[ Music ]
The objective is clear.
Develop an integrated strategy
for improving children's behavioral health
in the State of Georgia.
The state government had set up the Inter-Agency Directors Team
or IDT, to fundamentally transform the coordination
of services for children's behavioral help.
The team was comprised of members from different agencies,
service providers and stakeholder groups.
Including, education, juvenile justice, public health,
community health and child and family services.
They've been meeting for over a year without making the progress
that they really wanted.
It was at this point that they reached
out for some expertise to help them.
Working with the Centers of Excellence
for Children's Behavioral Health,
at the Georgia Health Policy Center,
the team developed their system thinking skills.
Using these thinking skills, they were able
to develop a collective vision of success.
This was an operational picture that they could use to think
about how their strategies would work.
Ultimately, they turned this picture into a strategy map.
Based on a series of interviews with IDT members,
we developed a map
of a children's behavioral health system.
This systems map is a set of understanding about how we think
that different pieces of system fit together
to generate the causes and the solutions
that we're looking for.
The map ultimately pointed out that there was a problem,
a potential area of concern, where funding
and rewards were set up in such a way
that it might not produce the systemic collaboration
that people were looking for.
The system had evolved
to perpetuate piecemeal coordination services
or disintegrated services.
The fundamental goal that people were trying to figure out
and understand, was how to keep children more in the community.
But if you look at it, they were in 2 different major areas.
They were either in a community, in a variety
of different settings or in institutions.
Think about how you could have children accumulating
in foster families, as opposed to being
in their regular families.
They could move down into foster families.
They could also move from the community into institutions.
They could move into either health institutions
or into corrections institutions.
It was this fundamental disparate way
that children were being served in the system, that could lead
to a disintegration or uncoordination of services.
Not surprisingly, that it evolved
to become a very service centric or push diagram.
Organizations had specific services, such as counseling,
education, that they were dutifully providing or pushing
to qualify children and their families.
In the first systems map, it was easy to see how
with limited funding,
the various stakeholder groups would end up competing,
forever shrinking resources.
Children were pulled from one place in the system
and pushed to somewhere else.
Although, there seemed little improvement
in their long-term development trajectory.
The main result was often that someone else became responsible.
And once you were responsible for someone,
you'd ask for more resources to take care of them.
It is definitely antithetical to collaboration.
No admonition to work together was going to work
when approaching from a provider's centric stance.
After the IDT increased their systems thinking capacity,
they were able to put aside the first map.
And to think about building an emerging vision
of sustainability.
They were able to think
about how this system might not be well set up,
if you push services, but rather created a different vision.
What would happen if you could think
about maximizing children's behavioral health in a way
that they grew up to be the types of adults
that we all wanted to see.
Which means, that they can hold a job or drive a car or live
on their own, if capable of doing so.
Starting with a stock of adults living this maximized quality
of life, they were able to develop a pipeline or a chain
that showed how children, as they grew older, can either be
on track or off track.
The goal, keep children on track as much as possible.
And if they fell off track, get them back on track as needed.
Co-building this map, helped the team visualize this system
in an alternate approach.
It was easier to mentally simulate and more visceral.
One collective insight they had was that the further
to the right, as children aged into adulthood, the symptoms
that were occurring, were much more problematic and costly.
Things like incarceration, homelessness,
substance abuse and crime.
There was little incentive in the system to spend money
on resources upstream, when all of the symptoms
that were the most costly, were downstream.
Using the map, they were able to develop a coordinated strategy
where they could all work together at funding
and moving investments upstream.
"Now I see how we can focus on a child at each stage
of their development and think about what they need."
"And how we can each coordinate our resources
to fulfilling that need."
"This map will be the foundation of our strategy," declared one
of the team's leaders.
Even 2 years later, the team uses a laminated version
of this map when they're thinking about strategy.
They use it to communicate to health commissioners.
They use it to communicate to stakeholder groups.
They use it in order to think
about how well their strategy is being implemented
and how they might change it.
It is a dynamic picture that helps them to guide strategy.
Using systems thinking, helps groups move into a space
of accelerated learning, where they reframe the goal.
In this case, they moved up to the 30,000-foot view
and were able to see the larger whole of the system
that were trying to change.
This helped them move from inaction to action.
By seeing how they were focusing on different parts of the system
in ways that were ineffective, they were able to move
into a more collaborative space.
The good news is that such population management systems
maps, can be applied to a variety of different situations.
Such as, violence, chronic disease or obesity.
And it can also be applied to non-traditional health issues,
such as education or employment.
A modification of the on track, off track map, can be applied
to risk and protective factors.
We developed such a map in conjunction with the CDC,
The National Network of Public Health Institutes
and the Georgia Health Policy Center.
The map was developed to better understand how
to prevent violence.
Similar to the IDT map, there was an aging chain,
where children could age into youth and age into adults.
Along the way, they could develop risk factors
for violence.
A few risk factors are, substance abuse, mental health,
including depression in the family, social isolation,
toxic stress and community violence.
As they age, these risk factors move from causing people
to being likely victims of violence,
to becoming perpetrators.
This creates powerful reinforcing feedback loops,
often referred to as vicious cycles.
Children who have experienced violence, become adults
who create violence, who then lead
to more children experiencing violence.
The good news is that there are also protective factors
that can move along with children as they age.
Such protective factors will keep them from being victims
or committing violence.
Such protective factors include, education and employment.
The maps are part of a tool kit that allows stakeholders
across the community health system and public social system,
to gather together and to ask questions like,
how can we reduce some of the risk factors
that are most prevalent in our community?
Where are places where we can work
to increase protective factors?
How can we work together in ways to communicate and engage others
in solving and working around these problems?
So, here's how you can build these types of maps.
One type of map I refer to as a state by state map.
State to state map is something similar to the IDT map,
where individuals can age up and simultaneously go back and forth
between states during an age category.
So, here's how you would do it.
You'd find some population health metric.
Let's say obesity or weight.
And then look at an age range.
And within an age range, classify individuals as being
in the healthy weight bucket or stock
or the unhealthy weight or obese stock.
Think about how they can flow into and out of those stocks.
Then you can think about moving them up to the next age range.
Once you've laid out the chain,
you can then start asking questions.
Pick a stock of most importance.
What's happening there?
Is it going up, going down?
Why? Then you can start thinking about investments
and opportunities for intervening.
Can you intervene more upstream and prevent the state
from getting worse as it moves downstream?
Is there opportunities for collaboration
that may not be there, where people are focusing on parts
of the stream, in different places with different emphasis?
Just use the map to start asking questions
about where you would put resources
and how you would move forward.
It's a great way to get people again focusing on the problem,
instead of focusing on what they're doing.
Another type of map I frequently use, is an attribute chain map.
Very much like the violence prevention map,
where you had risk and protective factors, aging up
or as at attributes, the to follow a person as they aged.
So, for example, if I was going to build one of those,
I would find what's the issue
or what's the attribute I'm most want to understand.
And think about maybe an age in which it starts to accumulate.
So, for example, when children are young,
they develop some skills.
As they age up, those skills move with them.
I started asking questions on how can I make sure that,
you know, at the age I'm trying to intervene, what is happening
in terms of the ability to build those skills
or to influence that attribute?
How does the attribute change over time?
Does it actually accumulate or is there a loss of it?
And think about again, as it moves forward.
This gives you an opportunity to think about managing a system.
Again because it's often the case
where you want an attribute later on, that you really need
to invest in earlier upstream.
How do you all work together again
to focus upstream resources to develop that attribute?
And there are a host of other questions you could ask
with this kind of map.
I hope you see that types of maps we've just explored,
can be useful in some of the very important situations
that you're trying to work on.
Many groups that I've facilitated,
have found that these maps have led to some creative
and unexpected insights.
Often, we find that where they've been applying resources
are the more obvious or more symptomatic problematic areas.
And that there's leverage in applying resources elsewhere.
These maps can increase your team's ability to engage
in the tough challenges, often pushed beneath the surface.
By building a shared picture of assumptions you're using
to solve problems, you're able to accelerate
and create an agile learning approach
and develop the shared leadership mindset you need.
You can start using these maps right away.
And I hope you do.