Our Organization and Community: Coming Together for Rural America
by Tim Size, President, National Rural Health Association
Published as the "President's Message" in Rural Health FYI, July, 1997
To serve as the association's president-elect and now president is a heady mix of new experiences, additional responsibility and jet lag. For someone who still remembers forty years later the thrill of grade school "show and tell," having my own national column is a real nice part of the mix.
Each year at this time, this space offers the new president an opportunity to share his or her goals or agenda. This could be a short column. My belief is that the president has one primary responsibility--to vigorously support the work of the Board of Directors, the members, the many who volunteer with NRHA and our excellent staff. The job of the president is to move the association's agenda, not his or her own agenda. That agenda has many facets but is easily summarized as the ongoing improvement of our collective effectiveness on behalf of rural health, in both the policy arena and in the market place.
Many of you were fortunate enough to hear both Leland Kaiser and Jennifer James at our annual meeting in Seattle. If you were like me, you left energized with their congruent vision of our potential to create virtual organizations--stronger, more collaborative, not exclusive to a single entity or place. Reading Dr. James's Thinking in the Future Tense is a good opportunity to learn more about how we can grow. A portion of Dr. Kaiser's ideas can be read at the On-line Forums hosted by The Center for Health Design at: <www.healthdesign.org/forum/es1.htm>.
In his "Need For A Design Paradigm" he poeticly summarizes the vitual national organization or system that NRHA can become:
"Natural systems work. Human systems don't work. Perhaps if we designed our social systems like natural systems they would work. Kevin Kelly discusses "subsumption architecture" in his book, Out of Control. This refers to design from the bottom-up with no more structure than needed to get the job done. Think of your organization in terms of neurobiology. This means maximum downward delegation to the cellular level. Monitoring, control, decision making, and accountability at the lowest possible level is the model of the future with the cortex coming into play only as needed, primarily in emergency situations. The human body depends upon the well-being and contribution of each cell. So does your organization."
"Our challenge is to change the old paradigm - to think outside the lines. We should honor our past but not be held captive by it. It is time for us to reframe - to change our ideas about many things. We need to co-create our communities. We should settle for nothing less. It is time to get out of our box and into the inclusive circle of community. We need a new design paradigm."
One thing we all know about rural health is the differences in perspectives and realities within and between our communities and states. The members of NRHA mirror (not perfectly) this diversity. Success when many people come together for a common cause requires that many voices be heard and that all offered talents be utilized. As president, facilitating and listening to this complex and sometimes noisy dialogue is a top priority. (I've always wanted to use cacophonous in a sentence but it was edited out.) Regarding you as an individual member, I may not always respond as quickly or thoroughly as I would like to do, but I need to hear from a good number of you; I will listen and try to be responsive. [Particulars are in the NRHA directory and on the NRHA web site; email is timsize@rwhc.com.]
Before some of you think I've gone off the deep end of some feel good new age leader type devoid of personal opinion or bias, do not fear; be assured that I still hold numerous passions. Many of you know of my long term interest in rural networking and Medicare equity. I will continue to work as an "in your face" advocate for these perspectives. Along this line, I had the honor to testify this spring about the Medicare budget bill on behalf of the National Rural Health Association (NRHA) before the U.S. Senate Finance Committee on the Medicare budget. Here are two sound bites that pretty much sum up our position; (the alert FYI reader will have seen part of each quote before but advocacy is "saying it early and saying it often"):
"As Medicare spending is considered, it is critical to understand how significantly disadvantaged rural providers already are by the current system. Across the board cuts that fail to recognize the Medicare payment inequities that discriminate against rural communities are destructive of rural health and the maintenance of local access to appropriate care."
"Eliminating wide geographic variations that currently exist will encourage managed care participation in rural areas. While managed care is not a panacea, it is important for rural to be on a level playing field so that those wishing to participate in these types of plans can have access to them. Rural communities are placed in an untenable steel vise when federal policy aims to move Medicare into managed care while at the same time federal policy has the effect of prohibiting the development of rural Medicare managed care."
I am going to use the rest of my allotted time with you to tell you something about a position paper approved by the NRHA Board of Directors last November, A Community Approach To Rural Health Policy Development. This paper forms the basis for a new NRHA initiative to assist the long term expansion of the scope and breadth of rural health advocacy. This is our chance to further implement the type of organization and relationships envisioned by Kaiser, James and others. We are currently in the process of seeking external funding to jump start our work plan. In the meantime, I hope we will incorporate as much as we can through our annual strategic planning and budget process.
The purpose of a Community Approach is that "America's major rural health voices better mirror the elements of a successful community--'strong and diverse leadership, vigorous and grassroots-oriented community action.' (Rural America, Lessons Learned, W.K. Kellogg Foundation, page 22.) While recognizing that all of us are members of one or more communities, for purposes of this paper, 'community members' are defined as individuals living in a rural community whose principle occupations are not directly related to health care, education or research.
When the plan is fully implemented, NRHA intends to have achieved the following:
1. "Expanded National Cross-Sector Policy Development. That NRHA create with other national rural associations a country-wide cross-sector forum to jointly address public policies related to community development, e.g. the interwoven issues of rural health, education, and economic development."
2. "Expanded State Cross-Sector Policy Development. That NRHA work with state offices of rural health and affiliated/developing state rural health associations to facilitate their creating with other state rural associations state-wide cross-sector forums to jointly address public policies related to community development, i.e. the interwoven issues of rural health, education, and economic development."
3. "Expanded National Participation/Leadership. That NRHA actively expand participation in the Association by community members and their organizations along with a concurrent development of Association leadership from this constituency."
4. "Expanded State Participation/Leadership. That NRHA work with affiliated/developing state rural health associations to actively expand participation in their associations by community members and their organizations along with a concurrent development of organizational leadership from this constituency."
The white paper again quotes from Rural America, Lessons Learned: "The Rural America Initiative helped identify the key elements of a healthy rural community: strong and diverse leadership, vigorous and grassroots-oriented community action. But perhaps more important, the Initiative also revealed some successful methods and common themes for obtaining those elements. Projects that were successful at creating lasting, meaningful change and making the biggest difference in rural America shared the following characteristics:
· inclusiveness
· flexibility
· an ability to build cooperation and collaboration
· skillfulness in developing trust
· sincerity
· an ability to communicate with institutional decision makers."
The rational for this approach, as stated in the white paper, continues as follows: "State and national forums need to become much more proactive in getting over traditional barriers to seeking out and bringing to the table a more diverse constituency. This is not a "70's" issue of assuring "fair" representation but a "90's" issue of becoming more effective through community based thinking and action and expanding the scope of coalitions open to us. While we have expanded who is at the table locally, we by and large have continued business as usual as we go about our state and national advocacy efforts, unnecessarily remaining isolated from natural allies by our professional "rural health" identities."
"NRHA as a whole and many of us as individuals in rural health today have long embraced concepts related to community-oriented primary care (COPC) in our day to day work. Part of this growing understanding is the result of some early pioneers getting their message across to the rest of us; part is a pragmatic response by rural interests realizing that a large system can accomplish an unfriendly take-over of an individual clinic or hospital but rarely the whole community."
"COPC is based on a community-wide assessment of health care needs and a prioritization of problems that the community wants to address... A key concept to the approach is that health professionals and other members of the community reach a broad understanding of the health issues and problems and only through mutual agreement establish priorities for solving the problems...As the leaders of a national community of advocates for rural communities we need to walk the talk and find a mechanism that will allow us to begin to think outside of a box limited by traditional national rural health issues and players."
As the work plan to implement this initiative was being developed, we were encouraged to be realistic about the long term implications for NRHA; consequently we made three key observations:
· "NRHA would continue its focus on rural health but do so with a greater awareness of the context and inter-connectivity of rural health with other rural issues."
· "NRHA would become more accessible and responsive to advocacy efforts of other state and national rural groups as we would hope they in turn would be to us."
· "NRHA would become more complex but more real; discussions would not be as much what we as an Association can do for rural communities but what rural communities can do for themselves through the Association."
Your reflections would be very welcome. Also welcome would be letting me know how you can help in this any other association work. Thanks.
