000b). Santa Cruz has been described as a bifurcated count y, which means that there are notable demographic differences between the north and south portions of the county. South County has a largely migrant and low inco me population (Rosenblatt, Giffin, Mills, & Friedman). This higher Hispanic/Latino popul ation creates a critic al need for bilingual staff and culturally competent servic es. This need is highlighted by Cultural Competence one of the values of the organizational culture of the system of care It is more of a culture thats created this ability to operate in th is kind of way. And I think that culture is a combination of the si ze of our community. The actual culture of Santa Cruz County. It really is a culture. Weve got people who think similarly and have shared values. Child Welfare Administrator, Santa Cruz County
40 Suggested artifacts, values, and assumptions of the organizationa l culture of Santa Cruz Countys system of care are presented in Table 5. Table 5. Santa Cruz Results Artifacts Values Assumptions Collaboration with Hispanic organizations; literature in Spanish; training and education on cultural issues. Cultural Competence Critical because of the high Hispanic population. Emphasis on understanding language and dialects of various agencies; collaborative efforts. Interagency Collaboration Necessary to seamlessly integrate services for children and youth At home, in school, out of trouble. SOC Values Accepted as an underlying core value to keep children in the community. Continuous development and system expansion. Willingness to Change Change is required for sustainability. The values identified in the factor s created by Santa Cruz County system stakeholders were: Cultural Competence, Interagency Collaboration, System of Care Values, and Willingness to Change The value most affected by local context is that of Cultural Competence, which highlights the systems st ruggle toward serving the local population. Cultural Competence was described by respondents as a core value of our system that is supported on all levels of program design and implementation. In the 2005-2006 fiscal year, approximately 45% of the youth being served came from Hispanic/Latino families. Maintaining the value of cultural competence was not without its challenges, as stakeholders described the difficulty of the implementation. It requires relentless attention and ongoing education, no ted one respondent. Cultural Competence was described as:
41 a core value of the System of Care, manifesting in strategic interagency processes to promote cultur ally relevant and sensitive services at all levels of the system. It incl udes an evolving focus on underserved and inappropriately served populations and a responsiveness to changing populations, including specific chan ge-efforts in key departments. The evidence of cultural competence is widespread in Santa Cruz County. For one, brochures and pamphlets across systems are widely available in Spanish. Training in cultural competence has risen from 26% to 84% of employees attend ing in the last five years, suggesting a strategic focus to the va lue of cultural competen ce. Other structures that have been created by stakeholders, wh ich include strong efforts in outreach and engagement to Hispanic youth and families. These include the development of alternate pathways to care, which involve Hispanic co mmunity-based organizatio ns rather than the formal public system, and with which Hispan ic families may be more comfortable and engaged. These artifacts demonstrate that th e Santa Cruz County system of care is committed to increasing their capacity to serv e those of other cultures, and that this commitment is visible in tangible artifacts (documents in Spanish, outreach materials) and also systemic structures (partnering with Spanish-speaking organizations to provide alternate entrances to the system for Hi spanic families that might otherwise avoid involvement in the traditional mental health system). Underlying the value of cultural competence is the idea that in order to serve the local population, the system must be open to idea of culturally sensitivity and appropriateness. Stakeholders indicate that there is alwa ys more to do in terms of increasing cultural competence, and that i t requires relentless attention and on-going education. This is evident through the ongoing training and efforts to serve minority youth in the system. Overall, cultural comp etence is an ongoing effort by stakeholders,
42 who must support this value because of the high percentage of minority youth in the system. The value of Interagency Collaboration was, for the purposes of Case Studies of System Implementation, originally categorized as a fact or related to system goals, not values. Upon examination of factors for incl usion of this analysis, the definition was reanalyzed for its content. Interagency Collaborat ion has been chosen as a factor related to system values, which is evident in the defini tion through the use of shared values, agency language, and a willingness to learn in the definition created by agency stakeholders. The definition is as follows: Interagency Collaboration is described as the formal and informal System of Care processes that are key to Santa Cruz County's system development. Interagency collabora tion promotes both structured and organic communication and embodies the willingness to learn and seek information about different childserving agencies. Elements of interagency collaboration include sh ared values that are based on welldeveloped cross-system knowledge and are tied to community need. Interagency collaboration promotes jo int training and strategic planning ventures. Interagency collaborati on and commitment are constantly renewed through changing leadership. This collaboration recognizes that the various "dialects" or languages of agency reform are often consistent with each other, allowing reform efforts from mental health, Juvenile Probation, Child Welfare, and Special Education to be mirrored and supported by agency partners. This collaboration helps achieve the seamless integration of reform efforts within participating System of Care agencies. A thorough review of Santa Cruz docum entation uncovers several examples of interagency collaborati on, with a specific attention to understanding other agencies. Examples of inter-agency retreats are av ailable through these documents, which are attended by various agen cy partners in an effort to learn more about one another and collaborate more efficiently. Respondents also emphasized the importance of setting aside personal ego. One common phrase sited in interviews wa s, Leave your egos at the
43 door. When agency partners come toge ther, they focus on setting aside ego and promoting collaborative actions in order to serve youth and families. This commitment to interagency collaboration was evident at multiple levels of the system, from the administrative to the services level. Th ese artifacts included jointly pursuing and administering grants to fund innovative serv ices, creating cross-di sciplinary service teams, co-locating staff across sectors, and creating opportunities for joint problem solving when differences in values or responses to families differed across agencies. For Interagency Collaboration, the assumpti on is that it is what we signed on for when we established our system of care, we spend a great deal of time meetings and working at integration, according to one admi nistrator. This quot e reveals that there may be a tacit agreement by stakeholders to work together. Similarly, one theme emerging from the data was that this type of collaboration is just the way things get done. The assumptions underlyi ng collaboration include sha red values (as stated in the definition), as well as the willingness to l earn, which is further suggested in the idea that different agency partners learn each others language or dialect, in an effort to improve collaboration. This evidence suggest s that Interagency Collaboration is deeply entrenched in the Santa Cruz County system of care. The system of care in Santa Cruz is guid ed by system of care values that bring various agency partners togeth er to achieve their goals. As stated by one stakeholder most people know and accept this as an underl ying core value. The definition created by stakeholders contains language that is reflected across thei r system of care [emphasis original]: System of care values is descri bed as the shared mission adopted across partner agencies to support the original mission of keeping children
44 and youth at home, in school, out of trouble. In addition, the values incorporate new initiatives such as the Mental Health Services Act and Child Welfare Reform which focu s on keeping children and youth safe and healthy. The artifact most tied to the system of care values are examples of language used by system stakeholders in the interview pr ocess. Without prompting, most agency partners reflected their work back to the id ea that children and youth should be at home, in school, and out of trouble. The phrase is on agency brochures and around staff offices. It is evident from interview data that this phrase is clearly repeated and understood by staff, who attempt to link their work with children and families to the goal of keeping kids in the community safe in th e home, in school, and out of trouble with the law. As stated on administrator, We try to infuse those values with our staff early on they coined the phrase Keep kids at home, in school, out of trouble. Also, agency partners are thoughtful about how these values tie in with system action. One probation officer st ated, Weve moved away from the institutional response but really try to have a seri es of graduated responses that are in the community with keeping the kid at home [emphasis added]. Similar quotes reflect that th ese goals guide services for children and families. System of Care Values are accepted as a fundamental core value of the system. One program manager stated, These values exist throughout the sy stem. We really believe in the missionboth clinically at the se rvices delivery level and fiscally at the administrative level. Many stakeholders resp onded similarly, stating that system of care values incorporate the entire system, but that they need constant maintenance to keep all agencies collaborating. The data indicate that the values of system of care are
45 present in Santa Cruz, and stakeholders ar e cognizant of system goals when designing services within the system of care. Connected to system of care values in Santa Cruz was the value of Willingness to Change. One program manager stated, With the core belief in system of care, being flexible and having a whateve r it takes philosophy keeps us going. This flexibility is described in the stakeholder defi nition of Willingness to Change: Willingness to Change is described as the crea tivity, flexibility, and whatever it takes attitude of staff in providing the best care possible within a wraparound philo sophy focused on family needs and strengths; continuous development and system expansion, including a focus on practical application of sy stem of care values an d principles; maintaining adequate supervisory and support struct ures to keep the System of Care robust and vibrant; and incorporatio n of new literature and training on Evidence-based Practices and reform principles within participating agencies. The documentation and processes in Santa Cruz are indicative of a culture that changes and adapts to local needs. One prev iously mentioned example is that of training on cultural competence, which they have increas ed to meet the ever-increasing needs of serving Hispanic youth and families. In inte rview data, administrators noted that they continuously search for funding opportunitie s and work across departments toward achieving system change. Stakeholders in Santa Cruz felt th ere was a shared understanding of the importance of change and also that it is second nature. The assumption of the willingness to change is that being creative a nd flexible allows providers to provide the best care possible (from the definition). Another assumption underlying this willingness is that the various collaborating agencies is Sa nta Cruz are open to the idea of system of
46 care values and the whatever it takes atti tude. All agency cu ltures demand it, said one policy maker in Santa Cruz. Again, the W illingness to Change in Santa Cruz appears deeply entrenched in their organizational cu lture, allowing stake holders to respond to varying changes in community needs. Westchester County Community Network Site Profile Westchester County, New York is 1,295 squa re miles and is the county located north of New York City. Westchester County has a population of approximately 920,000 people (U.S. Census Bureau, 2000c). The We stchester County Community Network has community networks in ten communities around the county, including Eastchester, Lakeland, Mount Vernon, New Rochelle, Peeksk ill, Port Chester, Whites Plains, and Yonkers. Each of these communities is dive rse, in terms of r acial/ethnic composition, income, and community priorities for childrens mental health. Suggested artifacts, values, and assumptions of the organizationa l culture of Santa Cruz Countys system of care are presented in Table 6. Table 6. Westchester Results Artifacts Values Assumptions The network structure Community Organization Model System must be adapted to various community context. Narrative of the leader who started the first network; Family members as leaders. Leadership Leadership should be shared. Strength-based at all system levels. Shared Values & Goals Necessary to drive the system, but not universal yet. Various responses to local challenges and issues. Courage to Change Stakeholders agree to face challenges together. We liked the community organization pi ece because it led to natural cultural competence. If youre gonna build some thing in a community, its gonna have the people in it ideas in it th at reflect that community. Administrator, Westchester County Community Network
47 This diverse urban landscape is similarly re flected in the structures and culture of the system of care. The va lues identified in the factors created by the Westchester Community Network were: Community Organization Model Courage to Change Leadership and Shared Values and Goals Providing services across a diverse county are reflects in many of the values of th e Westchester County Community Network, and the community organization model strongly reflects the response to this local diversity. Westchester Countys commun ity model can be seen as a response to the local context. The system of care structure incl udes ten separate community centers that function within a county that has many diverse n eeds. This structure allows the system to respond to problems and challenges at the comm unity level. More than a structural design, inherent in this mode l are several values critical to the system, including the belief that the community is responsible for re sponding to these needs. It was defined as: The Community Organization Model is central to Westchester Countys system of care. It refers to a strong belief that the community has responsibility for its children and families, and that communities, organized at many levels including the Network level, are key to the success of children and families at high risk/high need. Wraparound and all of the other system of care concepts are built on this framework. While the Network model is Westchesters creative step, it is based on this underlying belief in the power of community and although the model had been replicated elsewhere, it is truly unique to the system of care in Westchester County. The very physical structur e of the system of care is a manifestation of value of community organization. There is an ongoing engagement of all partners in communitybased problem solving around specific issues. Anyone is able to cal l a network meeting (at one of the ten community centers around the county), which creates flexibility in response to local concerns. This organizat ion around local networks allows system
48 stakeholders to be responsive to small sect ors of the county that have very different needs. An example of this local problem so lving is that of fire-setting youth within a particular community, in which the local co mmunity partners were able to mobilize quickly to assess and then address the issue with addi tional training, services, and supports. Partnering with the local fire depa rtment to address fire -setting issues with youth illustrates a strong ex ample of this community organizing. The example of the response to fire-setting youth is evidence of the value of co mmunity organizing. This is directly tied to the belief reflected in the definition of Community Organization Model, that the community has responsibility for its children and families. A few assumptions underlie this value of community organizing. The first is the assumption that the system must be adaptiv e at the community le vel, given the stark demographic differences between communities within the county. As stated in the definition, the assumption is that communitie s, organized at many levels including the network level, are key to the success of children and families. This assumption is perhaps the most fundamental to the system of care, as it cr eates the culture and structure necessary for the system to operate. The other assumption embedded in this valu e is that of community responsibility. As cited in the definition, it refers to a strong belief that the community has responsibility for its children and families. As one administrator noted, Community organizational is really saying to an entire community, Youre all responsible. This was a consistent sentiment throughout all le vels of the system, with one case manager remarking, Were all responsible I feel were all responsib le in making it work. As
49 evidenced by these data, this assumption of community responsibility is held by system stakeholders across levels of authority. The Courage to Change in Westcheste r County was closely tied to values apparent in the Community Or ganization Model. The definition of Courage to Change strongly involves the notion of the community facing challeng es together. The definition for Courage to Change is as follows: Courage to change refers to willingn ess to take the system to the next level and collaborate with one anothe r to effect change, being unafraid to speak openly and honestly about what does or does not work. It also involves taking steps backward or s topping the action when necessary. Partners make an implicit agreement to face challenges together, take risks to achieve goals, and support one anot her throughout the process. Having the courage to change means willingne ss to create new solutions and think outside the box. They share a belief that the system is a dynamic process and that it must change and grow to be vital. Data is used to refine the issues, engage families in the process, bring together system partners, and foster the growth and development of the system in order to bring about needed change. Artifacts for this value include, as evidenced in the definition, the use of data to bring system partners to the ta ble. One salient example was th at of truancy at one of the communities. Community data showed that truancies were high in this community, specifically because it was not reported until a high number of truancies was reached for a particular student. A large community network was called, in which community members, system stakeholders, and school re presentatives came together to change the way in which truancy was reported by the schools The data further indicated that this helped to resolve the issues of high truanc ies. Many stakeholders through interviews cited this as a narrative exam ple of a community coming together to create change. The artifacts that indicate that the Courage to Change is closely tied to the Community
50 Organization Model, as the system responds to challenges and cha nges in an organized manner. For Courage to Change, the data indicate d that it was a cons tant process, and inherent in the definition is the agreement of stakeholders to face challenges together. The Courage to Change was cited by stakehol ders as what makes the system work and a constant process. An assumption is also found in the definition of the value, as an implicit agreement to face challenges together take risks to achi eve goals, and support one another in the process. This indicates th at at its very basic level, the Courage to Change is an implicit value of the Westchester Community Network. In the Westchester Community Network, th e value of leadership was striking in that the notion of leadership is shared acro ss agencies and systems. More importantly, data indicate that families participate in this shared leadership. Leadership in Westchester is defined as: Leadership within the Westchester Community Network began with one charismatic leader who exhibited energy, a sense of purpose, and the ability to communicate well. This le ader strategically hired some likeminded people, and this core group, wh ich continues to exist, became a leadership think tank. Leadership with in the system is based its vision, on shared principles and values, and continues to communicate a sense of purpose and future possibilities. The leadership in the county is enthusiastic, energetic, and pragmatic a nd strongly believes that leadership must be shared across agencies and sy stems. This shared leadership is identified, recruited, and supported on every level and from every system. The definition of Leadership pointed to one charismatic leader, and stakeholders were quick to articulate stories abou t this leader at the creating of the first of the ten community networks in Mount Vernon. A sentiment reflected in interviews was that it was her vision and connections that re ally started the whole process. Despite the
51 focus on this one leader, data indicates that leadership is shared and accessible. The processes in Westchester indicate that leaders are brought up through the systemstakeholders in leadership positions provide narratives of working at the ground level as case managers. Another clear notion of the culture of lead ership that was often articulated by case managers and line level staff is that of family members as leaders. This is also a visible structure. At family meetings, family member s are positioned at the head of the table which makes it visible that they are not merely participants in the pr ocess, but are leading it. Sometimes, being a professional, the fa milies look to us as leadership, noted one case manager, but I look at the families as leadership. Because they know the real needs of their family and they have been doing it, and they will continue to do it when were gone. Sometimes they may not think so, so its up to us to encourag e and promote that. Observational data indicates that these processe s are evident at the child and family level. The assumption uncovered for leadership is that there is a very broad view of leadership and that leadership is shared Another critical assu mption noted by system stakeholders is that leadership should be responsible for developing and fostering both Courage to Change and Shared Values and Goal s. I think the Courage to Change comes from the leadership, noted a school advo cate in the Westches ter County Community Network. Leadership has to create those shared values and goals, noted one administrator. Again, this is c onsistent with the no tion that leadership is responsible for creating and disseminating cultural mo res (Anderson, 2002; Schein, 2004). The Shared Values and Goals of the Westchester Community Network were found by stakeholders to be apparent pretty much on a daily basis. The definition of
52 Shared Values and Goals articulated by sy stem stakeholders goes beyond traditional system of care philosophy to place emphasi s on strength-based a pproaches, as well as social justice goals, defined as the goal of helping children and families succeed within their communities. The definition was described as: The System of Care in Westches ter County is based on a slowly and carefully built shared vision whic h is grounded in core values and articulated across partners. In th e Westchester Community Network, Shared Values and Goals are collectively agreed upon, clearly articulated, and take continuous effort. A constan tly restated values base provides continuity of mission across agencies providers, and communities that includes commitment to individualized care and serving children and families within the community. The values base is aimed at meeting social justice goalsthe succes s of youngsters who would not otherwise achieve successand includes strength-based approaches to both families and systems. The most strongly visible artifacts relate d to this value evid enced the value of strength-based, which was evident, as stated in the articulated value, at all levels of system implementation. The system is genui nely strength based, in that partners strengths are identified and utilized to best serve children and families within the county. At family and team meetings, the strengths of the families are clearly posted on large pieces of paper that adorn the walls during fa mily meetings. At the training site for wraparound case management, posters on the wall remind employees that the strength of the family should always be articulated before problems. At system-level meetings, the first thing shared by members are successes. Strikingly, at meetings observed by the research team, leaders present at the mee ting reminded system me mbers dealing with a particularly challenging issue, We celebrate the small successes. Many stakeholders reported in interviews that the shared values and goals were among the most important factors of system implementation. Shared values and goals
53 were described by respondents as the heart and soul of the work and provide a roadmap of the system. The data indicates that the shared values and goals of the system truly are shared, and the assumption is that even though theyre not universal yet, according to some interview respondents, the values base is becoming more common across systems on federal, st ate, and county levels.
54 Chapter 5 Discussion Scheins Model of Or ganizational Culture Schiens model of artifacts, values, and assumptions allows us to understand some key components of organizational culture in ch ildrens mental health systems of care. This model adequately explains organizational cu lture in systems of care, and fits the data that were analyzed. The model explains some of the components and processes of organizational culture in systems of care, but fails to explain all of these phenomena. Primarily, it fails to explain the processes of a value being manifested in an artifact, or how assumptions emerge as values. The model explains that artifacts both re flect and reinforce the values in the system of care. A salient example of this was in Region 3, where the co-location of staff and acknowledgement that the only differe nce between staff members of various agencies was who signs the paycheck. These ar tifacts, while demonstr ating a reflection of the value of collaboration, serve to reinfor ce the value. Anothe r example of artifacts reinforcing the values is that of the phrase At home, in school, out of trouble, the oft quoted mission statement of Santa Cruz County. This phrase reflects the values of the system, but also reinforces the mission as system stakeholders hear or see the statement. These examples serve to highlight the usefulness of organiza tional artifacts, as systems can create structures and processes th at are reflective of their core values. Colocation is more than just evidence of collabor ative relationships, but serves as a strategy to nurture collaboration. It is a strategic process that helps to strengthen this value. In
55 the example of Santa Cruzs training on cultural issues, while an artifact of the value of cultural competence, targeted training serv es as a concrete strategy to increase stakeholders capacity to perform work in a culturally competent manner. Given that structures and processes were created by stakeholders that reinforce system values, their role as organizational artifacts should not be overlooked. Although they may not fall into what might be cons idered a cultural arti fact (like language, artwork, or logos), these struct ures are created to reinfor ce an organizations values. Language as an artifact was highly availa ble in the data. Although this may result in part because of the nature of narrative data (interview transcripts, self-report, observations), language may be critical to transmit complex values within an organization. Santa Cruz County, as an exam ple, places a great deal of emphasis on the understanding of interagency language and has determined the study of agency lingo a precursor to their value of effective collaboration. The question remains, however, do assumpti ons and values have to translate into strongly defined artifacts? Although many of the artifacts in this study fit with the value, identifying or aligning an artifact w ith a specific value c ould be challenging. Artifacts, as described by Schein, are the eas iest elements of culture detectable by an outside researcher, and some of the examples found through the analysis of these data include examples that were harder to uncover (language in interviews, survey data). The most difficult values to align with artifacts ar e those that are described as the heart and soul of the work or just the way we do thi ngs. Things like system of care values, responsiveness to change, and leadership s eem to exist on a level thats closer to assumptions, those tacit rules that gu ide behavior in an organization.
56 Using this model to uncover data on or ganizational culture in systems of care allowed for the discovery of common elements at the three sites. Generally, the assumptions and values were most common across sites, with artifacts being highly variable across sites. Other Models Schiens model, though multidirectional, is not very dynamic. This makes it more difficult to place in the context of a system of care. Other models are more dynamic, and focus more on the processes on how an assumpti on translates into value, and how values are then observable as artifacts (see Hatch, 1994). Another possible approach to the analysis of the organizational culture at all three of these system of care sites c ould be informed by Joanne Ma rtins three perspectives of organizational culture (1992). The integration perspective of organi zational culture is the idea that the system members are focused on shared values and are relatively homogenous within the system of care culture. If the integration perspective were to hold true, then members of the vari ous child-serving agencies with in a system of care would share the values of a system of care, regardle ss of their parent agency. This perspective would hold for these long-standing system of care sites, but perhaps not a community that was just beginning to integrate agencies. For this type of environment, Martins differentiation perspective might hold true: that there are many differences in organizational culture, and the beliefs that are espoused by stake holders would not be strongly evidenced by any cultural artifacts. Cross-Site Themes
57 The common themes that emerged around the notion of organizational culture were strong at these three site s. Cross-site analysis reve aled evidence of pervasive cultural values at all three. A few strong findings emerged from the data that warrant further exploration. The examination of systems of care via Scheins model, (artifacts, valu es, assumptions) lead to a deeper understanding of the organizational culture of systems of care. The following five hypotheses were ge nerated from cross-site anal ysis of the data. Any of these findings can and should be further invest igated in relation to organizational culture in systems of care. 1. System of care culture is based on the va lues and principles created by Stroul & Friedman (1986; 1994) All sites identified a value-based implementa tion factor specifically related to the values and principles of a system of care ( Shared Visi on in Region 3, System of Care Values in Santa Cruz, and Shared Values and Goals in Westchester). Furthermore, other value-based implementation factors have embedded in their definitions system of care values and principles as outlined by Stroul and Friedman (1994). For example, in Region 3, the definition of Family and Youth Participation is driven by the goal of family/driven/youth guided care, which is an explicit system of care value. In Santa Cruz, Cultural Competence describes another syst em of care value. In Westchester, Leadership is based upon shared princi ples and values. Although this finding is not surprising, si nce systems of care are supposed to be based on system of care values and principl es defined by Stroul and Friedman. that outline these systems, the results indicate that th ey are present in system of care culture.
58 Also, this follows Scheins idea that shared values are frequently identified as an important aspect of an organiza tions culture (Schein, 1985, 1990, 2004). 2. System of care culture in cludes a willingness to change. All of the study sites defined a factor re lated to change, which included a specific willingness to change the system in th e face of challenges or growing needs ( Responsiveness to Change in Region 3, Willingness to Change in Santa Cruz, and Courage to Change in Westchester County). Despite diffe rences in titles, factors at all three sites identified a willingness of system stakeholders to create change. Further, the assumptions underlying this concept of chan ge were identified as second nature and there was no other way to do system of care work. The con cept of change at these sites was reflective of their adaptability to various local contexts, includ ing population, issues of concern, and funding demands. Of all of th e findings related to organizational culture, change appeared to be the most inhere nt and tacit for system stakeholders. 3. System of Care culture is adapted to local context One of the most striking findings is that of the research sites ability to adapt to varying contexts. This includes how organiza tional culture at the system of care sites reflects the needs of each community. System s of care are supposed to be communitybased, with services and decision making resting at the community level (Stroul & Friedman, 1986, 1994). The adaptation of local context is strong evidence that the systems investigated for this study are grounded within their communities. For Region 3, the value of Collaboration was identified as critical for success within a rural/frontier environment. This is not to say that collaboration is not a value in the other systems, but was explicitly tied to the rural culture of the Region. Due to a lack
59 of resources and manpower in this communit y, the need to share resources was found to be critical. In Santa Cruz, Cultural Competence was a value with strong roots in the community. In a system where more than 25% of the local population is of Hispanic origin, and approximately 45% of youth served in the system are Hispanic origin, cultural competence is critical to access and appropriateness of services. Again, cultural competence was not exclusive to Santa Cruz (Westchester County also does extensive work in adapting services to fit with cultural needs of thei r population), but was found to be most evident in their organizational culture. In Westchester, the Community Organization Model was the value most closely tied to the context of their system of care, as the county has varying communities with sharply different population needs. The te n networks across the county served populations with vastly diffe rent socioeconomic, racial, and ethnic populations. The underlying assumption of this value was that th e Westchester system has to adapt to these unique communities across the county. Of the three systems examined in this study, Westchester County was perhaps the most adap tive, as the adaptation was a necessity at not only a system level, but at the in dividual community level as well. Because systems of care are intended to be community-based, it is not surprising to see the adaptation to local needs. But it can be observed that in the cases of these three systems, specific structures and processes were put into place to be proactively adaptive to community needs. 4. Shared leadership is critical to culture, but not person-specific. Leadership, often a cri tical factor in system implemen tation, is said to be closely tied with organizational culture (Schein, 2004). Leadership was prom inent in the sites,
60 but the data suggests that orga nizational culture was not depe ndent upon this leadership. According to a leader in Westchester, I l ook at creating a culture and climate thats not dependent on me. You wanna promote a culture thats gonna continue. This sentiment accurately captures the place that leadership pl ays in the cultures of these organizations. Though a value, leadership in and of itself should not be responsible for creating a culture. Rather, a strong leadership should be values within an organization, with the understanding that leaders within an orga nization are responsible for promoting the values of an organization. 5. Collaboration underlies many values of culture Collaboration was specifically defined as a value in both Region 3 and Santa Cruz, but collaboration was also evident in Westchester County, t hough not specifically identified as a value by system stakeholde rs. Collaboration in Westchester County was evident in the Community Organization Model, as implicit in that value is the community working together to serve childre n, and it is also evident in the Courage to Change, which also refers to system partners willi ngness to Collaborate with one another to effect change. What is most interesting about collaboration is that the artifact of collaboration (co-location) was evident at all th ree sites, to various extents. Collaboration requires partners to share a responsibility of the system (Anderson, McIntyre, Rotto, & Robertson, 2002), and also collaboration in considered crucial for the development and sustainability of systems of care (Chorpita & Donkervoet, 2005). Given the barriers to collaboration that are often present in serv ice systems, including mindsets, bureaucracies, and the location of services (Anderson, McIntyre, Rotto, & R obertson, 2002), a culture of collaboration may be the very thing that he lps sustain a system. Future study is
61 necessary to understand the impor tance of a cohesive organizational culture in systems of care. Emic/Etic Approach Both emic and etic approaches were us ed in this study. An emic element is information or narrative that comes directly from the culture that is studied (Harris, 1976). In this case, the definitions that were generated at each site were emic, meaning that the stakeholders developed these fact ors and definitions. Researchers use emic accounts when trying to understand local meani ng (in this case, the local implementation factors) (Harris, 1976). Thes e factors were then classifi ed into the four different categories by the RTC Study 2 research team. The etic approach to these data was done in order to facilitate comparative cross-site analysis. The distinction and use of both emic and etic approaches was useful in the comp arison of the community-based systems with differing contexts. It can be difficult to thoroughly compare the locally-identifie d factors created by system stakeholders. The factors should not be considered static The importance and relative emphasis of each f actor and its component parts changed over time as the systems developed and as they continue toward sustainability. Also, because the factors were emic, its possible that across sites, they could be classified si milarly by an external researcher. As an example, Courag e to Change, Willingness to Change, and Responsiveness to Change are all describing a similar value. Because these definitions were etic, they were all labeled differently by the communities. The researchers of the Study 2 team have determined these to be different names for the same factor. As
62 another example, the Community Organi zation Model of Westchester County, as previously stated, could be Westchester Countys version of collaboration. Another caveat of these definitions is that they are multi-layered and comprised of many component parts. As an example, Leadership in Westchester County has components of system of care values in its definition. For Santa Cruz County, Interagency Collaboration include s leadership and shared valu es as component parts. Upon closer inspection, the definitions crea ted by sites highlight the complexity and interplay of values, and how these values are connected to each other (for a more detailed analysis of factor definitions, see Ferrei ra, Hodges, Kukla-Acev edo & Mazza, 2008).
63 Table 7. Cross-Site Results Limitations Artifacts Values Assumptions Region 3, Nebraska Co-location; paycheck Collaboration Required for success in rural environment. Three-legged stool Family & Youth Partnerships Critical to system success. The Chili Story. Leadership Required for the shared vision; everyone is a leader. All stakeholders able to articulate a shared vision. Shared Vision SOC principles benefit children and families. Adapting the EICC from the ICCU Responsiveness to Change There is no other way to function. Santa Cruz, CA Collaboration with Hispanic organizations; literature in Spanish; training and education on cultural issues. Cultural Competence Cr itical because of the high Hispanic population. Emphasis on understanding language and dialects of various agencies; collaborative efforts. Interagency Collaboration Necessary to seamlessly integrate services for children and youth At home, in school, out of trouble. SOC Values Accepted as an underlying core value to keep children in the community. Continuous development and system expansion. Willingness to Change Change is required for sustainability.. Westchester, NY The network structure Community Organization Model System must be adapted to various community context. Narrative of the leader who started the first network; Family members as leaders. Leadership Leadership should be shared. Strength-based at all system levels. Shared Values & Goals Necessary to drive the system, but not universal yet. Various responses to local challenges and issues. Courage to Change Stakeholders agree to face challenges together.
64 This research study was secondary qualit ative data analysis of previously collected information, in which research quest ions, and therefore in terview questions and research protocols were not re lated to organizational culture. However, because the study was centered on implementation, evidence of orga nizational culture at all three levels was still uncovered, and no substantial questions were unanswerable due to a lack of data. The study only included 3 cases of establishe d systems of care, so results may not be generalizable. The three cases that were sele cted for analysis were highly variable and provide data for contexts th at vary in terms of populat ion, community variability, and system structure. Also, there were no data available to compare with the established sites. An examination of the extent to wh ich organizational culture is observable at lessestablished systems would offer a helpful comparison. Suggestions for Future Research Given that Scheins model does not t horoughly explain the processes by which organizational culture is created and rein forced, future studies should apply more dynamic and complex models to the study of or ganizational culture in systems of care. Although the model may easily be applied to si ngle agencies and organizations, systems of care are coordinated arrays of services that involve the interaction and collaboration of various agencies and providers, often w ith conflicting mandates and organizational processes. The hypotheses generated from this st udy should be tested. The hypotheses from this study indicate the following: system of care culture is driven by values and principles defined by Stroul & Friedman (1986, 1994), it is adapted to f it the context of the local community, the culture must be one of a w illingness/responsiveness to change, a system
65 of care culture must be championed by lead ership, and collaboration is a critical component of system of care culture. A longitudinal study of how organizationa l culture emerges in a developing system of care might provide more insight in to how the different of levels of culture emerge over time. Future study may also include examining how close or distal individual agency employees (from child welf are, juvenile justice, education) are from the larger system of care cu lture. An understanding of how members of various childserving agencies assimilate into the system of care culture may also provide insight for stakeholders that are attempting to develop a valu e-based system. Conclusion Stakeholders within the system of ca re communities of this analysis of organizational culture were chosen for their ability to serve youth with SED and their families. Stakeholders within these system s challenged and encouraged each other to work toward the goal of improving outcomes for children and families. All of these systems were well-established (operating ~20 ye ars). The larger purpose of this research study was to further understand how successful systems of care develop and sustain themselves. The analysis of the organizational culture of these communities offers insight into what values are most criti cal to system of care functio ning. The complexity of how communities come together to form a syst em of care with a unique culture warrants further exploration through the use of ot her models and research methods.
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72 Appendix A: Semi-Structured System Impl ementation Interview Guide for RTC Study 2: Case Studies of System of Care Implementation Historical Development of System of Care 1) Please tell me a little bit a bout the history of your system of care and your role in the process of developing or implementing it. Initial context Triggering conditions Identifiable change agents Foundational strategies Mid-course changes or realignments 2) How would you describe the population of ch ildren and youth with serious emotional disturbance and their families in your community? Clear identification of who the system is intended to serve Issues of context or need specific to this community Change over time 3) What goals does your system have for this population? System of care values and principles Change over time Identification of Factors Affectin g System of Care Implementation 4) What strategies have been used to develop a system of care that can serve the needs and achieve its goals for children and youth with serious emotional disturbance and their families? Fundamental mechanisms of system implementation Structures/processes re lated to networking, access, availability, administrative/funding boundaries Centers identified factors Participants role or contribution 5) What strategies do you think have most a ffected the implementation of your system of care? Clear definition of the named factor from perspective of participant Centers conceptua lization of factors Articulation of why this fact or has had such an effect Participants role or contribution Relationship among System Implementation Factors
73 6) How have staff and stakeholders been invol ved in implementation of your system of care? Are there certain groups of staff and stakeholders that have been key to the process? Collaboration across agencies Leadership Governance Direct service Family involvement Evaluators 7) Do you think any of the strategies you identi fied were more impor tant or fundamental than others? Remind participant of fact ors he/she has identified 8) Do you think the strategies you identified worked best because they happened in a certain order? 9) Are there strategies that worked best in combination with other strategies? 10) How has the process of system implementation been communicated to staff, stakeholders, and the community? 11) What would you change about the process of implementing your system if you could do it again? 12) What strengths and successes do you asso ciate with implementing your system of care? 13) What challenges do you associate with implementing your system of care? Conditions that impede system development Strategies designed to meet the challenges 14) What kinds of information do you get about ho w the system of care is performing and how do you use it? Achievement of system goals and outcomes 15) Describe any mechanisms that have been developed to sustain your system of care. 16) Is there someone else who would be important for us to talk to, to help us understand the implementation of your system of care? 17) Is there anything you would like to add to this interview?
74 Appendix B: Local System Implementation Factors Region 3, Nebraska Collaboration is described as a process that involves relationships and partnerships with families, providers, child/family serving entitie s and other leaders. It is characterized by a commitment to shared vision, and mission and support by all participan ts to system of care objectives. Collaborators have mutu al respect for one anothers roles and responsibilities. They le verage, share and maximize resources and also share responsibility and accountability. Collaboration involves a commitment to learning and providing educational opportuni ties for system partners. Family and Youth Participation is described as an important process through which the roles of families and youth are in tegrated within the system. In these roles, family and youth participants are involved in all critical aspects of the system including service delivery, planning, implementation and eval uation. Families and youth are valued as participants in the system a nd their involvement allows ot her stakeholders to understand the importance of family voice, choice, and leadership in the organization. Family and youth participation is facilita ted by a strong family organization. The expressed goal of family and youth participation is family driven/youth guided care. Leadership is described as a process that s upports a strong and shared vision among empowered stakeholders including agencies, fa milies and providers. Leadership is based on a strong commitment to the values, goals and mission of the system of care and a belief in the systems ability to achieve resu lts. Leadership facilitates the sharing of authority and responsibility, and it fosters a vi sion for the future and an understanding of how to get there. Leadership is characteri zed by all system stakeholders accepting and having the power to carry out their responsibilities. Resource Commitment is described as a key support for system implementation that includes access and availability of quality staff and providers, continual skill development, knowledge of financing mech anisms, understanding how to use existing dollars more efficiently, and availability of state and federal funding support. In addition, the commitment of resources includes the effect ive use of cost data to monitor and assess the results of system efforts and suc cessfully plan program implementation. Responsiveness to Change is described as innovation as we ll as the willingness to adjust planning and implementation based on the syst ems experiences. Innovation is reflected in the ability to combine models and try ne w approaches to service delivery and system design. The flexibility to adjust planni ng and implementation is created by the availability of constant feedback and the wi llingness to take action on feedback given. Processes that support constant feedback include meetings at all levels and across all parts of the system and 360 feedback loops. This responsiveness includes being open to changes that provide funding opportunities.
75 Shared Vision is described as a strong desire to achieve better outcomes for children and families that is based on a common belief that system of care principles will benefit children and their families. This shared vision also includes building upon modes of service delivery that are ali gned with system of care valu es and principles including access to community-based services throughout rural and frontier regions of the system, implementation of promising practices and evidence-based care, and using the wraparound approach to deliver services and supports. Stakeh olders describe a determined effort to communicate this vision. State-Level Support is described as a key aspect in sy stem of care sustainability and is characterized by patience and persistence n th e development of a shared understanding of perspectives and needs and a mutual effort to problem solve. The state provides financial support to the local syst em of care and recognizes the cost effectiveness of a system of care approach. Santa Cruz County, California Braided Leadership is described as the informal Syst em of Care governan ce structure that supports the interagency System of Care mission, outcomes, and fiscal development. Elements of braided leadership include that th e System of Care is included in individual agency mission statements. This allows the System of Care values to be maintained despite changing state-level commitment. Br aided leadership also involves sharing resources and risk as well as shared problem solving. A shared fiscal focus and the use of braided funding approaches is an important aspect of braided leadership. This collaborative approach to leader ship allows partner agencies to work strategically in the planning and implementation of services wh ile maintaining their individual agency identities and roles. County-Level Support is described as a local willi ngness to support funding for the system of care. This support is grounded in values but also based on the achievement of consistent program and fiscal outcomes. County-level support manifests in continued program support through various challenge s and opportunities as well as ongoing investment in children and families. Cross-System Expertise is described as a willingness to engage in cross-system learning; an ability to integrate the fiscal and clinic al knowledge in specific individuals/groups that is necessary to create and sustain progra ms; a willingness to unde rstand the department languages and cultures of pa rticipating agencies; and a willingness to understand differing contexts across agencies and levels of the system. Cultural Competence is described as a core value of th e System of Care, manifesting in strategic interagency processes to promote culturally relevant and sensitive services at all levels of the system. It includes an evol ving focus on underserved and inappropriately served populations, and a responsiveness to changing populations, including specific change-efforts in key departments (e.g., Disp roportionate Minority Confinement efforts to reduce overrepresentation of minority you th in detention; Outreach and Engagement
76 efforts through the Mental Health Services Act to Latino youth and fa milies; an extensive training and education focu s on cultural issues). Family, Youth, Community Partnerships is described as increasi ng involvement of family and youth leadership at all levels of the syst em, as well as the increasing involvement of community-based agencies and other community partners in creating healthy pathways into the community for families and youth who are often stigmatized and disenfranchised. Interagency Collaboration is described as the formal and informal System of Care processes that are key to Santa Cruz County's system development. Interagency collaboration promotes both structured a nd organic communication and embodies the willingness to learn and seek information about different child-serving agencies. Elements of interagency colla boration include shared va lues that are based on welldeveloped cross-system knowledge and are tied to community need. Interagency collaboration promotes joint training a nd strategic planning ventures. Interagency collaboration and commitment are constantly renewed through changing leadership. This collaboration recognizes that the various "dia lects" or languages of agency reform are often consistent with each other, allowing re form efforts from mental health, Juvenile Probation, Child Welfare, and Special Educat ion to be mirrored and supported by agency partners. This collaboration helps achieve the seamless integration of reform efforts within participating System of Care agencies. System of Care Values is described as the shared mi ssion adopted across partner and community agencies to support the original mission of keeping children and youth at home, in school, out of trouble. In addition, the values incorporate new initiatives such as the Mental Health Services Act and Child Welfare Reform which focus on keeping children and youth safe and healthy. Willingness to Change is described as the creativity, flex ibility, and "whatever it takes" attitude of staff in providing the best care possible within a "wraparound philosophy" focused on family needs and strengths; cont inuous development and system expansion, including a focus on practical application of system of care values and principles; maintaining adequate supervisory and support structures to keep the System of Care robust and vibrant; and incorporation of ne w literature and training on Evidence-based Practices and reform principles within participating agencies. Westchester County Community Network, New York The Community Organization Model is central to Westchester Countys system of care. It refers to a strong belief that the community has respons ibility for its children and families, and that communities, organized at many levels including the Network level, are key to the success of children and fam ilies at high risk/high need. "Wraparound" and all of the other system of care concepts are built on this framework. While the Network model is Westchester's "creative step," it is based on this underlying belief
77 in the power of community; and although the mo del has been replicated elsewhere, it is truly unique to the system of care in Westchester County. Courage to Change refers to willingness to take the system to the next level and collaborate with one another to effect change, being unafraid to speak openly and honestly about what does or does not work. It also involves taking steps backward or stopping the action when necessary. Partners make an implicit agreement to face challenges together, take risks to achiev e goals, and support one another throughout the process. Having the courage to change m eans willingness to create new solutions and think outside the box. They share a belief that the system is a dynamic process and that it must change and grow to be vital. Data is used to refine the issues, engage families in the process, bring together sy stem partners, and foster the growth and development of the system in orde r to bring about needed change. (Family & Youth Movement) The development, nurturance, and full investment in the viability of a free standing, independent family organization is viewed as critical to the system of care in Westchester County. It is described as a reciprocal relationship between the family organization and government in which power is shared with families and there is a level of trust between the tw o groups. The family organization has greatly expanded over time, has a very solid fiscal ba se with diversified f unding, and is integral to policy development, program planning, dir ect service, training and evaluation. Family resource centers throughout Westchester se rve as hubs for the system of care. Westchesters youth organization is an independent organiza tion that emerged from the family organization and is mentored by a lo cal mental health and community service organization. The family and youth move ment components have numerous shared activities including participation in system level meetings, community meetings, and powerful planning committees. Leadership within the Westchester Community Network began with one charismatic leader who exhibited energy, a sense of purpos e, and the ability to communicate well. This leader strategically hired some likeminded people, and this core group, which continues to exist, became a leadership thi nk tank. Leadership within the system is based its vision, on shared principles and va lues, and continues to communicate a sense of purpose and future possibilities. The l eadership in the county is enthusiastic, energetic, and pragmatic and strongly believe s that leadership must be shared across agencies and systems. This shared leader ship is identified, r ecruited, and supported on every level and from every system. The System of Care in Westchester Count y is based on a slowly and carefully built shared vision which is grounded in core valu es and articulated acr oss partners. In the Westchester Community Network, Shared Values and Goals are collectively agreed upon, clearly articulated, and take continuous e ffort. A constantly restated values base provides continuity of mission across ag encies, providers, and communities that includes commitment to individualized care and serving children and families within the community. The values base is aimed at m eeting social justice goalsthe success of youngsters who would not ot herwise achieve successand includes strength-based approaches to both families and systems.