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From Services to a System: A Case Study

A. Introduction
B. A Common Issue - Preschool Speech and Language
C. Committed Resources - Government as a Partner
D. Effective Leadership
E. Belief in Partnership and Collaboration as a Strategy
F. A Shared Vision
G. Sincere Commitment from all Partners
H. Productive Outcomes - Sharing Information and Maintaining the Vision
I. Conclusion
J. References

By: Sherryl Smith, Consultant

Sherryl Smith has been involved in community based health promotion for 22 years in Ottawa. She holds a degree in Nursing Education and after a brief career teaching nurses in Kingston, she "evolved" into a community developer/educator. Sherryl is a strong advocate of comprehensive and collaborative approaches to promote healthy communities and healthy families. She has written several guides to facilitate community work including Supporting Family Support, Stop Smoking: a Program for Women and Reaching the Hard to Reach. She has been an active member of First Words-Ottawa-Carleton Preschool Speech and Language Program and is currently the Health Promotion Coordinator at Somerset West Community Health Centre in Ottawa.

Summary
Integration and inter-sectoral collaboration or partnering appear to be compelling forces driving many community initiatives in the social service and health sectors in the '90's. While the ideology makes common sense, putting the concepts into practice is more difficult and the efforts of many community groups fail.

Inter-sectoral partnering is both a process and an outcome, with a goal of providing better services. This article will trace the development of First Words, a comprehensive integrated system for preschool speech and language development in Ottawa-Carleton, Canada. Based on criteria for successful inter-sectoral partnership from research literature, the process used to develop inter-sectoral collaboration is explored.

A. Introduction
Requests go out to community groups to develop proposals for service delivery on a regular basis. The concept of partnering has been a requirement for most requests for proposals (RFP's) in the '90's. Partnering involves sharing visions, capacities and power to build something different. The challenge in communities has been to find ways to come together with shared visions and values that are authentic rather than expedient. Collaboration, when forced, has the potential to split from the pressure. The First Words project has been able, in just a two-year span, to develop both effective processes and results.

Inter-sectoral partnering is the process of creating joint initiatives across two or three sectors. Sectors can mean both societal sectors such as business, government and non-profit organizations or administrative divisions such as education, health, or justice. There is growing international recognition that inter-sectoral partnering can foster systemic change and systems change, both needed as we move into the 21st century. The recent Jakarta Declaration on Health Promotion into the 21st Century discusses the need for new responses.

"There is a clear need to break through traditional boundaries within government sectors, between government and non-government organizations and between the public and private sectors. Cooperation is essential. Specifically, this requires the creation of new partnerships for health on equal ground between the different sectors at all levels of governance in society."

This imperative has been based largely on growing evidence that supports the notion that health is attained by addressing all the factors determining health, most of which are outside the "health" sector. The determinants of health include access to meaningful employment, having the support of families and friends and early childhood development. The prevalent notion that access to high quality health services will guarantee "health" is now challenged by effective research.

Literature reviews have revealed a consistent set of criteria essential for inter-sectoral collaboration to work effectively. These include:
* a common issue
* committed resources
* effective leadership
* belief in partnership and collaboration as a strategy
* shared visions
* sincere commitment from all partners
* productive outcomes.
B. A Common Issue - Preschool Speech and Language
A request for proposals was issued by the Ministry of Health in 1996, inviting community groups to submit plans to develop comprehensive and collaborative systems to deliver preschool speech and language services. As stated in the guidelines,

"the purpose of the initiative is to develop preschool speech and language service systems and reduce the disparities in availability of preschool speech and language services between districts in the province."

The Ministry guidelines for proposals were focused on a defined age group - the preschool years, and a single issue - speech and language development. These two criteria made collaboration easier as a very specific network of services were involved. Community groups were asked to submit plans to accomplish two tasks:

1. Develop collaborative systems - a process; and
2. enhance services for families - the results.

This article focuses on the process.

C. Committed Resources - Government as a Partner
The need to develop a system for preschool speech and language services was the focus of this initiative. Systems change requires time and commitment from leaders, potential partners and finances. From its inception, there was a strong recognition that all sectors had to work together. Clear and flexible guidelines were provided by the Ministry which laid out the requirements for the project.

" . . . the guidelines are structured to ensure the development of a system that encompasses all potential speech and language service providers, uses preschool resources that are already present in each district, and makes available a full range of service components. The guidelines are flexible and will help each district to develop a system tailored to the particular requirements of its population."

Research supports the need for inter-sectoral partnerships to be able to make their own rules, adapt goals and engage new partners. A commitment made by government of $20 million across the province ensured the success of the initiative and enabled local human resources to be made available to launch the project. Much of the success of the project was a result of the provincial government committing resources and allowing for local ownership.

D. Effective Leadership
Although the call for the creation of a system came from the Ontario Ministry of Health, the project had the support and cooperation of the Ministry of Community and Social Services and the Ministry of Education, (since then amalgamated into the Office of Children's Integrated Services). This demonstration of high-level collaboration was an important indicator and facilitated the ability to gain community-level cooperation in the initiative. For example, some local partners received their funding from the Ministry of Community and Social Services and a letter sent to them from the Ministry encouraging cooperation was an important step in building trust in the process.

Planning responsibility was vested in the local District Health Councils, which provided legitimate and neutral leadership.

Respecting the guidelines, a Stakeholders' Task Group, with broad representation, was formed in the fall of 1996. The task of bringing stakeholders and potential partners together was made easier by the clear identification of an issue that was important to them all - the enhancement of preschool speech and language services.

There is another leadership factor that has led to successful collaboration. The leadership for the project, after Ministerial approval, was assigned to an agency outside of the usual child development network. Pinecrest-Queensway Health and Community Services was awarded the responsibility of administering the funds on behalf of the Steering Committee for the Preschool Speech and Language Program of Ottawa-Carleton. They have played "a third party neutral" role which has enabled the development of partnerships and cooperative agreements between agencies that have traditionally been perceived to be in competition for services.

E. Belief in Partnership and Collaboration as a Strategy
A task group of agency representatives was called together in late 1996. The membership came from a representative group of individuals and agency personnel who had a stake in the outcome and who were known to the District Health Council as leaders in their field. Some had worked on joint projects in the past and had developed relationships with each other, while others met for the first time as a result of the project. The Task Group had three primary functions:
1. to manage coordination and integration of services;
2. to plan; and
3. to guide the implementation of enhanced services.

F. A Shared Vision
Developing a shared vision was a fundamental first step to ensure success for the project. One of the earliest tasks of the Interim Task Group was to develop their own goals and operating principles to guide the development of the district plan. A facilitated process was organized that resulted in the following goals and principles. They were focus-tested, as part of the collaborative planning process, with many stakeholder groups and have proven to be effective "footings" for a strong foundation in the ongoing development of First Words partnerships.

Research in the concept of collaboration supports the importance of shared vision and values as fundamental to the success of collaborative efforts. After several meetings, the task group was able to agree to the following:

Goal of First Words Every preschool aged child who requires speech and language services receives services to maximize their potential for performance of daily activities required for personal and social interaction at home, at school and in the community.

Principles of First Words:
- Value of Speech and Language Development for Preschool Children
- Emphasis on Prevention and Early Identification
- Continuum of Service
- Accessibility and Responsiveness
- Collaboration and Partnership
- Parents as Partners
- Building on Strengths and Maximizing Professional Resources
- Quality and Accountability

G. Sincere Commitment from all Partners
First Words has ensured that partnerships have been developed between organizations. The distinction between organizational commitment and individual enthusiasm is a critical factor in sustainable collaboration. The development of clearly understood protocols and agreements with partner organizations has facilitated integration. For example, protocols between the Region of Ottawa-Carleton (Health Department) and First Words were developed, clearly outlining intake procedures and decision "trees" used by Parent-Child Info. Line staff. Sign-off for these agreements has been at senior levels of the organization, indicating a serious commitment to inter-sectoral collaboration.
The Steering Committee, established to govern the First Words Program, is contracted with the Ministry of Health and is accountable for the outcomes of the Initiative. This contractual agreement required a serious commitment from organizations involved. The First Words project determined to begin implementation of services immediately and to work with the Interim Task Group. This broad stakeholder group provided continuity to the process and was able to move in the direction of implementation of service enhancements very quickly and efficiently because of the relationships of trust that had been established during the planning phase. After one year, the Interim Steering Committee membership conducted an intensive review of the stakeholder governance model. Feedback comments in answer to the question, "What are key elements contributing to success of implementation coordination?", obtained from the document, "Firming Up the Foundation", include this one which confirms the need for commitment: "Commitment of professionals and parents; the use of community people through the process."

H. Productive Outcomes - Sharing Information and Maintaining the Vision
A highly effective communications plan has been a key factor in sharing the successes and widely disseminating new resources for the community. The most recent September 1999 Update lists many successes, including the provision of over 30 community-based screening clinics, making services "for parents concerned, but not sure, that their children may be experiencing delays." "More than 1400 children were accessed in 1998/99 and the average age for assessment was under three years of age."

The Communications Working Group has participated in creating many new resources to enable parents and other providers to identify and refer children and their families for assessments and treatment of speech and language problems. Many sectors have been involved in both the development and dissemination of resources. For instance, bookmarks were distributed by local bookstores and libraries. The Loeb grocery chain placed parent education flyers in grocery bags. Collaboration with the Early Childhood Education faculty and students has resulted in improved awareness of language development milestones.

The Communications Working Group is an example of a highly effective strategy leading to the successful implementation of First Words. The concept of working groups is an effective strategy in sharing and disseminating information because it:
* invites the participation of many others interested in the issue without a long-term commitment of time;
* utilizes community expertise in a highly effective form;
* is an efficient and resourceful use of professionals; and
* it has brought together sectors and experts who may not have worked together before.

Regular communiques, the availability and wide distribution of the Steering Committee and Working Group Minutes have kept the process transparent and accountable to the community. This accountability includes formal evaluation, which has been a critical piece in ensuring outcomes are positive. Regular surveys of parents and service providers, in addition to regular service utilization data all contribute to a positive outcome for the First Words Program. As one parent expressed, "I liked that the service could take place at different locations . . . The help that I received immediately opened a new door of learning for my child and gave me better direction in what skills I should be teaching him."

I. Conclusion
The early days of the partnership reflected a high degree of fear and anxiety on the part of many whose territory and mandate were threatened. Skillful leadership and a commitment to the goals and principles were the binding forces that kept the process moving in a positive direction. The challenge was to simultaneously develop a collaborative working relationship and deliver better services to families. Achieving an optimal balance has been one of the key successes of First Words. Many win/win results have reinforced the reasons for undertaking this initiative. "When we go into a community to get something done, we are courageous when we act alone, but crazy if we think we can do it on our own."

Astroth, K. (1992) More than Good Intentions: A Development Model for Building Strategic Alliances. New Designs.

Richardson, William C. (1998) Inter-sectoral Collaboration: The Sound of Three Hands Clapping. Speech delivered to the Kellogg Foundation.

The Jakarta Declaration on Health Promotion into the 21st Century. (1997) 4th International Conference on Health Promotion.

Waddell, S. (1998) Partnering for Results: Inter-sectoral Partnerships. User Guide to Inter-sectoral partnering. USAID Handbook.

Winer, M. and Ray, K. (1994) Collaboration Handbook: Creating, Sustaining and Enjoying the Journey. H. Wilder Foundation.

Wright, A. and Chansonneuve, D. (1998) Firming up the Foundations. Consultation document.