Chapter 3. Developing and Maintaining Relationships

Regional Coalition Collaboration Guide

Recruiting

Assess Your Regional Environment

Before initiating relationships with potential coalition stakeholders, it is important to assess your region's business environment. An environmental scan can range from having informal conversations with key business leaders in your region to developing a formal market research methodology. Performing ongoing investigations in the community will provide coalition leaders with information about the larger external environment that will help them develop strategies that address unique needs, opportunities, and competition in the community.

This research also can provide coalitions with insight into the cultural context within which they operate. Different parts of the country will have distinctive cultural norms, and coalition leaders will need to develop appropriate approaches to building relationships.

For example, Better Quality Information (BQI) sites in the Midwest successfully leverage the inherently collaborative culture in this part of the country. In particular, Minnesota Community Measurement did not encounter some of the competitiveness that other sites did because the health care system in Minnesota is not for profit. Consequently, from the outset stakeholders were more inclined to collaborate on health care quality, and leaders developed a strategy based on this knowledge.

Persuasion Versus Coercion

Regardless of geographical location, an important part of building a regional coalition is the ability to persuasively communicate to stakeholders your vision and the benefits of contributing data. Persuasion, which by definition is nonadversarial, is better suited to the collaborative nature of coalitions than threats that underlie coercive tactics. BQI leaders agree that coercion and the "hard sell" are not as effective in building relationships as appealing to how the coalition will serve the potential participants' interests.

From the first contact with stakeholders, be as transparent as possible about what the coalition hopes to accomplish, acknowledging tensions, concerns, and competitions up front and candidly. It also is advisable to cultivate relationships with influential senior leaders in the organization you want to recruit. These senior leaders, in supporting the coalition's objectives, can become advocates for others to join the coalition.

Lastly, it is helpful to develop a list of selling points that communicate the value stakeholders will receive when they participate in a regional coalition. For example, selling points that the Center for Health Information and Research in Arizona used to bring stakeholders together include:

  • Providing a snapshot of how their individual data compares to deidentified competitors to allow stakeholders to see a more comprehensive picture of care in the community.
  • Emphasizing how data sharing will enhance care by tracking patients in the community who move around to different emergency rooms in the area.
  • Making the case for how joining the coalition will contribute to tracking regional statistics of who gets care, what kind of care, what the costs are, and so forth, all of which contributes to reforming the national health care system.

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Key Groups

When identifying potential participants, coalition leaders should consider a broad and diverse group of organizations that contribute data to ensure a more comprehensive set of data. In addition to health plans, hospital associations, and physician groups, the following groups and organizations in your community are important stakeholders with whom to cultivate relationships:

Business Coalitions

Minnesota Community Measurement partners with the Buyers' Healthcare Action Group, an important business coalition in the community in Minnesota. Working synergistically, the two groups have moved the health care quality improvement missions of both organizations forward expeditiously and in a way that reduces confusion and redundancy in the marketplace.

The Wisconsin Collaborative for Healthcare Quality benefits tremendously from the collaboration between physicians and one of its business partners, The Alliance. An employer-owned and -directed cooperative, The Alliance works to obtain affordable, high-quality health care for the 105,000 employees and dependents of its 170-member employers. Unique to BQI sites, this employer-driven group runs a portion of the data analysis for the Wisconsin collaborative.

The Pacific Business Group on Health, a business coalition of 50 purchasers that seeks to improve the quality and availability of health care while moderating cost, founded and currently manages the California Cooperative Healthcare Reporting Initiative.

Quality Improvement Organizations

In each State, Quality Improvement Organizations (QIOs) work with consumers, physicians, hospitals, and other caregivers to refine care delivery systems so patients, particularly those from underserved populations, get the right care at the right time. (For a comprehensive list of QIO listings, visit www.MedQIC.org.) The QIOs also safeguard the integrity of the Medicare Trust Fund by ensuring payment is made only for medically necessary services and investigating beneficiary complaints about quality of care.

Coalition leaders should consider having discussions with the local QIO early in the convening process to determine how they can work together. For example, from the beginning, Minnesota Community Measurement has had a good working relationship with Stratis Health in Minnesota and finds the QIO helpful in breaking down complicated quality issues. Stratis Health staff serve on Minnesota Community Measurement committees and have a seat on its board of directors.

Some of the BQI sites have encountered resistance from QIOs or have found that because the QIO's focus is concentrated on its scope of work, it is unwilling or unable to work with coalitions. Consequently, some relationships with QIOs range from partnerships to informal relationships. Massachusetts Health Quality Partners currently is partnering with MassPro (the Massachusetts QIO) and the Massachusetts Medical Society to develop a quality improvement curriculum that integrates improvements in clinical quality with improvements in patient experience. The Indiana Health Information Exchange has a cooperative relationship with Health Care Excel (the local QIO), but the two organizations have yet to establish an official business relationship.

Medical Associations

Although some associations initially may be reluctant to join the coalition, coalition organizers can emphasize the inevitability of public reporting and how the association's early involvement will help to define and influence the process and eventual product. Medical association participation also benefits the coalition. For example, having the Minnesota Medical Association at the table gave physicians a voice on Minnesota Community Measurement committees. The Minnesota Medical Association, a founding sponsor, also holds a seat on the Minnesota Community Measurement board of directors. Consequently, the Minnesota coalition gained credibility among physicians, which helped persuade others to participate. Similarly, the Massachusetts Medical Society was a founding member of Massachusetts Health Quality Partners.

Non-Health-Related Organizations

Part of building a community coalition involves developing partnerships with non-health-related organizations to capture as much data as possible. In Arizona, the Center for Health Information and Research, for example, has recruited a large, area supermarket to join its wide-ranging array of community groups and businesses that participate in its coalition. Having these kinds of partners on board broadens the data used in reporting.

State Legislature and Government Agencies

The BQI sites have found different ways of engaging their State legislatures and governments. Some have worked with the legislature to mitigate a lack of willingness to share claims data; however, others warn that although one legislative session can mandate sharing data, a subsequent session can reverse or modify the mandate.

Some sites have State officials as board members. This can add to the coalition's credibility. Massachusetts Health Quality Partners, for example, originally had two State representatives on its board—the medical director for Medicaid and a representative from the Department of Public Health—both of whom were able to represent the important public sector in Massachusetts Health Quality Partners' quality improvement work. Establishing relationships with commissioner-level officials early also is very valuable for enhancing the coalition's credibility.

Tip: Keep membership small at first. When first forming a coalition, the broader it is, the more difficult it is to get things done because your agenda will need to be broad to address all interests. It takes time to methodically build a broad coalition that is effective.

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Selecting a First Project

The Importance of Early Successes

Having an early success is crucial during the formative stage of the coalition's development. Although the coalition's mission and vision may be inspiring, enthusiasm for the project will stall if results are slow in coming. A highly visible, unequivocal early success establishes the feasibility of the coalition's goals, promotes rapport and trust, and builds excitement and momentum. It may even quiet critics.

For your first project as a coalition, identify an issue that is small enough to ensure success but dynamic enough to generate attention among stakeholders. It should be something around which various groups can coalesce and successfully accomplish together. The Indiana Health Information Exchange undertook a messaging project (discussed in Chapter 6) that was small but successfully built a bond among stakeholders.

An early success serves the dual purpose of demonstrating to stakeholders that the coalition is capable of delivering on its expressed goals and helping generate energy internally for the team. The Wisconsin Collaborative for Healthcare Quality convened in 2002 to announce its goal of producing a report within a year. This focus galvanized the coalition and gave all participants—provider organizations and business partners—something to work toward together as a way to build trust and translate a concept into reality.

Instead of beginning as a quality reporting group, the Center for Health Information and Research focused its first efforts in 1998 on promising to build a database, despite criticism that the data were too disjointed for such a resource. After establishing Arizona HealthQuery, which successfully integrated health claims records from public and private data sources into a database, the Center for Health Information and Research reinforced its credibility by then taking specific data requests—such as how many kids have asthma in a given location—and delivering a comprehensive number in 2 weeks.

Early failures, if handled properly, can also reinforce credibility and build rapport. Admitting openly and honestly when the coalition has fallen short in delivering on a promised goal demonstrates the team's commitment to transparency and improving the process. When the Center for Health Information and Research delivered the results of a data query at one of its data partner meetings, a partner pointed out that data were wrong. Upon reviewing the data at the meeting, the center acknowledged that the data interpretation was indeed wrong, adjourned the meeting, and sent a corrected report with a note explaining what was done to correct the data.

Maintaining the Coalition

Among the important factors involved in maintaining a coalition are demonstrating continuous value to stakeholders and cultivating trust. However, coalitions of all sorts can encounter general difficulties that can sap its vitality, such as poor group dynamics, lackluster participation from members, and unproductive activities. Specific challenges regional coalition leaders should be prepared to address in include:

  • Timeliness. Stakeholders do not always provide data on a timely basis. The Center for Health Information and Research has a standing schedule with its stakeholders for routine data transfers, but data partners often need multiple reminders. Recognizing the need to maintain a positive relationship, the center politely and persistently encourages them to contribute while considering the voluntary nature of their relationship.
  • Turnover. High chief executive officer and chief medical officer turnover in stakeholder organizations can disrupt the continuity of the relationship. For some sites, these officials are the only members of their organizations involved in the regional coalition. In addition to working with chief executive officers, the coalition should find ways to communicate and engage with other senior leaders in stakeholder organizations as well, such as by contributing articles on the coalition to employee newsletters.
  • Burnout. With stakeholders often participating in simultaneous collaboratives, answering numerous surveys, and serving on multiple committees, burnout can be a challenge. Be mindful of stakeholders' busy schedules and other commitments.
  • Competition. When bringing together many different stakeholders, many of whom are competitors, identify areas where they compete and areas where they are willing to collaborate.
Tip: Involving chief executive officers in the collaborative process is important for some coalitions. Other coalitions have found that working closely with an organization's quality experts, such as medical directors, and periodically updating the chief executive officer is sufficient.
Page last reviewed April 2008
Internet Citation: Chapter 3. Developing and Maintaining Relationships: Regional Coalition Collaboration Guide. April 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/collabguide/collabguide3.html