cally, and ensure accountability to local needs (Calico et al., 2003). Committed leadership of senior clinicians and administrators is key to the institutional and environment changes necessary to achieve improved quality of care and patient safety—a task that may at the same time be more difficult in rural areas because of personal connections that amplify feelings of blame for errors and easier because of the fewer layers of bureaucracy in rural health care delivery (Wakefield, 2002).

The W. K. Kellogg Foundation’s Leadership for Community Change program offers an example of how community-based rural leaders can be cultivated. Begun in 2003, this program will work closely with local organizations at six rural and urban sites around the country to recruit a cohort of fellows (25 per site) who will participate in a mix of classroom training, mentoring, and networking at the national level over a period of 2 years (W. K. Kellogg Foundation, 2004). The program emphasizes the training of leaders already in place in their communities, rather than the identification and grooming of potential leaders from outside of the community, thus strengthening existing local resources.

Future leaders of rural health systems might also be cultivated through formal educational programs that broaden young health professionals’ skills and knowledge of leadership competencies, health care organization and management, community planning and collaboration, epidemiology, and social and environmental services (Wheat et al., 2001). One approach that should be considered is the development of combined degree programs in public health and one of the clinical professions (e.g., medicine, pharmacy, nursing) that incorporate experiential learning opportunities in rural communities.

Recognizing the need for stronger leadership throughout the health care system, the National Center for Healthcare Leadership (NCHL) was established in 2001 (NCHL, 2003). With support from The Robert Wood Johnson Foundation and the W. K. Kellogg Foundation, NCHL’s transformational leadership project has identified core competencies for health care management to ensure that management leadership is available to meet the needs of the health care sector, and has established an Advanced Learning Institute. Consideration should be given to establishing a learning collaborative for rural communities that could apply and build upon the work of NCHL and others.


Rural communities, like much of America, face significant challenges in closing the quality gaps in both health care and population health status. In

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