“Why did you write this book?” is always an intriguing question and rarely comes with a simple answer. Writing a book is a difficult undertaking. So, what was it that caused me to sit down at a computer day after day, hour after hour, and write down what happened in my workplace over the last 20 years at Cincinnati Children’s—and 20 years before that at the University of Cincinnati and Drake Center—and in the greater Cincinnati community? What did we learn about delivering services that families and communities want? How was learning turned into lessons and guidance for working in the nonprofit world? What was it that made my experiences unique, but at the same time, universal? The answer lies in my belief that by capturing 40 years of experience and developed wisdom, I could help others walking a similar path, people and organizations who choose to address big social issues and are not paralyzed by the enormity of the task. These are people who know that not one of us is successful alone, and that it is through collaborative thinking, deep reflection, and holding ourselves to high standards that we even begin to make the smallest change.

As I retired and began to consider how to spend the time that was left to me, I reflected about what had been important over those working years. Family, friends, and dogs came first and have always been key to who I am. But beyond that, what did I learn in my life of designing and implementing programs for young children? Writing this book began as a way to consider my experience and to be more objective, not only about what I learned, but also—and more important—what I did and whether what I and my colleagues did truly made a difference for children. And, if so, how?

What are the lessons for other nonprofit organizations working to address and remedy large social problems? What is transferable across strategies to provide support to people in early childhood, adolescence, and aging? As I have moved away from the daily operation of leading the Every Child Succeeds (ECS) program in greater Cincinnati (www.everychildsucceeds.org), a nonprofit with an annual budget of close to $8 million, I have been able to see our work from a broader, more realistic perspective, as though someone brought new lighting to reveal unseen new facets. Patterns have emerged that made me think of those dragons that were vanquished and those that were merely prodded. I was able to see more clearly what we did well and where we could have improved. So, this book provides an opportunity to capture those learnings, and make them available to others, as my lifetime-­developed wisdom and reflections can perhaps be meaningful for other nonprofit leaders.

I am proud—infinitely and forever—of what we were able to do in the two decades since our founding. We were given significant tools to work with and guidance that was invaluable, but I think that what we did most successfully was to take what we were given and use it well. ECS is a relatively small nonprofit, and a single case study cannot serve as a generalization for all nonprofits. However, I believe that it is a useful empirical reference as an organization that grew responsibly, used resources effectively, and demonstrated value. There is guidance here for existing and new nonprofit organizations working to address social issues, including organizational executives, board members, staff members, students, and consultants, as well as lessons for funders, policy makers, community leaders, and the people who use services delivered by nonprofit organizations.

But with the lessons, there are still questions—complex questions about programs that span generations. What works? What doesn’t work? What is really needed? What can we afford? What evolved over time? But what I have kept in mind is this: Over our first 20 years, we served 28,000 families (website of ECS) and at least 56,000 caregivers and young children. Their lives were changed through engagement with us. They received more than 700,000 home visits delivered by a corps of caring, talented, well-trained home visitors. We have evidence to prove that we positively influenced the health and well-­being of those people we served. We are often asked about why, if our program is so good, our community metrics have not moved, and my answer is always the same—when you serve only 20% of those who need your service, you cannot significantly change a community metric. But––and this is crucial—the lives of 56,000 mothers and babies were changed. Science tells us that what happens in those first 1,000 days of a child’s life has relevance for a lifetime, for two and three generations. I will not apologize for serving only 56,000. Rather, I continue to be proud of what we did, but I ask myself how we might have done more.

I grew up as the daughter of a pediatrician in Charleston, West Virginia (a pediatrician who made house calls––they did that years ago). We seem to be moving back to that model today. When I was a small child, my father often took me with him on those calls. I learned early that being in the house with the family allowed him to make better decisions and recommendations. He was a trusted, valued member of a team for the child and, in time, the siblings and the extended family. He had a way of practicing pediatrics focusing on the parent and the child, but also saw them in the larger environment of the family constellation, the neighborhood, and the stresses upon the entire family that would affect their lifetime trajectory.

Harkening back to what my father learned about the families he served by visiting their homes, the COVID-19 pandemic has brought new insights to many of today’s health providers. In May 2020, Jennifer Haythe, MD, a cardiology professor at Columbia University, in a short Wall Street Journal editorial (Jennifer Haythe, “House Calls Are Back—Virtually,” Wall Street Journal, May, 7, 2020, Eastern Edition), reflected on her experience as a physician during the pandemic. She wrote that though the virtual visits she was making were not ideal for every appointment, they were giving her “insight into the patient’s lives that only a house call would provide.” And that “COVID-19 has taken much from us, but it has given us back this connection to our patients.”

Within the last few years, the concepts of hope and trusted, positive relational experiences have emerged as the best way to engage families—to build on their strengths, to understand that even in the face of trauma, resilience and strength, they can overcome what is negative; and that having even one caring adult giving that positive relational experience can make a difference. Years ago, I worked with a young man who had belonged to a gang in Chicago. He got out. He reported seeing his friends shot on the way to school and his sister afraid to go out of the house. I asked him, “What was it that allowed you to be here today?” His response consisted of two words, “My grandmother.” “She cared about me,” and he was not going to disappoint her. Intuitive and real. Moreover, many studies point to the importance and value of having that single caring adult in the life of a child, particularly in the early years. Professionals in medicine, psychology, child development, and other fields now embrace the importance of these relationships as foundational to lifelong health and well-being. That has been the work of our nonprofit, and if anything, the work needs to grow. But within this book, I will offer not only our experience, but also ideas we can offer to other nonprofits working to address an array of social needs.

We experienced the stress and challenge that most nonprofits face—to solve a huge, seemingly intractable problem with the lowest budget—and then sustain the initial success. But, fortunately for us and for the families we served, we emerged in the late 1990s into a community that recognized that there was a critical problem to be solved—how to support families in the first three years of a child’s life in order to ensure a positive life trajectory. We were given extraordinary support from our business community and our three founding partners, United Way of Greater Cincinnati, the Cincinnati Children’s, and the Cincinnati-­Hamilton County Community Action Agency (CAA). We were given the latitude we needed to craft our program and deliver it.

Now, 20-plus years later, nationally known and respected, ECS has weathered storms, embraced welcome windfalls, and responded to evolving challenges, but has always held true to its original mission: to ensure that all children can get the best possible start in life. Over the years, science has reinforced and elaborated upon our original basic concept that the first 1,000 days of life are important and foundational to all that follows. Our intervention strategy has been proven to be sound and the prevention focus correct (Shonkoff et al. 2012; Shonkoff et al. 2009). We have celebrated their accomplishments with our families and the hope they bring for the future. So many times, as I met with our families and talked with them about their experiences, I came away humbled yet ever more eager to support them in building upon their strengths, resilience, and opportunities. We walked beside them. Not in front. Not behind. ECS was—and continues to be—as a partner walking together. And, after all, isn’t that the magic and the hope for the future?

My personal work reflects decades of senior leadership with more than three dozen nonprofits—as president, board member, volunteer, paid staff, and consultant—on topics ranging from blood banks to health care, to community activism, theater, and fine arts. Issues related to families and early childhood are not appreciably different from those in other focus areas for nonprofits tackling social challenges. Similar challenges face organizations working on the well-being of youth, seniors, or people with disabilities. The systems (and funders) that provide guidelines and expectations for our work heavily influence what happens. Those factors have a profound impact on the potential for success of any nonprofit endeavor. I’ve contemplated ways to begin to tackle this challenge by holding programs accountable for their expected outcomes—working together to identify those outcomes; determining how the information will be gathered and analyzed; and mindful of what funders expect. One of our board members said it this way, “Find the simplest possible measurement that will tell you what is going on.” It needs to be a joint process with decisions made in advance rather than changing the rules after the work has begun. Yet, for programs and organizations of long standing, funding priorities and public perception of the problems change over time, some for the better, and some less so.

In the face of such changes, maintaining focus on the mission and vision of the work is essential and requires steady leadership. In 2007, I wrote to one of our board members to thank him for his guidance, and I ended the letter this way:

Far too often we forget our roots. We forget the endless meetings, the people who urged us to be better than we thought we could be, the people who saw the future and helped to lead the way. Here in Cincinnati our leaders and our community gave us the support and vigor we needed to go forward each day, and that is what I remember when we are triumphant and when our world grows cold. Thank you for the confidence you placed in us.

ECS stands on solid ground and can say with pride that over the last 20 years, more than 28,000 families made up of 56,000 people were helped. The services improved the developmental trajectory, life course, and opportunities for thousands of children, and their families were changed in a positive way. How we did it is the story I’m going to tell.

Part 1 of this book describes the evolution of ECS as a nonprofit focused on families and young children from 1999 to 2021, as a case study. Understanding that our greater Cincinnati community is but a microcosm of the broader world, we have learned, on a small scale, about the challenges and barriers to scaling programs and the importance of focusing on what works. We have learned much about the challenges and limitations facing small nonprofits who tackle big social issues. Part 2 of this book shares principles of nonprofit management from collaborations, to private and public-­sector partnerships, to measurement and financing. The word focus is one that you will read repeatedly, because it is at the very center of what happened during my time with ECS and is essential to the principles highlighted in Part 2.

Of course, no one individual represents the full history or life course of an organization. I retired from ECS in January 2021, leaving the organization with an exemplary staff; local and national respect and recognition; and most important, documented positive outcomes for thousands of families. We created a strong institution where none existed before. With new leadership, ECS continues operation, faces new challenges, and plans strategically for the future. As emphasized in this book, changing sociopolitical times call for wisdom, collaborative thinking and execution, accountability, and even bravery, always keeping the mission in mind and building upon programs that are producing what they promise.

We have a moral imperative to make the home, the village, and the society for that child a safe, stable, and nurturing environment for relationships. The late US Representative Elijah Cummings of Maryland expressed in his words the same understanding of those of us who work with children—we live in the present, but we are committed to their future: “our children are the living messengers we send to a future we will never see. . . . Will we rob them of their destiny? Will we rob them of their dreams? No—we will not do that.”

Years ago, I was selected as a winner of the national Purpose Prize, for people over the age of 60 using their accumulated wisdom in their second half of life to make significant social change—to turn life lessons into purposeful projects. Ideas ranged from the ethical treatment of farm animals to food insecurity, to using children’s artwork to decorate corporate offices. They were small and large projects, but each one powerful. And they collectively had an important lesson: Change cannot always be all-encompassing; rather, change can mean working within our own organizations, linking with others where possible, keeping a common goal in mind, and sharing strengths. That may be why I was chosen for this award, as I have held to my mission and vision throughout my career, most notably in my later years. Change in the world can, as Margaret Mead famously said, come from “a small group of thoughtful, committed citizens.” (Mead 2005) I hope this book will inspire others to lead, join together, and innovate in ways that foster significant social change, at whatever scale, from a deeply held vision.