This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.
Please go to www.ahrq.gov for current information.
Chapter VI. Contribution of Partnerships and Other Key Factors to Project Success and Sustainability
are promoted to address health problems because they can often achieve what no
organization can do on its own. Diverse partners, with different strengths and
networks, can increase resources to address a problem, broaden the reach of
interventions, and persuade others to adopt innovations. The power of
partnerships comes not just from combining resources, but capitalizing on each
partner's strengths, capacities, and influence with different audiences to
create synergy (Lasker, et al., 2001). They can help create the tipping point
that leads to widespread adoption of innovations and ideas (Gladwell, 2000).
assumption behind the PFQ program, which we built into the evaluation
framework, was that the relationships among the lead grantee organizations, key
collaborators and target organizations or providers would be critical for
achieving buy-in to evidence-based changes for improving health care quality,
safety, and security. Strong support from each project's key collaborators and
target organizations, as framed in the rationale for the PFQ program, was key
to the implementation and sustainability of health care improvements.
chapter examines the composition and structure of the partnerships created in
the 20 PFQ grant projects, assesses the elements of effective partnerships, and
discusses other important factors that contributed to the projects' success and
sustainability. It concludes with a set of lessons for AHRQ about how to
structure effective partnerships to translate research into practice on a large
A. Variation in Partnership Structure and Composition
provided relatively little guidance in the RFA on the structure of the
partnerships, or who should be involved. The agency recognized that the
diversity of organizations targeted to achieve improvements, and the specific
types of changes proposed to translate evidence-based research into practice,
required flexibility in selecting the most appropriate partners and deciding
how they would work as a group.
structure and composition differed across the projects first and foremost by
their grant focus, as shown in Box 3. The bioterrorism and emergency
preparedness projects generally formed partnerships with target organizations
that were looser and more informal than those focused on clinical quality or
safety improvements. This may reflect the fact that the first set of projects
sought to assess needs and develop tools, whereas the second set was more
likely to seek change within the targeted organizations.
Box 3. PFQ Project Partnership Models
with Provider Organizations & Practitioners
Direct Relationship between Leadership Team and Target Providers
- American College of Physicians.
- American Medical Association.
- American Medical Directors Assn.
- Assn of California Nurse Leaders/CalNOC.
- Catholic Healthcare Partners.
- Child Health Corp of America.
- International Severity Info Systems.
- Lehigh Valley Hospital & Health Network.
- New York State Dept. of Health/RDHHAR.
- Physician Micro Systems, Inc./MUSC.
- Research Triangle Institute.
- VNSNY (Phase I diabetes collaborative).
Intermediaries heavily involved in work with Target Providers
- American Academy of Pediatrics.
- American Hosp Assn/HRET.
- VNSNY (Phase II acute care hospitalization reduction).
Partnerships with Health Care Purchaser, using
target organizations as study participants
- The Leapfrog Group.
Partnerships using Target
Organizations as Advisors or Study Participants
- Altarum Institute.
- Texas A&M Univ.
- CT Dept of Health/Yale New Haven Health System.
For example, the bioterrorism preparedness projects led by
JCAHO and Connecticut Department of Health/Yale New Haven Health System used
target organizations as participants and subjects in studies and training
courses. Target organizations also provided information, data, and lessons for
studies on bioterrorism preparedness, or participated in modeling exercises and
case studies, conducted by Altarum Institute and Texas A&M University, and on the value of performance measurement for JCAHO's other study.
Partnerships formed around the two purchaser-led projects
also reflected the role that payers play in the health system. Both HealthFront
and The Leapfrog Group worked closely with local coalitions of employers, large
health plans, and large companies. While their ultimate quality improvement
targets were physicians and hospitals, respectively, the two project teams had
little communication or collaboration with providers, other than as survey
participants. When they wished to communicate with providers, the most common
model was to use them in a convening role. For instance, HealthFront, Altarum
Institute, and Texas A&M University organized and held seminars with target
organizations to present their preliminary or final results, and discuss how
the results could be used in practice.
Partnership structure differed in the 14 projects that
focused on clinical quality and safety improvements, usually seeking close
working relationships with target organizations. Project leadership teams
worked directly with provider organizations or practitioners in the design,
implementation, and assessment of the effects of interventions to translate
research into quality improvements, though the strength of the relationship
differed. These projects typically had three partnership components, which
varied in the regularity of their communication:
Leadership Team, consisting of PIs, co-PIs, and project directors or
managers, who communicated at least weekly, and sometimes daily during certain
periods, on tasks as diverse as grant management and reporting, provider
training, advisory group consultations, research design, data collection and
analysis, and target organization relations.
Relationships between the Leadership Team and Target Organizations, through such mechanisms as annual or semi-annual training workshops, learning
collaborative sessions, site visits, and conference calls with leadership team
members and other intermediaries and support organizations.
Support through Linkages between the Leadership Team and Advisors, whose support could be organized into formal advisory groups that met at the
start of the project, and occasionally after that, or as an informal group,
with advisors providing expertise and input into the design of the intervention
For these projects, the relationships with target audiences
were critical to changing behavior. While all of these grantees partnered with
the target groups, they differed in how heavily they relied on intermediary
partners to support the targets. Twelve projects had direct relationships
between grantee leadership teams (PIs, co-PIs, and other key collaborators) and
target organizations, and used other individuals or organizations to provide
training and technical assistance. These projects typically targeted fewer
provider organizations, with the exception of PMSI/MUSC, which targeted over
100 primary care practices, but conducted site visits and conference calls with
a smaller subset.
In the other strategy-used by AAP and AHA/HRET plus VNSNY in
the second phase of its project-intermediary organizations played a stronger
role in the partnership in order to: 1) increase the amount of training
and support to a larger number of providers, and 2) build capacity to support
and train providers independent of the lead grantee.
For example, AAP worked with more than 180 pediatric
practices. To do so, it involved state AAP chapters in recruiting
pediatricians, organizing training workshops, and providing on-going training
and technical assistance. AHA-HRET's palliative care unit expansion strategy
used partnerships with six exemplary palliative care programs, which served as
learning labs for 60-70 hospital teams that made site visits and provided some
post-site visit support to those teams. VNSNY described its project evolution
as a switch from a "retail" strategy in its first learning collaborative project
on diabetes care, where it worked directly with home health agencies, to a
"wholesale" strategy in its second collaborative project, where it is working
with 10 collaborating QIOs in order to reach almost 70 home health agencies to
reduce acute care hospitalization among home health patients. In all three
projects, a secondary but key goal was to build capacity of the intermediaries
to carry on the work on their own, as part of a strategy to assure
Return to Contents
B. Factors Behind Successful Partnerships
Certain characteristics and processes appear to
contribute to effective partnerships in PFQ projects, based on themes that
emerged from interviews with project PIs and their partners. This analysis
primarily concerns the 15 projects that tested quality interventions. It
excludes those that used partnerships primarily to produce knowledge-the
bioterrorism preparedness projects and the quality improvement study projects
led by RTI and JCAHO.
1. Position of Lead Organizations and Intermediaries
AHRQ expected lead organizations to
be well-situated and capable of influencing directly the target organizations
that were the focus of quality improvement efforts. Most grantee agencies, or
others in the leadership team, were well-positioned to influence target
organizations by virtue of being national or state associations representing
the target organizations. According to one PI, "Having the credibility of the
[national association] behind our work was helpful." In two cases, grantees
were health systems that owned or were affiliated with the target providers
(CHP and Lehigh Valley). VNSNY is a recognized leader in the home health
field, giving it credibility among its peers. One of the home health agency
staff in its project said, "Because of the size of [VNSNY] and the work they've
done, agencies are very proud that it's one of our agencies that really
spearheaded this... there's a sense of credibility to that."
In one instance, the lead organization had existing
regulatory relationships with the organizations targeted for project
interventions. This held certain advantages. It made it easier to recruit
target organizations because they felt that they could not refuse. "When [they]
ask something of us, it's not a good idea to say no," said one participating
organization. It also gave the lead organization a chance to turn their
historically adversarial relationship with providers to a more helpful one. The
downside is that regulators still wield power over the target organizations, so
the latter felt obligated to take on more than they could handle. Had the
target organizations felt comfortable enough expressing this to the project
leadership team early on, the project design could have been modified to
improve the intervention's success and sustainability.
2. Experience and Skill in Managing Partnerships
Despite having strong potential for influencing target
organizations, not all grantee agencies or leadership team partners had
experience or skills in managing partnerships. Several national association
PIs admitted that this was their first attempt to create working relationships
on quality improvement activities with members, and considered it a great
success just to show they could implement the partnership. But implementation
is not the same as effective management, and some were better than others at
building consensus, defining structures and processes for work to progress,
developing leadership and joint ownership of the project, resolving conflicts,
and finding ways to maximize each partner's strengths and contributions.
Partnership management takes time. The projects with
more partners, more partnership groups, and more intense levels of
collaboration with providers or target organizations had to spend more time
managing the interactions and communication among all the partners. Sometimes,
there was not enough time to do all the partnership management that some
believed necessary to make the project work better. According to one PI, "I
might have tried to do more one-on-one with everyone in the group [to gain
consensus and work through problems] to supplement the monthly calls." Another
project ran into similar problems in creating a partnership at the national
level. According to one PI, "National partnerships need a lot of care and feeding,
constant reminders and tasks. You need to keep up the momentum, [and] I think
this project probably caught on to that a little late." One project limited the
demands of partnership management by delegating responsibility and money to
partnerships at the local level. The grantee organization communicated with
local pilot projects to get progress reports, and assess their need for
technical assistance; but the pilots rather than the national organization
assumed most of the partnership management function. These experiences suggest
the need for projects involving partnerships to build in adequate time for
partnership management, and to consider the costs and benefits of creating
partnerships at different levels.
3. Partners' Prior
History in Working Together
Some projects had the advantage of
starting with an existing partnership to which they could add new quality
improvement targets or approaches. Projects led by The Leapfrog Group, the
American Academy of Pediatrics, Lehigh Valley, CHCA, California Nurse Outcomes
Coalition, and Catholic Healthcare Partners had distinct advantages in this
regard. Their intended target organizations or intermediary partners were
already organizational members or affiliated providers, making both the task of
recruiting them easier and minimizing the need to start from scratch in
defining common goals. According to one respondent, the project leadership team
"has been together for so long. We are all equal in the design process, and
having an effective team that has been together for so long has been
The 14 CHCA members who had worked together under the "Child
Health Accountability Initiative" banner had some experience and success in
joint quality improvement projects before they began the PFQ project, and
therefore had a head start in working together. Based on their early
successes, the rest of the CHCA members wanted to join their efforts. But
integrating into the project was challenging. Even though the new partners were
already members of CHCA, they had not previously been exposed to the QI
concepts and approaches or data collection requirements of the project. Getting
them up-to-speed on the core partners' values and mode of operation took almost
a year, slowing down the project's momentum. However, the PI believes that in
the long-run, the time invested to integrate these organizations into their
quality improvement efforts will have a large pay-off in expanding the number
of children's hospitals involved in more rigorous and measurable QI activities.
Other projects began with little or no history of
partnerships between the lead agencies and the target organizations, so they
had to spend time building trust and a common vision to be successful. For
example, the AMDA Foundation had prior relationships with the medical directors
of nursing homes, but not with the staff most responsible for quality
improvement in these facilities—directors of nursing. AMDA Foundation staff
therefore had to build relationships with these individuals. VNSNY and ISIS
also had to quickly establish partnerships with provider groups; they did so by
holding semi-annual meetings and regular conference calls, which rapidly
created group cohesion and facilitated an open exchange of ideas and lessons.
4. Involvement of
Target Organization Administrators and Staff in Decision Making
According to emerging health care organization theory on
partnerships, partners' roles in decision making and partnership governance are
critical factors in partnership effectiveness. (Mitchell and Shortell, 2000;
Shortell, et al., 2002, Bolda, et al. 2006). The experience of the PFQ
projects provides some support for this theory. Partnerships that involved
partners in making collective decisions on the project's intervention were more
successful in gaining buy-in and long-term commitment to the intervention.
Partnerships that used partners to advise and legitimize the efforts of the
lead organization seemed to have less success in gaining target organizations'
commitment to adopt or sustain the intervention.
Involving administrators from participating organizations is
critical, according to some of the PFQ project partners. "You've got to have
administrative buy-in to support this," according to one PI. Even in a large
health system such as Catholic Health Partners, there are limits to the
"command and control" approach. "The HF advocates that have been very
successful have had complete buy-in from [their managers]... this just shows
that if you are starting something like this, you have to have commitment from
administration." While involving target organizations in project decision
making may take more time to achieve consensus on goals, strategies, or
tactics, it may create stronger buy-in in the end and appears to result in
greater commitment of resources and long-term organizational change.
Some of the most successful projects involved people at all
levels of the target organizations deciding how to adapt the intervention to
their organizations, which helped produce tangible improvements and fostered
better teamwork. ISIS and VNSNY, for example, not only involved administrators
and nursing directors, but also nursing assistants and home health aides. ACP
invited teams of physicians, nurses and office managers to their
practice-based, team-oriented training programs on diabetes care improvement.
According to one of the partners, "What's remarkable is that, in terms of
process, the office administrators are saying [the ACP training] is helping
them feel like they're more part of the care process, and now they understand
how they can fundamentally improve care. This has opened up dialogue between
physicians and staff in how they can improve quality and makes the practice
feel like they have social value."
Meetings among staff from the participating
organizations to share and learn from each other were also important factors in
success. According to one respondent, "The interactions we had with other
facilities [in the study] were great. Our meetings with [them] helped us to
develop best practices." In another project that had prior relationships but
had not met in person before the PFQ project, one respondent said, "My
partners' involvement contributed to the project's progress. The ability to
meet with the partners through in-person interactions in a concentrated,
focused way has led to interesting work, and I've learned a lot." Another
interviewee claimed that, "Creating a learning network has helped us move
forward. Everyone having the opportunity to say, 'here's what I learned this
week, here's what's working and here's what's not working,' that's an
5. Partners who Can
Promote Sustainability and Broader Diffusion
In several PFQ projects, partners changed over the
life of the project, depending on their strengths and connections. Some
partners are better suited to test an approach, while others are needed to take
an intervention to scale. The Leapfrog Group, for example, selected a small
group of regional purchasers from its membership to test different approaches
to quality incentive programs in the six pilot projects. But for broader
diffusion, Leapfrog is working with a larger number of its employer coalition
members for its "regional roll-out" initiative. Similarly, VNSNY worked with a
small group of eight agencies willing to test the use of the IHI rapid cycle
quality improvement learning collaboratives in the home health setting. But
for its wider diffusion efforts, VNSNY (and ISIS in a follow-on project) are
involving quality improvement organizations (QIOs) in different parts of the
country to take their approaches to scale. To the extent that VNSNY can build
capacity in QIOs to carry on rapid-cycle quality improvement in the home health
care setting, it will expand this approach to a larger group of home health
agencies than it could in the first phase of the project.
17. ISIS is pursuing a similar strategy in its work with six QIOs to replicate the "real-time," computerized care
process documentation system in 30 more nursing homes, using digital pens or facility IT systems. This work is
supported by a separate AHRQ Health Information Technology grant.
Return to Contents
Proceed to Next Section