Leadership Stories

Leadership is Not a One-woman Show: Facing Change and Turbulent Times
Angela Ellison, MA

In this leadership story, Ms. Ellison looks back to when she took over the helm of the newly established West Side Family Center. The Center, designed to provide comprehensive maternal-child health services in one location, emerged as a strategy to reduce infant mortality in one of Chicago's chronically underserved communities. Through hard work and dedicated leadership, the Family Center has been able to preserve and sustain these much-needed programs despite ever-changing funding and reimbursement schemes. The Center continues to operate today! Thus, the story is one that demonstrates success. However, the path to success was circuitous, with predictable as well as unforeseeable twists and turns — not to mention outright detours — as four partners came together to fulfill their mission and form a state model for collaboration.

The Family Center concept grew out of the Healthy Start Project, a federally-funded initiative to reduce infant mortality by 50% by 1996. Initially, the Healthy Start project funded 15 programs nationwide including five in Chicago. These five entities formed the Chicago Healthy Start Consortium and convened a task force to address issues of sustainability. The family center concept was proposed and agreed upon, as were the essential services to be provided by each center. Written protocols and guidelines were developed and each of the five coordinating entities set about to establish independently functioning, but conceptually similar centers to serve clients in the six Chicago neighborhoods experiencing the highest levels of infant mortality.

In one locale, Healthy Start had funded two entities to provide comprehensive services to the residents in a specific catchment area. One agency delivered medical care, the other offered case management services. Once the center concept was approved, these two groups decided to continue to work together under the auspices of the larger consortium.

As this more formal relationship was being established, two other agencies were embarking on a partnership to offer WIC services within a new, conveniently located, spacious building. Many of the state and city officials, spearheaded by representatives from the Illinois Department of Public Health (IDPH), recognized the benefits of bringing all four together in one location. This lead to the establishment of the Near West Family Center with its two original partners, two additional partners and an expanded array of services.

A One-Stop Shopping Model of Family Care

The Family Center concept called for a "one-stop shopping" approach: A mother, her children and her family would be able to access a wide array of services designed to support a family. The service schema directly grew out of the earlier state-funded "9/90" Infant Mortality Reduction Initiative that sought to reduce the neighborhood's infant mortality rate to 9 deaths per 1,000 live births by 1990. As part of that initiative, researchers had sought input from local residents concerning the barriers they experience when seeking prenatal care. The service schema, often referred to as an ecological model, addresses the physical, social and emotional health of mothers, infants, children and the family in the context of the neighborhood and the larger community.

Overarching Objectives

All agencies involved in the Healthy Start Consortium had long histories of working together in different milieus. They had collaborated on a variety of projects and in situations of varying intensity. At the time, it was believed that the consortium was ideally suited to address the needs of neighborhood residents. The family center model would meld the best attributes of each partner, enhancing the services provided to the community. The following objectives guided the efforts of the partners as they committed themselves to the project:

Provide holistic care to families in the target communities.
Improve the overall emotional, physical and mental health of program participants.
Improve the quality of life of clients.
Empower participants (through training and support) to advocate for themselves as well as their families.
Assist in the economic growth and viability of the communities served.

Furthermore, since the family center concept was added to the list of models supported by the federal Healthy Start program, the Chicago Healthy Start Consortium was charged with an additional goal: It was designated to provide mentoring to other Healthy Start projects around the country. Consortium staff would provide consultation to other grantees regarding the family center model and consortium development.

Challenges During the Early Years

There was jubilation and pride at the ribbon cutting ceremony the day that the West Side Family Center officially opened for business. These sentiments remained and over time served to buffer disappointments and setbacks as major changes occurred internally and in the external environment. Ms. Ellison was a consistent and persistent force that weathered these storms with her agency partners and teammates. In remembering her role, she states, "From the very beginning and for a long time thereafter, it seemed that I was living in an environment of constant change . . . I had to keep reminding myself that I could not stay in one place and worry about situations over which I had no control or power. I couldn't ponder why events were occurring in a particular way. Over time, I learned to be flexible and to further develop what I believe are essential leadership qualities."

Problems Endanger the Center's Survival

Ms. Ellison faced many administrative and programmatic difficulties during those years. While they can be separated into external threats and internal weaknesses, the two are inextricably linked and had to be addressed together.

External Threats

Loss of federal funds. Support from the Healthy Start Program office (funneled through the State) to carry out the Chicago Healthy Start Initiative was cut by two-thirds. These cuts resulted in the loss of Center staff and eventually compromised the long range plans for sustainability. In spite of the cuts, Center staff was expected to reach the same goal - reduce infant mortality by 50% in a five-year period - with fewer staff and services. This seriously threatened the ecological model upon which the "one-stop shopping" family center concept was founded. Staff was also expected to continue to provide consultation support to other health professionals. While it was true that staff had been forewarned, the timeframe for budget cuts was not definite. Though expected, the steep cuts forced the leadership to implement drastic steps to guarantee the continued success of the Center's programs.
Changes in state organizational structure. Due to reorganization at the state level, the program responsible for overseeing Healthy Start contracts lost its autonomy and was no longer housed in an independent division. This agency was subsumed under a megaentity, one which combined several major departments under one leader for health services. As a result of the restructuring, there was increased competition for priority status and more energy had to be expended to ensure that communication with and access to key decision makers were effectively maintained.
Changes in executive leadership at the original collaborating agencies. Almost simultaneously, the two administrators who had jointly hired Ms. Ellison (and to whom she reported) resigned their positions. Thus predictable relationships, with known levels of support, understood buy-in, and even the occasional opposing viewpoint, were no longer in place. She was faced with the daunting task of operationalizing a struggling program while at the same time selling and promoting it to new and aggressive chief operating officers.
Changes in HMO and managed care guidelines. These modifications placed restrictions on the health care providers. Thus, at one point, some Family Center clients could not be referred to medical providers within the partnership. Externally-caused referral issues created generalized confusion on the part of the patients as well as the case managers within the center. The overall result was that while recruiting efforts were successful in reaching neighborhood residents who were interested in the services, the patient census declined.
Changes in clientele and emerging issues of cultural competency and diversity. Originally, it was assumed that the Center would serve a predominantly African American population (90-95%). While this was true at the beginning, the patient base subsequently shifted and expanded. Within four years the base of clients receiving comprehensive care was 60% African American and 40% Latino. In response, the Center instituted changes in staffing, recruited Latino or bilingual providers and case management personnel, and conducted training and educational seminars.

Internal Weaknesses and Limitations

Loss of services. The loss of funding had its greatest impact on services that were considered less essential or not critical to the well being of pregnant women. While medical care services remained and continued to be billable, cuts were made in the areas of job readiness, substance abuse and childcare services. These three areas were part of the original service matrix developed to implement the family center concept. Their elimination ran counter to the lessons learned from the earlier Infant Mortality Reduction Initiative.
Low patient volume. In the first year, the Center did not see the anticipated number of patients and operated at approximately 60% capacity. While health indicators clearly demonstrated the need for services, many hurdles had to be overcome. As an example, case managers had to become familiar with all programs in the service matrix and learn to make broad-based referrals.
Lack of administrative cohesion across services. At times, clients were required to provide the same information over and over (particularly demographic data) because there were more partners and programs housed under one roof than originally was anticipated. The lack of internal communication contributed to the clients' perception that they were being cared for by four unrelated agencies rather than being enrolled in a comprehensive program. A central intake system and related training became necessary in order to prevent a decrease in patient satisfaction and eventual loss of clients. Such a system was more convenient for the clients and for the Center. The central intake process also provided a means of monitoring and tracking patient flow.
Limitations to the marketing plan. Since the original medical and social service providers had an established referral link, marketing strategies targeted constituencies external to the Family Center. However, with the addition of the new partners, there were many clients who routinely circulated through the facility, utilizing perhaps only one service at a time. Thus, there was a need to develop procedures for internal referrals and a marketing approach directed toward each collaborating partner.
Different levels of buy-in. There was some reluctance expressed by the board of one collaborating agency to commit resources to a new venture. Furthermore, partners entered the relationship at different points in the process of establishing and maintaining the partnership. As indicated, two of the member agencies had been involved from the very beginning as the vision, mission, goals and programs were being drafted and finalized. These two entities had the benefit of years of discussion and dialogue. Other partners joined as pre-determined plans were being put into action. While these plans were complementary to each agency's core mission, the venue (integrated services) was different. In a related vein, the levels of interdependency within the partnership varied among agencies. For some partners, the Family Center was a bonus - it enhanced their core programs and raised their visibility. For other partners, the Center became critical - the cuts in funding and changes in reimbursement rules had pushed them to the edge of extinction.

Key Factors Facilitating Partnership and Program Survival

This partnership was established for the sole purpose of successfully operating a family center to address the needs of pregnant and parenting mothers and their families. There are several key characteristics and personal traits that Ms. Ellison believes allowed the program and partnership to continue until the present time.

In discussing the balance between maintaining the vision and getting the work done, Ms. Ellison says, "Successful leaders need to be visionaries, but they also need to be able to connect the dots. In addition, they need to be able to convey in writing how the dots connect and be able to demonstrate to others how they connect. In the past I focused more on the big picture. In this initiative, I had to get used to the fine details."

Ms. Ellison is able to reflect on features of her own leadership style and capabilities by recalling activities that occurred during her watch. She is well aware that leadership is not a one-woman show and recognizes the support and contributions of others to the success of the collaboration.

Leadership consistency and constancy. While changes were occurring both externally and internally, Ms. Ellison remained a key player who could carry the banner and interact at all levels. She was knowledgeable about past history, informed regarding activities that were occurring at the center, and cared about what was trying to be accomplished. She was able to look for and see areas of success. Thus, she made a conscious effort to dispel doubts and increase commitment by "telling and retelling the Center story" as often as she could and in as many arenas she could access - in the board room, at the various health departments, at meetings with the leaders of the partnership, at general Healthy Start Consortium meetings, and during orientation and training sessions for the staff.
Recognition by funders. Despite the cutbacks and the administrative reorganization at the state level, key Center proponents were willing to provide the time and support necessary for program development, program implementation and quality control monitoring. In addition, the State of Illinois recognized the Center's contribution and provided opportunities for "show and tell" image enhancing visits from dignitaries and elected officials.
Commitment of community residents. Many members of the Center's staff either lived or had lived in the community. Some of these staff members remain at the Center today. These individuals promote the Center in the community, telling friends and neighbors about the services that are offered. At the same time, they offer comments based on their personal observations and feedback they receive during their routine interactions. High visibility in the neighborhood is extremely important for the Center's viability as 90% of the Center's clients hear about it through word of mouth.
Sound operating structure. Ms. Ellison utilized her strong administrative background, coupled with her extensive knowledge, experience and well-honed negotiation skills to establish a solid foundation for the Center. Written protocols and procedures originally developed for two agencies were reviewed and revised to reflect the participation of all partners. New operating guidelines were crafted in consultation with all members and circulated for approval by all entities. Procedures for handling complaints were agreed upon with the understanding that they would be consistently applied across all programs. This strong foundation created a structure for collaboration. Specific administrative policies were guided by a philosophy which valued the community, promoted the worth of the individual, and honored the partners' core commitment to the health, quality of life and well being of the community.
Consistent communications. In addition to developing sound operating systems, channels of communication were established. Written materials were developed and client activities were documented. Data was collected and reviewed on an ongoing basis - It was tabulated and prepared in different formats for distribution to staff and presentation at meetings. Materials were routinely shared with other local family centers. Ms. Ellison and staff also traveled to provide on-site consultations addressing Healthy Start and family center issues. Special funding was received to convene and host regional conferences and to document presentations and program discussions.
Leadership is not a one-woman show. Leaders also have to be able to follow. I firmly believe you have to be good at what you do and then you have to Do It! At the same time, it is critical that you not only recognize but also acknowledge your limitations. Sometimes leaders must be able to step back and let other, more competent individuals assume center stage - particularly for those roles and situations in which the leaders themselves lack skills or training. While it seems so basic to say that leaders must also follow, not everyone is willing or able to do this. Equally important, leaders must establish a climate and framework within which this concept of team is nurtured and can flourish.

Program Accomplishments

The Family Center's "one-stop shopping" concept faced challenges from the beginning. However, the program approach has been proven to be successful. Infant mortality on the Near West Side fell and has remained at this lower level.
Despite federal and state budget cuts, the Family Center has operated for six years. It is still in its original location. The number of clients has doubled overall and tripled for one of the partners. Approximately 600 mothers, children and their families access the Center's services every month. Of these, approximately 60 are new to the Family Center.
The Center is known and respected by funding agencies. This has enabled it to compete for scarce government resources.
Administrative systems that were developed when the Center was founded still work today. This attests to careful planning and is key to the overall smooth operation of the Center.
The majority of the staff comes from the neighborhood. Some staff members, especially the community health workers, have been with the parent agency for 15 years. In addition to the administrative advantages of a stable staff, this has increased the stature and visibility of the Family Center in the community.

Leadership Lessons Learned

Ms. Ellison has compiled the following observations on collaborative leadership based on her experiences at the West Side Family Center. Among the key characteristics of collaborative leaders are:

Leaders must keep their eyes on the vision. Their vision must be 360°.
Leaders must be ever-diligent. They cannot rest on their laurels and accomplishments, but must be looking ahead, anticipating the next challenge.
Leaders must tell the story of success in as many arenas as possible. Leaders need to be consistent, persistent, credible voices while advocating for their programs and constituencies.
Leaders must understand the need to serve many people without sacrificing the quality of the services. Systems to achieve both these ends must be developed.
Leaders must document program outcomes and impact. Program sustainability largely rests on outcomes - and credit for good outcomes cannot be accomplished without clear documentation.
Leaders must keep abreast of trends in their program area and in the population they serve.

Closing Thoughts

Ms. Ellison says, "If you ask me to look back over this experience and think about personal traits that influenced my leadership and served me well during these processes, several key characteristics come to mind.

Ambition - Ambition not in the sense of striving to be at the top, but ambition to be the best, and to be good at what I do.
Fairness - It is important to understand that all people are equals and must be treated with respect. This has to be part of your underlying philosophy.
Ability to look at a situation from someone else's perspective.
Ability to anticipate questions, to reflect, to make objective assessments and consider creative solutions.
Ability to see and maintain the vision. The vision has substance above and beyond specific directives and operational considerations."

In closing, Ms. Ellison says, "You must have a vision, but you also have to have belief that it will work. I am committed to reducing infant mortality for low-income families. I am passionate about improving the lives of clients who are underserved, and that's why I am where I am today."