The authors are with Quantum Foundation, in West Palm Beach, Florida. This post is based on a consultant’s report. The authors also presented on this topic at the Grantmakers In Health annual meeting in March 2013.

In philanthropy, it’s easy to focus on our successes. It’s obvious when a project or grant goes well. Often, we know more about our successes because we naturally choose to examine them more closely. We talk about them. We share them. We celebrate them. Looking back on initiatives to identify and learn from failures is much harder, but arguably more valuable.

Quantum Foundation is a private, perpetual grant-making organization based in West Palm Beach, Florida. When a local community-funded hospital was sold in 1995, the proceeds were used to create and endow a foundation to fund health-related projects in Palm Beach County. Most associate Palm Beach County with great wealth, but we also have wide disparities in income and education, vast rural tracts often worked by migrant laborers, and diverse cultures, religions, and languages. Since its founding, Quantum Foundation has given away more than $100 million to try and ensure that every resident has the opportunity to lead a better life through high-quality health care.

In 2012 the foundation decided to embark on a strategic retrospective of our work. Our fifteenth anniversary of grant making seemed like the right time to take stock and carefully examine some of our initiatives. We wanted to identify where we had done well and where we could do better. We contracted with FSG consultants to review our health access projects. Our 2007–2008 Federally Qualified Health Center (FQHC) development initiative emerged as the best example of a project with clear wins and losses.

Over the next few years, grantmakers will be wrestling with the complexities and as yet unknown implications of the Affordable Care Act (ACA). Foundations across the country will be looking to increase the capacity of local providers to deliver health care services. While our lessons emerged within the context of an FQHC development initiative, they certainly have broader relevance for other strategies.

The current situation in many ways mirrors where we found ourselves in 2007 when Quantum’s board made a bold decision to lead the development of a coordinated system of public/private FQHC sites in our county. The goal was to increase health care access for residents while making use of the federal dollars slated to become available through the Health Center Program New Access Point funding opportunity, which is managed by the Health Resources and Services Administration (HRSA).

Quantum Foundation approached six health care entities and offered grants to help them take advantage of the promised federal dollars by applying for FQHC status. With the benefit of hindsight, here are four vital lessons we learned as a result of this project.

Lesson 1: Carefully examine your assumptions and your approach.

We were operating under the assumption that most local clinics would want to become FQHCs and that the federal dollars associated with the status (approximately $650,000 per year) would be enough to encourage clinics to apply. However, existing clinics did not necessarily want to change. The FQHC model simply did not make sense for all clinics.

Our assumptions were also based on a belief that the proposed federal dollars would materialize. When the 2008 economic crisis hit, the number of FQHC access points projected to be approved dropped from 350 to sixty. Our whole initiative suddenly faced a fresh set of parameters mid-stream.

The implementation of the ACA will no doubt throw similar curve balls, and while they can’t be predicted, an elastic approach and organizational agility in responding to change will be key to any grant-making organization’s success.

Lesson 2: Clearly identify each stakeholder’s role and your own expectations.

It seemed plausible that by creating a great facility that offered high-quality care, a clinic would naturally earn a solid patient base. It didn’t pan out that way. Some of the clinics we funded had trouble recruiting and retaining staff and attracting and retaining patients. Projections proved to be overly optimistic, and the sites were underused.

Were all our expectations too high, or were some of the stakeholders unclear about ownership of responsibilities and accountability? Upon closer examination, we came to the conclusion that any major initiative requires clearly articulated buy-in from key stakeholders at the outset. A broad-based community-led initiative that champions the cause and clearly expresses the need has the greatest likelihood of success.

Lesson 3: Build in contingencies—of time and money.

Any initiative which has systemic change as its goal is enormously challenging. It’s going to be a marathon, not a sprint. Much like a construction project, it’s wise to assume it will cost more and take longer than anyone estimated. While a series of milestones can be identified so that there are reasons to celebrate along the way and maintain enthusiasm, it’s likely going to be a long haul.

Lesson 4: Articulate your exit strategy before you enter!

A foundation’s exit strategy (the when and the how) ought to be clearly identified before the first step is taken, so nobody is surprised or disappointed when it inevitably happens. The nature of a grant cycle is that it ends. How else would new grantees and new ideas ever get their chance to be funded? Sharing that philosophy from the start helps set up the responsibility of grantees for sustainability and allows for a gracious partnership closure.

As a nation, we’re entering an unprecedented period of change in our health care system. No doubt, many organizations will be embarking on bold projects, just as we did. In the grand scheme of philanthropy, our story is small, but the lessons are big, and they are relevant. Perhaps some of the challenges from our journey might inform your proposed strategy. Consider which of the above issues might be relevant to your projects and share both your successes and your failures with your colleagues from other foundations. It’s why we all do the work we do in philanthropy—to share, to learn, to grow, and to not only do good work but to get better at doing it.

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