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Laurel K. Leslie, MD, MPH Associate Professor of Medicine and Pediatrics Tufts Clinical and Translational Science Institute Tufts University Boston, MA. Great Starts: Leading Change in Your State. Promoting Change. Opportunity Improve mental health well-being of children in foster care

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great starts leading change in your state

Laurel K. Leslie, MD, MPH

Associate Professor of Medicine and Pediatrics

Tufts Clinical and Translational Science Institute

Tufts University

Boston, MA

Great Starts: Leading Change in Your State

promoting change
Promoting Change
  • Opportunity
    • Improve mental health well-being of children in foster care
  • Danger
    • Change is unpredictable, costly
    • Requires people and organizations to change
    • Competes with other initiatives
Leading Change By John P. Kotter & used by the Children’s Bureau Training and Technical Assistance Network

Create a climate for change

  • Create and increase urgency
  • Create a team
  • Get the vision and strategy right

Engage and enable for change

  • Communicate the vision for buy-in
  • Enable action

Implement and sustain change

  • Create short-term wins
  • Don’t let up: build on gains and produce more change
  • Make it stick: Anchor new approaches in the culture
tufts research team
Tufts Research Team

2 national studies:

  • 2009-2010 (Charles H. Hood Foundation)
    • Examine state policies and best practices and disseminate to child welfare agencies
  • 2011-2012 (William T. Grant Foundation)
    • Identify types of information states using to develop plans
    • Investigate monitoring approaches
step 1 create and increase urgency
Step 1. Create and Increase Urgency

Identify medication use as a systems problem

  • “This issue has never been looked at on an organized basis. It has always been left up to the individual case workers.” -Child Welfare

Gather data on medication use

  • “The data brought us together.” -Child Welfare

Build on multiple “messages”

  • “We’re hearing it from the line and we’re certainly hearing it from the feds and so that’s certainly making us take a little bit of a closer look more so than we ever have before.” -Child Welfare
what drives urgency around this issue
What Drives Urgency Around this Issue?

Child welfare

  • Line workers’ concerns
  • Advisory/consumer board concerns
  • Leader or champion

Other child-serving agencies

  • Mental health reform for children served by public systems
  • Medicaid: cost, safety and quality initiatives
  • Pediatrician/Psychiatrist best practice efforts

External factors

  • High profile media cases
  • Legislative or accountability commission attention
  • SSI investigations
  • Federal attention (e.g., GAO, ACYF)
step 2 create a team 1
Step 2. Create a Team (1)

Include all key stakeholders

  • Requires content expertise beyond any 1 agency.This “can’t be done alone.”

-Child Welfare

  • “Include all of the stakeholders in the policy development - get them to voice their concerns and be a part of the process. Will likely lead to greater buy-in with the policy.” –Child Welfare
  • “It wasn’t until we made it a larger conversation that we made progress. Don’t develop policy-practice in isolation.” -Child Welfare
who are you partnering with
Who are You Partnering With?

Common partners:

  • Medicaid (82%)
  • Mental health (73%)/MCO (18%)
  • Juvenile justice (23%)
  • Academics (64%)
    • Medicine/Psychiatry
    • Pharmacy
  • Judiciary (23%)
  • Consumers (e.g., youth and caregivers)
other partners
Other Partners

Indian Health Services

Contract agencies: residential, foster care, adoption

Health department

Professional organizations (AAP, AACAP)

Funders (Casey, local foundations)

Neighboring state agencies or academic institutions

Other states in a collaborative

linking across systems
LinkingAcross Systems

“There’s not a tight recognition that your medication management needs to be really tight with your ongoing therapies and your social support system. They’re sort of too delinked in my opinion and to the extent that we can bring them back together, I think, is the important piece.” -Medicaid

“The shortage that we have with child psychiatrists in this state, especially in . . . some of our rural areas. These kids are seen by primary care physicians, so what can we do to our sister agencies to help them understand mental health issues because they are not psychiatrists? “ -Child Welfare

step 2 create a team 2
Step 2. Create a Team (2)

Find the people with the skills you need

  • Agency
  • Content (ex: pharmacy, IT)
  • Power, expertise, credibility, leadership, and management skills
  • Role of “boundary spanners”; requires multiple perspectives—not just data and requires concerted effort among and across agencies
  • Build on existing high functioning teams
step 2 create a team 3
Step 2. Create a Team (3)

Use them in the multiple way(s)

  • Guiding coalition (core team )
  • Advisory boards/panels
  • Project-based teams
  • Advocates or supporters
  • Criteria
step 2 create a team 4
Step 2. Create a Team (4)

Identify, acknowledge, and address differences across agencies

  • Language/terminology
  • Missions
  • Eligbility criteria

Hold each other accountable

  • Organizational Agreements , MOUs, or Guiding Principles
  • Public meetings
step 4 get the vision and strategy right
Step 4. Get the Vision and Strategy Right

Vision and strategy

  • Articulate your vision
    • What is it?
      • Appropriate mental health treatment : “ The right care at the right time.”
      • Meds reduction: “Too much, too many, too young”
    • Characteristics: Imaginable, desirable, feasible, focused, flexible, easily communicated, measurable
  • Develop your strategy

“We had a whole group. We came up with a vision. We came up with principles and guidelines of where we want to be. Then we came up with strategies and plans and actions. Then we moved forward in implementing quite a few of those.” -Child Welfare

step 4 communicate the vision
Step 4. Communicate the Vision


Metaphor, analogy, example, story, picture

Multiple forums


Two-way communication

step 5 enable action 1
Step 5. Enable Action (1)
  • Ask:
    • What do you need to implement your vision?
    • What resources are available that you can leverage for change?
    • What new resources are needed and where can you get them?
  • Personnel-new hires, training
    • Leadership, IT, staff level
  • Technology/data systems
  • Organizational structure
  • Procedures and policies
  • Evaluation
  • Funding
leadership training
Leadership Training

“I along with some of the other managers have participated in some of the work that is being done by ACF in terms of the leadership academies. I think that –so that is where some of it has come from. I think as we have looked at change and change in our agency, we are getting some –just talking more about and getting technical assistance as well on how we are going to move through the change process.” -Child Welfare

facilitative structures
Facilitative Structures

Organizational structure:

  • “And what's interesting is that we all sit in the same building. We have a central office where those directors sit together in the same little pod. And then we are together within the same building and we aren't siloed by floor. Does that make sense? Like public health sits next to us. Medicaid is on the same floor. So we don't silo ourselves as far as like behavioral health has their building, we have ours.” -Child Welfare


  • “What we do is we combined monies across all the different –there are always different funding sources. We had like fourteen or fifteen different funding streams serving basically the same kids in the community, just depending on which door they walked through. . . So we then allocated those[blended] funds to communities . . .who then get together to plan the services for the individuals.“ -Child Welfare
  • Grants-contracts and/or research grants; may require partnership with academics
    • Federal (NIH, SAMSHA, CMS)
    • State
    • Learning collaboratives
    • Health department QI projects
step 5 enable action 2
Step 5. Enable Action (2)

Partner with other states

  • Expanded network for ideas, policies, and procedures
  • Expertise and capacity you lack

The QI motto: Share often and

borrow shamelessly!

implement and sustain change
Implement and sustain change

Create short-term winsDon’t let up: build on gains and produce more changeMake it stick: Anchor new approaches in the culture

step 6 create short term wins
Step 6. Create Short-Term Wins

Provide evidence that work is worth it

  • How will we evaluate our efforts?

Help fine-tune vision and strategies (QI processes)

Keep key stakeholders engaged

  • Reward change agents with a pat on back
  • Keep leadership, champions, staff on board
examples of wins
Examples of Wins

Examples of specific projects

  • Agreement on core outcomes
    • Too much, too many, too young
  • Youth empowerment
  • Transition-age youth
  • Cross-agency kids (CW, MH, Ed)
  • Shared databases
steps 7 8 don t let up and make it stick
Steps 7 & 8. Don’t Let Up and Make It Stick

New approaches sink in only after it’s clear they work

  • Need to have mechanism(s) for identifying change as a win and disseminating the wins

Make successive changes that are compatible with vision and with culture you are seeking to build

May involve turnover

concluding remarks
Concluding Remarks

"Together we can reach the heights of excellence and perform the extraordinary."