Lloyd Michener, professor and chair of the Department of Community and Family Medicine at the Duke School of Medicine and a family doctor for 30 years, shared his perspectives on how to enhance the culture of health care and public health collaboration to build a culture of health. The format of the discussion was a facilitated conversation with attendees over lunch, moderated by Paul Mattessich of Wilder Research. Culture involves norms, values, attitudes, standards of behavior, assumptions, language, and vocabulary, Mattessich said. Formal structures and institutions are also part of culture. There is not one common culture, and within cultures there are subcultures. Cultures can also be distinct, having minimal interaction with other cultures. For further background, Mattessich referred participants to a literature review of the research on collaboration, first published by Wilder Research in 1992, with a second edition in 2001 and a third edition forthcoming (Mattessich et al., 2001). The report seeks to identify factors that influence the success of collaboration, which he noted was difficult because most of the research on collaboration comprises case studies and is not amenable to meta-analysis. The conversation that followed highlighted informal elements of culture that can either facilitate or inhibit collaboration to improve population health.
Michener was prompted by Mattessich to share a very successful example of collaboration between health care and public health and why
he thought it was so successful. Michener cited the collaboration between the Medicaid agencies, primary care practices, and public health in North Carolina as an example of success. This collaboration has led to a statewide 65 percent reduction in admissions for children with asthma over the past 5 years. He noted that agencies in the city of Boston, taking very similar approaches, have seen an 80 percent reduction. Michener stressed that bringing primary care and public health together magnifies the effect that each has separately. Working together can achieve outcomes that make a difference in people’s lives.
Finding the Right Partners
Mattessich asked Michener for his observations on the diagram by Mary Applegate of Ohio Medicaid of micro-, meso-, and macrosystems in practice (see Figure 2-1). Most of the early work is at the micro level, Michener said, inside a system or community of practice. Linking this work at the local level correlates to the mesosystem level, and linking programs within counties and states is the macrosystem level. A key question is how to get organizations and structures aligned to support each other’s interests and connect the networks. He stressed the importance of identifying who should be included and reaching out to those who may not have been asked.
Research shows that having an appropriate cross section of members is an important factor influencing the success of a collaboration, Mattessich added, and it is important at all levels in the structure (e.g., local, state) as well as within organizations. Problems can occur if part, but not all, of an organization is involved in the collaboration. (e.g., if practitioners start to move ahead too quickly without bringing their management on board; if chief executive officers make promises without considering the practical and operational issues).
Michener highlighted several foundations that are pulling together public health, primary care, and community organizations to align around shared issues (e.g., the Advisory Board Company, the Colorado Health Foundation, the de Beaumont Foundation, The Kresge Foundation, and the Robert Wood Johnson Foundation). Pamela Russo from the Robert Wood Johnson Foundation said the foundation has fostered communities of practice and is also very interested in collective impact. She noted that multisector collaboration is very challenging and asked Mattessich to comment on the return on investment for collaboration. He concurred that multisector collaboration across disciplines that start further apart than public health and primary care is much more difficult (e.g., bringing together finance and public health). There are promising case examples of where collaboration has been cost-effective or cost-beneficial. Differ-
ent sectors have come together in multiservice centers around affordable housing, nutrition, exercise, access to primary care, and so forth.
Sanne Magnan said that the Institute for Clinical Systems Improvement in Minnesota has competitors sitting around the table, including medical groups, hospitals, and health plans. She observed that healthy competition can be an element of collaboration. Transparency allows partners to see each other’s progress and strive to do better.
Speaking the Language of Collaboration
Michener concurred with the importance of connecting within one’s own organization and highlighted the role of language in inviting others to participate. In many cases, for example, primary care and public health use the same words but with different meanings. A hospital chief financial officer speaks in terms unfamiliar to many in health care. Language differences are both disciplinary and cultural, Mattessich said, and have evolved over long periods of time. Some language is deeply ingrained within a system, he observed. For example, a social worker, a health care professional, and a schoolteacher will refer to the same person as their client, patient, and student, respectively.
Several participants offered examples of situations where language has been a barrier or a facilitator to collaboration. “Population health,” for example, means different things to different people. Some hear “integration” and interpret it to mean others want their money or are invading their “turf.” It was observed that “alignment” is often a more palatable term than “integration.” Mattessich added that collaboration has to be perceived as being in the self-interest of the participants. All parties need to understand that what can happen in the aggregate, as a result of their joint efforts, can be of benefit to them. The cost needs to be worth the risk. It was pointed out that workers’ organizations are population health organizations concerned about improving the health and safety of vulnerable people, but most are not familiar with the language of population health. As we change our language, Michener said, others find they can join in and work toward common goals.
Strong Leadership for the Journey
Mattessich reiterated the point made during the case study discussions about the importance of leadership in successful collaborations. Sometimes initiatives are built around a charismatic leader, and attempts to replicate and take them to scale do not always work. Michener noted that examples such as Million Hearts and others show what can be achieved in communities and states through collaboration if the necessary elements are in place. Michener said fear of failure often gets in the way of
success, and leaders should be “given permission” to try new approaches without fear and learn from those that turn out less than ideal. Progress is a journey, he said.
Michener was asked to comment on the advantages of collaboration and the perceived disadvantages or barriers. A major benefit of collaboration is that it brings people together and brings them “back to their roots,” he responded. Most people who enter the fields of medicine, public health, or social work do so because of a desire to help others and to be a part of something larger than themselves. Bringing people together, with the goal of working more effectively together than separately, taps into deeply held values that people have not lost, but perhaps have lost sight of over time. Those deeply held values help to overcome the initial barriers between different community members. A second, related advantage of collaboration, he said, is the sense of being more effective and making a difference more broadly in the things that really matter (beyond one’s own patients and clients, for example). A third, also related, reason to pursue collaboration is that it works, and it can be fun, he said. So much focus is placed on perseverance and on measuring success by how much effort is expended. Collaboration means that others are there to help take the load off. If we can be willing to let go, there is a sense of relief and a sense of joy and motivation in being part of something larger than oneself.
A challenge to collaboration is what Michener described as a sense of marginalization in primary care and public health, a feeling of always being at the bottom, which makes some suspicious about collaboration. The term “integration” raises fears that a group’s already limited funding will now be going to a different group. Within medicine, the culture is very focused on one’s own practice, he said, while collaboration offers the possibility of being successful on a larger stage. Other barriers to collaboration are the inability to work with data and inexperience with teamwork. Primary care groups are often not trained in these areas. Internal office teams may function well, but there is limited experience in working with external teams. As mentioned earlier, language issues and fear of failure are also barriers.
Collaboration is a tool in a tool set, suggested George Isham of HealthPartners, and is not the answer to everything. He suggested pros and cons to collaboration be considered with respect to what the partners are trying to achieve together. In collaborating, an organization or individual gives up maximizing one’s own outcome as an individual player; however, the organization or individual gains the power of working with others and acquires access to other skill sets to achieve a goal that could not be achieved alone. Population health demands that multiple sectors
work together, he said. Mattessich concurred that collaboration is a tool, not an end in and of itself. He noted that some foundations have required collaboration as a prerequisite for obtaining a grant, which has led to various problems. Although this requirement has sometimes brought agencies together, they did not really know what to do once they were together. The culture and technology were not developed such that they could collaborate. The literature suggests that a collaboration should have a unique purpose that none of the members has as his or her sole purpose. Otherwise, he continued, the initiative can be seen as threatening to that individual member. All members should be able to see how participating in the collaboration meets their self-interest, meets the community interest, and yet is not subsuming their own purpose.
Collaboration also requires relationships and trust, Michener said. Mattessich said that from the collaboration research over the past 30 years, the two elements that stand out as being extremely important, transcending all forms of collaboration, are mutual understanding and trust among the participants and communication. For any collaboration to be effective, there must be communication and trust. If trust is not there initially, the work must be paced in a manner that allows for trust to be built.
Phyllis Meadows of The Kresge Foundation offered her opinion as a public health practitioner and as a philanthropist, saying that she could not imagine any problem that has been addressed effectively without some level of collaboration. She agreed, however, that there is a level of readiness and a certain amount of skill and competency that must be in place to be effective in a collaboration. There are also some contextual realities that need to be in place, along with political will, the opportunity, and the space and resources to do collaboration, she said. The research strongly validates the point that a history of collaboration in the community will greatly influence the success of any new collaborative initiative, Mattessich said. If the social, political, and other cultural elements are there, people are more prepared to collaborate. If those elements are not there, a new culture needs to be created, starting slowly to foster collaboration over short-term goals so that a history develops.
It is time to shift from trying to get things started to looking at who is missing from the table and inviting other people to participate, Michener concluded. Continually look for who is missing because circumstances continue to change. Collaboration is built on the fundamental elements of trust and person-to-person communication, Mattessich said. Sometimes it is the informal relationship building (e.g., coffee shop conversations) that fosters progress and a culture of collaboration.
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