Collaboration among a litany of health care and community-based organizations (CBOs) has become a popular approach to pursuing health improvements in cities and towns across the United States. Examples of cross-sector coalitions can be found in the work of Way to Wellville, the Institute for Healthcare Improvement’s 100 Million Healthier Lives initiative, and, in many cases, the winners of the Robert Wood Johnson Foundation’s (RWJF’s) Culture of Health Prize.
Over the past few years, health care and community-based providers have expressed to me a combination of excitement and fear about integrating their work with that of others. The prospect of finding partners to achieve more than one could alone is inspiring, and the prospect of losing oneself in the process is frightening.
In March, I had the opportunity to moderate a session at the Learning in Collaborative Communities (LinCC) meeting in Denver, which was hosted by the Health Research & Educational Trust (affiliated with the American Hospital Association) and was funded by the RWJF. At the LinCC meeting, representatives of ten community-based collaboratives from across the country gathered to share experiences and develop skills to strengthen their hometown partnerships.
I designed an exercise to elicit the hopes and fears of participants about working in these collaboratives. In advance of the meeting, I received the participant list and divided participants into three role-based groups according to the kind of role and organization in which they worked. The resulting breakout groups were hospital leadership, hospital community outreach (including community benefit managers), and CBOs.
In the meeting, I provided each group with a template and asked them to identify their hopes and fears for collaborative work based on a realistic understanding of the role they occupied in their organization. After about twenty minutes, each group reported out to the others before all participants reflected on and discussed what they heard.
Below is what I took away from that discussion, which is inevitably commingled with some of what I’ve learned in other, similar conversations along the way.
- Health improvements: All groups were aligned in their hopes for improved health outcomes. Of course, matters became more complicated when it came down to which outcomes should be prioritized in a given collaborative. The hospital outreach group mentioned a particular interest in outcomes that could be improved and measured in the near-term. One hospital employee said, “I need a quick win” to justify the time she was spending on the collaborative. On the other hand, CBOs were fearful that the collaborative would fail to focus on improving the outcomes of the most vulnerable because such outcomes would require more time and money to improve.
- Financing: All groups mentioned some combination of hopes and fears related to financing. Unsurprisingly, everyone mentioned a hope for new or additional resources. (For hospital leadership and outreach, this hope may be justified by precedents set by some state policies and by research grants that provide funding for hospitals to address social determinants of health. CBOs may have been anticipating receiving funds from hospitals for their work as part of an accountable care organization (ACO) or community benefit project.)
Individual breakout groups were more specific about their financial fears. Members of the hospital leadership group were concerned that improving health of the community would have a negative impact on their revenues because of decreased utilization of services. Administrators in that group were also afraid of being asked to fund the work of the collaborative. Members of the hospital outreach professionals group shared a fear that improvements in health outcomes would put their organizations at a disadvantage when it came to benchmarking them for risk-adjustment purposes. More personally, the outreach professionals voiced concern that they would be seen as the bearers of bad news in their communities if they could not deliver the kinds of funding that other collaborative members expected. For their part, CBOs shared a fear that hospitals would soon be competing with them for community health improvement grants.
- Control: All groups mentioned some version of a fear related to losing a sense of control over their work. Participants in the hospital leadership group shared candidly that they were fearful about stepping on the toes of other organizations but also were committed to being a key stakeholder in whatever activities a collaborative undertook. Hospital outreach personnel feared “not getting credit” for the work they were doing. CBOs were clear that “ceding control” was among their fears. These fears seemed equal in importance to the ones described above related to financing, suggesting that even if incentives could be magically aligned, identity threats to each organization might remain.
- Time: All groups mentioned some variation of fear related to wasting time or ultimately being unsuccessful. Hospital leadership included “fear of failure” on their list, and hospital outreach added “fear that nothing will change” to their list. CBOs included “fear of wasting time” and “there’s other work to do” to their list. The latter comment raises a critical insight related to community collaboratives. Despite “improving health outcomes” being a point of widespread agreement amongst the represented parties, that aim is no one’s core business. Each of the breakout groups could have said something akin to “there’s other work to do.”
- Politics: There was dissonance among the breakout groups related to the role of politics in the work of a collaborative. Hospital leadership voiced a hope that the collaborative would provide an opportunity to influence public policy, but participants in that group were also blunt about their fear that the group would “become political.” I took this to mean they were uninterested in being asked to take an advocacy stance on issues not directly related to their organizations’ well-being. CBOs, on the other hand, were hopeful that the collaborative they have been participating in would develop a “unified voice in advocacy.”
In debriefing, I asked whether anything anyone said surprised the others in the room. Even after a prolonged silence, no one admitted to being surprised. We might chalk this up to “group exercise fatigue” or an effort not to appear naïve, but I suspect that participants really were not surprised because they had already ascribed some version of these hopes and fears to people in their own collaboratives. Nevertheless, when I asked people how it felt to go through this exercise, one said, “It felt good to be honest.”
Community health collaboratives are hardly unique in facing these kinds of organizational challenges. In interprofessional groups, there is almost always an inherent tension between unity and diversity. The unity is generally what brings people together. The experiences of collaboratives at the Health Research & Educational Trust/RWJF LinCC meeting suggest that improving health is the shared interest around which people are rallying. All parties enthusiastically embraced this goal rhetorically even if their operational and financial interests were not yet in full alignment.
Managing the diversity inherent in interprofessional groups can be trickier. In the Denver exercise, I noted divergence along a range of issues described above. Before dismissing these as fatal, it is worth recognizing that these collaboratives are designed to build upon the unique resources that health care and community-based organizations contribute to population health. At the individual level, it is the nutritionist’s (or the lawyer’s, or the community organizer’s) professional difference from the nurse that makes her valuable to the shared work at hand. The diversity that can make these collaboratives difficult is also what makes them promising.
At the close of the exercise, the meeting participants asked what advice I might have for managing these dynamics. I offered three pointers of things to avoid.
- Avoid scapegoating other individuals in the collaborative. Tempting as it may be to write someone off as a “bad partner,” most disagreements are born of deeper role- and organizational-related roots as opposed to character defects.
- Resist asking people to leave their professional identities at the door. Such an ask defeats the purpose of the collaborative, and most groups that try this find it impossible to do anyhow. Instead, invite members to share their commitments, goals, and fears openly so they can be fodder for strategy making.
- “Do not let the perfect be the enemy of the good.” Especially where financial incentives are not yet in alignment, long-range strategic plans may be difficult for a collaborative to produce. Keep moving, however incrementally, by finding alignment in whichever small areas it exists. In the course of doing so, members will build relationships that serve them well in taking on larger risks and tasks in the future.