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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  • Sherry Immediato

    Thanks to the authors for flagging an important development need for all of us, and some useful tips!

    In my experience in the corporate world, academia and an extended family dinner table that sometimes resembled a Fellini movie, aggressive debate is as problematic as politeness. One of the questions that captured my imagination almost 40 years ago was posed by Peter Senge: Would you expect to see more disagreement in an aligned or an unaligned organization? If you reflect on your experience, you might not have an immediate answer because for most of us, the reality is that the nature of the disagreement in the two cases is different. In an unaligned organization, it’s often every man/woman/entity for itself. Conflict may be explicitly personal or subterfuge may dominate. By contrast, there is often lively debate in an aligned organization because passions run high about achieving the end result. There are therefore two important points that I think need to be amplified about discomfort and transformation. First and foremost, there needs to be an excellent reason to go through the discomfort, and that reason is shared aspiration. If we know why we’re here, working on the relationship – being vulnerable, taking risks in telling the truth and giving feedback, as well as taking it in, disclosing interests and concerns – has a context that makes it worthwhile. As the authors note, a group needs time and space to know the values and vision they share, and revisit them as motivation.

    Second, even with commitment, good intention and ground rules, many of us have bad habits in conversation that are designed to win the argument (or smooth things over, as the authors note) rather than to get smarter and wiser together. I’ve benefited from the coaching of Chris Argyris, and three of his colleagues who have advanced this work at Action Design – Diana Smith, Bob Putnam and Phil MacArthur. While there are many tips and techniques they’ve imparted over the years, the most important is probably an awareness of aligning intention and practice around genuine inquiry and generative advocacy. It’s a real challenge to listen with a true desire to understand someone with a different view, or to offer your own with a real openness to being challenged to find a yet better solution. While we are almost all fortunate enough to have some in our communities with this ability, as the authors suggest, it can be helpful to intentionally build this capacity more broadly, and thankfully, there are many great resources out there to support us. I am grateful to have had many experiences over the years when simple inquiry encourages either problematic or normally quiet group members to make the comment that changes everything.

    One of the things I’ve found helpful is to identify some positive images that reinforce the behaviors you want to promote. For some groups, the idea of the “loyal opposition” has provided a breakthrough. If everyone embraces dissent as essential for improvement, it becomes much easier to put aside politeness in favor of usefully disagreeing. Sometimes overcoming a common enemy is the key. Some groups use the parallel of their “man on the moon by the end of the decade” to fuel competitive effort and learning. Finally, groups benefit from aspiring to outdo themselves, knowing that it is indeed possible to collaborate at a high level. It helps to have examples from the past where the community has done what was needed to transform. These are often precipitated by a significant opportunity or problem, and they represent the players, even decades ago, at their best. As an example, the Gen-H movement (formerly Collective Impact on Health) in Cincinnati was launched with a reminder that Cincinnati became home to the modern fire department (and the first steam fire engine) in1853. These innovations – both technical and social – required significantly new ways of working together, moving from a fair degree of chaos and competition (among small private companies) to a higher level of coordination. Leaders today could easily see the parallel and took pride in building on a local tradition of system transformation for the common good.

    Bold goals naturally call forth our best selves. Jane and Matt usefully illustrate the importance of engaging in difficult conversations. When I think about what has helped the process most once our goals are clear, the simplest thing we can all do is tune into whether we are having the conversations we most need to have – instead of either skirting them politely or loudly! Perhaps the discomfort that will then help might be this simple: those of us who tend to be more quiet need to step forward and speak our truth in a timely fashion, and those of us who tend to be more vocal need to step back and listen, and speak in a way that invites genuine conversation. I suspect this will be an area of lifelong learning for me, and appreciate the reminder!

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