Collaborative governance the key to improving community health

Health care delivery and payment are undergoing profound change. But embedded in this transformation is a broader focus on improving overall health and quality of life in the communities health care organizations serve. 

This expanded purpose is being expressed in a number of ways, including:

• Health care organizations revising their mission statements to drive work that not only focuses on delivering affordable, safe, high-quality care but also on improving community health.
• Clinicians applying what has been learned from caring for individual patients to improving the health of entire populations of patients with similar diseases and conditions.
• Health care providers and payers sharing risk for delivering the right care in the right setting at the right time to provide greater value to patients and communities.
• Hospitals and their clinicians taking responsibility for care and treatment delivered outside the hospital walls in a variety of community-based settings (nursing homes, home care, skilled care facilities and so forth).
• Health care organizations joining with other community partners to understand and address community health needs and factors such as lack of education, crime, poverty and other social issues that can negatively affect health status and quality of life.

A recent study conducted by the American Hospital Association’s Center for Healthcare Governance with support from the Baxter International Foundation provides insights into partnerships that improve community health: insights about their structure and function, mission, vision, and sustainability and governance. The center’s study focused on community partnerships involving selected recipients of the Foster G. McGaw Prize for Excellence in Community Service (“Organizations in the Study,” below). Results of 34 interviews with hospital and health system leaders and others affiliated with the partnerships were analyzed by a panel of partnership experts and participants to identify themes and perspectives that can be considered and adopted by others in this emerging field.

The study concludes that a collaborative governance model may be a promising approach for governing a next-generation “system for health” comprising community partners, including health care organizations, focused on achieving the broader aim of community health improvement.

As one study participant said: “It seems we have two-level governance thinking. We have to change ourselves as health care organizations, but we also have to figure out how to engage community partners and empower them to carry out the important work of improving community health without us being the controllers and directors of the process. There’s always governance that exists at the health system level, but that’s not the same as governance of a broad range of community health improvement activities. The fundamental question is, Should there be a true community governance model, and what would it look like?”

Governing factors

The study report, “Learnings on Governance From Partnerships That Improve Community Health” (the AHA’s Center for Healthcare Governance, 2016), discusses collaborative governance as a model that unites organizations and boards with common interests and common missions in integrated thinking, planning and doing to achieve collective impact and share accountability for outcomes that support the common good. This model, the study says, has the potential to accelerate the transformation of health care from a system of organizations working in silos to a system focused on multisector collaboration to improve community health and well-being.

Study participants shared observations on factors that can influence the effectiveness of collaborative governance. Because partnerships can be complex, sometimes involving hundreds of organizations and individuals working on dozens of initiatives, study participants suggested that collaborative governance should focus on achieving success through simplicity. Partnerships can benefit from adhering to a simple set of foundational principles to guide their work and governance (“Principles for Collaborative Partnerships,” below).

Governance structure and function in well-established organizations with enduring and focused missions, such as hospitals and health systems or other organizations that sponsor community partnerships, may not apply to partnerships. Partnership governance may need to be more fluid and flexible to engage a broad range of partners to address evolving community needs. Despite community partners' different cultures and very different worlds, study participants noted that better understanding of the need for investment in community health partnerships and in better health outcomes results when representatives from partner organizations serve on the partnership’s policy-setting body or board or on the hospital or health system board.

Study participants said that sustainability, even in partnerships where collaboration is strong, requires determining who’s in charge and what role governance should play. One panelist suggested that partnership governance should provide overarching coordination of partnership efforts “to study, prioritize and resource problems and then drive the work to resolve them, educate, assess, measure, improve and advocate.”

Identifying competencies for governance and leadership can foster continuity and help sustain partnerships for the long term. A variety of individual and collective competencies that can support partnership success emerged from the study (“Competencies for Partnership Governance and Leadership,” below).

Study participants said that hospital and health system governance must evolve to encompass a focus on the community. They noted that traditional governance of hospitals and health systems already has broadened beyond its primary focus on financial oversight to include increased emphasis on patient safety, patient engagement, compliance, and strategic thinking and planning.

Study participants encouraged hospital and system boards to engage the community and its various voices as trustees further expand their oversight to include community health improvement. One study partnership, for example, has a 25-member board. Eleven seats are designated for community entities such as area health departments that are considered vital to the work of the partnership.

Change agents

The study concludes that the size and scope of hospitals and health systems specially positions them to advance the work of community partnerships through collaborative governance.

The study report suggests that collaborative governance — defined as a model that unites organizations with common interests and missions in integrated thinking, planning and doing — is ideal for hospitals, health systems and their partners because it holds the potential to accelerate change by encouraging organizations with sometimes conflicting agendas to work together for the common good. Study panelists said this will likely be the governance model embraced by health care organizations and their partners as they try to improve community health and well-being.

The report contains a series of recommendations for hospitals and health systems and partnerships to consider as they deepen their commitment and increase their capacity to improve community health.

Recommendations for hospitals and health systems include ensuring a governance commitment to a robust effort to improve community health. Implementing this recommendation might start with convening a board retreat to examine the organization’s current commitment and review lessons learned from the center’s study. An outcome of such a retreat might be that the board adopts a mission commitment to improving community health and participates in finalizing and prioritizing strategies to address it. Health care organizations and their boards should communicate with key stakeholders about the organization’s commitment to community health and take action to build a “culture for health” organizationwide.

As health care boards expand their focus on community health improvement, they may choose to reflect that focus in the board’s structure. While some boards might address community health issues through their finance, quality or strategy committees, appointing a board community health improvement committee and developing a charter to guide its activities is one way to create a home for this work.

Boards also should ensure the organization participates in a community health needs assessment and addresses results with community partners. Hospitals and health systems should work with their partners to identify and address barriers to community health improvement.

Partnerships, the study recommends, can begin or strengthen their work by assessing community health-related bodies that might be willing to collaborate on initiatives that meet shared goals. Such an evaluation can help determine an initial list of partners to participate in a CHNA.

The center study report and a companion document are resources partnerships can use to evaluate options for governance. Consideration should be given to creating a durable structure for the partnership; determining its mission, vision and values; and identifying ways to efficiently coordinate and resource community health improvement efforts.

The study report also recommends the joint creation of a competency-based, multidisciplinary community partnership board. The work of this board can include developing governance principles; establishing strategic goals for the partnership; working through committees and task forces to oversee work on goals and objectives; and developing and monitoring performance metrics to measure progress toward desired outcomes.

Those interviewed in the study recommend that partnerships and their boards adopt a commitment to continuous improvement. For boards, this commitment should include regular evaluation of board performance to identify and address opportunities for improvement. Partnerships also can benefit from continuously refining their operations. Activities might include conducting real-time assessments of emerging community health needs; periodically reviewing the partnership’s progress; incorporating new partners; and reviewing fund allocation to achieve maximum impact.

Study participants also offered advice for community partnerships based on lessons learned in the participants' own groups. They stressed the importance of recognizing that improving community health is a goal that cannot be accomplished by a single organization. And while collaboration is critical to success, they recognized there needs to be a shared understanding of the hospital or health system’s role in the partnership.

Participants also suggested that the readiness and sustainability of a coalition of partners is essential and cautioned against moving forward too quickly. They observed that challenges sometimes arise when working with partners who may be well-intentioned but are used to working alone; change occurs when they come to understand the value of collaboration.

Study participants advised that change also requires more than simply identifying a community need; a focus on results is critical. Other factors for partnership success include establishing an infrastructure, staffing stability, aligned interests, a shared passion for the partnership mission and support for governance.

Participants also emphasized the need for partnerships to involve the community in planning for and setting partnership priorities. As one study participant suggested, “Plans cannot be based on what the organization thinks the community needs.”

Are you ready?

Given that community partnerships and their governance continue to evolve, with many still in the early stages of development and sustainability, the study report also offers a readiness assessment for community partnership governance. Assessment questions address issues for both hospitals and health systems and partnerships to consider.

Issues for hospitals and health systems include the level of organizational leadership commitment to community health improvement, the extent to which the organization’s culture is community-focused, current board and leadership engagement in the community, and the current level of resources devoted to community benefit and community health improvement.

When a hospital, health system or other large community organization evaluates whether to take on the role of providing anchor support for a community partnership, considerations include whether the anchor has the ability to cede control of the partnership’s agenda to other partners and to “lead from behind.” Anchor organization boards and executives should have in-depth discussions about the best use of their resources to improve community health. Anchor organizations also need to determine their ability to provide financial, staff and other expertise to support the partnership’s work, and their willingness to be accountable to priorities, not funding.

The success of a partnership depends on its members having a common understanding of its mission and vision. Partnerships should evaluate the extent to which their members share a recognition of the community’s definition of a “healthy community,” have the ability to focus on partnership purposes instead of self-interest, and have a common understanding of key partnership priorities and initiatives.

Collaborative work and governance require conditions that foster effective engagement among stakeholders. Questions for partnerships to consider include: Do partners understand the value of collaboration? Are their missions and purposes well-aligned? Is the level of trust among partners sufficient to put aside competitive interests and collaborate for the good of the partnership and the community? Do partners share an inclusive mindset, continually looking for and engaging new members to advance the work? Are partner roles clearly defined?

Multiple organizations and individuals working and governing together to achieve collective impact can benefit from common goals and structures that enable and empower their efforts. Setting bold targets that exceed what any one partner can accomplish alone and being accountable to goals benefiting the entire community beyond the needs of a single partner reinforce the value of collaboration.

Identifying competencies to guide selection of partnership leaders and governing body members can help foster partnership continuity and sustainability. The level of communication with sponsoring organizations and the community about a partnership's goals, initiatives and performance speaks to its commitment to transparency. In addition to evaluating factors like these, partnerships should assess whether the benefits of a more formal governance structure may outweigh less formal approaches to governing as the coalition grows and develops.

The readiness assessment also asks leaders to consider to what extent attributes of successful partnerships, including collaboration, common understanding of impact, disruption of the status quo, flexibility, innovation and being mission-driven, are reflected in their group.

The center’s research builds on the conclusions of other studies focused on community health improvement. For example, the findings and recommendations of a study of 12 successful partnerships to improve community health (Lawrence Prybil et al., Improving Community Health Through Hospital-Public Health Collaboration, Commonwealth Center for Governance Studies, 2014) are similar to and reinforce the conclusions of the Center for Healthcare Governance's study. Studies by the Robert Wood Johnson Foundation, the Institute of Medicine, the Trust for America’s Health and other organizations also are focused on supporting and strengthening work to improve our nation’s health.

A companion document to the study report, “Community Partnership Profiles” provides more details about the study organizations' partnerships, including their governance, staffing, and resources and funding.

Mary K. Totten (marykaytotten@gmail.com) is senior consultant for content development for the American Hospital Association's Center for Healthcare Governance.

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Principles for collaborative partnerships

A study by the American Hospital Association's Center for Healthcare Governance suggests a number of simple, foundational principles to guide health care partnerships:

1. Partnerships must be community-driven. Partnerships and their governance will look different from community to community and must be flexible to meet each community’s needs, resources and characteristics.
2. All stakeholders must be meaningfully engaged. All community stakeholders should be represented in determining, planning and executing governance priorities.
3. More can be achieved together than alone. Stakeholders working together synergistically to leverage one another’s resources and talents can achieve collective outcomes beyond what they can by themselves.
4. Partner equity ensures sustainability. All stakeholders are considered equal. Anchor institutions that provide substantial financial and other support to the partnership may need to play the role of convener or facilitator and relinquish control of the agenda in order for the partnership to succeed.
5. Community health and well-being improvement is a shared core purpose. As stewards of community resources, members of the partnership’s governance structure must be committed to working together for the community’s benefit. The community’s health and well-being is the focal point of partnership work.
6. Creative approaches are needed to tackle all-encompassing problems. Partnerships must be mindful of maintaining a long-term perspective, making data-driven decisions, seeking out best practices, taking calculated risks, and being bold and innovative.
7. A “systems approach” ensures continuity. This approach helps create a solid foundation for building and aligning integrated delivery systems for improving and maintaining community health.
8. Goals and progress reporting ensure accountability. Change requires a keen focus on results. Clear metrics; use of reporting formats such as balanced scorecards; consistent monitoring of performance; and communication with the community about progress all build trust and hope.
9. Governance must be structured to ensure sustainability. Partnerships that last depend on governance based on a clear mission and purpose, shared commitments among partners, adequate funding, a plan of action effectively implemented and demonstrated progress.

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Competencies for partnership governance and leadership

The study found a number of competencies, both for individuals and among partners, that help partnerships achieve success.

Individual Competencies

Personal characteristics: Well-respected and trusted community leader; demonstrates integrity and humility; driven by passion, not power; inspires and influences others.

Collaborative skills and behaviors: Values partnership and teamwork; strives to build consensus and cohesiveness; flexible; cooperates to address common needs; looks beyond self-interest; shares leadership with other partners to serve the best interests of the partnership.

Knowledge and expertise: Able to analyze data and perceive trends; asks questions to understand root causes; thinks critically; deals with complexity effectively; seeks creative approaches to address challenges; able to think strategically and see the big picture; comfortable with uncertainty and ambiguity; contributes insight; willing to make difficult decisions based on information and evidence; understands strategic partnerships and networks.

Collective Competencies

Behaviors: Mission-focused; committed to respectful relationships among partners; inclusive; continually seeking partners that are critical to the success of the collective.

Knowledge, skills and expertise: Experience in strategic planning and implementation; data and trend analysis expertise; knowledge of epidemiology and population health; experience with models of community collaboration; fundraising skills; background in financial planning and management; participation in advocacy at the policy level.

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Organizations in the study

Allegiance Health (Jackson, Mich.): A 480-bed health system serving south-central Michigan since 1918, working with more than 500 partner organizations and community members on 15 collaborative initiatives. Governance model: “Community-based Governance With Allegiance Health ‘Backbone’ Support.”

Crozer-Keystone Health System (Springfield, Penn.): Five-hospital system serving the five-county Delaware Valley region, working with more than 75 partner organizations and community leaders on numerous initiatives. Governance model: “Broad Engagement With Community Boards.”

Henry Ford Health System (Detroit): System encompassing multiple hospitals and medical centers serving a tricounty area of southeast Michigan since 1915, working with more than 200 partners on numerous initiatives. Governance model: “Grassroots Entrepreneurialism Guided by a Strategic Pillar Focused on Community.”

Memorial Hospital of South Bend/Beacon Health System (South Bend, Ind.): Community-owned system including 526-bed Memorial Hospital, which has served St. Joseph County since 1893, working with more than 40 partners on some 30 initiatives. Governance model: “Strategic Seeding of Innovative Community Interventions.”

Mt. Ascutney Hospital and Health Center (Windsor, Vt.): A 35-bed hospital and health center serving a nine-town area in Windsor County, Vt., and Sullivan County, N.H., since 1933, working with 42 community partners on 28 initiatives. Governance model: “Community Governance With Intentional and Inclusive Representation.”

Palmetto Health (Columbia, S.C.): Hospital network serving Richland County and surrounding areas in the South Carolina Midlands region, working with more than 200 partners on numerous initiatives. Governance model: “Strategic Investment and Leadership in Community-driven Health Improvement Initiatives.”

St. Joseph’s/Candler Health System (Savannah, Ga.): A 714-bed system serving Savannah and the Low Country district of South Carolina, working with 40 partners on more than 50 initiatives. Governance model: “Governance Support for Mission-driven Grassroots Community Programs.”