Principle #4: All Involved In Planning
The planning is interactive, with the plan for the cooperative being the result of, and feeding into, the plans of the individual participants.
One theatrical but powerful example of ignoring the need for local input and preferences involved the Cooperative within months of its incorporation in 1979. Two regional health planners, with the very best of intentions, were practically driven from the bare wood stage of Wisconsin's historic Al Ringling Theater after their presentation of a unilaterally developed plan for local consolidations and closures. The plan was not implemented and did not contribute to further discussion of how rural health care in southern Wisconsin could be improved. Since then, local Wisconsin communities, understanding the scarce resources they face, have restructured more hospital activity than were ever dreamed of by central health planners during their zenith.
While the staff of RWHC are respected as well informed and creative professionals, the Cooperative's planning process focuses on determining the preferences and needs of the participating hospitals. Both the annual work plan and budget are driven by how the hospitals perceive they can make the best use of the Cooperative as a regional resource to assist their own local ability to survive and prosper. The State of Wisconsin's support for the Rural Medical Center as an alternative model for rural hospitals in 1992 flows directly, if not at some length, from a single RWHC administrator's input into the annual RWHC planning process in 1988.
With funding from the Robert Wood Johnson Foundation, RWHC implemented cooperative benchmarking: the continuous comparison of the functions and processes of similar hospital and non-hospital departments in order to identify and implement best practices. This project started from the request by a RWHC administrator for relevant comparative standards amongst RWHC hospitals but became more process oriented as a RWHC staff member became aware early of the potential application of Total Quality Improvement methodology to health care. More recently hospital feedback has led to the shortening of the time for completing an individual benchmarking cycle as well as increasing the involvement of other effected departments within each participating hospital. RWHC programs are not the result of central office direction nor of a single local hospital - they are the result of both, an interactive process amongst RWHC hospitals and staff.
Russell Ackoff, in A Guide to Controlling Your Corporation's Future, promotes the idea that by meaningfully including all parts of the organization in the planning process, by making the planning process interactive, all those who can effect the organization's outcome develop a vested interest in it's overall success. (Ackoff, R. L. 1984.)
Opposition to central private or public initiatives is frequently belittled as irresponsible local preferences for service regardless of cost. If for a moment however the proposition could be entertained that people are not automatically "backward or ignorant" when they fight against centralizing initiatives, some local preferences might be discovered to be rational. From the perspective of a local provider, it is rational to oppose initiatives which certainly lose local services and employment while gaining only a trivial portion of the larger system's uncertain savings.
While desperate or weak organizations may have no option but to accept patronizing assistance within larger networks or submit to more explicit and bold direct takeovers, healthier communities with greater productive potential respond more favorably to an approach based on mutual respect and responsibility with an appropriate sharing of risk and benefit. Communities and health care organizations must have genuine involvement in the planning and implementation of decisions that affect them. Dr. Susan Jenkins from the University of Georgia's Cooperative Extension Service puts it all very succinctly when she says, "If you come out of a (traditional) central office but still have that corporate mind set, you're not networking." (Personal conversation.)
Cooperative Behaviors to Encourage
- Cooperative leaders and staff need to balance their personal vision with their responsibility to discover and implement the vision of the cooperative as a whole.
- Identify common opportunities and threats as threads to support united efforts.
- Work to facilitate cooperative programs consistent with local programs and vice versa, be aware of the variety of local situations facing individual cooperative participants.
- If you are based within a traditional organization, remember you need to "switch over" to a more interactive planning style when you're working with the cooperative.
- Consult regularly with the cooperative for ongoing "midcourse" corrections, every cooperative meeting is both a board meeting and a focus group of customers.
- Make sure that each time the cooperative meets it is doing so to make one or more significant decisions.
- Treat cooperative meetings as the important corporate meetings that they are.
Behaviors to Discourage
- Don't get "hung up" on administrative "rights" as the board of a cooperative is also its primary or only group of customers.
- Don't take a "vertical or authoritarian" mentality into your "horizontal or collaborative" relationships.
- Never say "yes" when you mean "no".
- Don't proceed until you have the critical mass of participants "on-board' and don't judge your success by whether or not you had 100% of those in the cooperative agree to participate.
- Don't forget to check for "false positive" approvals regarding new cooperative programs, they are a particular risk of "cooperative group think."
Principle #5: Big Picture Understood
Participants need to know where the network is headed and where they are going within the network.
RWHC has a motto of saying it early and saying it often - we are not particularly concerned about "over communicating". A number of RWHC's more significant initiatives such as the development of a loan guarantee program, various quality improvement projects and advocacy for major education reform within the University of Wisconsin's health professional schools are multi-year efforts. Such projects require the ongoing reminder of their significance to individual RWHC hospitals, notwithstanding their earlier participation in the planning processes that led to these projects.
Just as RWHC has begun to network more at the state level, it has been actively promoting the establishment of partnerships between rural hospitals and public health departments within each county. RWHC has taken the position that the nation's emerging health care reform movement will require rural hospitals to look beyond the individual patient to see the whole community as a "new patient". Simultaneously, it will require them to recognize and respect existing initiatives by a variety of important public health organizations. Typically, many of us in the acute care sector have limited our definition of health care to patient care and that generally means visiting with a specific individual, forming a diagnosis, prescribing treatment, providing or referring for treatment and follow up as appropriate. Successful outreach to a community requires similar activities in an expanded context of the community as "patient" with a more complex array of partners.
The experience that RWHC hospitals have had in developing partnerships with each other is now beginning to be expanded into other spheres. Two RWHC hospitals have been invited along with hospitals in New York City, Philadelphia and Phoenix to develop proposals for a national demonstration project to develop community partnerships in order to better serve people with low income, three other RWHC hospitals have begun to work with their county public health department without any external funding. Wisconsin's Rural Health Development Council has accepted the suggestion of RWHC to make collaborative community decision making a priority for the technical assistance it is willing to provide rural hospitals and communities.
While not a new metaphor, participants need to see the larger picture printed on the puzzle box, a vision of how the puzzle fits together, how they fit in. What is the cooperative's mission, strategy and how are they a part of it? Where is the cooperative headed and where are they headed within the organization? Each participant needs an opportunity to create a personal vision of their own future with respect to the cooperative.
Participants need to understand the "strategy and direction" of the network or government policy or of any other corporate power that can substantively effect their future, if a local organization's leadership does not have a reasonable understanding of its environment, its employees will be similarly in the dark. Without that understanding every one's work will be substantially impaired.
Cooperative Behaviors to Encourage
- Networking is in large measure information and communication - make sure this is an unequivocal strength for cooperative leaders and staff.
- Cooperative goals and objectives, once determined, need to be continually communicated - "say it early and say it often."
- Recognize and without judgment account for the various levels of knowledge among the participants - develop efficient communication devices to allow for significant variation in the degree of prior knowledge or experience.
- Work to get all stake-holders, not just the participants' formal representative, the opportunity to understand the cooperative's plan.
- Give participants enough information to know when and how to ask for more information - a middle ground between keeping participants in the dark or hiding the trees in the forest of a million pieces of paper.
Behaviors to Discourage
- Don't assume that individual participants are too busy to be interested in a particular issue, this may often be the case (but let participants do the screening).
- Don't surprise the cooperative with unexpected news, good or bad.
Principle #6: Participants Effect Their Own Future
The desire for local autonomy needs to be made to work for the cooperative through the promotion of collaborative solutions that enhance self interest.
When RWHC began operations, many observers were highly skeptical about whether or not it would last, let alone make any real contribution - that rural hospitals' traditional need for autonomy would prevent any meaningful joint activity. Certain initiatives such as the development of the capability for RWHC to manage some of its own hospitals have been seen as precluded in large part due to this issue of autonomy. Some shared services have been under subscribed as hospitals have chosen local options when at least from the perspective of RWHC staff, a cooperative approach offered a better service at a lower cost. Notwithstanding these problems, the history of RWHC has been one of steady movement forward as collaborative approaches have been designed that respect the autonomy of each hospital.
RWHC staff attempts to look at the half of the glass that is full, it does not see it as their job to manipulate RWHC hospitals to do what staff perceives as the "right" thing, they see their job as developing and maintaining significant alternatives that will be accepted and sustained by the RWHC hospitals. The desire is not to make the hospitals "dependent" upon the cooperative but demanding of it through the strength that they gain, in part from the cooperative.
It is particularly destructive to the human spirit, and body, to hold an individual or group responsible for an outcome in a stressful environment but depriving them of the authority and resources to act. Karasek and Tores have found that the right to have control over one's work effects more than personal dignity, that it is a significant risk factor for coronary heart disease. "The primary work-related risk factor appears to be a lack of control over how one meets the job's demands and how one uses one's skills." (Karasek, R & Theorell, T. 1990.) Unilateral externally imposed policies by a regional HMO or threatened cutbacks in the availability of visiting medical specialists are routine occurrences for rural providers, chipping away at their sense of being able to effect their own future.
Dr. Helen Grace, a senior staff member of the W. K. Kellogg Foundation speaks to this issue when she says that the Foundation "... assists communities in solving the problems which they define, according to solutions they propose. To make the best use of the available resources, staff members of the Kellogg Foundation seek to understand the problems facing communities around the world, and to work with these communities to clarify and prioritize their concerns and to identify first steps toward reaching doable answers." (Grace, Helen K. 1990.)
The importance of individualism in our culture is one of the great American myths - not that it isn't true but that it is so true that we fail to pay it much notice, encompassing our lives like water does a fish. While it is unlikely that such a powerful, culturally driven self-image can be hung on a hook outside the workplace door, many organizations seem to adopt that premise.
Cooperative Behaviors to Encourage
- The role of the staff is to facilitate rather than control cooperative board decisions.
- The cooperative board decides what are its decisions to make.
- Make it clear nothing happens to participants unless they want it to happen.
- Use a decision-making process based on consensus for decisions that directly affect all participants.
- Avoid framing any issue that directly affects individual participants in terms of a search for a cooperative-wide right or wrong answer, facilitate each participant determining what is the right or wrong answer for their situation.
- Remember that a vote on the cooperative board for the cooperative to proceed with a project is not the same as that participant agreeing to be part of that particular project.
- Emphasize that the success of many projects is largely dependent upon the participant assuming full responsibility for implementation of the participant's piece of the cooperative-wide program.
Behaviors to Discourage
- Don't set up situations where the cooperative judges or use judgmental language about a participant.
- Don't take on the responsibility of being a missionary to "save" each participant from the consequence of their own decisions.
- Don't ever take a participant's participation for granted either as a customer or as part of the governance process.
- Don't set up situations in which the cooperative or an individual participant feels pressure to move forward but hasn't had the opportunity to make an informed decision.
Principle #7: Accountability Up Front
Participants in the cooperative, including cooperative staff, must always know up front what the rules are and what is expected of them.
The Rural Wisconsin Hospital Cooperative has been fortunate to have been a very stable group of hospitals, excluding an unsuccessful experiment with Affiliate members and one merger, only one member has withdrawn over a thirteen year period. Discussions at RWHC Board meetings are frequently comparable to user focus groups and equally valuable - staff and hospital participants know what is and what is not expected of them. The one member that withdrew, a rural referral center, did so as its undeclared interest in using RWHC as a vehicle to market its own services had not been satisfied. Participation in all Cooperative shared services requires a signed contract, not so much as to permit legal enforcement but to assure that all parties in the partnership have thought through up front the expectations of all of the participants.
RWHC has been equally fortunate in being able to attract high caliber personnel with minimum turnover, individuals who do more for less than they would in many less challenging jobs. In part this is because there is a tradition that even in a relatively unstable field, evaluation of individual performance is based on those elements of the job that the individual could personally effect and that individual contributions are recognized and rewarded to the degree possible.
The University of Wisconsin is one of the country's great land grant universities and as such it has a greater, not lesser, responsibility to work to meet Wisconsin's need for generalist physicians, nurses and physical therapists in underserved communities. The Cooperative has been asking that the University assume "co-ownership" with it and others to more effectively address the state's need for additional providers in both its rural and inter-city communities, that it works with us as a full partner. To that end and as a beginning point in the partnership, RWHC has advocated that the UW System should commit up front to saying how it will and to what extent it will adjust its production of health professionals in response to the state's need for providers in underserved communities while maintaining program quality.
The importance of accountability within a cooperative is based on the observation that individuals and cooperating organizations work best when they receive timely feedback and that this feedback is based on mutually agreed to expectations. To due otherwise is to generate hostility or withdrawal.
If instructions or rules that a RWHC hospital needs to follow are changed retroactively, there is the potential of a ripple effect within each hospital. A retroactive change to the hospital frequently translates into a retroactive change for individual hospital employees. While employee oriented organizations can frequently buffer employees from external capriciousness, there are limits. At a minimum, they can not diminish the damage done to an individual who has worked hard in one direction to find out that the results of her labor are now unimportant, unneeded. If that happens too often, RWHC hospitals and employees with options, will begin to exercise them.
Picture the image of people working together within a network or organization when mutual expectations are understood up front and respected, compared to the ambiguous and faceless environment of most public or private bureaucracies. The fundamental variable in most networks or organizations may not be the participants but the environment, most of us have experienced the power of our work to either inspire or to suffocate.
Cooperative Behaviors to Encourage
- Clearly define roles: who is responsible for what, who decides, who develops criteria, who gets to see cooperative data.
- Record in writing all agreements and expectations.
- Like all corporations, develop and utilize appropriate planning and budget documentation.
- Make the cooperative's verbal commitment its bond, particularly around "political" negotiations that have not or won't be reduced to writing.
Behaviors to Discourage
- Don't ever speak for or obligate the cooperative or individual participants without their prior consent.
- Don't let familiarity and a collaborative agenda create sloppy business habits when it comes to spelling out an agreement about who is responsible for what.
Principle # 8 Decisions Can Be Appealed
A clear non-threatening appeal mechanism is needed to insure individual rights against arbitrary actions.
The use of the cooperative strength of RWHC hospitals has been used to force an appeals process when faced with a potential breach of contract by a single large urban based HMO, individually few could have justified the necessary prolonged legal challenge to enforce the contract but through concerted joint "inquiry" into the legal options available, further legal action become unnecessary. A particularly attractive feature of a multi-hospital insurance program, the RWHC Trust, was the ability of the participating hospitals to have appeals about disputed claims judged by their peers familiar with their work setting rather than a distant bureaucracy limited to only its written rules.
A need for relief from arbitrary action can also happen even before a relationship is developed. Rural health care providers, however financially sound, are frequently "red-lined" or excluded from increasingly national and international capital markets - an arbitrary action from the point of view of a well run rural hospital. "Bond market looks askance at rural and small urban facilities that need cash, meanwhile, high powered institutions benefit from fat ratings, cheap rates." (Nemes, Judith 1992.) As an initial response, RWHC has established a pilot loan guarantee program for RWHC hospitals in cooperation with the Robert Wood Johnson Foundation and the Wisconsin Health and Education Facilities Authority. Use of the pool is based on objective rural sensitive loan criteria applied by RWHC colleagues with a final determination by the state hospital bond authority. The pilot is initially financed by a $500,000 low interest loan from the Robert Wood Johnson Foundation. RWJF support for this private sector pilot was used as an incentive for the State of Wisconsin to invest $500,000 for the same purpose. Lenders to those hospitals who are accepted by both Programs will have 50% of loans with a principle up to $500,000 guaranteed in case of default: 10% through a hospital reserve fund, 20% by the State and 20% by RWHC.
Cooperative Behaviors to Encourage
- Make it easy for participants to express a reservation, concern or complaint.
- In the case of a dispute that is not being resolved to both parties satisfaction, the participant should always be informed how best to make an appeal to the cooperative as a whole.
- Remember that the participant's right to appeal to a peer is one of the distinctive and appealing characteristic of a cooperative.
Behaviors to Discourage
- Do not enforce your "rights" unilaterally or quickly against any participants however clear you believe your case to be.
Summary
Most major reform alternatives to the single payer Canadian approach require that private and public purchasers of health insurance or plans organize themselves cooperatively under a few regional brokers or "sponsors" to negotiate with newly organized regional networks of providers. As both sectors are more attuned to "competition" than the cooperation that will be required by such proposals, the experience of the Rural Wisconsin Hospital Cooperative and other networks is perhaps more timely than ever. There is a need for innovative inter organizational relationships that, in DePree's words, encourage participants "to do what is required of them in the most effective and humane way possible." Success in health care requires new private, public cooperative attitudes, processes and structures built fundamentally upon an understanding and respect for real people working in local community based organizations.
Resources
Ackoff, R. L. 1984. A Guide to Controlling Your Corporation, New York: Wiley,
DePree, M. 1989. Leadership is an Art, New York: Doubleday
Eisler, R. 1988. THE CHALICE & THE BLADE, Our History, Our Future, San Francisco: Harper
Grace, Helen K. 1990. "Building Community: A Conceptual Perspective" INTERNATIONAL JOURNAL OF THE W. K. KELLOGG FOUNDATION 1, no. 1: 20-22.
Greenleaf, R. K. 1977. Servant Leadership, New York: Paulist Press: 60.
Nemes, Judith 1992. "Hospital borrowers finding it tougher to scale the wall on Wall Street." Modern Healthcare 22, no. 25: 59.
Kanter, R. M. 1990. When Giants Learn To Dance, New York: Simon & Schuster: 18.
Karasek, R & Theorell, T. 1990. HEALTHY WORK, Stress, Productivity, and the Reconstruction of Working Life, New York: Basic Books: 9.
Zuckerman, H. S. and D'Aunno, T.A. 1990. "Hospital alliances: Cooperative strategy in a competitive environment." Health Care Management Review 15, no. 2: 21-30.