Matt Guy

Senior Project Consultant

Jane Erickson

Project Director

For some, family holidays provide great joy and merriment—the scene from a Norman Rockwell painting. For others, however, sitting down to a family dinner is an exercise in self-restraint, with every guest working diligently to avoid politics, sports, certain other family members, or another topic that may create discord. The goal at these family dinners: don’t make waves, smile politely, use “please” and “thank you,” get in the car, and go home no worse for wear.

Dodging discomfort in this way is not limited to families. In fact, it’s a common challenge facing regional multisector partnerships working to improve the well-being of residents, especially those with a wide and diverse set of members. Partnerships often involve many sectors; about half of the 237 partnerships surveyed in ReThink Health’s 2016 Pulse Check reported active participation from 10 or more, including public health and health care delivery, as well as government, social services, education, community and neighborhood organizations, and academia, among others.

While a partnership’s members may have distinct institutional objectives, priorities, and values, they are coming together with a shared goal to transform the health of their community. Working together to advance health will inevitably require trade-offs between the participating institutions. So, to make real progress they need to master the art of healthy confrontation. They must be able to have difficult conversations, address complex issues, and resolve internal conflicts, all while effectively sustaining collaboration.

In our work [Matt spent years as the executive director of a multisector partnership in Pueblo County, Colorado–the Pueblo Triple Aim Corporation (PTAC), and Jane is the project director of ReThink Health Ventures, which is designed to advance health transformation in six regions across the country], we’ve seen multisector partnerships accomplish impressive movement toward their goals. But much of their early progress typically is made around the edges, on issues or projects that everyone in the collaboration is amenable to. While these projects are important, they usually are the low-hanging fruit, and focusing on them alone will not have a measurable impact on population health.

At ReThink Health, we distinguish these incremental “improvements” within a system from more transformative change, when the members in a multisector partnership commit to redesigning key elements of their system to achieve substantively better results, such as a health care provider shifting to a value-based payment system, or programming to reduce recidivism (including criminal justice reform).

This type of transformation requires an unprecedented amount of communication and coordination, and it understandably can bring about conflict within the group. This is the time when the decisions the partners make may no longer be win-win, and the path forward may have a significant impact—positive or negative—on certain members of the group. For example, the participants may find themselves competing for scarce resources, disagreeing over which should be the lead organization, or many of the other difficult structural and institutional changes required to truly have a long-term impact on community well-being.

These discussions are difficult, and, unfortunately, we’ve observed that they take place too rarely, in even the most successful partnerships. Regional health efforts often get stuck because the partnership is more comfortable living in harmony and making marginal improvements, rather than addressing the elephants in the room and moving true change forward. What can leaders of multisector partnerships do to ensure their members are adequately prepared to embrace, rather than dodge, discomfort in the name of progress?

  • Ensure your members have opportunities to get to know the others around the table at a personal level. The people having these difficult conversations may represent organizations, but they are people first. It is always easier for individuals to find common ground when they connect with each other. This can be as simple as starting your meetings with a check-in: ask each attendee to answer a personal question that encourages everyone to get to know each other beyond just the representative from X organization.

    Opening meetings on a personal note sets the stage for respectful dialogue, and encourages participants to have new conversations around the edges of your meetings. In Pueblo, PTAC’s Steering Committee has used weekend planning retreats as a way for groups to connect more informally and to encourage the building of personal connections.
  • Set an expectation that all partners communicate about their interests, values, and business models—and then ensure you have the group norms and processes established to continually enable this level of sharing and openness. Candor and transparency, grounded in trust, are critical. Each member of the partnership will have their own priorities and interests, and these will not always overlap or harmonize perfectly. But if competing interests are identified and named, and if the members expect that they are to be open to discussion and engage in candid conversation about what’s at stake, they are better positioned to identify systemic solutions to move a transformation agenda forward.

    For example, if your partnership is revisiting or developing its vision, create a space for all members of the group to articulate their institution’s values, interests, and priorities. Encourage members to articulate how the vision of the partnership supports the work of their institution, and also name where there may be possible conflicts—both with the work of the partnership, and across institutions. Have an ongoing practice of sharing this information with new group members, and emphasize that your mission will only be accomplished when all are open about their institutional stances.

    PTAC’s Board created a culture where executives of competing health care entities and community organizations agreed to align their organizational goals and commitments with PTAC’s. Participants were encouraged to openly name where their organization goals were in conflict with PTAC’s as a means (not deterrent) to agreement. For example, hospitals on their board would communicate how and why they would lose business and be potentially hurt financially if PTAC were to achieve some of its goals of moving the community from traditional sick care to a focus on prevention and well-being. This lead to robust dialogue about how hospitals could modify what they were doing to align with the work of PTAC, appreciating that they were not in a position to entirely shift their business models.
  • Name the elephants in the room. A potential issue may be clear as day to one member, while another sees a completely different picture. Have a group practice of naming–out loud–when it feels like a sticky issue isn’t being expressed or addressed.
  • Be respectful–with each other and about the process. The tone with which challenging conversations are had almost always impacts the outcome of the conversation. Set shared group norms that encourage creativity, positivity, and an intent to work together through challenging issues. Use techniques like Appreciative Inquiry to frame potentially contentious topics. The goal is to discuss issues through a lens of exploration and discovery: focus on shared goals and interests, increasing overall value (not just benefits to a single organization), and thinking about what’s worked in the past.

    Often groups will structure conversations around what hasn’t worked, what the “problem” is, and how a solution will negatively affect various institutions. While it’s important to address these things, you’ll get a better outcome if the group approaches the conversation from a positive, generative stance, rather than assuming a deficit from the get-go. Importantly, inviting an outside facilitator to guide discussions and ask the hard questions may be a good idea—especially if the issue at hand is particularly sticky.
  • Recruit members who are excited to work together differently, and can navigate tough conversations. This kind of collaboration requires a unique skill set. It is invaluable to have at the table individuals who see the importance of collaborating across organizational values, are able to effectively build relationships, and help everyone stay focused on the larger goals of the group.

“Going along to get along” is not the right strategy for health transformation. Progress is going to take work; it’s going to require hard conversations and confrontation. But in the end, if we commit to the hard work, if we try not to dodge the discomfort, we will be able to make a real leap forward in transforming health—not just around the margins but in dramatic and measurable ways.

The personal views and opinions expressed in this blog (and in any comments) are those of the original authors only, and do not reflect the opinions of The Rippel Foundation or ReThink Health. Neither The Rippel Foundation nor ReThink Health is responsible for the accuracy or validity of any of the information contained in the blog or any comments. All information is provided on an “as-is” basis.

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