Sustainability for Community Quality Collaboratives: An Overview of the Art & Science of Building Staying Power

Introduction

Sustainability, in its simplest terms, is the ability to sustain or continue over time. For Community Quality Collaboratives, the pursuit of sustainability means building, maintaining, and refining an infrastructure that supports and advances the mission of the organization as market and stakeholder expectations change. Sustainability is not limited to funding or succession plans, but encompasses organizational structure, financial planning, the community of participants, and their approach to collaboration.

While there is no “silver bullet” that will guarantee success, there are powerful lessons to be learned from organizations that have faced and resolved similar challenges. These lessons come from a broad range of sources, including health and non-health care services, nonprofit entities, for-profit businesses, and supporting disciplines.

“This is no casual challenge,” said former U.S. Department of Health and Human Services Secretary Mike Leavitt, when he introduced the concept of a Learning Network at the first annual meeting of the Agency for Healthcare Research and Quality (AHRQ) in September 2007. “What I see is a network, literally, across the entire country where every community has or is part of a value exchange. And through that value exchange we're able to develop information that is local but nationally standardized, and that people who are at the physician- and provider-level can deal directly with a local organization but know that it is part of a larger, national rollup.”

This overview is one component in a technical assistance program on sustainability developed by AHRQ for its Learning Network for Community Quality Collaboratives. The goal of this program is to support Community Quality Collaborative leaders and members in defining strategies that will lead to productive and financially sound collaboratives that grow, thrive, and deliver significant value over time.

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Life Stages: Designing for the Present and the Future

As a starting point, leaders should recognize and understand the Community Quality Collaborative's stage of development in the life cycle of the organization. The challenges and opportunities facing a Community Quality Collaborative will vary depending on its stage of development and the prevailing forces in its local market. A variety of published models and tools exist to define organizational life stages.

For the purpose of this program, a simplified model is presented below, and the table that follows defines activities, questions, and desired outcomes typical of a Community Quality Collaborative in each stage.

Building Sustainability in Each Life-Cycle Phase

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Managing Complexity: Artfully Blending the Stakeholder Organizations

Blending the established organizations that make up a Community Quality Collaborative into an effective collaborative is an important and potentially complicating factor for each Community Quality Collaborative. Each participating organization will have its own design and goals, based on its life-cycle stage, which may or may not coincide with the overall stage of the Community Quality Collaborative. This will provide opportunities to leverage the experience and insight of the member organizations. It also will challenge the collaborative leadership to achieve and maintain balance among the stakeholder organizations.

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Value Is the Core

Community Quality Collaboratives are founded on the principle of collaborating to deliver value. Yet, stakeholders have different perspectives on priorities and approaches, leading to variations in the emphasis they place on types of value.

In particular, the Social Return on Investment Model defines three overarching categories of value:

• Social Value: "[W]hen resources, inputs, processes, or policies are combined to generate improvements in the lives of individuals or society as a whole."¹
• Economic Value: "[P]roviding additional inputs or processes that increase value, thereby generating a product or service that has greater market value. ..."²
• Socioeconomic Value: "[M]aking use of resources, inputs, or processes; increasing the value of these inputs. ... [G]enerating cost savings for the public system or environment of which the entity is a part."³

A critical consideration in sustainability planning is understanding what stakeholders value: What motivates them to actively participate and contribute? This perspective helps successful collaboratives match the types of value expected by stakeholders with the types of funding available.

The Business Model Insights section of this document provides insight into how several successful collaboratives align value creation with funding.

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Common Community Quality Collaborative Value Propositions

A value proposition is defined as: "The unique added value an organization offers customers through their operations."⁴ One recommended sustainability strategy for Community Quality Collaboratives is to results that are valued by each of the four stakeholder groups—purchasers, plans, providers, and consumer organizations - in order to sustain their interest and support.⁵

Following is an overview of common categories of value offered by Community Quality Collaboratives. Most organizations offer value in several or perhaps all of these categories, while maintaining focus on central themes.

Public Good

This approach involves contributing to common knowledge or improving services of benefit to many and creates social value. Many efforts of Community Quality Collaboratives and similar organizations contribute to the collective knowledge and improved practice of health care. For example:

• The improvements in patient care generated by the Pittsburgh Regional Health Initiative's Perfecting Patient Care^sm model are transferable to practitioners at large.
• All the organizations studied, along with most Community Quality Collaboratives, publish health care quality information for the general public via Web sites and printed materials. By educating and engaging consumers, these organizations are increasing public knowledge and demand for quality services.

Access to Data

This approach involves sharing, comparing, and applying health care data in efficient, secure, and empirically sound ways and may create any of the three types of value: economic, social, and socioeconomic value, depending on how the information is applied. Collaboration leads to the richest data sets by combining information that would otherwise be evaluated separately. This provides stakeholders with added value. For example:

• The California Cooperative Healthcare Reporting Initiative (CCHRI) coordinates data gathering about California health plans and produces a comprehensive report. The public report is published online, and CCHRI members have access to additional details and expert discussions about the data.

Business Opportunities

This approach involves improved access to customers or service providers, reduced cost to serve, improved pricing or revenues, and insight into new products and services, and it creates primarily economic value. By working together on collaborative programs, business providers, such as health plans, build relationships with current and potential customers. For example:

• The California Quality Collaborative targets providers in the lowest performing counties in California for focused attention. This approach provides value to the selected providers by improving their services and ability to compete for business, while also benefitting health plans, purchasers, and consumers by raising the bar on quality across the state.

Publications

This approach involves sharing information with a broad audience through published reports, papers, Web sites, tools, and other documents and may create social or socioeconomic value. There may also be economic value if the publications generate revenue.

• In some cases, publications contribute to the public good by making information widely available.
• In other cases, stakeholders may receive and value documentation that is not publicly available. For example, collaborative participants may have access to preview materials before they are published or to view detailed data that is not part of a summarized report.

Membership

There are benefits of participation, which include access to other leaders and information. Collaborative stakeholders may place high value on the interaction and information provided by the Community Quality Collaborative. Specific benefits of membership may include:

• Knowledge Sharing: Sharing information among stakeholders; often live or real-time.
• Networking: Opportunities to connect both formally and informally with industry leaders and subject-matter experts. Collaborative participants have many opportunities to make connections and learn from each other, as well as from industry thought-leaders at conferences, retreats, and working sessions.

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Leading Practices

Successful collaboratives consistently apply organizational focus and discipline—the science component—as well as creativity—the art—to the following seven leading practice areas that directly impact sustainability:

1. Responding to Compelling Market Circumstances
2. Maintaining Effective Leadership
3. Achieving Balance Among Stakeholders
4. Delivering Tangible Value
5. Communicating Proactively
6. Establishing a Transparent Management Style
7. Employing Rigorous Prioritization

Each leading practice is described in detail with examples in this document. The seven leading practices were the result of online research, interviews with staff and stakeholders conducted during the case studies, and review of documents provided by each organization.

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Leading Practice No. 1: Responding to Compelling Market Circumstances

This practice addresses the two fundamental questions: What are the challenges in our region?; and, Why are we best suited to address them? Successful collaboratives identify and respond to compelling events, which engage and motivate key people to take action. Following are several examples of compelling circumstances that have directly contributed to the launch and continuation of multi-stakeholder collaboratives devoted to improving health care:

• Quality Imperative: The complexity of the American health care system and the recognized gaps in quality, as captured in the sentinel report Crossing the Quality Chasm, published by the Institute of Medicine in 2001, are quite compelling.⁶ According to the Network for Regional Health Improvement, a new consensus is emerging on the value of evidence-based care, measurement and reporting of performance, and rewards for results.⁷
• Escalating Cost: Since 2000, employment-based health insurance premiums have increased 100 percent, compared to cumulative inflation of 24 percent and cumulative wage growth of 21 percent during the same period.⁸ This trend has created significant pressure on stakeholders, including purchasers, providers, and consumers. These market conditions provided a high degree of motivation for stakeholders, such as those participating in the Puget Sound Health Alliance and the Pacific Business Group on Health, to collaborate to find more effective solutions.
• Challenging Business Climate: The Pittsburgh Regional Health Initiative grew out of a major initiative to advance the competitive position of the Pittsburgh business community. Leaders at the Allegheny Conference on Community Development—predominantly corporate CEOs—recognized the importance of health care and agreed to collaborate around promoting quality and development in the health care arena.

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Leading Practice No. 2: Providing Effective Leadership

This practice ensures that organizations have the right mix of talent and energy to deliver results. Along with passion and experience, the most successful leaders bring with them broad, established, and trusted networks of diverse contacts who may contribute support, ideas, resources, or funding to the collaborative.

For example, the Puget Sound Health Alliance began with a strong start under the passionate leadership of public executive Ron Sims. Sims "convened a broad-based leadership group, the King County Health Advisory Task Force, to develop an integrated strategy to address the systemic problems facing the health care system in the Puget Sound (Washington) region."⁹ The task force, chaired by two local experts, brought together a broad group of stakeholders, including employers, physicians, a nurse practitioner, a pharmacist, and legal, labor, and economic experts.¹⁰

The task force recommended the creation of a regional partnership to provide the leadership necessary to implement an integrated set of system improvement strategies, which became the Puget Sound Health Alliance.¹¹ Sims was instrumental in recruiting other employers to the Alliance and demonstrating personal leadership in the county's own health benefits program. The momentum grew with the recruitment of Margaret Stanley, an esteemed executive with broad experience from a variety of market perspectives, and continues under the leadership of Mary McWilliams.

This practice leads to successful collaboratives becoming a trusted source or "go-to" forum for critical issues. These organizations are often sought out as a sounding board for new ideas. This, in turn, creates opportunities to reach new stakeholders, resources, and funding opportunities.

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Leading Practice No. 3: Maintaining Balance Among Stakeholders

This practice includes balancing perspectives, skills, and work effort on multiple levels, as well as understanding the historical context of the collaboration. Collaboration is the centerpiece of the Community Quality Collaborative program. While there are disciplined methods for developing teams and facilitating collaboration, achieving a productive balance over time is often a fine art

• For example, the Puget Sound Health Alliance has refined the balance among members, along with the expectations for participation, over time. Currently, the Alliance has a very broad reach, encompassing more than 160 members. Every member contributes financially, and the work is distributed and balanced across the group.
• Governance also plays a critical role in achieving balance. Successful groups, such as the California Cooperative Healthcare Reporting Initiative and California Quality Collaborative have fine-tuned their governance approaches. Both maintain a thoughtful balance of stakeholders at the steering group-level that typically leads to consensus decisions. On the rare occasions when consensus is not possible, voting has been structured to ensure broad representation among stakeholders.

For more information on governance models, please refer to the individual case studies included in this toolbox.

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Leading Practice No. 4: Delivering Tangible Value

This practice addresses one fundamental question: Do we consistently deliver tangible results that are valued by our stakeholders? Demonstrating tangible value is critical to securing and sustaining funding, particularly in the business sector where funders and participants must demonstrate a return on their investments. In case study interviews, every stakeholder who also represents a business echoed the need for this practice. Yet, as discussed previously, stakeholders will have different expectations about what value the Community Quality Collaborative should deliver, which may include social, economic, and/or socioeconomic value. It is critical for the Community Quality Collaborative leadership to have a clear understanding of these expectations and a structured plan to deliver.

• For example, the Pittsburgh Regional Health Initiative galvanized a community to a shared goal of infection reduction and reduced central-line infections by 68 percent across more than 30 hospitals. This tangible outcome was the direct result of applying other leading practices, including leadership, transparent management, and rigorous prioritization.
• The California Quality Collaborative delivers quality improvement training to providers who receive low scores on clinical quality. The specific projects were selected based on market data comparing performance across 58 counties in the state, which identified that low performance was clustered in four counties. The training is funded by health plans and free to the participating groups, while the resulting improvements provide value to many stakeholders: Consumers receive better care; the low performers learn to improve their service; and the health plans and purchasers see improvement in their overall quality scores.

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Leading Practice No. 5: Communicating Proactively

This practice ensures that both the mission and the results of the organization are well known through frequent communication of a "value story" that is clear and consistent. Successful organizations not only deliver what they promise, they make sure that current participants and potential future stakeholders understand the value delivered and the mission it supports. This is accomplished through a variety of avenues, including Web sites, news coverage, publications, speaking engagements, and informal contacts through the broad networks of the leaders.

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Leading Practice No. 6: Establishing a Transparent Management Style

This practice applies effective and enlightened management disciplines such that the Community Quality Collaborative is modeling the behavior desired in the health care market, including transparency, data-sharing, benchmarking (both formal and informal), and using sound data to make informed decisions. For example:

• Successful collaboratives typically share a wide variety of information about the operation with stakeholders and the general public. This practice builds trust and credibility, which are building blocks for other leading practices.
• Each of the successful collaboratives studied publishes a significant amount of information about its programs, staffs, and budgets on its Web site. While organizations may differ significantly, they often will gain insight and ideas by comparing and contrasting their practices with the information shared by successful collaboratives.
• Furthermore, successful collaboratives are profiled frequently in industry reports, such as this sustainability program, to provide insights and benchmarks for others, as well as to elicit feedback and ideas about what works. To demonstrate progress that supports sustainability, Community Quality Collaboratives should seek and apply relevant benchmarks-formal and informal-for both programs and management practices. It may be challenging to identify relevant benchmarks for management practices owing to variations in the market and the priorities of each organization. However, AHRQ's Learning Network is a good starting point for Community Quality Collaboratives to compare processes and successful strategies with each other through project director calls, forum postings, and informal queries.

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Leading Practice No. 7: Employing Rigorous Prioritization

Making choices among worthy projects is often a challenge, particularly when working with stakeholders with strong opinions. Leading collaboratives differ in their approaches to choosing projects, but all apply an agreed-upon methodology. "Steer clear of trying to do everything," advised Peter Lee, executive director of national health policy for the Pacific Business Group on Health. For example:

• The Puget Sound Health Alliance has defined a matrix within its strategic plan that weights all initiatives within a total of 100 points. This structure provides a clear roadmap for stakeholders and staff.

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Leading Practices 'To Do' List

Each Community Quality Collaborative and its leadership likely will have experience in several of these leading practices, but they may be less experienced or facing new challenges in other practice areas. The following checklist offers suggestions for next steps toward developing a sustainability plan that builds on these practices.

The Community Quality Collaborative Sustainability Toolbox includes templates and examples to assist in designing and completing these steps.

• Evaluate current application of leading practices within the Community Quality Collaborative - A checklist of documents is provided in the toolbox. (Go to Item 5: Prework Checklist)
• Survey stakeholders to ensure alignment around leading practices — A sample survey tool is provided in the toolbox. Simple Web-based instruments work well and are inexpensive to administer. (Go to Item 6: Three survey samples)
• Identify additional practices within the Community Quality Collaborative or its member organizations that may be of benefit - This is an example of where the blending of organizations can benefit the collaborative. The leaders on your board of directors or from programs within the Community Quality Collaborative may have experience and insights about leading practices or lessons learned from their own organizations.
• Define or refine a sustainability plan - Planning for sustainability typically will be integrated with the strategic planning process. The toolbox includes components that may be incorporated into a comprehensive strategic plan, including a sample Prioritization Model (Item 7) and Development Committee Plan (Item 9).
• Share insights through the AHRQ Learning Network.

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