Layers of Leadership

Reprinted with permission from Trustee magazine September, 1998, pgs. 18-24.

Improving the health of an entire community may sound overwhelming, but in an age of capitation, cost containment, and not-for profits trying to justify their tax status, addressing social problems that negatively affect health makes sense. Logic tells you that you can't go it alone, but for an industry that has taken to the competitive business model like the proverbial fish to water, working with other organizations makes the job all the more daunting. So the Community Care Network (CCN) vision is a useful tool for orienting health systems toward the health of populations and communities.

Evolving community care networks are guided by the following five goals:

By working toward these goals simultaneously, changing systems learn how to best serve populations and communities in cooperation with other local resources.

At first glance, hospitals and health system leaders appear ready to take on these collaborative and integrative challenges.  After all, trustees and CEOs are familiar with many of the CCN goals. They have experience with leading and managing complex organizations. They are informed and well respected members of the community with broad interests and involvement.  The organizations they oversee often bring to the table a strong capacity for problem solving, adaptation, and systems management, in addition to their obvious importance as major players in the health care system. To top all this off, many leaders have embraced or survived mergers, alliances, system integration, and other forms of multiorganizational cooperation.

Broad-based community health networks have been forming in community after community nationwide. The American Hospital Association began tracking these networks-which go by a variety of names-in 1993. Hospital participation in networks was 19 percent in 1994 and 26 percent in 1996.

These partnerships adopt many different approaches to improving the overall performance of their local health care systems.  Some focus on assessing and reporting community health problems. Others emphasize maximum citizen participation so that all resources can be brought to bear on community improvement. In many areas, health care organizations put their effort behind finding ways to collaborate with their competitors. Some try to teach community members as well as health care professionals about how to navigate the system effectively. Still others focus on developing their capacity for care management and managed care.

These innovative efforts stem from a growing recognition that improving population and community health requires participation from a variety of community sectors. Participants often include insurers, business alliances, schools, churches, social service agencies, public health departments, local governments, and community based organizations, in addition to health systems, hospitals, clinics, and physician groups.

THERE ARE LAYERS, AND THEN THERE ARE LAYERS

Let's use a hypothetical case, based on several actual cases, to examine some of the ways health care leaders meet the challenges of collaboration.

Jim Hansen is the CEO of Marvin County Public Hospital.  As part of ongoing board education, the first item on last month's meeting agenda had Jim describing the activities of the community care network in which the hospital participates.   Because Jim and the trustees like to keep well informed about current trends, he started with some background on community health collaborations generally.

Jim then described the progress of the hospital's local community partnership. The immunization effort, which had been increasing rates for three years, now included every health care organization in the community.  Just last week, the head of the public health department told him that they were within weeks of reporting concrete outcomes: measurably lower incidences of certain childhood diseases.  Department staff only had to check the data one last time.  Then the partnership could finish cleaning up the report and release the results.

In addition, Jim said, yet another major local employer was signing up for the Working Well program. Employers who had participated since the beginning claimed they could demonstrate real reductions in missed work time, and they credited the program.

He had begun noting the network's progress on the school health education and careers program, when Bill Richards, along time board member, interrupted him.

"I'm still not sure what this is all about," Richards said. "This community care network stuff sounds good. And, of course, I believe in our community. Anything we can do to make it a little better, well, I'm all for it. But we don't really know what good it's going to do us. After all, the county commissioners appoint us to this board. And, while most of the time they consider the hospital to be a millstone around their necks, we've got a lot of people who want it to survive. This collaborative stuff doesn't mean much to them. They just want the hospital to be here when they need it.

"Another thing that's bothering me is how much of your time is being spent on these partnership projects? After all, it's the hospital that's paying your salary, not the partnership!

"At this point, almost all the time allocated to this agenda item had been used up. Jim could tell that the board chair sensed his uncertainty. Should he launch a long discussion about whether and how community care networks make sense? Or should he politely thank Bill for his candor, offer to get that question on the next board agenda, and move on to the next item? The board chair glanced at her watch and said, "Jim, maybe we could revisit that question next time. Why don't we move on to our review of the hospital's financial performance?

"As Jim drove home, he reflected on Bill's comments. "His concerns are legitimate," he thought. "I need to do a better job of educating the board about the partnership and why our participation is important. Maybe I should ask the coordinator of the network to attend our next regular board meeting. Maybe she could help refresh their memories on the why and how of our involvement."

No matter how experienced you are as a trustee or how willing you may be to consider new and exciting opportunities, there are many fountains of doubt and skepticism in today's shifting, often ambiguous, health care environment. Change and ambiguity are part of what makes meaningful participation in collaborative community health partnerships such a challenge for the governing teams of hospitals and health systems. But there are more specific and helpful ways of looking at the big changes happening all around us.

LAYERS OF LEADERSHIP-AND TURF

Let's assume that, as a hospital trustee, you are your hospital's representative in a community health partnership. You are enthusiastic about this new opportunity. After all, the hospital's mission clearly states that its purpose is to "improve the health of the community." Furthermore, the hospital has always been the center of health care in the region, one of its largest employers, and has a board composed of some of the most influential people in the area. You soon learn, however, that partnership governance departs significantly from traditional notions of institutional governance. Consider these challenges:

Perhaps the most critical feature of partnership governance is not directly evident at first glance. Governing body members of community based partnerships typically wear two hats-one as a leader and policymaker of the partnership, and another as a representative of their organization. It's a tricky business to recognize and address two partially overlapping sets of interests when decisions that may benefit the partnership could be detrimental to the organization, or vice versa.

This kind of challenge might be called "layered turf."  It's not the same as the more clear cut turf problems that emerge when two organizations or individuals compete directly for the same spot, attention, investment, service, or product line, as though only one can have it. Here, both entities are expected to occupy the same spot by their decision makers.

Hospital trustees will recognize this dilemma. It's similar to the dilemma of a medical staff representative who sits as a voting member on the hospital board. At times, the interests of the medical staff may be diametrically opposed to what is perceived by the board as in the best interests of the hospital. This situation sometimes creates a "double bind" for that individual. One can't resolve the dilemma, but neither can one avoid it.

The apparent solution is a continual game of dress up: putting on one hat as quickly as another comes off. Often, the best one can hope for is not to be embarrassed or accused of duplicity.

DRESSING FOR SUCCESS

There are things you can do to smoothly match up the places where your hospital board and your partnership governance functions overlap. Naturally, developing interpersonal trust creates bonds or alternative channels of communication that can over come some of these problems. But the best first step is to choose partners carefully. More mature community care networks have developed explicit rules for identifying, evaluating, and admit ting partners. Here are some tried and true criteria:

ACTIONS SPEAK LOUDER THAN WORDS

A second recommendation is to choose partnership activities that stick the partners together in just the right place. The best partnership activity may not always be the one that makes the most sense at first blush. If you believe the partnership itself can add value to certain activities, it is also true that certain activities are not appropriate for the partnership. We have also found that an upfront requirement of meaningful resource commitment binds the partners together.

Bear in mind, though, that a meaningful resource committed to the partnership by, for example, a council of churches may be quite different than a meaningful resource committed by the hospital. A council of churches might best spread the message of collaboration through its clergy speaking before their congregations, while a hospital might best commit medical and epidemiological expertise.

On top of this, it's important to expect the partnership to help the partners so they don't consume so much of their resources that they can't serve their traditional functions.

The chance of turf overlap increases when similar types of health providers and financial contributors participate in the partnership. In other words, successful collaboration in some markets may require that the partnership adopt special limitations about what it can do. While this does run counter to the common notion that it's best to include everyone and to create a wide ranging agenda, more mature partnerships accept that, to be productive, they can't pretend to be everything to everyone. One partnership made three years of solid progress in a hotly competitive health care environment by adopting a simple guideline by which to judge potential initiatives: "It only gets on the table if none of the partners can do it well independently."

CONFLICT MANAGEMENT, NOT CONFLICT AVOIDANCE

Even when joint activities pass the competition test, partner ships still face conflict. One of the chief benefits of collaboration, after all, is to learn how to productively challenge some of the traditional assumptions held by the partners. These long held assumptions are often the source of resistance to change.

For example, community health information systems are tricky because hospitals and other providers legitimately consider certain information proprietary, or even confidential. The idea of sharing health information across organizations is often ruled out. But in one evolving CCN, the governing body served as a forum to air partner concerns and eventually got a commitment on record that partnership interests would override individual organizational concerns with respect to community health information. The partnering organizations agreed that, after following law and regulatory requirements, all community health information from any source would be available to all partners. In other words, the governing body helped the partners agree to a new rule that would help them know the circumstances under which they could break the old rules.

Getting to that point wasn't easy and took about two years. The voluntary nature of participation, and the limited control the partnership can exercise over its member organizations, severely restricts the use of authority, contracts, or incentives to resolve conflicts. But learning how to accept and work with conflict can be a huge step for partnerships. The Harvard Negotiation Project provides excellent tips for conflict management (see sidebar, Negotiating Agreement Without Giving In).

CREATIVELY CONNECTING THE LAYERS

After consideration, Jim developed an action plan to address both the importance of the hospital's participation in the collaborative community partnership and the concerns of the board, the commissioners, and the public. So he suggested to the board chair that she appoint Bill Richards to head up an ad hoc committee to work on the plan, which consisted of the following:

Now Jim actually looks forward to the next board meeting and launching his new work with Bill and the other trustees.

Improving patient and outpatient care is a continual process. It's the primary work of the hospital. And the new challenges of orienting the local health care system toward population and community health are especially exciting. These challenges bridge the hospital's past and present with its future.

WINIFRED M. HAGEMAN is a Seattle based governance consultant; RICHARD J. BOGUE is the AHA's senior director of governance pro grams in Chicago. This article is based on the work of the CCN Governance Project team: Jeff Alexander, Ph.D., University of Michigan; Richard J. Bogue, Ph.D., AHA; Winifred Hageman, Hageman & Umbdenstock; Bryan Weiner, Ph.D., Tulane University; Howard Zuckerman, Ph.D., University of Washington.