DEFINITION AND OVERARCHING THEMES
The topics for the cross-cutting sessions discussed in the preceding chapters were selected to assist participants in implementing the applications of the priority areas described in the Quality Chasm report (IOM, 2001:96):
Synthesize the evidence base and delineate practice guidelines.
Organize and coordinate care around patient needs.
Provide a common base for the development of information and communications technology.
Reduce suboptimization of payment.
Simplify quality measurement, evaluation of performance, and feedback.
In addition to those topics, a session on coalition building was added in response to feedback received during preliminary inquiries with summit community participants. Since coalitions were viewed as an effective structure for catalyzing change, additional knowledge and skills for developing mechanisms for community engagement were a priority for community participants. Thus the goal of this session was to identify strategies that can be used by communities to integrate and support the work of diverse coalition stakeholders and enhance attainment of their common goal of improving the quality and efficiency of care. In addition, attention was given to public and private partnerships and ways to obtain human and financial resources, as well as expertise.
The following definition of community coalition building was adopted by the working group and helped guide the ensuing discussions (IOM, 2002; Sofaer, 2003):
Coalition building aims to build an organizational structure that integrates and supports the work of multiple, diverse stakeholders—often at both the local and national levels—on a focused and shared goal, in this case improving care quality and efficiency at the community level. Such coalitions, sometimes referred to as partnerships or collaborations, may foster visibility and information exchange; serve as planners, coordinators, or implementers of joint activities; mobilize broader support for an initiative; or promote policy changes. Coalitions that span the public and private sectors have been encouraged.
Participants in the session on coalition building focused on three key strategies for developing and sustaining effective coalitions: (1) identify those who should to be involved in the coalition, (2) obtain agreement on a common objective, (3) determine how the achievement of this objective can be measured. At the summit, four community coalitions shared their strategies and lessons learned in engaging many diverse groups around a mutual goal: the Greater Flint Health Coalition (GFHC), the Mid-America Coalition on Health Care Community Initiative on Depression (MACHC), the Pediatric/Adult Asthma Coalition of New Jersey (PACNJ), and the Rochester Health Commission (RHC). The MACHC initiative is described in Box 4-1 in Chapter 4; the other three initiatives are described in this chapter.
Identify Those Who Should Be Involved
The participants concurred that one of the most important steps in the process of activating a coalition is getting the right people to the table. In the recruitment phase of coalition building, care needs to be taken to ensure a proper balance among stakeholders—at both the community and organizational levels. Although there is no set number of people that should participate, emphasis should be placed on casting a wide net to ensure that multiple perspectives are represented and to harness a range of skills and resources (Sofaer, 2003). Often, this involves bringing together groups that have competing interests, which can prove challenging. RHC (see Box 7-1) illustrates the evolution of a coalition influenced by stakeholder relations.
Participants also discussed leadership within a community coalition and desirable characteristics for individuals assuming this role. They cautioned against either appointing a strong expert as a leader, who might limit dialogue, or relying solely on the energies of a charismatic leader, whose departure could result in the coalition’s demise. Rather, the notion of “servant leadership” was embraced—a facilitator who is capable of bringing together a group of people with varied agendas, slowly developing trust, and then building consensus on what must be done to achieve a mutually desired outcome (Greenleaf, 1983). It was also pointed out that this leader must be culturally competent, not only with regard to race and ethnicity, but also in balancing the strategies necessary for community organization at the grassroots level with those required to build interagency groups or business coalitions.
The Rochester Health Commission (RHC), established in 1995, is a nonprofit, community-based organization with representation from a broad array of stakeholder groups, including consumers, business leaders, health care providers, and insurers. RHC was designed to be (1) a source of independent, objective health care information; (2) an advocate; and (3) a convener.
An early initiative undertaken by RHC involved public reporting of information on health plan and provider performance. This initiative provoked great turmoil, particularly when it was extended to hospitals. The commission then received a grant under the State of New York Healthcare Reform Act that sustained it for the next year and a half until it held the Summit on Rochester Healthcare in 2000. That summit produced a new finance structure for RHC, with operational expenses being derived from health insurance premiums. Additionally, the summit launched the Rochester Health Forum (RHF) as an arm of the commission to serve as a vehicle for community input and consensus building. The RHF helped redefine the commission’s role, which now focuses on facilitating local interventions to improve the delivery of quality care.
To identify priorities, RHC used the “one-text” negotiation process, through which ten initiatives to embark upon were identified (Fisher and Ury, 1991; Program on Negotiations at the Harvard Law School, 2004). Examples are implementation of communitywide clinical guidelines for care, interventions focused on reducing medical errors, and strategies to address shortages of health care workers. Two further initiatives were subsequently added: improving support for end-of-life and palliative care, and implementing communitywide hospital orders, linked to the national Leapfrog Group (The Leapfrog Group, 2004). The former initiative was featured at the summit for its work dedicated to improving pain management in cancer, as well as in other conditions requiring pain control, which spans a range of care settings from physicians’ offices to nursing homes and hospices (Farley et al., 2003).
Obtain Agreement on a Common Objective
Once a coalition has been assembled, the next critical step is to identify a common objective that supercedes differences in interests or perspectives—to determine early in the process what the salient issues are for each participant and then negotiate a win/win solution addressing those issues. Maintaining transparency and revealing biases and conflicts of interest up front are paramount, since individuals by nature are inclined to act out of self-interest, and organizational interests often surface strongly in coalitions. The rallying point should be the creation of community-focused goals that the coalition can tackle collectively.
Session participants raised concern that the consensus-building process often results in action being taken on the “lowest common denominator,” rather than on a “stretch” goal. They suggested the need to avert such behavior,
which tends to push sensitive but worthy issues off limits. Typically, this is best done at the outset, when mutual trust is beginning to be established. Rather than settle for less challenging goals as a way to achieve consensus, a track record of one or two successes should first be established, and having thus built trust, the coalition can move on to higher goals.
PACNJ provides an example of how a coalition can quickly be solidified and take action if it joins forces around a common objective. See Box 7-2 for a description of that group’s initiative.
While some coalitions evolve a long-term vision over time, the working group on pain control in advanced cancer articulated a mission statement
The Pediatric/Adult Asthma Coalition of New Jersey (PACNJ) was formed by a group of volunteers who decided to band together and marshal resources around the common goal of improving asthma care in their community. What brought this objective into focus was Camp Super Kids, a 1-week residential asthma camp for children sponsored by the American Lung Association of New Jersey. Although the children would leave the camp with their asthma under control, organizers found that 30 percent of the children each year were “return campers” and had not retained the skills they had been taught to self-manage their condition.
To address this problem, the American Lung Association of New Jersey and the New Jersey Thoracic Society convened a meeting of interested individuals across the state who were working on implementing the guidelines of the National Heart, Lung, and Blood Institute. From an initial group of 50 people, PACNJ has grown to include 150 members. Remarkably, this effort evolved without any seed money or external mandate to assemble.
The coalition consists of a steering committee whose members serve as cochairs on six task forces: school, child care provider, physician, community, managed care, and environmental. This multifaceted approach was adopted to ensure that all the forces influencing high-quality asthma care would be addressed in a cohesive fashion. A window of opportunity presented itself to the coalition when the State of New Jersey passed a law requiring that asthma action plans be on file for all children carrying inhalers and that school nurses and personnel receive asthma education—all within a 180-day time frame. PACNJ quickly mobilized and launched its first project—a statewide satellite broadcast targeting asthma management in the school setting. Funding from the U.S. Centers for Disease Control and Prevention through the New Jersey Department of Health and Senior Services and from the United States Environmental Protection Agency, Region 2, sustained the effort. Since then, the coalition has expanded its scope to include adults and is looking at ways of incorporating information and communications technology to facilitate compliance with asthma action plans. Additionally, the group is exploring a research endeavor with the University of Medicine and Dentistry of New Jersey to measure the effects of public law on health outcomes (The Pediatric/Adult Asthma Coalition of New Jersey, 2003).
during the summit. The group identified as its key objective to “raise the bar on public awareness and clinical performance,” making it unacceptable to tolerate bad pain management. With this as its central issue, the group identified two ways to activate the community: (1) coordinate a public information campaign, led by the American Pain Association (APA)—an action item to which the APA committed at the summit; and (2) ask national professional groups and associations to formally adopt and implement the working group’s mission statement. Box 7-3 presents that statement, along with concrete measures defined by the group that would be used to measure achievement of this objective (see the next section).
Every person living with cancer can count on, and every clinician can promise, that the patient can live to the end of life without having to endure unacceptable cancer pain.
Definition of Success by 2006
Determine How the Achievement of This Objective Can Be Measured
Participants stressed the importance of coalitions measuring both quantitatively and qualitatively the impact they are having on their communities. To this end coalitions must establish objectives and agree on which measures are necessary to document progress (as was done by the working group on pain control in advanced cancer). Such metrics must be meaningful for diverse members of the community and for an array of stakeholders and yet be straightforward and limited in number. There should be a focus on processes and outcomes that impact change in the real world and assess the degree of penetration the coalition has achieved within a defined community. The role of measurement is not only to document progress. Measures that are concrete, actionable, and supported both by scientific and community consensus become a powerful expression of shared accountability. This shared accountability, in turn, reinforces community cohesion and guides the rational distribution of coalition resources to needed areas. In addition, documented and credible measures of success attract additional support and resources. GFHC illustrates the evolution of a coalition over time and the incorporation of measures to demonstrate the group’s contribution to the community (see Box 7-4).
The heart failure working group suggested that community activation is an important strategy for overcoming barriers to the delivery of high-quality care for this chronic disease. They called for community-based performance reports by 2004 and community-based performance measures by 2007. Box 7-5 outlines strategies proposed by this working group to heighten awareness of the current gaps in heart failure care within the community, and thereby motivate initiatives to achieve the needed improvements. These strategies included holding dialogues at the grassroots level with a diverse set of local groups to learn what resources the community needs to play a dominant role in improving heart failure care,
conducting local demonstration projects to implement these ideas, influencing local leadership to elevate the problem and create the will for the improvement to come from within the community, developing local media campaigns and sharing heart failure patients’ stories, and engaging business coalitions to support improvement initiatives.
The Greater Flint Health Coalition (GFHC) was formed in 1992 by several community leaders to examine issues affecting Genesee County’s health status. This initial core group of advocates launched three pilot projects: increasing smoking cessation, decreasing cesarean births, and increasing diabetes awareness.
In 1996, GFHC reorganized, becoming a broad-based organization with funding from the insurance, provider, and purchaser sectors. This transition helped solidify the collaborative nature of the coalition, positioning it to address a wide array of health care–related issues. Since then, GFHC has expanded its outreach to encompass 16 initiatives, and its membership has grown to include providers, purchasers, consumers, committed citizens, government representatives, and faith-based organizations.
An example of a GFHC initiative currently under way is the Mid-Michigan Guidelines Applied to Practice-Heart Failure program (GAP-HF), which was featured at the summit. This program is designed to increase inpatient compliance with American College of Cardiology/American Heart Association guidelines and to promote the seamless transfer of patients from the hospital to their primary care physician. Hospitals participating in the program are provided with a number of resources, such as an intervention toolkit complete with standing orders, nursing critical pathways, and a discharge contract. Additionally, clinicians and administrators have access to a physician–nurse team trained in guideline implementation, and each participating institution is given a report card documenting performance on standardized heart failure quality indicators.
By working collaboratively with multiple stakeholders, GFHC has been able to significantly improve the health care of its constituents. For example, outcomes from the coalition’s Acute Myocardial Infarction/Guidelines Applied in Practice project, directed at improving adherence to evidence-based guidelines for acute myocardial infarction, demonstrated a 22 percent increase in counseling for smoking cessation, a 15 percent increase in appropriate prescribing of cholesterol-lowering drugs, and a 24 percent increase in prescribing of ACE inhibitors—interventions all proven to be effective in the treatment and management of heart disease (Greater Flint Health Coalition, 2003; Mehta et al., 2004).
In summary, focused group actions (as opposed to individual actions) linked to relationships among organizations, such as are found in coalitions, are useful approaches for solving complex system-level problems. In forming and sustaining a coalition, it is critical to identify and balance diverse stakeholder groups. Coalitions must commit to a long-range vision—buttressed by early successes and evolving over time to suit the tasks taken on as the group matures. Establishing objectives and agreement on measures for assessing progress makes it possible to document progress and develop shared accountability among coalition members.
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