• Strategy: Collaboration can be viewed at different levels, with increasing benefit accruing to rural practitioners as the collaboration increases.
  • The vertical structures of large organizations make communications difficult and diffuse responsibility for effective decisionmaking. Middle managers are reluctant to give firm responses, and frontline staff do not receive the history or the actual documents related to a project.

    Strategy: Use detailed agendas and meeting minutes, and disperse them widely; include staff members from multiple levels within the organization whenever possible; publicize significant accomplishments.

  • Frequent turnover of participants.

    Strategy: Prepare a plan for orientation of new participants. Determine the information needed to bring new staff up to date on projects. To the extent that systems and procedures are in place and documented, personnel changes should be less disruptive.

  • Different forces drive each organization to begin using clinical guidelines and outcomes such as the requirements of NCQA and JCAHO and bottom-line finances.

    Strategy: Use pilot programs to demonstrate how one project can be used to satisfy various needs.

  • The existence of different levels of knowledge regarding clinical guidelines and outcomes research.

    Strategy: Provide educational opportunities for participants as well as encourage participants to learn from one another.

  • Statistics: sample size and ceiling effects.

    Strategy: Projects must be carefully selected to ensure adequate sample sizes for analysis of characteristically smaller rural data sets. Projects must be carefully selected by taking into account the possible influences of ceiling effects. For example, as an outcome measure, "smoking cessation" may be a poor choice if most of those who will stop smoking have already done so.

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