14 November 2012 - Nova Scotia Health · PDF file14 November 2012 . Co-authors: Carolyn (Lynn)...

Working Together Toolkit - Primary Health Care, Capital Health, Nova Scotia i

14 November 2012

Co-authors: Carolyn (Lynn) Edwards, Dr. Rick Gibson, Shannon Ryan Carson Primary Health Care, Capital Health, Nova Scotia

Contact: [email protected]

A USER

GUIDE THE WORKING TOGETHER TOOLKIT

Working Together Toolkit - Primary Health Care, Capital Health, Nova Scotia ii

Table of Contents

INTRODUCTION ........................................................................................................ 1

BACKGROUND ......................................................................................................... 1

THE CONTINUUM ..................................................................................................... 2

KEY CHARACTERISTICS ............................................................................................ 5

GETTING STARTED .................................................................................................. 6

THE WORKING TOGETHER TOOL: THE STEPS AND PROCESS ....................................... 6

GUIDING PRINCIPLES ............................................................................................. 10

A WORD ABOUT CHANGE ...................................................................................... 11

SUMMARY ............................................................................................................. 13

APPENDIX A: WORKING TOGETHER FRAMEWORK .................................................... 14

APPENDIX B: WORKING TOGETHER – A PRACTICAL TOOL ......................................... 15

APPENDIX C: WORKSHEET 1: EXAMPLE OUTCOMES ................................................. 19

APPENDIX D: WORKSHEET 2: ACTION PLANNING .................................................... 24

BIBLIOGRAPHY ...................................................................................................... 25

A USER

GUIDE THE WORKING TOGETHER TOOLKIT

Working Together Toolkit - Primary Health Care, Capital Health, Nova Scotia 1

Building strong working relationships to improve health outcomes is important. If you are taking the time to review the Working Together Toolkit, you and your organization have recognized this importance. This toolkit is based on the Working Together Framework and its constructs or component parts. Based on evidence in the literature, as well as experiences in working with others, a Working Together Framework was developed by Primary Health Care, Capital Health. The focus of this framework is on groups of individuals within or across organizations who wish to work together in some fashion for an intended outcome. Inter-professional collaboration between individuals or clinical disciplines is not the intended focus of this work as there is much evidence based information that has been developed and found elsewhere that guides this type of working together.

Evidence related to organizations (or individuals representing organizations) working together is found through published articles on inter-organizational relationships and partnerships. Key themes arising from the literature are captured in the Working Together Framework (Appendix A). They include:

• There is a spectrum or continuum of working together,1,2,3,4,5,6

• Each category on the working together continuum has differing goals and outcome focus

which we have defined to include four key categories - communication, cooperation, coordination, and collaboration

• There are key characteristics that if present, can support successful working relationships. For example, the level of trust, the decision making process, or accountability can have an impact on a working relationship. If key characteristics are not present, it may result in working relationships that are not as strong as a group may want. Therefore, attention to characteristics becomes important.

WORKING

TOGETHER INTRODUCTION

WORKING

TOGETHER BACKGROUND


• Relationships can take time to develop and go through phases, and; • Be explicit about the intended outcomes of working together

In a working relationship, two or more independent organizations, organizational units, groups, or agencies make a commitment to work together on something that concerns them both. They come together in pursuit of a common goal, often with the expectation that by working together, they will achieve more than they would by working separately.7,8

Through a literature review and consideration of key source documents in our local context, as well as from what we continue to learn from our years experience in working with others and/or organizations, we have developed a common framework and an accompanying step-by-step Working Together – A Practical Tool (Appendix B). As well, two different worksheets are included – one focuses on example outcomes (Appendix C) and the other focuses on action planning (Appendix D).

Not all working relationships require the same degree of time, resources, or interdependence. Various authors in the literature refer to different types of working relationships. We define the continuum as having four key categories – communication, cooperation, coordination, and collaboration. In communication relationships,9 individual groups or organizations retain autonomy and generally keep resources separate. Information is considered a resource and it is shared

WORKING

TOGETHER THE CONTINUUM

For the purposes of our work, we are calling this type of relationship ‘working together’ and chose the following definition: “when two or more groups, agencies, organizations, or organizational units work together towards a common aim”. Adapted from: Frearson, A. Partnership self-assessment toolkit: A practical guide to creating and maintaining successful partnerships. East Leeds Primary Care Trust.


freely between the parties. Information is exchanged on topics of mutual interest and it may be one way, unstructured and infrequent, occurring only when needed. In cooperative relationships,1 individual groups or organizations retain autonomy and generally keep resources separate. Information sharing becomes more of a dialogue, but is still limited to one or two activities where information is shared to assist in an increased understanding of each other. The relationship is informal and participation is voluntary. The relationship can be short-lived. The risk to partners is minimal and there is only a small effect if one of the partners withdraws. There is no requirement to change existing practices, but the partners may make minor modifications in the way they work to accommodate each other or to limit duplication. In coordination relationships,1 individuals, groups or organizations remain separate, but agree to align activities in some fashion. As a result, there is a more intense relationship than in communication or cooperation relationships. As the relationship progresses beyond the sharing of information, the level of commitment increases. There is some measure of joint planning and perhaps even joint funding, which requires some formalization of shared structures and processes. Information exchange becomes routine and levels of trust increase. It becomes harder for partners to disengage. The risks are greater, but so are the potential benefits. In collaborative relationships,1 individual groups or organizations build strong linkages and become interdependent to bring about system change by radically altering the way that they think, behave, and operate. There is a common goal to devise solutions for complex problems (the sort of problems with multiple interconnected elements that are hard to untangle, which cut across policy and service areas and resist solutions offered by single agencies). Taking even greater risks, organizational activities are aligned and some or all resources are pooled. Trust is essential. Building trust takes time, so these relationships are generally longer term, with a greater degree of formality.

As you can see from the above descriptions, being purposeful about the intent, time, and energy in building and maintaining relationships will be beneficial in meeting intended outcomes.


The terms or labels referred to in the literature vary from author to author. Collaboration and partnership are the terms that are used most frequently. These terms are what we often use to refer to all situations in which we work with others. In the strict sense of the word, a partnership is a formal agreement to share power with others in the pursuit of joint goals and/or mutual benefits.10,11

This is often grounded in legally binding arrangements. In many cases, however, our working relationships do not involve contracts or formal agreements.

Communication, cooperation, and coordination are equally valuable and important points on the continuum as collaboration. Research does not always show that collaboration achieves the results initially intended or is the most effective use of resources.12,13,14,15,16 Not every project requires collaboration.1,11

To this end, collaboration and partnerships are interchangeable in language. We communicate, cooperate, and coordinate with others who we may call partners. However, it is not until the key characteristics and the goals that describe collaboration on the continuum are present that we enter into what is truly meant by collaboration or partnership. It is as important to be purposeful with the language as it is to be clear about the intention of the working together.


When present or not addressed, key characteristics can act as supports or barriers, respectively, to effectively working together. The key characteristics contained in the Working Together Framework were chosen based on a thorough review of the literature and a thematic analysis of characteristics that were described as critical to working together. The most frequently listed characteristics are included in the framework to guide your work with others.

CATEGORY CHARACTERISTIC DESCRIPTOR

Relational Vision What is to be accomplished. Must be concrete, attainable, and ultimately, measurable

Goals and Outcomes

The public statement of what the organizations expect to achieve individually and by working together

Trust The ability to form expectations about aims and partners' future behaviors in relation to those aims

Power The ability to perform or act effectively

Functional Decision Making How decisions are made. The ability to compromise.

Information Exchange

The exchange of thoughts, messages or information, as by speech, signals, writing, or behavior

Resources The degree to which resources (staff, space, budgets, knowledge, etc.) are shared

Structural Membership and Leadership

Who is involved, how they are connected. Engaging all relevant players. How leadership shows itself.

Accountability Where the individuals and groups who are working together see their obligations

WORKING

TOGETHER KEY CHARACTERISTICS


The main components of the Working Together Framework (Appendix A) and the Working Together - A Practical Tool (Appendix B) will assist you in working through important steps as you build and/or maintain strong working relationships. Becoming familiar with the framework and using the tool can help provide clarity about the purpose of working together and about the type of working relationship that you currently have or would like to reach in the future. Having conversations as partners and reflecting on the framework and tool can take the working relationship to a more effective and productive place.

The Working Together - A Practical Tool can be used in three ways: 1. Complete the tool together with the partners, people, groups, etc who are working

together 2. Complete the tool independently by all partners. Once completed by all partners it

would be followed by group discussion 3. Complete this tool on an individual basis where it can act as a reflective guide when

working with others The optimal approach suggested is to hold group conversations with all partners present. This conversation allows open and transparent discussions about the many factors that can shape how we work with others. Through these discussions clarity is often achieved about the intended outcomes, type of relationships, and any differences in opinions and perspectives are revealed. It is recommended to use a planned process to support and facilitate the conversations. The tool has four steps, which are outlined below.

WORKING

TOGETHER GETTING STARTED

WORKING

TOGETHER THE WORKING TOGETHER TOOL: THE STEPS AND

PROCESS


STEP 1: IDENTIFY THE PARTNERS, PROJECT, AND OUTCOMES The first step involves identifying the partners that will be working together as well as the project or initiative that they are working on. Before jumping into the working relationship, it can be very valuable to discuss if all the partners that should be part of the discussion are present. This may seem to be an obvious step, but we often think of the ‘usual suspects’ when working together. There may be a partner group who we did not initially identify that can add something new and innovative. Was any group or partner missed? Was any group or partner included that may not be required for this specific initiative? It is also important to be specific about the initiative or project that the partners are addressing as it can provide clarity about how the partners want to work together and what they want to achieve. Given that different partners sometimes work together on multiple projects or initiatives, it can be difficult to identify specific outcomes or discuss key characteristics if the partners are reflecting on varying projects that have very different purposes and deliverables. Finally, it is critical to identify the outcomes that partners hope to achieve. The evidence is weak on the benefits of entering into intensive working relationships, yet intuitively we understand that the complexity of the system requires us to do so to support the health of the populations we serve. As well, we may find ourselves devoting much time and energy to working with others when we are not really clear on the intended outcomes. This lack of clarity often leads to failure. It is therefore important that partners are explicit about the intended outcomes, which provide a common understanding of the focus of the working relationship and the indicators of success. There are various levels of outcomes to consider. A list of example outcomes is included in the worksheet included in Appendix C. The list is not exhaustive. Partners are encouraged to identify any outcomes that are not described in the appendix.


EXAMPLE OUTCOMES17

Individual Level

Improved self-management

Better clinical outcomes

More willing to talk about health concerns

Better access to community resources

Opportunities for personal and professional growth

Organizational Level

Improved services

Increased capacity for outreach

Improved treatment protocols

Increased awareness and demand for organizational expertise

Improved data systems

Partnership Level

Improved partnership functioning

More stable partnership structure

Strategic expansion of networks

Increased collaboration among partners

Improved ability to leverage resources

Community Level

Increased resources

Increased community awareness of health issue

Data that can be used by other agencies to garner additional resources

Increased community engagement in health

Increased advocacy and consumer demands

LONG TERM OUTCOMES

Decreased morbidity and mortality; Improved quality of life; Improved population health


STEP 2: IDENTIFY CURRENT CHARACTERISTICS This step involves reflection on the key characteristics required to support effective working relationships. Partners identify characteristics that CURRENTLY exist for the initiative or project identified in Step 1. Thinking about characteristics that exist (or not) can help identify the kind of working relationship that currently exists. If all of the partners are filling out the Working Together – A Practical Tool as a group, the discussion that occurs could lead to different opinions about what characteristics exist or not. The conversation could result in increased clarity about the current working relationship and the characteristics that are needed to support a stronger working relationship. STEP 3: IDENTIFY THE POINT ON THE CONTINUUM OF WORKING TOGETHER This step involves partners becoming familiar with the continuum of working together. Partners may want to review the continuum together to ensure a common understanding. As a discussion occurs about the continuum, partners consider not only the initiative and the intended outcomes identified in Step 1, but also the characteristics identified in Step 2. Each step of the tool therefore builds on the preceding steps. The toolkit supports increasing knowledge and discussions about the type of working relationship that exists and that which is desired, the target end point on the continuum. Identifying the current and end points on the continuum can be challenging given relationships can move between the different stages over time. If this step is being explored as a group, discussion could reveal some differences in opinions regarding the type of working relationship that exists (e.g., communication, cooperation, coordination, or collaboration). Differences can offer valuable insights, which can lead to increased understanding among partners to work together more effectively. (Reminder: Communication, cooperation, and coordination are equally valuable and important forms of working together. Research shows that collaboration does not always


achieve the results initially intended. Collaboration may not be the most effective use of resources.) STEP 4: REFLECTION After completing Step 1 to 3, please review and discuss. Reflection and/or discussion could help increase how effectively the partners may work together in order to meet the identified outcomes. The Working Together - A Practical Tool identifies key questions that the partners or groups may want to consider.

There are a number of guiding principles that underpin successful working relationships.5,18,19

• Working together is hard work, not a soft option

Principles are generic and apply across different sectors, organizational levels, and different policy areas. The manner in which they are used, however, will vary according to the environment and context.

• Working together involves breaking out of our “either/or” boundaries • Working together take time to develop and require patience • Information exchange is critical at all points on the Working Together Continuum. • Working together often costs before it pays • Working together must be realistic and must aim for what can be achieved. It

must not be set up to fail by being too ambitious • Relationships generated by working together will involve tension and conflict –

creative tension and constructive conflict

WORKING

TOGETHER GUIDING PRINCIPLES


We could not have a Working Together Toolkit related to working with other groups, agencies, or organizations without a word about change. Working together in a purposeful way with stated outcomes represent a change for many people and their organizations. The pace, volume, and complexity of change in health care have increased significantly during the last decade and are expected to continue. In order to be world leading, all leaders must not only say we are patient and citizen focused, but must participate in implementing, creating, and adapting the health system to be so. A critical part of this process is learning how to be smart when working together. The new paradigm of change is driven by people throughout all levels of an organization. It calls on us to look towards short and long term results. It requires us to engage in a rapid pace and show courage. Engaging in change is not precise and managing change is both an art and science.

WORKING

TOGETHER A WORD ABOUT CHANGE


In “Switch: How to Change Things When Change Is Hard,”20

These may be helpful for you and your working partners to use as a guide.

the Heath brothers identify simple, easy steps to consider when making a change.

How to Make a Switch

For things to change, somebody somewhere has to start acting differently. Maybe it is you; maybe it’s your team.

Picture that person (or people). Each has an emotional Elephant side and a rational Rider side.

You have to reach both. You also have to clear the way for them to succeed.

In short, you must do three things:

DIRECT the Rider

• FOLLOW THE BRIGHT SPOTS. Investigate what is working and clone it. • SCRIPT THE CRITICAL MOVES. Do not think big picture, think in terms of specific

behaviors. • POINT TO THE DESTINATION. Change is easier when you know where you are

going and why it is worth it.

MOTIVATE the Elephant

• FIND THE FEELING. Knowing something is not enough to cause change. Make people feel something.

• SHRINK THE CHANGE. Break down the change until it no longer spooks the Elephant.

• GROW YOUR PEOPLE. Cultivate a sense of identity and instill the growth mindset.

SHAPE the Path

• TWEAK THE ENVIRONMENT. When the situation changes, the behaviour changes. So change the situation.

• BUILD HABITS. When behaviour is habitual, it’s “free”. It doesn’t tax the Rider. Look for ways to encourage habits.

• RALLY THE HERD. Behaviour is contagious. Help it spread.


• Working together occurs when two or more groups, agencies, organizations, or

organizational units work together towards a common aim • The ways that we form relationships are referred to as the working together continuum

The four categories are communication, cooperation, coordination, and collaboration • Each category of working together is defined by the outcomes and key characteristics • We often say we are collaborating or partnering when we really mean that we are

communicating, cooperating, or coordinating • All forms of working together are equally valuable. Research shows that collaboration

does not always achieve the results initially intended or is the most effective use of resources

• We may call every group that we work with ‘partners.’ However, we are not entering into a partnership until we are on the collaboration point on the continuum!!!

• How we set out in the beginning of a working relationship may be different to how the relationship actually evolves

• Be explicit about the outcomes that you hope to achieve as a result of working together. • Reflect on the principles of working together and change process • Create a Working Together Action Planning Sheet

As you use this Working Together Toolkit, please feel free to share your experiences and suggestions for improvement. We continue to evolve and improve this work.

Rick Gibson, MD Shannon Ryan Carson Carolyn (Lynn) Edwards EXTRA Fellow EXTRA Fellow EXTRA Fellow Chief Health Services Manager Health Services Director DDFP Primary Health Care Primary Health Care Capital Health Capital Health Capital Health

WORKING

TOGETHER SUMMARY


APPENDIX A WORKING TOGETHER FRAMEWORK


Building strong working relationships to improve health outcomes is important. If you are taking time to complete the Working Together – A Practical Tool you and your organization have recognized this importance. Based on evidence in the literature as well as experiences in working with others, a Working Together Framework was established by Primary Health Care (Capital Health). This framework and other related documents are included in the Working Together Toolkit. Not all working relationships require the same degree of time, resources, or interdependence. The Working Together Framework identifies a continuum with four key categories - communication, cooperation, coordination, and collaboration.

The Working Together – A Practical Tool is based on the framework. The tool helps partners describe their intended outcomes and the current status of their working relationship. It provides increased awareness of the type of working relationship that partners may want work towards in the future. It provides opportunities for group discussion and reflection on areas that partners may want to focus on to support working together more effectively. The tool has four steps. The first step involves identifying a project or initiative well as the outcomes that partners hope to achieve. The second step involves identifying key characteristics that exist for the partners working together. The third step involves identifying the category of the working relationship. The fourth step involves reviewing and reflecting.

STEP 1. IDENTIFY THE PARTNERS, PROJECT, AND OUTCOMES This tool can be completed in three different ways: 1. It is optimal to complete this tool together with the partners and groups who are working together. 2. The tool can be completed independently. Once completed by all partners, it should be followed by a group discussion 3. The tool can be completed an individual basis where it can act as a reflective guide when working with others.

Identifying outcomes that partners hope to achieve provides a common understanding of the focus of the working relationship. It also provides partners with indicators of success.

Initiative or project: Date completed:_______ _____

Partners working together: _____

Tool completed with partners or independently:

Outcomes can occur at different levels such as: 1. INDIVIDUAL LEVEL - addresses outcomes for the clients or patients that the different partners serve. 2. ORGANIZATIONAL LEVEL - focuses on outcomes for each partner that resulted from working together.

3. PARTNERSHIP LEVEL - deals with how the working relationship changed over time 4. COMMUNITY LEVEL - addresses how the partners work has affected the larger community

List the partners’ intended outcomes for the identified initiative or project:

TIP: When identifying outcomes, an example list is provided in the “Example Outcomes” worksheets that are included in the Working Together Toolkit.

APPENDIX B WORKING TOGETHER – A PRACTICAL TOOL


STEP 2. IDENTIFY CURRENT CHARACTERISTICS The characteristics listed in this table can help support effective working relationships. Identify the characteristics that CURRENTLY exist for the initiative or project identified in Step 1. This can help identify the kind of working relationship that currently exists for the specific initiative that is being addressed.

If the tool is being filled out as a group, discussion can lead to different opinions about what characteristics exist or not. The discussion can result in increased clarity about the type of working relationship that currently exists and the characteristics that are needed to support strong a working relationship.

VisionGoals and Outcomes Trust Power

Decision Making

Information Exchange Resources

Membership and Connections Accountability

What will be accomplished. Must

be concrete, attainable and measureable.

What the partners will achieve

individually and by working together.

Confidence about the aims of working

together and future behaviours of

partners. The ability to rely on each other.

The ability to perform or act

effectively.

How decisions are made and the

ability to compromise.

The exchange of thoughts, messages

or information through speech,

signals, writing or behavior.

The degree to which resources are shared (staff,

time, space, budgets,

knowledge, etc).

Who is involved, how they are connected.

Engaging all relevant players.

Where the individuals and partner groups

who are working together see their

obligations.

Information sharing limited to a common interest, goal, or topic.

Independent goals. Minimal trust required. Power remains with each partner group. Lower risk to individual partners.

Independent decision making.

Information sharing is about a specific topic and may be one way. Not structured, not frequent.

Resources remain with individual partners.

Minimal informal connections that link partners. Flexible membership, specific to a topic.

Main commitment and accountability remains with individual partners. Some adaptation

q q q q q q q q qAdapting to each other or accommodating others actions and goals.

Independent goals. Minimal interdependence.

Minimal trust required. Power remains with each partner group. Lower risk to individual partners.

Generally independent decision making. Joint decision making as necessary, usually through an optional consultative process.

Information sharing about specific topics by all partners. Not structured, not frequent.

Resources remain with individual partners.

Occassional connections that link partners. Low key relationships, increasing leadership involvement.

Main commitment and accountability remains with individual partners. Some adaptation and accomodation.

q q q q q q q q qDeveloping joint policies and/or programs. Reviewing each others mandates, policies and practice and developing a shared vision.

Semi-interdependent goals that result in increasing inter-dependence. Sharing of work more than sharing of resources.

Conditional or work-based trust. Evolving trust based on prior relationships.

Some power sharing specific to the goals. Overall control over resources and effort remains with each partner. Increased power sharing leads to medium risk to individual partners.

Decision making can be independent or shared, depending on the goal. Formal stucture for decision making.

Routine, structured communication. Formalised project-based and/or issue-based information sharing.

Increasing shared resources and effort.

Regular and planned connections that link partners. Focused, organized, engaged leadership and increasingly consistent membership.

Commitment and accountability with individual partners as well as to the other partners, or projects.

q q q q q q q q qSystem change. Changing the way partners make decisions about policies, programs, use of resources and ultimately how partners support their people, groups, citizens, or communities.

Negotiated shared goals. Seeking the advantage that can result from working together to achieve goals that cannot be reached by individual partners acting alone.

Requires a high level of trust that is generally based on previous working relationships.

Control over some resources and effort is shared. Greater risk to individual partners as each gives up some control.

Formal structures ensure ongoing face-to-face communication, with each participating partner exercising shared power in decision making. Decisions ideally made by concensus.

Open, frequent communication through multiple formal and informal routes and established channels. Strategic, planned and timely communication.

Collective resources, including finances, labour and/or information.

Sufficient size, strong connections. Members involved seen as relevant and credible. The parties know and agree on who is involved and in what capacity. Skilled, shared, consensus-building leadership.

Commitment and accountability is to community and "working together" first and individual partners second.

q q q q q q q q q

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Colla

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Characteristics Relational Functional Structural

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STEP 3. IDENTIFY THE POINT ON THE CONTINUUM OF WORKING TOGETHER • Read and become familiar with continuum of working together.

• For this particular initiative, reflect on the outcomes identified in Step 1 and the characteristics identified in Step 2. Please identify the: (a) current point on the continuum (b ) target end point on the continuum

Identifying the current and end point on the continuum can be challenging given relationships can move between the different stages over time. If the tool is being filled out as a group, discussion can occur regarding the type of working relationship that exists (e.g., communication, cooperation, coordination or collaboration). The discussion can reveal some differences in opinions. Differences can offer some valuable insights, which could lead to increased understanding among partners to work together more effectively. (Note: Communication and cooperation are equally valuable and important points on the continuum as collaboration; research does not always show that collaboration achieves the results initially intended or is the most effective use of resources)

Continuum The Goal. The Promise What we hope to achieve by working together Our Commitment to Each Other

Communication To share general information about one or more topics of mutual interest. We will communicate when needed.

Cooperation

To provide each other with balanced and objective information and knowledge to support a common understanding. To ask for and listen to feedback from each other. To match and adjust the type of work that must be completed to meet the goals of each partner. To support each other to complete the required work. To limit duplication.

We will keep each other informed, listen to and acknowledge concerns and desires and provide feedback on how that input influenced our decisions.We will reach agreement to adapt and accomodate each others actions and goals and modify the way we work (usually minor).

Coordination

To work together, usually through established mechanisms, to meet a specific goal. To align some resources and efforts, have some shared processes, and rely on the support of each partner. To make sure that the organizational mandates, concerns, ambitions, policies and practices of the partner groups are understood and considered. To address an area of need where partners believe working together will be more effective than working separately.

We will develop specific joint policies and programs and align resources and efforts in support of specific goals. Commitment and accountability will be to individual partners and the project. We will work together to ensure that individual partners concerns and aspirations are reflected and provide feedback to each other on how that input influenced decisions.

Collaboration

To bring about systems change by radically altering the way that we think, behave, and operate. To bring together the resources, knowledge, skills and capabilities of partners to develop solutions for complex problems. To work together on an area of need or a problem that cannot be effectively addressed by individual partners. To work closely with each other at each step of decision making and implementation.

We will abandon "business as usual", forge new relationships, negotiate shared goals, and learn new ways of working together. We will share resources and power. Our commitment and accountability will be to the working relationship first. We will look to each other for advice and innovation in formulating solutions and incorporate that advice and recommendations into decisions to the maximum extent possible.

Current Point on the Continuum

Target End Point on the Continuum


STEP 4: REFLECTION AND NEXT STEPS After completing Step 1 to 3, please review and discuss the following questions. Reflection and/or discussion could help increase how effectively the partners may work together in order to meet the identified outcomes

Given the time, energy, and resources that are required to work together, will working together achieve more than working separately? What do you lose? Do the gains outweigh the losses? Can the intended outcomes be achieved by working independently or can they be achieved by working together?

What steps or actions can the partners take to build on existing characteristics? Based on use of this tool, what characteristics should the partners focus on first and why?

What steps or actions can the partners take to help minimize any barriers?

TIP: Review Step 2 and consider the characteristics that do not exist that the partners may want to exist.

How will the partners know if the identified outcomes will be achieved? When, and how often, will the partners review the identified outcomes to determine if any progress is being made? Who do the partners need to report to about outcomes (e.g., public, policy makers, funders)?

TIP: An “Example Outcomes” worksheet is included in the Working Together Toolkit. This worksheet provides a list of possible outcomes that may result from working together. Outcomes are listed in four different levels: 1. Individual, 2. Organization, 3. Partner, and 4. Community. The worksheet provides examples only. It is not an exhaustive list. Partners are encouraged to identify any outcomes that are not included in the worksheet.

What priority areas - will be addressed first by the partners working together?

TIP: The “Action Planning” worksheet that is included in the Working Together Toolkit provides more information to help identify and address any priority areas.


The Example Outcomes worksheet is a reprint from: Robert Wood Johnston Foundation. (2008).17 The tools for building clinic-community partnerships to support chronic disease control and prevention. Washington University

APPENDIX C WORKSHEET 1: EXAMPLE OUTCOMES

Individual Level Outcomes

Yes Somewhat No Not

Applicable or Don’t Know

Are you collecting data to measure this outcome?

Yes No

As a result of the partnership’s work, have the people the partnership serves…

(Check one answer for each numbered item) Check one

1. Increased their knowledge about the health issue?

2. Improved health behaviors? 3. Improved key clinical outcomes? 4. Asked more questions about their

health?

5. Increased their knowledge about community resources and services?

6. Increased their use of community services appropriate for patient needs?

7. Used clinical services more appropriately?

8. Become more involved in the program itself (e.g., served on committees or boards, provided peer mentoring)?

9.

Reported change in family involvement in healthy lifestyles (e.g., support for or participation in healthy eating and physical activity)

10. Other:

11. Other:

12. Other:

13. Other:

14. Other:

Note: In the current form this checklist generally applies to any chronic disease or condition. It can be tailored to address a specific disease by identifying the disease specific health behaviors and clinical outcomes. For example, for diabetes, the clinical outcomes of interest may include hemoglobin A1c, blood pressure, blood lipids, body mass index, etc. Specific behaviors might include some of AADE 7

TM

, i.e., healthy eating, being active, monitoring, taking medications, problem solving, reducing risks and healthy coping.


Organizational Level Outcomes

Yes Somewhat No Not Applicable or Don’t Know

Are you collecting data to measure this

outcome? Yes No

As a result of the partnership’s work, have the organizations in the partnership (yours and the others)…

(Check one answer for each numbered item) (check one)

1. Created a better trained workforce (staff and volunteers)?

2. Experienced greater administrative support for partnership program(s)?

3. Increased capacity for outreach?

4. Increased organizational capacity to support consumers’ engagement in their health and health care?

5. Improved program or treatment approaches or protocols?

6. Increased access to services?

7. Increased the number of patients with a medical home or primary care physician?

8.

Increased physician referrals to support services such as self management education, exercise classes, etc?

9. Increased awareness and demand for your organization’s expertise?

10. Other:

11. Other:

12. Other:

13.

14.

15.

Yes No No, Already Exists

Not Applicable or Don’t Know

16. Developed shared approaches or standards of service delivery?

17. Developed coordinated referral systems?

18. Developed client/patient appointment systems?

19. Other:

20. Other:

21. Other:


Partnership Level Outcomes

Yes No

Not Applicable or Don’t Know

Are you collecting data to measure this outcome?

Yes No As a result of working together, is there . . . (Check one answer for each

numbered item) (Check one)

1. Increased trust among partners? 2. Improved coordination among partners? 3. Reduced duplication of effort or service? 4. Improved conflict resolution among partners? 5. A better understanding of partner’s roles?

6. Improved ability to identify and address barriers to working together?

7. A better understanding of what partners need from their participation?

8. Increased involvement of partners in the partnership?

9. Increased collaboration on spin-off projects?

10. Increased likelihood of partnership sustainability when project specific funding ends?

11. A level playing field among partners to interact more as equals within partnership?

12. An evolution from “what can the partnership do for us” to “what we can do together”?

13. An increased ability to leverage resources from other agencies (e.g., space, expertise, new partners, volunteers or funds)?

14. Other:

15: Other:


Community Level Outcomes

Yes No Not

Applicable or Don’t Know

Are you collecting data to measure this outcome

Yes No

As a result of the partnership’s focus (e.g., diabetes, heart disease), does the community the partnership serves have …

(Check one answer for each numbered item)

(chec

(check one)

1. More information, programs, and services that address the health issue?

2. Better access to information, services and programs that help them manage that health issue?

3. Increased awareness of the health issue?

4.

Access to data the partnership generated to garner additional resources for the partners or other organizations in the community?

5.

Increased involvement in advocacy or consumer demand for services and programs that address the health issue of concern?

6.

Improved access to environments that support health (e.g. clean air, safe places to walk, access to healthy food)?

7.

More local or state level policies that support, health care, healthy behaviors and/or healthy environments.

8.

9.

10.

11.

12.


The Action Planning worksheet is a reprint from: Robert Wood Johnston Foundation (2008).17

The tools for building clinic-community partnerships to support chronic disease control and prevention. Washington

Taking Action – Making Improvements

Date of completion: ___________________________________________________

As a group, discuss any patterns you observe regarding areas of agreement/disagreement and satisfaction/ dissatisfaction.

Areas of strong agreement: ________________________________________

Areas of strong disagreement: ___________________________________________

Areas with satisfaction: _________________________________________________

Areas with dissatisfaction: _______________________________________________

Decide which issue of concern your partnership would like to address first (and a timeframe for addressing other issues if more than one emerged). There is no one best course of action. Your decision about where to start may be based on a number of factors, e.g., the degree of disagreement or dissatisfaction in a specific area, the importance of the issue to the partnership, opportunities and resources available to take a specific course of action, readiness of the group to make changes, a combination of these, or other factors unique to your partnership.

APPENDIX D WORKSHEET 2: ACTION PLANNING


Taking Action—Making Improvements

The following questions may be used to guide the development and implementation of and accountability for plans your partnership makes to improve the relations, function or structure of the partnership. Use a separate form for each issue targeted for improvement 1. Indicate an area your partnership has targeted for improvement. What specific action will you take to try to improve this situation?

Focus: Action:

2. What do you hope will be the impact of making this change? Are there any downsides to making this change?

Impact: Possible downside:

3. Describe the steps you will take to make improvement: a.Who is responsible for what tasks? b.When are the actions to be completed? c. How will you measure success? Note: You may want to write these as SMART objectives -Specific, Measurable, Achievable, Relevant, and Time-Specific

Who: When: Measure of success:

4. Do you anticipate any obstacles? If so, how will you address them?

Obstacles: Response:

5. What might help this change come about? Facilitators:

6. How will you maintain this improvement? Maintenance:


1 Keast R, Brown K, Mandell M. Getting the right mix: unpacking integration meanings and strategies. International Public Management Journal 2007;10(1):9-33. 2 Mandell M, Steelman T. Understanding what can be accomplished through interorganizational innovations. Public Management Review 2003;5(2):197-224. 3 Ahgren B, Axelsson R. Evaluating integrated health care: a model for measurement. Int J Integr Care 2005 discussion e03, e09;5:e01. 4 Konrad EL. A multidimensional framework for conceptualizing human services integration initiatives. New Directions for Evaluation 1996;1996(69):5-19. 5 Leutz WN. Five laws for integrating medical and social services: lessons from the United States and the United Kingdom. Milbank Q 1999;77(1):77. 6 Browne G, Roberts J, Gafni A, Byrne C, Kertyzia J, Loney P. Conceptualizing and validating the human services integration measure. Int J Integr Care 2004;4:e03-e03. 7 Weiss ES, Anderson RM, Lasker RD. Making the most of collaboration: exploring the relationship between partnership synergy and partnership functioning. Health Educ Behav 2002 Dec;29(6):683-698. 8 Lasker RD, Weiss ES, Miller R, Community-Campus Partnerships for Health. Promoting collaborations that improve health. Educ Health (Abingdon) 2001;14(2):163-172. 9 Browne G, Roberts J, Gafni A, Byrne C, Kertyzia J, Loney P. Conceptualizing and validating the human services integration measure. Int J Integr Care 2004;4:e03-e03. 10 Kernaghan K. Partnership and public administration: conceptual and practical considerations. Canadian Public Administration 1993;36(1):57-76 11 Hunter DJ, Perkins N, Bambra C, Marks L, Hopkins T, Blackman T. Partnership Working and the Implications for Governance: issues affecting public health partnerships. 12 Keast R. Joined-up Governance in Australia: How the Past Can Inform the Future. 2011.

WORKING

TOGETHER BIBLIOGRAPHY


13 Audit Commission (UK). Governing Partnerships: Bridging the Accountability Gap. 2005. 14 Jolley G, Lawless A, Hurley C. Framework and tools for planning and evaluating community participation, collaborative partnerships and equity in health promotion. Health Promotion Journal of Australia 2008 08;19(2):152-157. 15 Boydell L, Rugkasa J, Hoggett P, Cummins A. Partnerships: The Benefits. 2007. 16 Dowling B, Powell M, Glendinning C. Conceptualising successful partnerships. Health Soc Care Community 2004 Jul;12(4):309-317. 17 Robert Wood Johnston Foundation. (2008). The tools for building clinic-community partnerships to support chronic disease control and prevention. Washington University. 18 Wildridge V, Childs S, Cawthra L, Madge B. How to create successful partnerships-a review of the literature. Health Info Libr J 2004 Jun;21 Suppl 1:3-19. 19 Building effective partnerships: Practical guidance for public services on working in partnership. London, U.K.. 20 Heath C, Heath D. Switch: How to Change Things When Change Is Hard. 2010. Random House of Canada.

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