Appendix J-2: Report #2: Louisiana Health Care Quality Forum
Appendix J-2: Sustainability Planning for Community Quality Collaboratives: Ten Key Questions to Guide Your Planning Efforts
Report #2: Louisiana Health Care Quality Forum
About the Louisiana Health Care Quality Forum
Part I: Determining Where to Focus
Question #1: Where are we? What can we learn from a fresh look at the organization and its approach?
Question #2: Where do we need to focus our efforts? (What are our strengths and weaknesses?)
Part II: Applying Leading Practices
Question #3: How do our stakeholders think we are doing as an organization?
Question #4: Are we on the right track with our programs?
Question #5: What results are the most meaningful?
Part III: Delivering on Our Promises
Question #6: How will we expand and diversify our funding?
Question #7: What other resources are needed to deliver on our commitments?
Question #8: Do we have the right governance structure to be nimble and effective?
Question #9: Who is responsible for driving development and sustainability?
Question #10: How will we monitor our progress?
Based on the real life experience of the Louisiana Community Quality Collaborative (Community Quality Collaborative), this report provides guidance to assist a Community Quality Collaborative in developing its sustainability plan. For six months in 2008, the Agency for Healthcare Research and Quality (AHRQ) funded a sustainability planning project for the Louisiana Health Care Quality Forum (LHCQF). Tools and templates, based on the work in Louisiana, are provided in the Sustainability Toolbox (see Web link below).
This report is one component in a technical assistance program on sustainability developed by AHRQ for its Learning Network for Community Quality Collaboratives. The program toolbox includes two reports based on real life experience in the pilot projects: one in Oregon and one in Louisiana. The goal of this sustainability program is to support Community Quality Collaboratives in defining strategies that will lead to productive and financially sound collaboratives that grow, thrive, and deliver significant value over time.
For more information about this program and to access the electronic documents in the Sustainability Toolbox, go to http://www.cvelearningnetwork.org/doc.asp?id=50.
The Louisiana Community Quality Collaborative, launched in 2007, had been in operation for about one year when the sustainability planning project began. In the aftermath of Hurricane Katrina, the Louisiana Health Care Redesign Collaborative put forth recommendations for redesigning and rebuilding the health care delivery system in Louisiana. More than 40 organizations came together in a truly collaborative effort to envision and build a much stronger system for all Louisiana residents.
As a result of these efforts, the LHCQF (which also became the Louisiana Community Quality Collaborative) was incorporated as a non-profit 501(c)3 entity and secured a 3-year contract with the State of Louisiana. This contract defined specific outcomes, while delegating the detailed shaping of the work to the LHCQF.
The remainder of this report summarizes the sustainability planning efforts in Louisiana.
As part of the sustainability program, seven leading practices were identified in three case studies of successful collaborative organizations. A key component of the recommended sustainability planning approach involves evaluating the application of these practices and targeting the biggest gaps for immediate attention.
The seven leading practices are:
- Responding to Compelling Market Circumstances.
- Maintaining Effective Leadership.
- Achieving Balance Among Stakeholders.
- Delivering Tangible Value.
- Communicating Proactively.
- Establishing a Transparent Management Style.
- Employing Rigorous Prioritization.
Each leading practice is described in detail in the Sustainability Program Overview.
This section provides insight into how to assess the current state of the collaborative and its environment. This assessment is critically important in determining if the Community Quality Collaborative is on track and where it should focus future efforts. Ideally, this portion of the planning should be conducted by a neutral party with "fresh eyes" to gain the most insight.
Question #1: Where are we? What can we learn from a fresh look at the organization and its approach?
With each of the sustainability pilot projects, the work began with a review of the current state, recent history, infrastructure, and programs. A checklist of items to review is included in the Toolbox. This review, along with initial discussions with the Executive Director, helped to narrow the focus for the Louisiana project.
In each of the two pilot projects, the consultant and executive leadership narrowed the focus to two or three of the leading practices (as listed above).
In Louisiana, prioritization was identified as an existing strength. The organization had created an effective structure based on four working Committees:
- Quality Measurement
- Medical Home
- Health Information Technology
- Outreach and Education
Each of the Committees was chaired and populated by volunteer stakeholders, and supported by the Executive Director as well as a part-time staff project manager. Priorities and goals had been clearly defined within each Committee.
Therefore, the sustainability pilot project was designed to focus on the following objectives:
- Applying the seven Leading Practices (listed on Page 2) effectively.
- Refining the balance of staff work to volunteer stakeholder involvement (an aspect of Leading Practice #3).
- Ensuring that the organization as a whole was demonstrating value (Leading Practice #4).
- Sustaining momentum.
- Identifying additional funding opportunities and potential barriers to success.
In hindsight, this list proved to be too ambitious for the timeframe and structure of the project. In this case, the focal point of the planning effort was an all-day annual retreat. While progress was made on all fronts, the process did not produce the desired comprehensive plan with succinct actionable strategies. Therefore, Community Quality Collaborative leaders are encouraged to be very focused and realistic when tackling sustainability questions.
This section provides insight into how to evaluate the application of leading practices, to ensure that the organization can deliver on its promises.
A key component of the Louisiana pilot project involved surveying key stakeholders about the effectiveness of the organization. In this process, survey forms in MS Word format were emailed to 65 participants. Each survey contained the same 30 questions organized around the seven leading practices and requested numerical rankings as well as written comments.
A template for this type of survey is included in the Toolbox. However, it is recommended that Community Quality Collaboratives shorten the length of the survey and use an online survey tool to streamline the process.
The response rate was good, considering the length of the survey, which showed a high degree of interest and engagement. Twenty-three respondents (35%) returned the survey, including a good cross-section from the four stakeholder groups. There were 348 written comments, which provided deeper insights for the planning process.
Following are some key findings from the survey:
- Respondents gave the organization high ratings for Overall Effectiveness.
- Multiple ratings and comments provided praise for the group's leadership and respect for the participants.
- Respondents believed the Louisiana collaborative was on the right track and supported the planned activities and deliverables.
- Several areas were highlighted for focus and attention:
- Need for diversified funding.
- Importance of stakeholder engagement and balance (Stakeholder balance received the lowest average rating, although the overall rating was still high.)
- Individual comments pointed to needing more involvement from nearly every stakeholder type (consumers, health plans, purchasers, individual providers), as well as from different geographic areas.
- Perceived lack of public awareness of the organization and its mission, including several suggestions to engage more press coverage.
- Importance of openness and communication within the Louisiana Community Quality Collaborative.
As a key component of the retreat agenda, each Committee presented its current plan and a progress update. There was lively discussion about the goals and needs in each program or subject area. As noted above, the priorities previously had been defined and were progressing under the Committee structure. However, the Board discussion revealed that some Committee participants were more informed, engaged, and effective than others.
Ultimately, the Board concluded that the right priorities were defined in the Committee plans, but that adjustments were needed in some cases to ensure consistent progress. For example, one Committee had experienced turnover in leadership. This Committee's work was less clearly defined and generated more discussion. At the retreat, a new leader was confirmed for that Committee.
Each Community Quality Collaborative will structure its programs differently. However, the experience in Louisiana points to the need for consistent tracking, information sharing, and coaching across all program areas. Community Quality Collaboratives should use clear and simple documents to track and report program status to leaders and stakeholders. Several examples of models, plans, and tools are included in the Toolbox.
A critical component in planning for sustainability is having a current, neutral understanding of what stakeholders value and will support. This was addressed at the Louisiana Board retreat. Following a detailed review of program priorities and Committee workplans, a group discussion was planned to address this question. While there was lively discussion, the process employed was not entirely effective and yielded more "lessons learned" than firm conclusions. More data gathering and preview discussions would have helped to shape and focus the discussion.
The discussion did yield a working list of high value assets, including:
- Award of CMS EMR demo.
- Community Quality Collaborative designation.
- Medical Home model
- Exploration/advancement of medical home concept.
- Thought leadership
- Information about national and state/local best practices.
- Participants on key advisory groups in the state.
- New fresh ideas.
- Education as to the current state of health care in Louisiana.
- Papers released by the Quality Measurement Committee.
- Dissemination of the Health Dialog Report.
- Increased visibility to physician use of HIT.
- Resource Guide.
- Health Plan Database.
A key component of the discussion centered around the concept of providing "nutrition" to interested stakeholders as the organization develops and grows. Several participants emphasized that the Louisiana Community Quality Collaborative may lose the interest and support of key stakeholders, such as employer/purchasers, if those stakeholders do not see tangible results.
For more information about effectively evaluating stakeholders' perspectives, see the Sustainability Toolbox and Sustainability Planning for Community Quality Collaboratives: Ten Key Questions to Guide Your Planning Efforts, Report #1: Oregon Health Care Quality Corporation.
The most important part of a sustainability plan is the execution. This section describes how the Louisiana Community Quality Collaborative identified needs and strategies to ensure that the collaborative delivers value.
Because the organization had a 3-year contract with the State of Louisiana, the timing for a strategic planning process was good. Before the end of the contract in 2010, the group needs to establish a more diversified and sustainable funding portfolio.
Specific funding opportunities were discussed at the Board Retreat, which generated a working list. The most important outcome was the recognition that more attention from the Board, and possibly outside expertise, was needed. The Board agreed to create a Development Committee to focus on critical development and funding issues.
Each Community Quality Collaborative should clearly define roles and responsibilities with respect to funding. In most cases, it is advisable to designate a small group to focus on development and funding. This activity may be assigned to a standing Committee, such as an Executive Committee, or a new Committee convened for this purpose. Examples of a strategic plan and dashboard for the Development Committee are included in the Toolbox.
In addition to funding needs, the consolidated review of all of the programs identified other resource requirements such as needs for technical assistance, information, and partnerships. From each of the Committee plans, the resource requirements were summarized into one master list to guide the Executive Director and Development Committee in focusing requests and securing support. This list highlighted that the four programs had related needs for certain types of support such as research, technology, and communications expertise.
It also is important to have a clear, well-documented picture of what it will take to achieve the stated goals. The organization already employed two professional project managers to support the Committees. This approach was recommended for the new Development Committee as well— to track goals, tasks, and projects in a similar fashion.
Both the stakeholder survey and the Board retreat highlighted variations in Committee effectiveness and perceptions of the Board's role. This was caused, in part, by different levels of engagement by individuals as well as the maturity of the respective Committees and their work. This variation affected the strategic discussions at the retreat, because not all participants were starting from the same place.
This is a common challenge for Community Quality Collaboratives, because time with the Board is very limited and must be carefully organized without becoming too orchestrated. In Louisiana, adjustments have been made to the Board and Committee assignments to achieve the desired balance and level of activity.
As discussed above, the solution for the Louisiana Community Quality Collaborative was to leverage a smaller group to work closely with the Executive Director on development issues.
For more information about governance models of other Community Quality Collaboratives, including Board sizes and Committee structures, see the individual Community Quality Collaborative profiles on AHRQ's Learning Network for Community Quality Collaboratives Web site: http://www.cvelearningnetwork.org/doc.asp?id=22.
Through its professional project management team, the Louisiana Community Quality Collaborative was already using workplans and dashboards with its program committees. These documents were created for the Development Committee as well, recognizing that the development effort requires as much attention and focus as program work.
Community Quality Collaboratives also should consider building an overarching resource plan that recognizes potential opportunities and/or conflicts between programs and committees.
In summary, the chart below illustrates the strategic planning process, which was applied in Louisiana as follows:
- The Vision and Universe of Possibilities had already been well defined.
- Four working Committees had clearly defined Priorities, which were affirmed at the Board Retreat.
- The planning activities at the Board Retreat were designed to focus on the intersection of Capabilities, Priorities, and Funding. As with many organizations, the biggest challenge of sustainability was in balancing these three factors.
- The process and retreat produced new insights and motivation to refine the Strategies, Execution Plan, and Monitoring approach.
This process yielded the following lessons learned for the Louisiana group, which also may apply to other Community Quality Collaboratives in their sustainability planning efforts:
- Breaking down the process is critical.
- Maintain a sharp focus: don't try to cover too much ground in one meeting.
- Select and tailor tools to your organization.
- Plan multiple sessions; include several in-person meetings.
- Acknowledge differences in style.
- Style of engagement.
- Preferred levels of detail.
- Types of documentation.
For more information, tools, and templates, please see the Sustainability Toolbox.
The author would like to thank the following people from the Louisiana Health Care Quality Forum (LHCQF) for contributing to this document: Shannon Robshaw, Executive Director, and the Board of Directors and staff.
The author wishes to thank the following people for reviewing this report: Jan De La Mare, MPAff, Agency for Healthcare Research and Quality; Karen Shore, PhD, Center for Health Improvement; Shannon Robshaw, Louisiana Health Care Quality Forum; and Peggy McNamara, MSPH, Agency for Healthcare Research and Quality.
AHRQ appreciates citation as to source. Suggested format follows: Lejnieks, L. Sustainability Planning for Community Quality Collaboratives: Ten Key Questions to Guide Your Planning Efforts; Report #2: Louisiana Health Care Quality Forum. Rockville, MD: Agency for Healthcare Research and Quality, December 2008.
We consider our Learning Network tools to be works in progress and always welcome your comments. Please forward suggestions to AHRQ's Peggy McNamara at email@example.com.